râles in the chest; the tongue is tremulous, and subsultus tendinum is present; no sleep; pulse 110, rather sharp; urine scanty, and high-coloured.

To have the wet sheet for one hour, and blankets for three hours. Milk and water to drink. The abdominal

complication was most marked in this case-a true typhoid gastro-enterite.

10th. Continues in many respects the same; the diarrhoea, however, has subsided. Was ordered a repe-, tition of the treatment, and the vinegar and water lotion to the head.

11th. Says he is better to-day; the skin is cooler, and inclined to moisture; face very little flushed; tongue becoming less dry and red; headache better; no pain in epigastrium or abdomen; bowels confined; urine free, and paler; less thirst; pulse 110, but not so sharp. To repeat the wet sheet as before.

12th. Convalescent; slept the whole of the night, and makes no complaint this morning, except of weakness, Face cool; headache gone; tongue clean and moist; urine free; pulse 64, very soft; appetite returning. To have mutton broth, and bread and milk.

13th. To have rice pudding and meat.

16th. Is able to walk in the yard, and may be considered well.

CASE III.

4. That the ordinary complications of fever are no arguments against, but rather for, its use.

5. That with this treatment, weak broths and milk and water, ad libitum, may be allowed.

6. That the first symptoms of the subsidence of the fever, were a cool and often moist condition of the skin, a diminution of thirst, and an improvement in the tongue. When these changes occur, the treatment must directly be discontinued, and bark, and better diet be ordered.

7. That some of the worst cases of typhus fever were convalescent and walking about on the fifteenth day from the commencemennt of the attack.

HISTORY OF TWO CASES OF POLYPUS UTERI.
By EDWARD JOHN SPRY, Esq., Truro, Surgeon to the
Royal Cornwall Infirmary.

(Read at the Annual Meeting of the South-Western Branch
of the Provincial Medical and Surgical Association, held
at Truro, July 16th, 1847.)

CASE I.

M. A. K., aged 43, was admitted into the Infirmary, on the 28th of January, 1847, as a case of menorrhagia,

Thomas Gafen, Irish, aged 14, of healthy habits, ill under the care of Dr. Carlyon. She is the wife of a for three days.

mason residing at Redruth, and the mother of nine children. She says that she enjoyed good health until two years since, when irregular vaginal discharges commenced, accompanied with pain in the back; that about nine months since she was seized with a violent pain in the abdomen, which obliged her to keep her bed for some time, during which she was attended by Mr. Roan, who told her that she had

July 8th. Face flushed and anxious; skin very dry and hot; tongue of a vivid red, and in the centre covered with a dirty cream-coloured fur, becoming dry and black in places; great thirst; throbbing pain in the head, epigastrium, and limbs; pulse 120, wiry, and small; considerable tenderness in epigastrium; gurgling in iliac region, accompanied with diarrhoea; the respiration hurried; frequent cough, and universal"a gathering in the womb;" that she has since sonorous râles in the chest; no sleep; urine scanty. Was ordered the wetted sheet for one hour, and blankets for two hours. Hair to be cut short, and the wetted cap applied. Milk and water to drink.

had every few days a profuse, sanguineous, and purulent discharge; that she has found no relief from medicine, and that lately the discharge has been almost entirely sanguineous, and occasionally so profuse

9th. Continues in all respects the same, except that as to cause fainting. the skin is somewhat cooler.

February 2nd. Dr. Carlyon being absent, the case fell under the management of Dr. Barham, who, this morning requested me to examine the patient, as he suspected the existence of a polypus, so called. The discharge of blood had been excessive during the night; her countenance was very sallow; pulse 100. I found a large tumour occupying almost the whole of the vagina, attached to the uterus, within the cervix,

10th. Wonderfully better; slept much in the night; aspect natural; no heat of face or skin, which is inclined to moisture; tongue moist, and losing its fur; very slight thirst; urine free; bowels open twice since the 10th, and has lost all pains in the head and epigastrium; pulse 76, soft. No further application was ordered.. On the 14th the boy was allowed to sit up, and have and although I could not avail myself of Dr. Simpson's meat, and was considered convalescent.

May we not draw the following conclusions from the facts adduced:

1. That the judicious use of the wet sheet has a powerful influence in relieving many of the most distressing symptoms of fever.

valuable uterine sound, I satisfied myself that there was no inversion, and that the tumour grew from the left side of the uterus, midway between the fundus and cervix, in which investigation I found a stout bougie a very useful aid.

12th. At Dr. Barham's desire, I applied a ligature to the neck of the tumour with the double canula,

2. That if applied very early in the disease, it may which procedure occasioned little or no pain. The

in some cases arrest its further progress.

3. That if used later in the disease it has a controlling influence, bringing the fever to a termination much earlier than by any other known treatment.

hæmorrhage, which, from the patient's account, was sufficient to fill an ordinary chamber utensil in twenty-four hours, ceased from that moment, and did not return up to the time of her leaving the Infirmary,

CASE OF EXTRA-UTERINE FETATION

which she did, on the 12th of March, in good health. The ligature was tightened daily, and I found it loose in the vagina on the seventh morning after the operation. The tumour is pyriform, of a very firm structure, but very vascular, and almost as pervious as a fine sponge, its lower surface has ulcerated, and the edges of that hollowed surface are flocculent.

CASE II.

Mrs. H., aged 42, mother of three children, had been in very good health until about three years since, when she began to be irregular, and for the last two years has been subject to very profuse uterine hæmorrhage. I saw her for the first time on the 22nd of April, of the present year; she was then very pale and sallow, and exceedingly weak from the almost continuous hæmorrhage that was going on. She complained of great pain in her back, and a sense of weight and pressure in the hypogastrium. Suspecting the existence of a morbid growth from the uterus, I induced, her

515

severe pain about the right iliac region, accompanied by general debility and slight constipation. Seven days before, she received medical aid from Mr. Spencer, who described her symptoms as those of great prostration, with a remarkably slow and feeble pulse, in fact, incipient syncope. It appeared almost evident to Mr. Spencer that she had lost blood, but having made diligent inquiry to that effect, he could in no way account for these formidable symptoms. Opium and ther combined were administered, and she had rallied considerably by the following day. The local pain first described was somewhat relieved by the application of two small successive blisters. The constipation yielded to gentle aperients, and at the end of a week medical services were discontinued. A few days subsequently, however, a relapse of the former symptoms prevailed, the costiveness presenting a more prominent feature in the diagnosis. The Oleum Crotonis, taken internally, bere readily produced the desired effect, and little or no further treatment appeared necessary.

On the 3rd of January, at 9 p.m., after sitting up for several hours, the patient was suddenly seized with severe pain in the right iliac region, and sank rapidly,

expiring after a period of two hours.

after a visit or two, to submit to an examination, when I discovered that the vagina was nearly filled with a large fibrous tumour, which bled freely under the gentlest pressure. Considering that there was no room for delay, I proposed a consultation with my friend Dr. Barham, who, concurring in opinion, as to the character of the tumour, and the seat of its attachment, (just within the os tincæ,) on the 30th of April I passed a ligature round it, as high up as possible, by the aid of the double canula, as described by Nissen, in "Richter's Anfangsgrunde." The application of the ligature, as in the former case, occasioned little or no pain; it was tightened daily, and on the morning of May 8th, I found the tumour detached. No hæmo-greenish hue, and the whole being semi-transparent, rrhage ensued from the first application of the ligature, nor has any returned to the present time.

Tremendous hæmorrhagic action came on, causing violent congestion of the head, lungs, and heart, and finally, of the abdominal viscera, which required to be met with suitable remedies, including the application of several dozen of leeches, and one venesection. The blood drawn contained very little crassamentum, and the patient informed me, that having accidentally cut her finger a few weeks before I saw her, a fluid escaped, almost colourless, from the wound. She has recovered, however, sufficiently to walk out, and being in the neighbourhood this morning, July 16th, I found her free from any urgent complaints. She told me that she bad been unwell twice since the operation, at regular periods, and that she was entirely without any sanguineous or muco-purulent discharge.

[These cases were illustrated by preparations.]

CASE OF

EXTRA-UTERINE FŒTATION WITHIN THE
FALLOPIAN TUBE, FATAL BY RUPTURE
AT THREE MONTHS OF GESTATION.

Reported by SPENCER COBBOLD, student at the
Norfolk and Norwich Hospital, and pupil of John
Green Crosse, Esq.

On the 10th of last December, Mr. Crosse was first summoned to Mrs. K―, who was suffering from

Autopsy forty hours after death.-The first feature of interest was the great distension of the abdomen, and the general exsanguine appearance of the corpse. The peritoneal cavity was loaded with dark, and chiefly coagulated, blood, (seven or eight pints at least.) As the investigation proceeded, a tumour was at length discovered in the right iliac fossa, (barely the size of a cricket ball,) the external surface having a delicate

allowing a fœtus to be distinguished floating in a quantity of fiuid. After separating the coagula from it, one third of the mass was observed to be enveloped by a cyst, the whole resembling in a great degree the universal ball and socket-joint; the pouch answering to the socket was evidently a part of the Fallopian tube, which had been enlarged and distended in so enormous a degree, by the contained and increasing fœtus and membranes, that at length it ruptured, giving rise to the hæmorrhage.

An elaborate and tedious dissection now followed; a ligature was applied to the vagina to prevent drainage, and the uterus and part of the vagina, together with the tumour, were removed en masse.

The uterus was

a little larger than in the unimpregnated state, and its inner surface was coated with a semi-gelatinous deposit, which could be easily scraped off with the handle of the scalpel; this deposit was about an eighth of an inch in thickness, and was all that the uterine cavity contained. The distended tube, after rupturing, had contracted at its base, so as to effect in part the expulsion of the fœtus and its membranes. In the right ovarium the corpus luteum was observable on section; no other change was remarked, excepting that its bulk was greater than that of its fellow. The passage between the cystic portion of the tube and the uterus was found impervious and obliterated. The left ovarium and Fallopian tube had undergone no perceptible change. Norwich, July, 1847.

CASE OF DELIVERY UNDER THE INFLU. æther-inhalation, was marked and decisive, by the

ENCE OF ETHER.

By HENRY B. PICKESS, Esq., Surgeon, Aylesbury. Ann Ricketts, of Aylesbury, aged 38, was taken in labour, on Tuesday, August 24th. The midwife in attendance stated that the pains were sharp and frequent for six hours, when the membranes ruptured, and the pains immediately ceased, and only occasionally recurred, until about forty-eight hours afterwards, when the midwife requested my attendance. I found her in active labour, pains strong and frequent, the os uteri well dilated, soft and flaccid, with the head favourably situated. At the expiration of about two hours, on making another examination, I found the hand presenting through the os externum, the shoulder, down to the outlet of the pelvis, and the right side of the thorax compressed within its cavity. I then endea. voured to turn the child, but was unsuccessful, owing to the strong expulsive efforts of the patient. A full opiate was then given her, and I requested the assistance of my friends, the Messrs. Ceely.

In about half an hour those gentlemen arrived, and in consultation it was agreed that under the circumstances, the duration of the labour, the wearied state of the patient, with declining pains, it would be desirable to put her under the full influence of æther by inhalation, previous to making another attempt at turning.

The process and its object being fully explained to the patient, she readily assented, and adroitly performed her part, under the superintendance of Mr. R. Ceely. In seven minutes the full effect of æther was manifest, and the operation of turning was commenced by Mr. J. H. Ceely. On introducing the hand into the vagina, that and the os externum were found more flaccid and dilatable than before, and the hand and arm were readily returned. The head was ascertained to be above the brim of the pelvis, with the chin resting on the os pubis, the feet on the back of the child, and consequently out of reach. A finger being introduced into each ham, the legs and feet with some difficulty, were at length brought down in succession. During this stage of the process, the uterus firmly contracted on the hand of the operator. The child being manifestly dead, the extraction of the head being impeded by its position and the contraction of the uterus, the delivery was completed by the introduction of the forceps. In a few minutes the placenta was expelled without hemorrhage, and the uterus found perfectly contracted. The time occupied in effecting the delivery was about seventeen minutes, and during the whole of this period, the patient was nearly motionless and perfectly unconscious. The inhalation of æther was wholly suspended about every three minutes, from the occurrence of stertor, which, however, was of short duration. In five minutes after the conclusion of the inhalation, the patient recovered herself, but for a time, she was incredulous of what had occurred, and when convinced, manifested equal surprise and delight, repeatedly affirming that she had been unconscious of all that had passed.

perfect unconsciousness and passive condition of the
patient to the otherwise painful and difficult process of
turning, although the uterine contractions were energetic
The patient speedily
during the whole process.
recovered without a single adverse symptom.
Aylesbury, September 5, 1847.

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 236.)

V. TERMINATION: PROGNOSIS. Acute meningitis in infants may have the following terminations:-I. In death. 2. In recovery. 3. In the transition to a chronic condition.

Of these the first is unfortunately by far the most frequent. Some authors consider that this form of the disease is less fatal than the tubercular form, but we know of no good authority for the assertion. If indeed the absence of the tuberculous element in this form of the disease and its occurrence in a previously healthy constitution might reasonably give us some hope of combating its progress with success, there is on the other hand to be taken into account, the violence of the inflammatory condition, and the rapidity with which cerebral disorganization is induced.

That there is, however, some ground for hope in the sporadic form of the disease, is fairly to be antici pated, since even when the disease is epidemic, some recoveries occasionally take place. In looking over the works on meningitis by Golis, Charpentier, and others, we do sometimes meet with instances in which real meningitis has been cured, although we regard the generality of the cases reported as cured, to have been instances of erroneous diagnosis. [In this remark we perfectly agree with the author, it has happened to us not seldom to have met with vaunted cases of hydrocephalus cured, which have in reality been nothing more than infantile remittent, with cerebral complication. Trans.]

It is no easy matter, if not quite impossible, to give anything like a scientific prognosis in this disease. Facts are wanting, and the disease must be re-observed. Independently of the termination in death, and in recovery, some authors consider that the inflammation may pass into a chronic state. We acknowledge that this may possibly be the case, but we do not know of a well-authenticated instance. In our experience, whenever there has existed a chronic or sub-acute inflammation of the membranes of the brain, it has been so from the commencement, and has been in the instance of a tuberculous subject,—a case in fact, of tubercular meningitis, and not of simple inflammation. In those cases in which the appearance of false membranes has led some authors to believe in the existence of chronic simple meningitis, we, as we have elsewhere The assistance afforded in this case by the use of stated, (Traité des Maladies des Enfans,) consider

1

ON INFLAMMATION OF THE BRAIN IN INFANTS.

517

the lesions to be the result of a former meningeal is the repercussion of eruptions of the scalp; among hæmorrhage. the cases which we have met with, the majority were either the subjects of, or had recently been cured of eczema, favus, or impetigo.

VI. CAUSES.

Direct causes, such as blows, &c., may induce meningitis in infants, as in persons of greater age. Parent gives the case of a child of ten years of age

VII.-TREATMENT.

The causes of meningitis are not otherwise than obscure, as might indeed be expected, when we consider the comparative rarity of the affection, and the imperfection in the history of infantile cerebral affections in general. Most authors agree in the great pre-who died of meningitis, the consequence of fracture ponderance of the tubercular form of the disease over of the orbital plate of the frontal bone; such instances that which we have denominated the simple acute form, are however rare. but they differ respecting the age at which this latter most commonly makes its attacks. Guersent, for example, states that in early infancy it is more common than the tubercular form. Bouchut affirms the direct contrary. In analysing a certain number of cases during the composition of this essay, we have ascertained, that simple acute meningitis may attack children of all ages; but that it is especially frequent in the first and ninth years. This is shown in the subjoined table :

It would appear from this table, that dentition has an intimate etiological connection with the disease, as it is most frequent at the periods of eruption of the

first and second dental series.

What we have said respecting the causes of acute meningitis applies still more forcibly to its treatment. We are not able, in the present state of science, to point out the most successful means of arresting the progress of the disease. The treatment is prophylactic and curative.

1. Prophylactic Treatment.-The hygienic rules which we have elsewhere insisted upon, in reference to tubercular meningitis, are only partially applicable to the disease in question. Instead of the tonic medicines, so applicable in the tuberculous constitution, it is necessary, in the probable subjects of this disease, to advise a cooling and slightly antiphlogistic regimen. The bowels should be kept free, and care should be taken to maintain an equable temperature in the extremities; the hair should also be kept short and thin, so that the head may be cool; and lastly, tepid baths should be frequently administered.

As we have no intention to write an article on

rules; but while upon the subject, we think it right to allude to the precautions which are necessary in treating the chronic-scalp eruptions of children.

Robust children are those most commonly the sub-hygiene, we shall content ourselves with these general jects of this disease, at least as far as our observation goes; and boys appear to be more prone to it than girls. According, however, to the experience of others, the influence of sex is not perceptible.

Meningitis may occur in all seasons, but a larger series of observations is necessary in order to determine whether it is more frequent at certain times of the year than at others. The distribution of the cases which form the basis of this memoir was as follows:

It does not appear therefore that the disease is especially prevalent in hot weather, though it is incontestably occasionally produced by insolation. M. Guersent alludes particularly to this cause:-"The prolonged exposure to the sun's rays is," he observes, "one of the most common causes of acute meningitis, especially in very young children. I have many times had proof of this, and particularly in one instance, in which an infant which had been left exposed to the mid-day sun in the garden, died of most extensive meningitis of the surface of the brain and cerebellum." (Dict. de Med.) Dr. Whitehead also attaches great importance to the influence of insolation. According to him it is the most potent of all the causes of the disease.-Medical Gazette, Jan., 1844.

Among the occasional causes of acute meningitis,

When the cutaneous inflammation occupies but a limited surface, it may in general be cured without risk; but on the contrary, when the diseased surface is extensive, the rapid denudation of the inflamed skin, by a removal of the scabs, may be followed by the worst consequences. Whatever be the explanation of this, the fact remains certain. Common sense then indicates, that in order to avoid danger these scalperuptions must be treated with caution, and as the injurious effects seem to be proportionate to the extent of the denuded surface, it is advisable to treat but a small portion at a time, and to encourage free action of the bowels as a derivative.

2. Curative Treatment.-Acute meningitis, as the most formidable inflammatory affection to which infancy is subject, requires an energetic treatment. The indications to be fulfilled are both general and special. Among the former we may mention-1st, active antiphlogistic treatment; 2nd, to favour the absorption of effused products; 3rd, to replace the antiphlogistic treatment by one vigorously derivative, during the period of collapse; 4th, to guard against all nervous excitement.

The special indications have reference to the exciting cause of the disease, and thus the treatment must vary accordingly as it succeeds to the rapid declension of a cutaneous affection, or assumes the convulsive or phrenitic form, or appears sporadically or epidemically :

Some writers then recommend the substitution of warm applications, and Romberg more especially approves of them; Guersent also speaks favourably of their use when there is little heat of head. We have no personal experience of this matter, but should question their advantage. A measure in which we have more confidence is the application of warm stimulating fomenta-substituted for the cold lotions. Calomel is to be

given internally, and mercurial ointment rubbed into the axillæ and thighs. If the child becomes pale, the The employment of blisters must next occupy our attention; writers differ somewhat as to the period pulse full, and the convulsions are less frequent, the most suitable for their use. Charpentier advises them continued application of cold must be suspended. If from the beginning, and applies blisters to the legs instead of the cataplasms, these being kept on only confirmed coma supervene, blisters may be applied within some hours of the commencement of the treat-sufficiently long to redden the skin, and then moved to ment; if no amelioration follows these, he then applies others to the thighs or abdomen, and again later, to the nape of the neck.

[In the management of the above case, there appears induce vigorous counter-irritation of the scalp, to us one great omission,-viz., the non-performance of namely, in those instances in which the disease has lancing the gums, with the exhibition of enemata. As supervened upon the retrocession of a cutaneous erup-centric from eccentric convulsions, the latter treatit is next to impossible in the first instance to diagnose tion. In these cases, blisters to the scalp, or frictions with croton oil, are strongly indicated; we give the preference to the latter, and could relate cases in which it has been followed by the best effects.