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About the seventh or eighth day some of these symptoms subside; the vomiting ceases; but the fever still continues; the pulse and respiration are irregular; the belly is retracted, and finally partial convulsions ensue, followed by coma and death.

repeated; but sometimes, as already stated, such repetition is unnecessary. When there is pain at the epigastrium, and other signs of gastric irritation, I would recommend the application of leeches to the part, taking care to encourage the bleeding by warm fomentations and light poultices. Next to bleeding Diagnosis. The diseases which are apt to be conI would rank severe counter-irritation. Colchicum, founded with acute meningitis, are, as may be imagined, digitalis, and antimonials, I have repeatedly employed numerous. Before we mention these diseases, we with great advantage. The observation applies like-shall enumerate those symptoms of the convulsive and wise to mercury. phrenitic forms which are most worthy of confidence in a diagnostic point of view.

When the disease recurs it generally has not the same intensity, and is, I think, more under the power In the convulsive form, we should attach great of medicine; we should now abstain from employing importance:-1. To the constant repetition of convulthe same active treatment as during the first attack,sions at short intervals. 2. To the acceleration of the and should content ourselves with combating the respiration, which cannot be accounted for by any inflammation by the moderate use of topical bleeding pulmonary lesion. 3. To the absence of all visceral inflammation, and of any indication of an exanthematic eruption. In the phrenitic form, the cardinal symptoms are,-intense headache, accompanied by frequent bilious vomiting and constipation, followed by delirium and agitation, alternating with stupor.

and counter-irritation.

ON SIMPLE ACUTE INFLAMMATION OF THE
MEMBRANES OF THE BRAIN IN INFANTS.

By Dr. RILLIET, of Geneva.

(Translated for the Provincial Medical and Surgical Journal.) (Continued from page 181.)

IV. GENERAL DESCRIPTION OF THE DISEASE. Form, Duration, Termination.-Acute meningitis declares itself under two forms, to one of which we give the name of " convulsive," the other "phrenitic." We do not, however, wish it to be understood either that convulsions are never present excepting in the "convulsive" form, or that the "phrenitic" is the form exclusively characterized by perversions of the intelligence; we merely wish to notify by these terms the predominance of certain symptoms.

Differential Diagnosis of the Convulsive form.-Convulsions in early infancy are very frequently symptomatic; but in this case they are seldom violent or so frequently repeated. Moreover, in the interval, the little patient recovers his sensibility, the respiration is not permanently accelerated, and the pulse quickly regains its normal standard. It must, however, be admitted that in many cases the diagnosis can only be established by the progress of the disease.

The distinction between convulsive meningitis, and other cerebral affections is still more obscure, and indeed it is often impossible. The error is not, however, one of importance, as the treatment, and too often the termination of all is the same.

The first disease which we shall endeavour to distinguish is hydrocephalus, with infiltration of the pia mater, the Wasserschlag of Gölis,

then undistinguishable. In other cases the "hydromeningitis" is the principal lesion, and we find only slight traces of purulent effusion. This disease, like the one from which we wish to distinguish it, also attacks very young infants; it sets in with fever, and a violent attack of convulsions, or with agitation and stupor, with transient and fallacious signs of amelioration.

The convulsive form is most commonly seen in very young infants. It commences suddenly by an attack of convulsions, general or partial, with more or less febrile disturbance. There is neither vomiting nor In certain cases this condition complicates infiamconstipation. When the convulsions, which are re-matory meningitis, and the main features of each are peated at brief intervals, subside, the infant is left either in a state of agitation, or profoundly comatose, with squinting, and sometimes perfect hemiplegia. In certain cases there is an approach to sensibility between the fits, but the amendment is but momentary, and death rapidly approaches either by coma or during a subsequent paroxysm. The convulsive form of meņingitis sometimes sets in more slowly, and the convulsions are not so closely approximated. The duration of this latter variety is longer, being from a week to a fortnight. Phrenitic meningitis is commonly observed in early childhood, and in many respects resembles the acute meningitis of the adult. It commences with fever preceded by a rigor; violent headache ensues, with photophobia, vomiting, and sometimes constipa-contraction of the fingers and toes,—a symptom which tion. The intellect suffers by the end of the first or second day, and the face assumes the peculiar wild look of the disease. Agitation and stupor alternate, and delirium is generally present. Subsequently there is grinding of the teeth, partial convulsions, rigidity of the limbs, a drawing of the head backwards, strabismus, and contraction followed by dilatation of the pupils.

The analogy between the disease and the convulsive form of meningitis is therefore perfect. In hæmorrhage into the arachnoid, we observe repeated convulsions as the earliest symptoms, but they are in general less violent than in meningitis, and the coma does not ensue so rapidily. According to M. Legendre, children attacked with meningeal apoplexy, exhibit

is not observed in meningitis; while, on the other hand, the excitement of the pulse and circulation which are witnessed in the latter disease, are not seen in meningeal apoplexy. Hæmorrhage into the pia mater also in some respects resembles convulsive meningitis, but it is a lesion of such rare occurrence that it need scarcely enter into our consideration.

ON INFLAMMATION OF THE BRAIN IN INFANTS.

These remarks conclude what we have to say respecting the diagnosis of convulsive meningitis from other organic lesions of the brain; but we must remember that the most important part of the diagnosis of the disease consists in its distinction from essential or symptomatic convulsions, since the treatment of the two forms of convulsion is obviously different.

What we have said in connection with "convulsive meningitis," applies equally to the phrenitic form. Cerebral hemorrhage, encephalitis, &c., may be confounded with it without any great damage; but it is not so with regard to cerebral congestion, tubercular meningitis, and those sympathetic affections of the brain which arise during the course of the eruptive or typhoid fevers. The following paragraph deserves the earnest attention of our readers :

Cerebral Congestion.—We have often propounded to ourselves the following question :-Ought we to consider those violent cerebral attacks, which either quickly prove fatal, or as rapidly subside, and the symptoms

of which are precisely those which indicate the onset of acute meningitis, as real instances of that disease? Post-mortem examination in these cases discovers neither pus nor false membranes, but oaly simple con.. gestion. Is this congestion to be regarded as the initiative stage of inflammation? The question is difficult of solution; but we neverthless consider that it should be answered in the negative, and for these reasons:-Inflammatory products of the brain form with such rapidity, that its whole surface may be covered with false membranes in a few hours, consequently the cases we have just mentioned ought to be distinguished from meningitis, both anatomically and by their symptoms. The diagnosis may, however, be here plainly established by the following comparative table:

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diagnosis is to be drawn from the ensemble of symptoms, and not from the individual characters of a disease. 2. The main element in forming our diagnosis is the consideration of the point of time at which the disturbances of the intellect and mobility originate. 3. That the invasion of tubercular meningitis may take place under three different states of the system-1st, after a longer or shorter duration of precursory symptoms; 2nd, during the progress of tubercular disease in other organs; 3rd, in perfect health. 4. That the first and third species are readily distinguished from acute simple meningitis; the error is more likely to be made between the latter and the second form. These preliminaries established, we shall proceed to lay down a brief summary of the differential symptoms as below:Tubercular Meningitis.

Simple Meningitis.

1. The children attacked 1. The subjects of tuberwall-developed, and do not cate, and often precocious are in general vigorous and cular meningitis are deliexhibit any signs of tuber- children. They are subject cle. Their relations too, to glandular enlargements, are healthy. and chronic eruptions of the skin. Their blood.relatives generally bear the stamp of the strumous diathesis.

2. The disease may appear as an epidemic.

3. Prior condition. The attack takes place during robust health, or if it is secondary, it follows some palpable external cause, or arises in the course of a non-tubercular malady.

4. Mode of attack.-Violent convulsions, intense fever, quick respiration if the infant is very young; or headache, fever, bilious vomiting. After a lapse of

In the phrenitic form, the first symptom is partial or general headache. Delirium does not appear in general until the lapse of twenty-four or thirty-twenty-four hours, excessix hours. Vomiting is sive agitation, delirium, and prostration.

and slight convulsions. generally present,

These symptoms appear almost instantaneously. Vomiting is for the most part absent.

Cerebral Hæmorrhage.-In some cases cerebral hæmorrhage closely simulates acute meningitis. Headache, convulsions, delirium, vomiting, and constipation, mark the onset of both diseases, and it is, therefore, difficult to decide, with certainty, which disease is present. The best guide to a correct conclusion is the high febrile excitement which characterizes meningeal infiammation.

5. Symptoms.-Headache intense, vomiting incessant, fever high, delirium fierce, constipation moderate.

6. Progress.-Rapid; convulsions incessant.

Tubercular Meningitis.-We now arrive at the most important portion of this essay, and shall endeavour to 7. Duration.-Death in point out the main distinction between simple and 24 hours, in some cases; tubercular meningitis. For clearness sake we would but generally at the end remind the reader of four circumstances:-1. That' of the third day.

2. The disease is always sporadic.

3. Prior condition.-The infant is observed to pine away and lose its flesh and strength. The disposition is altered, the appetite fails, and the prime viæ become deranged.

4. Mode of attack.-Convulsions never the first symptoms; the transition from the first to the second period of the disease insensible; the coming on of the second stage marked by headache, vomiting, and constipation; the intelligence sometimes unaffected. When the precursory symptoms are absent, the disease is ushered in by vomiting, moderate headache, and fever.

5. Symptoms.-Headache not intense, vomiting not so urgent, constipation obstinate, fever moderate. 6. Progress.-Slow.

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We have thus gone through the list of the cerebral affections with which simple meningitis may be confounded, we shall now notice the distinction between it and certain formidable cerebral symptoms, which declare themselves without any appreciable lesion of the brain, as for instance, during the progress of fevers. And first of

Small pox.-This disease is sometimes at the onset mistaken for meningitis.. The most important ele. ments in the diagnosis, are the consideration of the reigning epidemic, the lumbar pains, and the time at which delirium appears, which in small pox, is seldom earlier than the third day.

Scarlatina. In adynamic scarlatina, children frequently complain of headache, and are seized with vomiting. We must look for our guide to the state of the tongue and throat, and the great heat of the skin, taking likewise into consideration the fact of the prevalence of the disease at the time.

Typhoid Fever. The same rules for forming a diagnosis are applicable in this disease as in small-pox, &c.; but in addition we are to remember, that in typhoid fever the headache is less intense than in meningitis, that the vomiting is less urgent. Some useful information may also be drived from the state of the lips and tongue, the pain in the body, the diarrhoea, and the state of the chest. Moreover, the symptoms which are analogous in the two diseases appear at different periods,-in meningitis at the commencement, in fever towards the termination.

(To be continued.)

CASE OF TRAUMATIC TETANUS: ADMINIS-
TRATION OF ETHER.

TO THE EDITOR OF THE PROVINCIAL MEDICAL AND
SURGICAL JOURNAL.

SIR,

I beg to forward you the following brief report of a case of traumatic tetanus in which æther was most successful in arresting the spasm.

continuing, he had thirty minims of liquor opii sedativus, every hour, and belladonna to the neck and jaws. He was perfectly under the influence of opium, but without any remission of the symptoms of opisthotonos.

Monday evening. The spasms now most violent. Half a drachm of æther, added to each dose of opium, and calomel freely given through the night.

Tuesday morning. No better, but decidedly worse. We now determined to try æther. This was adminis tered by means of Boott's apparatus. He was soon under its influence, and immediately all contraction and spasm ceased, and he got into a most comfortable sleep, which lasted full ten minutes. As soon as he became sensible the spasm and contraction returned, but scarcely so violent. He again inhaled the æther with the same result. He had it a third time; it again relieved him, and he was left asleep, and on visiting him I found he could open his mouth better. He was most anxious to have it again, but a violent spasm came on before I could get it to him, followed by another, and he immediately sank.

I am, Sir,

Yours truly,

H. H. BROUGHTON.

Dobcross, near Manchester,
Saturday, April 24, 1847.

Hospital Reports.

QUEEN'S HOSPITAL, BIRMINGHAM.

CLINICAL REPORTS OF SURGICAL CASES
UNDER THE TREATMENT OF WILLIAM
SANDS COX, ESQ.

By PETER HINCKES BIRD, one of the Resident
Medical Officers.

(Continued from page 181.)

CASE XXVII.

EXTENSIVE INJURY OF THE HAND.

Eli Holloway, aged 15, admitted into the Queen's Hospital, on August 24th. He states that about half an hour previously his hand was severely wounded by a circular saw, which cut off the little finger of the right hand, and severely lacerated the two next; he lost but little blood at the time.

On Saturday, March 20th, I was called at 6 a.m., to Charles Prescott, a miner, residing two miles from this place. I found the left arm completely shattered by a large stone falling on it; he had not lost much blood, his comrade had tied a piece of cord tight round his arm, which completely checked the bleeding. He had walked home, a distance of a mile from the shaft where the When admitted the little finger was found gone, and accident occurred. I immediately amputated below there was present a deep lacerated wound on the back the elbow-joint; three arteries required ligatures. He of the hand, extending from just below the head of the went on exceedingly well for some days. On Wed-metacarpal bone of the little finger to that of the nesday, the 24th, he was most anxious to get up, and on the wound being dressed, union had taken place by the first intention. On Saturday, the 27th, I found him sitting up and dressed; he said he was quite tired of bed. In the evening he sent down, stating he had taken cold. He had some aperient medicine sent him.

On Sunday the symptoms of tetanus became marked; there was considerable rigidity of the muscles of the neck and jaw, and difficulty in swallowing. He had an enema with turpentine, calomel, and an active apericnt, which soon operated. The symptoms

middle finger; the metacarpal bones of the middle and ring fingers being shattered. He was rather pale; he did not complain of much pain in the parts; pulse 75, pretty strong.

It was determined that the middle and ring fingers should be removed. An incision was made on the back of the hand below the seat of injury; the metacarpal bones were sawn through, and a flap formed from the palm of the hand; there was not much hemorrhage; the patient bore the operation remarkably well; the stump was dressed, and a roller lightly applied; he

ILLEGAL PRACTICE OF MEDICINE.

237

was then put to bed, and ordered to keep the hand the leg has subsided; two fresh wounds have broken damp with a cold lotion. out and discharge freely.

26th. Doing well; wound discharges healthy matter; not in any pain; sleeps well.

June 27th. Since last report fifteen pieces of bone, some of them an inch and a half long, have come away

September 1st. Improving; the wound is looking at various times; is in no pain; can walk about; very little inflammation present; health improved. healthy, and heals rapidly.

10th. Healing; looks healthy; appetite good. 17th. Nearly healed; general health improved. 21st. Quite well.

In injuries of the hand no more should be be removed than is absolutely necessary, but in this case the extensive injury would not permit the attempt of saving more than the thumb and fore-finger, which forms a useful but rather an unseemly member. The fore-finger and thumb are much more useful than the other fingers, for indeed all the delicate movements are performed by them, and should therefore, if possible, be saved; there are other fingers to compensate in some measure for the loss of one, but the loss of the thumb can never be supplied.

CASE XXVIII.

NECROSIS.

July 14th. Seven pieces of bone have come away since last report, two of which came from an opening in the upper part of the tibia.

20th. Much better in all respects; no more bone has come away; inflammation subsiding. To be dressed as before; the fungous edges of the wound require to be touched with Argenti Nitras.

August 3rd. The skin again became red and painful. Apply poultice.

September 21st. Since last report as many as twenty pieces of bone have been discharged; the matter is healthy, and the parts not painful; general health good. 28th. He still remains in the hospital.

The tibia is the most frequent seat of necrosis, and this disease is most common from twelve to eighteen years of age. Every bone in the body is subject to necrosis; but those bones which are superfical, and enter into the formation of the extremities, are more

Edward Ferraday, aged 16, of strumous diathesis, zinc-worker, admitted into the Queen's Hospital April 17th, 1846, under the care of Mr. Sands Cox. He states that about nine weeks ago he dropped off from some height, and sprained his ankle, the foot becoming quite numbed at the time; was under medical care, and had leeches and cold lotions applied, had probably some share in bringing on the disease.

frequently affected than others whose situation is deeper. This case is remarkable for the great number of pieces of bone of various sizes which came away at different times, and also for the slight nature of the

and was lanced near the ankle in two places. He

states that he felt two pieces of bone loose before he

came into the hospital.

accident which is said to have been the cause of the disease. The scrofulous constitution of the patient

PROVINCIAL

Present state. There is much swelling about the Medical & Surgical Journal.

WEDNESDAY, MAY 5, 1847.

ankle-joint of the right foot; there are also four fistulous openings, with fungous granulations, three on the inner side, and one on the outer; the ends of the tibia The law has been compared to a net, and fibula near the ankle-joint appear enlarged, and feel rough; various depressions can also be felt on the through the meshes of which little fishes are upper third of the tibia; the ulcers discharge a thin allowed to escape, and great fishes to break. flaky pus; the motion of the joint is impaired, it❘ Such is very certainly the case in respect to that causes him but little pain; the skin is red and shining, portion of it which relates to questions of and painful to the touch; the redness extends half-medical practice, and though occasionally one of way up the leg; appetite good; tongue clean; sleeps well. Ordered to have the parts constantly poulticed. 19th. A small piece of bone was removed from one of the openings this morning.

23rd. Since last report two pieces have been discharged, and another wound formed; he feels easier; health improved.

the smaller fry may be caught, as in the instance of the singularly unfortunate individual whose trial is reported in another column, the exceptional occurrence is chiefly remarkable on account of its extreme infrequency, and the difficulty of securing the captive, who after all, will shortly be returned to his original element, doubtless again to follow up his former malpractices, though perhaps with more cunning and caution, so as to escape the consequences. The mischievous part of the matter is that the judicial institutions of the country are not merely set at nought, but are continually brought into contempt, and the public are fleeced by the cupidity, and miserable sufferers in every way from the ignorance and most cul22nd. Much better; the inflammation extending up pable rashness, of a host of sharpers, of various

27th. Two pieces of bone have come away since last report, one of them was about an inch and a half long. 30th. Rather better. To have the wounds dressed with simple dressing, with apertures left for the discharge, which is now thick and yellowish; also to have a damp roller loosely applied.

May 1st. The roller caused much inflammation and pain, so that it was obliged to be discontinued; two of the openings have healed, and the rest discharge a thick healthy pus. To continue the poultice.

descriptions, who are virtually upheld in their depredations by those whose province it is to protect the unwary from all such designing pretenders.

of strength and activity,* the offender is allowed
to escape. Well does one of our contemporaries,
in an admirable analysis of the evidence given
on this trial remark, that “this Cronin case
has an influence far beyond that which it derives
from the pseudo-scientific evidence given on
the occasion; that influence extends to the
lives of the public, which are, by the result,
left at the mercy of all sorts of prescribers and
dispensers,-the neglect of the one and the
ignorance of the other are not regarded as
culpable; and while we are left to infer, that
according to that perfection of reason-the
law-there was no criminality in this case,
no pains are taken by the legislature to
prevent the recurrence of instances of a similar
kind."
See page 247.
+ Medical Gazette, April 16,

The spirit of quackery is widely extended through all ranks of the community, and for the simple reason, that with all the outcry about the increase of knowledge, the intellectual pabulum afforded by the literature of the day is of the most unsubstantial and trashy description. The wisdom of the nineteenth century is but a wide spread of shallow waters, and accordingly noisy quackery and superficiality of every kind find favour, when the more solid acquirements which result from study and reflection are neither appreciated nor understood. All ranks of the community, as we have said, are more or less imbued with this spirit of quackery; the main difference is, that the altogether ignorant are caught by the grossest delusions of the itinerant mountebank, who parades his worm-nostrums,—his vegetable powders. his rapid cures in "cases of secresy," &c.; while the so-called educated classes flock in | On the Pathology and Treatment of Scrofula; being crowds to fashionable hydropathic establishments, or complacently swallow the infinitesmal doses of fashionable homoeopathic doctors, together "with the infinite deal of nothing" in the guise of reasoning, with which the absolute inertness of the one system and the dangerous activity of the other are commonly accompanied.

Cases of manslaughter arising out of the practices of quackery, are becoming fearfully frequent; but it would almost seem, that in the ratio of the ignorance and presumption of the offender, are the chances of his escape from punishment. In the case of Flitcroft, though the man was proved to be an ignorant uneducated person, utterly unacquainted with disease, and every way incompetent, and it was shown that two lives had been sacrificed to his incapacity, had the trial been on a charge of manslaughter, he would, in all probability, have escaped-the rights of a corporate body being considered in the eye of the law more worthy of protection than the lives of the unfortunate individuals who were deluded by his pretensions. And had the offender, instead of being absolutely ignorant of medicine, as he was, been the most accomplished physician or surgeon of the age, he would have incurred the same penalties. In the case of Cronin, where the charge was for manslaughter, though poisonous agents of the most active and dangerous character prescribed, and where in particular, there was, to say the least, a lamentable and most culpable carelessness, in not sufficiently designating a preparation not to be found in the national pharmacopoeia, and for which the formulæ given by different authorities, vary greatly in point

were

Review.

the Fothergillian Prize Essay for 1816. By ROBERT MORTIMER GLOVER, M.D., &c. London, 1846, 8vo, pp. 315. Plates.

From the very extensive analyses which have already appeared of the chapters of this excellent work, which treat of the chemical and microscopical investigations into the nature of scrofulous and tubercular matter, we shall, in the present notice, devote attention mainly to other points, and more especially to the etiology and treatment of the disease.

Dr. Glover gives a concise, and at the same time, a

comprehensive statement of the results arrived at by his fellow labourers in this most interesting field, together with those of his own carefully-conducted

investigations and experiments, which entitle him to the greatest credit, both for impartiality and candour. He is a strong advocate for the identity of scrofula and

tubercle, as will presently be shown. The analogy existing between them has not been unknown to, or denied by, observant medical men, even prior to the light which chemical analysis and the microscope have thrown upon the subject. Their absolute identity is still, however, a matter requiring farther elucidation, as these means, like morbid anatomy, may be regarded as showing the effects of morbid action, rather than affording information on the nature of such action itself. One thing, however, is certain-viz., that the more intimate our acquaintance with the pathological changes which diseases produce, either in structure or functions, becomes, the more rational also will be the system of therapeutics used for the obviation of such conditions. Dr. Glover's opinion may be at once known by the following brief extract, from pages 25 and 26:-"We adopt, in its fullest extent, the statement of Lugol, which makes scrofula,-i. e., the

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