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Fracture of the Base of the S’lull; Death y’ A utOp8!J.(Under the care of Mr. FERGUSSON.)

The readers of THE LANCET have probably followed withinterest the lectures of Mr. Hilton on Fracture of the Base ofthe Skull, (vols. i. and ii. therein will be found factsand arguments to prove that this lesion may take place, andthe patient recover; and this circumstance is certainly worthrecollecting, as we may at a moment’s notice be called to casesof this kind where a prognosis is anxiously requested by thefriends; but we should, in the meantime, not neglect to payproper attention to those cases in which the results have beenfatal, that the notions of the nature and progress of the lesionwhich are already in our possession should be verified andrendered trustworthy. With this view we beg to adduce thefollowing case :-John K-, aged fifty-seven years, was brought, on the

4th of December, 1852, during the night, to King’s CollegeHospital, in a state of insensibility, and bleeding from the leftear. He was not, however, completely unconscious, for hewould mutter something when loudly spoken to. The pupilswere contracted, and the pulse small, quick, and irregular;the face pale, and the surface generally cold. From the state-ment of the friends, it was learned that the patient had beendrinking at a public-house, and that on coming out his foothad slipped, and he had fallen against the stones in the road.

Cold was applied to the head, and sinapisms to the calves ofthe legs and soles of the feet. About one hour after admission,the patient vomited, and sufficiently recovered himself to walkthe whole length of the ivarcl to the watercloset; but he soonmerged again into a state of insensibility. Thus he remainedfor two days, the pulse being 84, hard, jerking, and veryirregular, and the face some what turgid. He was now bled totwelve ounces, whereupon the pulse improved at first, becomingsofter and somewhat quicker; but towards evening it againassumed its former character. During the day slight bleedingoccurred from the left ear. On the third day, the state of in-sensibility continued, there was much turgidity of the face, andthe pupils continued much contracted. The pulse was 128,hard, and bounding, and the carotids beat violently. An injec-tion of turpentine and castor oil was administered, and nowfor the first time the urine escaped involuntarily. A littlemore haemorrhage from the left ear took place, and the patientwas bled from the temporal artery. Very little relief was,however, obtained, and during the night the patient graduallysank, and died in a state of coma.

Post-?iWi’tcm examination.-On taking off the scalp, a Iquantity of effused blood was found underneath it on the leftside, indicating the position of the injury. The skull-cap being Iremoved with the dura mater, a small quantity of bloody serumwas found in the cavity of the arachnoid. On the right side,and in the lower portion, the substance of the anterior lobe.was broken down, and covered with a large clot. On the leftside the hemisphere was also lacerated in two places, andcovered with smaller clots. Considerable efiÌ1sion of blood hadtaken place into the middle fossa. On examining the bones, afracture was found extending from the squamous portion of theleft temporal bone across the petrous portion, and along thecourse of the lateral sina to the left side of the internaltuberosity of the occipital bone. From about the centre of thishorizontal fracture, a vertical one extended to the height ofabout one inch and a half towards the vertex of the skull.There was a considerable quantity of bloody serum in thelateral ventricles.

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GUY’S HOSPITAL.

Fibro-Plastic Tumour developed under the Influence ofFriction.

(Under the care of Mr. BIRKETT.)THE subject of the exciting causes of tumours is somewhat

obscure, and in most of the latter which we have to treat it isaltogether impossible to come at anything like certainty as to theexciting cause. Adipose, vascular, fibrous, and bony tumoursare often met with in subjects who have not the most remoteidea of the exciting cause of the growths. Here and there,hcwever, we can trace one peculiar cause—viz., friction. Byconstant rubbing, it would appear that a kind of bursa isformed, which latter becomes by time and by filling up aregular tumour. We recollect a patient of Mr. Hancock,at Charing-cross Hospital, with whom a soft kind of tumourdeveloped in the nape of the neck, owing to the play of a ropewhich in his trade rubbed against that region. Mr. Birketthas had a case in which habitual pressure by the handle

basket had the same results; let us see what kind of growthsprang from this pressure.I A young man of the age of nineteen applied to Mr. Birkettin the summer of 185U, on account of a swelling in the left fore-arm. He was enjoying remarkably good health, resided in thenorthern suburbs, and had been in the habit of carrying abasket, the handle of which he slung over the affected arm.The patient first observed a small, globular, hard, and

movable lump in the site of the present swelling from six toseven years before his application to Mr. Birkett. It has been

entirely painless, and merely from its size the inconvenience ofwhich he complains has arisen.

It was at once apparent that a new growth existed, and fromits depth and situation it was necessary that he should comeinto the hospital to have it removed. He could not, however,then give up his time, and he again consulted Mr. Birkett inOctober, 1851.The tumour had not increased, and had continued painless;

it had only slightly inconvenienced him, and his health wasrobust. The long axis of the tumour corresponded with thatof the forearm, and measured about five inches and a half; itstransverse diameter was about two inches and a half. It waselevated about one inch above the surface of the forearm.Although but slightly movable, it could be, as it were, detachedfrom the radius and ulna,-at least there were no indications ofany union to, or growth from them. The tendons of the flexorsublimis muscle might be traced to the lower end of the tumour,and the impression was that the belly of the muscle was infront of it.The diagnosis of the tumour became a matter of considerable

interest, but was attended with many difficulties. The age,healthy aspect, and robust strength of the patient precludedthe idea of the growth being carcinoma, while its mobility andapparent freedom from attachment to the bones of the forearm,would scarcely admit of the supposition that it was enchon-droma. Having seen, upon a previous occasion, a lipoma de-veloped in the same region, Mr. Birkett thought that thisgrowth might be of that nature, but its extreme solidity, firm-ness, and unyielding texture was very different from it. It didfeel slightly lobulated, however, in this character thereforeresembling the adipose tumours.On the 7th of October, 1851, Mr. Birkett removed the tumour

by making a vertical incision through the integuments,separating the fibres of the flexor sublimis muscle, and detach-ing its connexions with the muscles around. It was veryeasily enucleated, and the only haemorrhage that occurred wasfrom a vessel deeply seated posteriorly to it. A considerable

portion of the wound healed by adhesion; other parts sup-purated, and in about a month cicatrization was perfect. Thepatient had full use of his hand and forearm, the movements ofwhich were in no degree whatever impeded.

Before the tumour was cut into it appeared to be a lobulatedmass, the surface exhibiting irregularities, but the whole

feeling very firm and hard. It did not appear to be surrounded

by a distinct capsule or cyst-wall. A section of the tumouris represented in the accompanying engraving. In its centre

was a cavity filled with a grumous fluid, and traversed bybands tending from side to side. The walls of this cavity wereirregular, and slightly resembled in places the columnar carneasof the heart. The solid parietes, which varied in thickness,were of a yellow tint, firm, and fibrous. No juice could beexpressed from them, and after the blood had macerated out,

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they exhibited the slightly indurating surface indicated in thedrawing. They were not at any time, however, very vascular.The elements constituting this morbid growth were nucleatedfibres, nucleated cells, fibres, and filamentous tissues. Thenucleated cells were of an oval figure, united together to formmasses, and were the chief elements of the entire mass. Muchof the fil)ro tissue exhibited a douhle outline, and the nuclei ofall the elements became much more distinct when treated withdilute acetic acid.

This tumour clearly belongs to the class described bv 11.Lebert under the term fibro-plastic, but whether arisingprimarily in the remains of effused blood, or originating in abursal formation, or in a simple cyst developed in the areolartissue, the walls of which had continued slowly to increase inthickness, must remain a subject of speculation and doubt.

FURTHER OBSERVATIONS ON THE CAUSEOF TUBERCULOSIS;

WITH SUGGESTIONS AS TO ITS PREVENTION.

BY JAMES G. ATKINSON, M.D.PHYSICIAN TO THE WAKEFIELD DISPENSARY.

IN corroboration and extension of the views I advanced in aformer number of THE LANCET, as to the probable cause oftuberculosis, my object is to show that the earliest stage of thedisease consists in a diminished vital power, produced byvarious external depressing agents; that this results in a moreenergetic oxidation of the tissues, as a consequence of theamount of vital force having been thus lost, which retained theelements of the azotized principles in the form, order, andstructure which belongs to them, and thus affording a lessmeans of restraint against the incessant tendency of the oxygenof the atmosphere to act on their elements; and I attemptedto show that tubercular deposits may, from the above causes,be regarded as the consequence of an irregular metamorphosisof tissues, and that these may be retarded, if not prevented,by the substitution of various forms of carbonized material,and that the only class of medicinal agents which may be con-sidered decidedly prophylactic are those which sustain thevital tenacity in opposition to the chemical effects of oxygen.Of this latter class, alcohol appears to hold a prominent place;and in addition to the facts which I have already brought for-ward, I will here quote the opinions on this head of Dr. Cottonand Mr. Ancell in their recently published works, which gofar to suhstantiate my views as to the fact of alcohol being inmany instances one of the safeguards from tuberculosis. The Iformer says, in the treatment of phthisis before tubercle is de- I

posited, that " Wine or beer in moderate quantity should beincluded in the diet list, and I have seen conscientious scruplesupon this matter overcome on many occasions with markedadvantage." * We also find that Mr. Ancell, although differingvery much from Dr. Johnson and others, gives the followingstatement on the prophylactic powers of alcohol:-" Facts arenot wanting which tend to establish that the tuberculous con-stitution, where there is no local disease, is benefited by themoderate use of these fluids, (alcoholic,) and this is sanctionedby theory, but then the stimulus must be moderate, uniform,constant, and accompanied by a generous diet, containing aproper proportion of these 2’uaininal principles, and essentialelements of food, &c." t He also quotes Dr. Peters, who re-marks, that alcohol would seem to produce a state of bloodopposite to that which obtains in this disease, and may thusprevent the development of it: and that the excessive use ofalcohol does not destroy life by producing tuberculosis, butrather by producing other diseases, as those of the nervoussystem and of the liver."

It is very true that no hypothesis can take the place ofstatistical evidence; but it is rather more difficult than whatat fir3t sight appears to be, to collect a suftlcieut amount ofdata to establish the truth or falsehood of my position. I have,however, endeavoured to furnish an approximation to correctresults by examining the reuistries of deaths in this town forthe last ten years, camxuencinm on the lst of May, 1843, to the1st of May, 1853; and although I a111 aware the numbers arefar too small to justify a decisive conclusion, they are, as far asthey go, All will admit that perhaps no classtakes more alcoholic stimulants, in proportion to the rest of

* The Xahu-c, Svrcptoins, and Treatment of Consumption. J3y R. P. Cotton,11Z.D. Pa"e 21)o.T A Trc’llCÌso on Tubercuiosis. By Henry Ancell, Esq. Page 459.

the inhabitants, than publicans. Thus I have selected theseout by way of experiment, to ascertain the relative mortalityfrom phthisis in this class of men. I have arranged the deathsunder the four following heads :-

0

It appears, therefore, from the above figures, that rathermore than one-sixth of the deaths amongst the whole popula-tion of the town arise from phthisis, whereas in publicansscarcely one-twelfth die from this disease during the sameperiod. But these numbers, if taken without correction, fallfar short of representing the real disparity between the deathsfrom phthisis among publicans, as compared with the deathsoccurring from phthisis among the population at large; for the33:29 represents the deaths at all ages; but as about one-half ofthat number occurred in persons under fifteen, and as personsrarely die of phthisis under fifteen, and as publicans are allabove fifteen, the naures should stand thus:-

Showing a general mortality among a(li-qts from phthisis ofrather less than 1 in 3, and in publicans, 1 in 12A. Now,allowing great latitude for accidental mistakes, still the mor-tality by phthisis in publicans is comparatively small. Whata more extensive investigation would prove, it would be diffi-cult to say; however, there is here sufficient to demand furtherinquiries.

These facts are, I am aware, at variance with the observa-tions of many excellent writers. I find Sir James Clark,nearly twenty years ago, remarks :-" We believe that theabuse of spirituous liquors among the lower classes in thiscountry is productive of tuberculous disease, to an extent farbeyond what is usually imagined-indeed, it is only necessaryto observe the blanched, cadaverous aspect of the spirit-drinkerto be assured of the condition of his internal organs." Again,’’ the cases that are likely to be cured by the stimulating planof treatment-by beef-steaks and porter-bear so small a pro-portion to the many that would be injured by it, that we donot consider it deserving of further notice." The late Dr.Graves, of Dublin, many years later, however, writes in avery different strain, and it is evidently apparent that medicalopinion is by no means agreed on this subject. He says :-"make your patient lay aside slops and tea; let him takewholesome fresh meat, bread, and good beer; the good dietwill invigorate the system, and so far from producing inflam-mation, will do exactly the contrary." t It may, however, beshown that in some cases drunkenness and dissipation have,without any doubt, been proved to be the positive excitingcauses. This we do not for a moment deny, and in some in-stances they indubitably are; yet this admission does notinvalidate the strength of my proposition; for I believe thatevery cause which tends to lower the vital tonicity acts as anexciting cause in producing tuberculosis, and nothing is morelikely to depress the system than the secondary effects result-ing from drunkenness and dissipation, and therefore in thismanner these may in some instances be productive of this dis-ease. It is the temperate use of alcohol for which I contend,which, by retarding a too quick metamorphosis of tissues,checks or prevents the protein compounds from being tooreadily acted on by oxygen, which state occurs in the enfeebled,or in those hereditarily predisposed. In a word, then, theabuse of alcohol may be an exciting cause in producing tuber-culosis; whereas, on the other hand, a moderate supply of thiscompound might possibly be used as a preventive agent inpersons predisposed to phthisis.

I might assert that it is almost the fashion of the presentday to consider tuberculosis strictly a blood disease. Mr.Ancel avers, " that the progressive debility is the progressivedecrease of vital molecular changes, first in the blood, andsecondly in the solids." This statement appears to requiresome consideration. Is it not more probable that the solidsfirst give way ? for of whatever the vital force may ultimatelyprove to consist, whether arising in consequence of certainmolecular arrangements in the particles of matter, or fromother unknown causes, yet with our present knowledge it may

* Cyciopsdia of Practical Medicine, vol. iv. 1S35, on *’ Tubercular Phthisis."By Dr. Clark. Paf;’éS 321 & 353.t C]Ì1úca] Lectures. By Dr. Graves. Vol. ii., page 103.