664

from its lower end. The wounded loop of intestine was thensecured in a clamp, which served the purpose well; it wasmade of two pieces of gum-elastic bougie (No. 10), aboutthree inches long, which were laid side by side and firmlytied together just above and below the wound in the pieceof bowel, which was laid between them. The peritonealcavity was then thoroughly flushed out with warm carbo-lised water, and the abdominal wound was closed, exceptwhere the clamped piece of intestine was left outside toform an artificial anus. The wound was dressed with iodo-form and absorbent wool. The man rallied from the opera-tion, but, gradually sinking, died six hours after it.Remaoks by Mr. OWEN.—When the patient was first seen

he was evidently suffering from peritonitis and shock, theresult of a blow or fall upon the front of the abdomen, thehistory at the time not showing clearly which. The collapsewas extreme, the outlook hopeless, and the prospect ofimpending death considerable. The amount of stimulationwas increased; and though the probability of the man havingsustained rupture of some viscus, or of some large vessel ofthe abdominal cavity, was discussed, it was deemed prudentto await the further course of events. In the meanwhile,the man’s wife was seen, and general consent to an intro-spection obtained ; no doubt it would have been better ifthe operation could have been performed earlier. In certaincases of buffer accidents, and other serious injuries of theabdomen, it may be expedient to open the peritoneal cavity,not perhaps immediately after theoreceipt of the injury, butlater on, in order that diagnosis may be assured, and adefinite and special line of treatment adopted. Withoutabdominal section the man with a ruptured liver or bowelis almost certain to die; operation might improve hischance of recovery. The indications for interference might bepersistence of the collapse, and invasion of acute peritonitis.In the above case a post-mortem examination could not beobtained-not, indeed, that there was great need for it.

YORK COUNTY HOSPITAL.A CASE OF CEREBELLAR HÆMORRHAGE; DEATH ;

NECROPSY; REMARKS.

FOR the following notes we are indebted to DTr. ArthurJefferson, house-surgeon :-Mary S-, a woman apparently aged about forty-five,

was brought to the County Hospital from the York RailwayStation in an unconscious condition. She was accompaniedby a female, who stated that the patient and herself werefellow-travellers from Lincoln to a town north of York.The woman knew nothing of the antecedents of the patient,only having become acquainted with her at a friend’s housetwo days before. From the statement of this person it ap-peared that she had met Mary S- that morning at Lin-coln Station by appointment; that they had agreed totravel together, not because Mary S-- was ill, but for thesake of company. All had gone well until they exchangedtrains at Doncaster, after waiting there about an hour. Ontheir getting into the York train, the patient, who pre-viously had apparently been quite well and cheerful, after afew minutes suddenly exclaimed that she felt sick anddizzy, and began to vomit. Her companion helped her to liedown on the seat and put a shawl over her; after this shevomited once or twice, and then, apparently, fell asleep.On the tickets being collected at York, however, it wasfound that she could not be roused. Directly the trainreached the station, a surgeon was sent for, who directedher immediate removal to the hospital, himself accompany-ing her. Since leaving Lincoln, three hours before thepatient became unconscious, and four hours before theirarrival at the hospital, she had had neither food or drink.On examining the patient, who looked quite placid and

exhibited no marks of violence, it was found that her pupilswere equally contracted to the size of a pin’s head, and quiteinsensible to light; there was no conjunctival reflex; shewas quite unconscious, and her limbs were flaccid. It wasnoted that as she lay on the couch she moved first one leg,then the other, slightly, to the extent of about an inch ; thiswas not a reflex act, and it occurred in an upward direction, notbeing due therefore to gravity. Her breathing was regular,but very shallow; there was no indication of rotation of thehead or deviation of the eye; her radials were apparentlyhealthy, the pulse regular, and compressible. On examiningthe heart, there was found a faint systolic aortic bruit, butno accentuation of basic second sound. A catheter was

passed ; some urine was drawn off and examined for albu-men, with a negative result. There was no evidence of re-laxation of the sphincters. It was concluded that the patientwas either suffering from hæmorrhage into the pons oropium poisoning, the former being thought the more pro-bable. Treatment for the latter condition was immediatelycommenced, the stomach-pump being put in operation,and an atropine hypodermic injection prepared. Thestomach had been partially injected, and a syringefulof fluid withdrawn, when the respiration ceased. Thetube was at once taken out and artificial respirationcommenced. This artificial respiration was continued(with the help of the assistant house-surgeon and -Alr.Kirsopp, who had brought the woman to the hospital) fora period of two hours and a quarter. About every fiveminutes during this time the artificial respiration wassuspended to see if the patient breathed, and the suspen-sion was continued until the pulse became irregular; onlyonce, however, did the patient breathe, and this was aboutfive minutes after the commencement of the artificial move-ments. It was found that the pulse, which remainedregular and fairly strong while the movements were con-tinued, on their cessation in about thirty seconds becamevery irregular; on recommencing, however, regularityreturned, though to secure this it was necessary to usesomewhat violent exertion. Finally, for the last tenminutes the pulse remained irregular and then becameextinct. Evidences of asphyxia for two hours before deathhad been marked; amongst others the patient’s pupils, beforeso contracted, became widely dilated, and remained so foran hour before death.At the post-mortem examination the usual asphyxial con-

gestion of all the organs was found; they were, however,apparently healthy with the exception of the heart, aorta,and brain. The heart presented in its right posterior aorticvalve a small needle-like bony spicule which kept the valverigidly extended; there was hypertrophy of the leftventricle and remains of old inflammation about the mitralvalve; its weight was ten ounces and a half. About the rootof the aorta were numerous atheromatous patches, in whichonly traces of calcification could be found. On removingthe skull-cap the meninges of the brain were seen to be con-gested ; and on next removing the brain a thin lamina ofsubarachnoid hæmorrhage was found over the under surfaceof the cerebellum and pons ; no superficially ruptured vesselcould be seen. On cutting into the brain the fluid in thesecond and third ventricles was found to be deeply blood-stained, and projecting from the iter a tertio into the thirdventricle was a blood-clot. On slitting up the iter and open-ing the cerebellum, this clot was followed into the fourthventricle, which, greatly distended, it completely filled.Horizontal sections were now made through the cerebellum,and in the left hemisphere a large clot was found, com-pletely tearing up and pushing aside the nerve structures;in shape this clot was oval, its larger end directed for-wards. Vertical section showed, again, an oval surface withthe larger end directed backwards; the surface of theclot extending posteriorly to within a couple of lines of theposterior inferior lobe. At one point in the clot, in theregion of the corpora dentata the blood was quite fluid.No ruptured vessel could, however, be detected, nor wasthere any sign of aneurysmal dilatation in any of the cere-bral vessels examined. The clot was left more or less in

position, and, together with the cerebellum, pons, andmedulla, placed in spirit. After the lapse of a fortnight theclot was peeled out from its bed, dried with blotting-paper,and weighed; its weight was found to be 312 grains. Thepons was now further examined, but exhibited no indirectlesion.At the inquest, the son, with whom the deceased had been

staying, stated that his mother’s age was sixty-four, andthat for the three months she had been staying with himshe had never complained of illness; he had always regardedher as a perfectly healthy woman.

Remarks.—From the fact that the portion of the clot inthe region of the left cerebellar corpus dentatum showedfluid blood, it would seem that the branch of the superiorcerebellar artery supplying that portion of the cerebellumgave rise to the haemorrhage. This artery is the one whichDr. Bastian points out as the most frequent cause of largelateral cerebellar haemorrhages. That the artery givingrise to the haemorrhage was a large one is proved bythe complete breaking-up of the cerebellar tissue aroundit, so that not only did it burst into the fourth ventricle,

665

but also spread forwards into the third ventricle, givingrise to the clot at that end of the iter a tertio, togetherwith the blood-stained fluid in the lateral ventricles, andagain backwards through the foramen of Magendie,causing the thin clot in the subarachnoid space over

the under surface of the cerebellum and pons. Althoughthe cerebellum in this case was primarily affected,yet the haemorrhage being so extensive, its pressure effectson the pons and medulla completely masked any symptomswhich might have arisen from the cerebellar disintegra-tion per se; the primary dizziness spoken of by thepatient’s friend possibly may have been due to this last.On the other hand, there does not seem to have been com-plete paralysis of the lower extremities, for the patientdistinctly moved not only the leg on the opposite side tothe lesion, but also the one on the same side, though onlyto so slight an extent that it was only by chance that itwas noticed. It is curious that the pressure effects shouldhave been felt at first so exclusively by the respiratoryportion of the ?2o?ud tital, for more than two hours after the cessation of respiration the heart’s action was con-tinued and the patient kept alive by artificial respiration.The gradual, permanent, and excessive dilatation of thepupils as the asphyxial condition became more markedis noteworthy, contrasting as it did so strongly withthe previous marked contraction. Again, although thepatient was sixty-four years of age and had atheromatousdeposits in her aorta (and one can only suppose cerebralarterial degeneration as well, though no aneurysmal dilatationwas anywhere detected in those arteries), still she exhibitednone of the other usaally accompanying signs of old age;indeed, her son, a man aged forty, looked as old as she did.Finally, the stomach-pump was used in this case in a purelyroutine manner; there was, so far as could be seen, noIeason to disbelieve her friend’s statement that nothinghad passed the patient’s lips for four hours before she wasbrought to the hospital, and also that vomiting had occurred.Under these circumstances there could have been littlechance of any opium remaining in the stomach, supposingthe drug to have been taken or administered before thewoman started, though, perhaps had she had a peculiarlylarge and indigestible meal at that time, some might yet- have remained.

__ __ ___

Medical Societies.CAMBRIDGE MEDICAL SOCIETY.

Antipyrin.-Phrenitisfollowing Otorrhœa.-Fracture of the Astragalus.

AT the meeting on August 7th, Dr. MACALISTER gave anaccount of the nature and uses of Antipyrin, and in iliustra-tion of its valuable antipyretic properties showed the tem-perature charts of two patients recently treated in Adden-brooke’s Hospital. Both suffered from phthisis, apparentlylimited to the apices of the lungs, and manifested by muco-purulent sputa, wasting, slight haemoptysis, and the physicalsigns of consolidation and cavity. In one case, that of aman aged twenty-five, hectic fever made its appearance;the morning temperature was 98°, the evening 1020. Anti-pyrin in fifteen-grain doses, administered twice in the’course of the afternoon, promptly reduced the range ofdaily oscillation to 1°, about the normal temperature. Anomission of the drug was followed by recurrence of thehectic ; but again the temperature fell, and was maintainedlow by five-grain doses given thrice a day. At the sametime the patient became more comfortable and slept better ;some tendency to sweating was checked by minim-doses ofsolution of sulphate of atropia. The other case, that of awoman aged forty-four, with still more urgent symptoms,- and a temperature ranging from 98° to 103°, was treated ina similar way with equally good results. The relief andgeneral sense of well-being produced by the medicine was anotable feature, and there was no untoward symptom. In.neither patient was any rash or marked nausea produced,and both were in little more than a fortnight so much betteIthat they were transferred to the out-patient department,Dr. MacAlister thought that in many affections in whichfever was a symptom it was sound practice to attempt tcreduce the temperature for its own sake, just as we try tc

soothe pain when we can, irrespective for the moment ofthe fundamental disorder; antipyrin of all the antipyreticshe had tried seemed to be the most powerful with thefewest disadvantages. if experience justified this con-clusion, the drug might talce its place beside morphia, beingthe allayer of fever as that was of pain.Mr. HYDE Hmzs narrated a case of Inflammation of the

Brain and Meninges following Otorrhcea. He was called onJuly 18th to see a fine young man, aged twenty-three, whoseprevious history was that he had scarlatina ten years agoand mumps four years ago. Since the first event he hadoccasionally suffered from otorrhoea of the left ear. Mr.Hills was told the patient had been suffering from earacheand a slight discharge from the left ear for five days. Hewas then suffering a good deal of pain in the left ear, withpains running up the side of the head. There was a slightmuco-purulent discharge from the ear. The pupils wereequal and acted well. He was and had been perfectly clear-headed. The temperature was 100’5°; pulse about 84. Hewas ordered to foment the ear and to take one-sixth of agrain of morphia every four hours whilst the pain lasted.In the evening the pain had increased. Temperature 105° ;pulse full and quick ; pupils equal. The morphia was dis-continued and two leeches applied behind the ear, and Dr.Humphry saw him in consultation at 9 P.M., when theleeches seemed to have had a marvellous effect. The

patient was calm and clear-headed now. Temperature 101°.Some antimony and acetate of ammonia was orderedevery four hours, and more leeches to be applied if the

pain returned. The next morning (the 19th), at 9.30 A.M.,his temperature was 97.5°; pulse about 80; pupils actingand equal. He had had a good night. In the evening histemperature was 101°. There had been some accession ofpain during the day, which the application of a leechseemed to relieve. At 3 A.M. the next morning (20th)Mr. Hills was called up to him, as he had a good dealof pain and was wandering. He gave him thirty grainsof bromide of potassium, which had a good effect. Duringthis day he was aphasic and rambling at times; but thispassed off by the next day (21st), and he was then in a sta-tionary condition, being on the whole very clear-headed,talking sensibly. He complained of a dull pain on the leftside of the head, and the temperature varied from 100° to102° ; pulse about 80; pupils acting and equal, except onone occasion, when the left pupil was certainly more dilatedthan the right, but this difference had disappeared on thenext visit. On the 22nd he complained of the pain as beingvery great, and extending more to the right side, but hisgeneral condition was much the same. He was ordered ablister to the back of the left ear, and one-sixth of a grainof morphia every four hours if the pain was great. Nextday the pain had much subsided; the top of the head wasblistered, and savin ointment applied. The patient showedno material change for the next two days. On the morningof the 26th he was fairly comfortable, and was quite rational.However, at 3.30 P.M. on that day he complained of muchpain, more especially in the body. His right pupil was thenfully dilated; the left was normal. Temperature 105.2° ;pulse quick and feeble. He was then in a semi-comatosecondition, and died at 5 P.M. Necropsy, made twenty-twohours after death, showed extensive meningitis at the baseof the brain, with purulent fluid and deposit of lymph,extending into the lateral ventricles ; and inflammation andsoftening of the brain substance in the lower part of theleft temporo - sphenoidal lobe, in which was an abscesscavity. There was no evidence of disease in the third leftfrontal convolution. On removing the dura mater from theleft temporal bone a small aperture was found throughwhich pus issued from a small cavity between the duramater and the bone, at the bottom of which was a tiny loosesequestrum, the part of the brain above this being the seatof the abscess above described. The tympanum containedmuch turbid fluid. blr. Hyde Hills remarked upon the greatvariation in the symptoms in this case, and the absence ofalarming symptoms on the morning of the day on which thepatient died ; the aphasia was also difficult to account for.

Prof. HUMPHRY showed the outer half of an Astragaluswhich had been separated by a longitudinal fracture, tra-

, versing the middle of the bone, and which had been removed’ successfully. The patient was under the care of Mr. J. B., Cross of Scarborough, who had presented the specimen tothe Pathological Museum at Cambridge, and the following) account of the case had been furnished by his assistant,) Dr. Walton:-H. W—, aged sixteen years, was cleaning