45

of the protruding mass, and a compress, soaked in solutionof perchloride of iron, was applied. On Nov. 6th a portionof the hernia was cut away, being nearly detached. Theice was discontinued, and warm fomentations applied.There were only three fits in twenty-four hours, but thepatient was becoming more and more torpid. Coma gradu-ally came on, and he died on Nov. 9th.

Autopsy, twenty-eight hours after death. - The internalsurface of the dura mater, corresponding to the upper halfof the right hemisphere, was covered with pus. The tip ofthe right frontal lobe was hollowed out into a fungatingcavity, and there were patches of pus and lymph here andthere over both hemispheres. There was marked purulentdeposit all over base of brain. The brain-substance wastough, and the left lateral ventricle contained a smallquantity of purulent fluid.CASE 2 -J. C-, aged sixteen, admitted Nov. 3rd,

with railway smash of lower end of right femur, done atnoon, but not admitted till 5.30 P.M. He was in such astate of depression from cold, shock, and loss of blood, thatamputation was out of the question, but by stimulants,beef-tea, &o., administered by mouth and rectum, he had sofar rallied on the following morning that at 10 A M ampu-tation by antero posterior skin-flaps was performed at mid-thigh. Careful stimulation by champagne, &., was requiredfor some time. There was great depression, and repair wasslow. The end of the bone became uncovered, and onDec. 10th about an inch was sawn off it. From that time

improvement was rapid, and on Jan. 4th the patient wasdischarged well. The case was treated antiseptically, andthough primary union failed from the low state of the

patient, the discharge was not great, and never in the leastoffensive.

CASE 3.-T. J-, aged twenty-four, admitted Nov. 4fb,at 10 P.M., with strangulated left inguinal bernia. On

visiting him the same night, I found that the house-

surgeons, Messrs. Williamson and Dixon, had partiallyreduced it, with some relief to the symptoms, which werenot then urgent. An ice-bag was applied, and he wasordered simple enemata, which were repeated four times inthe night with still further relief ; but at noon on Nov. 5th,as vomiting was present, and was becoming stercoraceous,an immediate operation was recommended, but only afterconsiderable persuasion submitted to. From the fact thatthe patient said he had had the hernia all his life, and thatthe right testis was not fairly out of the canal, congenitalhernia was diagnosed, and the operation proved the dia-gnosis to be correct.

Chloroform having been administered, an attempt toreduce the hernia was made, but failed, and the operationwas then performed in the ordinary manner. It was neces-sary to open the sac, an attempt to return the contentswithout doing so having failed. A knuckle of congestedgut, and a portion of omentum which occupied the scrotum,were then readily returned, the testis being exposed. Thewound was closed hy sutures. On Nov. 8th the pulse andtemperature were normal, on the 9th the last sutures wereremoved, the wound having healed, and on the llth he wasdischarged with a truss.

CASE 4.-On Nov. 6th, J. B-, aged twenty-nine, was ad-mitted with a large venous nsevus, occupying the left side ofthe forehead and the left cheek and eyelids, closing the eye,and giving the patient rather a frightful aspect. In 1863the nsevus, then just beginning, was removed by ProfessorPirrie, of Aberdeen, with the écraseur. In 1870 he wasunder the care of Professor Spence in Edinburgh, and bythe application of galvanism its growth was arrested. For

nearly five years it remained stationary, causing little in-

convenience ; and then again began to enlarge, in conse-quence, he believes, of a blow. By firm pressure thenævus could be nearly emptied, and when the pressure wasremoved it slowly rose like a sponge.On Nov. 15th the current of a twecty-cell battery was

passed through the part on the forehead, by needles intro-duced at different points, and the following day that partwas found firmly coagulated. The needles were appliedthree times afterwards, at intervals of about a week, to thecheek and eyelids, and considerable coagula formed. OnDee. 16h the forehead part of the nsevus was much reducedin size; but as some of the punctures in the cheek weresuppurating, he wished to go home for a time until theyhealed.

On Nov. 7th I had the following operations :-Lithotomy in a boy of three years, who had had symptoms

of stone for eighteen months. His growth seemed to havebeen arrested, his appearance being that of a child of

eighteen months. A uric-acid stone, the size of a largefilbert, was extracted. The boy went home on Dec. 2nd.

Necrosis of tibia in a girl of thirteen. A large superficialsequestrum, consisting of fully half of the subcutaneoussurface, was removed. The patient rapidly recovered, andwas discharged with the wound nearly healed on Dec. 2nd.

Sinuses round shoulder-joint in a man of thiity. About ayear ago the left humerus was fractured at the surgicalneck by a large piece of iron falling upon it, and he was aninmate of the Ingham Infirmary, South Shieldq, for aboutthree months. The sinuses had openings behind and infront of the deltoid insertion. The openings were enlargedsufficiently to admit the finger, an the sinuses were foundto pass quite round under the origin of the deltoid. No [)

exposed bone was detected there, but the sinus in front wasfound to diverge, and under the pectoral muscles a frag-ment of bone, smaller than a pea, was found and extracted.Under treatment by rest, the arm being bandaged to theside and motion of the joint prevented, the progress to re-covery was almost uninterrupted, and on Nov. 30th thepatient left the hospital with the sinuses healed and freemovements of the joint.In conclusion, I wish to express my great obligations to

my house-surgeon and dresser, Messrs. J. D. Dixon andR. Knox Tait, for their unremitting attention to the cases,and the careful and complete notes from which I havedrawn up the report.

A SKETCH OF THE RECENT EPIDEMIC OFTYPHOID FEVER IN PARIS.

BY DR. BOURDON,MÉDECIN DE L’HÔPITAL DE LA CHARITÉ MEMBRE DE L’ACADÉMIE

DE MÉDECINE.

I DESIRE to place before the readers of THE LANCET abrief account of the epidemic of typhoid fever with whichParis is at the present time affected. This disease, as iswell known, is endemic in our capital, and an exacerbationtakes place every year during the summer and autumn.This year, however, the disease has spread considerably, andhas attained the dimensions of an epidemic; for, in thesecond quarter of the year, the total number of typhoidpatients in the hospitals of Paris amounted only to 169,with a mortality of 20 per cent., whilst in the third quarterthe number of those affected rose to 714—that is to say,was more than quadrupled, and the mortality reached theenormous proportion of 39 per cent.

If we investigate the atmospheric conditions, whichmight be regarded as constituting the causes of this

epidemic, it will be found that in the months ante-cedent to the outbreak the rainfall was below the ave-

rage proper to this period of the year - that there hadbeen, in fact, a great drought. The temperature rose asusual, and remained moderate for some time. On the 9thof June, however, it suddenly increased, and continued ex-

i cessively high till the 17th August. On the 18th of August’ it fell considerably, and the rains bega.n. In September the’ drought had passed away; 69 millimetres (2’76 inches) of. rain fell.. The exacerbation of the disease distinctly coincided with, the dryness and heat, and we may notice that the paroxysm

is marked much more by the excpss of the mortality thanby the number of patients. It diminished with the cessa-

! tion of the heat and dryness. The most severe cases- occurred in August, The number of cases continued tob augment subsequently to this period, but the relative mor-

tality underwent a sudden reduction.Etiology -The first question, then, is-Are we to regard

these exceptional atmospheric conditions as the cause ot the1 epidemic. No doubt ca.n be entertained that the lowering3 of the level of-water in the subsoil exposed a whole seriesy of putrid foci, and that the excessively high temperaturewas well adapted to induce fermentation, and at the same

46

time to favour the diffusion of the euvia produced, bycausing an unusual amount of evaporation. May we notthen attribute to the miasmata, so developed, the leadingpart in the genesis of the typhoid fever?’Whatsoever may have been the iinflence of this cause on

the outbreak of the disease in August, the epidemic, whichhad dimiuished during September and the beginning ofOctober, burst forth with renewed intensity towards themiddle of this month, and continued to rage ti’l November;so that the mortality, which had fallen to 163 in October,rose to 929 in November. It is satisfactory to add that

during the last week [Dr. Bourdon’s paper is dated the8th December] the new cases, as well as their severity,have been steadily on the decline.

In regard to individual causes, we find the same predis-posing causes as in other epidemics of typhoid fever: inthe first instance, old age and youth; imperfect acclima-tisation ; then all debilitating causes, unfavourable hygienicconditions, grief, violent emotions, the exhaustion followingdelivery, aud especially consequent on lactation; and lastly,contagion, of which several examples could be cited. It isremai kable that this epidemic, notwithstanding its gravity,was only very rarely observed in those who had been pre-viously attacked. Relapses, on the contrary, were frequent.Forms —The forms observed have been very various, but

those which were most prevalent were the ataxic, ataxo-adynamic, and mucous. The most common complicationswere those of the respiratory organs ; many patientssuffered from pulmonary congestion and from broncho-pneumonia., especially in the second outbreak of this disease.A certain number of intestinal haemorrhages and perfora-tions occurred, and in one instance suppurative peritonitiswithout perforation.

Prognosis -The prognosis is, of course, associated withthe mortality which has already been referred to. 39 percent. is an enormous proportion, but this has fallen to 20per cent., notwithstanding the larger number of patientsattacked; and I doubt whether this mortality will be main-tained during the second exacerbation of this disease, if Imay judge from my service in l’H6pital de la Charite, inwhich the proportion of deaths has been scarcely 13 percent,., and in 1’Hopital des Enfans only 11 per cent.The employment of the thermometer has proved of extreme

value in the prognosis of the disease. Thus, when thetemperature taken in the axilla rose abuve 104° F. (40° C.),in the evening, and did not fall or fell but little in the

morning, the state of the patient was very serious. Yetseveral cases of recovery occurred, under the use of coldsponging or baths, in cases where the temperature rose to105’8°F. (41° C.) in the evening, and fell one or two degreescentigrade in the morning.

Treatmert.—In simple cases and in those of moderateintensity the treatment has consisted in the administrationof acidulated drinks, of saline purgatives repeated everyother day, and demi-lavements of warm water on the alter-nate days, in the application of poultices to the belly, andin giving food consisting of beef-tea, milk, and claret (Bor-deaux) diluted with water; when adynamic symptoms ap-peared thirty to forty five grains of the liquid extract ofchinchona were prescribed, with vin de Bagnols, and in manycases the drink recommended by Todd.In the ataxic form, musk in doses of from 6 to 12 grains

(40 to 90 centigrammes) sometimes proved effective. Insevere cases recourse has been had to sponging with waterthree or four times a day, at a temperature of 68° to 70° F.(20° to 22° C.) In cases of hyperthermy this proceedingwas of the greatest possible value. In some cases not onlydid the temperature fall, but satisfactory perspiration wasestablished. I constantly employ this measure, even whenthere is congestion of the bronchi, or that general conditionof bronchitis which usually accompanies typhoid fever, andI do not find that these pathological conditions are in-creased.

I have never ventured to administer repeated cold baths.Many of my colleagues at the hospital, however, state thatthey have proved serviceable in their hands in ataxia, andespecially in hyperthermy. I must acknowledge, however,that I doubt the expediency of producing violent effectsin a malady in which congestion of the viscera may soreadily supervene. Some facts in regard to haemoptysis

1 These etiological details are borrowed from the remarkable memoir ofDr. Besnier, of the Soclét6 Médicale des Hôpitaux, Nov. 3, 187B,

and of pneumonia which have recently occurred afterthe employment of cold baths have, I believe, somewhatcalmed down the enthusiasm that they originally inspired.In the tboracic form characterised by exaggerated bron-chitis or intense pulmonary congestion, I have had occasionto be thoroughly satisfied with the application every nightand morning of numerous dry cups (20 to 30) to the chestand thighs. When these morbid states are persistent, and,above all, when they are superimposed on pneumonia, Ifollow up the dry cupping with a series of flying blisters.It is remarkable that in a disease in which eschars form so

easily on the skin, I have never, either in this or in pre-ceding epidemics, observed gangrene affect the portion ofthe skin that had been vesicated. In the cases where re-

lapses occurred, and which were in most instances due tosolid food having been given at too early a period or in toolarge a quantity, a return to the former treatment wasusually successful.

It only remains to mention an accident I have observedon several occasions, and which bears on the subject ofalimentation. Towards the close of the disease, or duringthe period of convalescence, I have seen some subjectssuffer from vomiting, and reject not only all solid food, butthe lightest drinks and even beef-tea. In all these cases Ihave been enabled to re-establish the digestive functionsby restricting the patient to an exclusively milk diet, witha fair proportion of lime-water for those that suffered fromdiarrboea, and solution of bicarbonate of soda for those whowere constipa,ted.

, Such is a résumé of the history of the typhoid fever thathas now been prevalent in Paris for some months, but whichis daily diminishing in severity and extent, and will, I hope,,soon disappear.

Paris.

ON THE PREVALENCE OF COLOUR-BLINDNESS.

BY HERBERT W. PAGE, M.A., M.C. CANTAB., &c.,ASSISTANT-SURGEON TO ST. MARY’S HOSPITAL.

IN the discussion on colour-blindness to which the

Arlesey railway accident has given rise, it has been

abundantly evident that there is still a widespread impres-sion that this peculiarity is not at all uncommon. A corre-spondent in The Times of December 28th calls attention to,the fact that in a recent examination of engine-drivers inSweden, " no less than 10 per cent. were proved to be un-able to announce properly the colour of the lamps"; and awriter in the same paper of December 30th quotes from thelate Professor G. Wilson’s book, " Researches on Colour-blindness," to show how large a proportion of the personssubmitted by him to examination was found to be colour-blind.

It is, I believe, on the statistics of colour-blindness givenby Professor Wilson in his well-known work that the im-pression, among the laity at any rate, as to the prevalenceof colour-blindness is based. At page 68 Dr. Wilson refersto the experience of Dalton, who was the first to make anyattempt to ascertain the number of colour-blind in thepopulation, and who found out of two classes of his studentsthat the proportion of colour-blind was 12 per cent. and8 per cent. respectively. Professor Pierre Prevost is namedas having estimated the proportion of colour-blind at 5 percent. Professor Seebeck "found 5 out of 40 youths in agymnasium at Berlin the subjects of colour-blindness.’’’Three thorough Daltonians " were found in a class of150 students by Professor Kelland. Five cases were foundin 158 of the Edinburgh police, and 5 out of 42 male attend-ants at the Royal Asylum, Morningside. Professor Wilsonhimself examined the soldiers quartered in Edinburgh, andfound as follows :-31 colour-blind out of 437 of the King’sOwn ; 14 out of 177 of the 7th Hussars; and 5 out of 123Artillerymen. Of the men under his own immediate ob-servation, 1154 in all, no less than 65 were found to becolour-blind. After reviewing all the sources of informa-tion at his disposal, he writes := For my own part, accord-ingly, I think it probable that the number of persons in