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Cases of Scrofulous Abscess; Earthy and Alkaline Phosphates.CASE 14.-James M-, aged five; was seen April 16th,

1845, with scrofulous disease of the hip; not feverish; is ableto hop about; lives on- milk, bread and meat; urine acid; onstanding, gave a slight deposit of urate of ammonia; containedoxalate of lime crystals; specific gravity = 1021,8. 66,145grammes precipitated by ammonia; earthy phosphates ==,070= 1,05 per 1000; 33,086 grammes precipitated by chlorideof calcium and ammonia; phosphate of lime ==,152 = 4,59 per1000.

CASE 15.-E. -, aged seven; was seen May 5th, 1845; illthree years; sore discharging on the foot and elbow-joint; nofever; bread and meat, and milk; water passed in the morn-ing early, before food, containing a visible sediment of innu-merable octahedral crystals; not strongly acid; filtered, specificgravity = 1027,7. 33,277 grammes precipitated by chloride ofcalcium and ammonia; phosphate of lime =,154 = 4,62 per1000.CASE 16.-Alex. D-, aged seven; was seen May 6th, 1845;

ill four years; abscess in the hand, elbow, and foot; lives onmeat, vegetables, and milk; urine passed in the morning beforefood; slightly acid; contains some few octahedra; specificgravity == 1022,5. 33,111 grammes precipitated by chloride ofcalcium and ammonia; phosphate of lime ==,168 = 5,07 per1000.CASE 17.—John W-, aged seven years and a half; was

seen May 7th, 1845; ill two years; sore under the neck; isrunning about; meat occasionally; urine passed between sevenand eight A.M., before food; no octahedra to be found; specificgravity = 1020,4. 33,043 grammes precipitated by chloride ofcalcium and ammonia; phosphateoflime==,144==4,35 per 1000.CASE 18.-James C-, aged forty, bootmaker; was seen

May 8th, 1845; swelling of the glands of the neck, one month;otherwise healthy; has insufficient food; urine passed eightA.M., before breakfast; acid; remained clear; no octahedrawere found; specific gravity = 1019,5. 65,164 grammes pre-cipitated by ammonia; earthy phosphates =,020 =;30 per1000 ; 33,013 grammes precipitated by chloride of calcium andammonia; phosphate of lime =,092 = 2,78 per 1000.

Conclusion.The following general summary of these cases will show

what are the variations which I have found on analysis; andit will be seen from the same table, that no deductions can bemade regarding the increase or diminution of the phosphatesin chronic disease:-

The first seven cases of diseased kidney show no increase ofphosphates, even when acute inflammation happened to super-vene. In Cases 8, 9, 10, a very small quantity of urine wassecreted, and hence, probably, the slight apparent increase inthe amount of phosphates. The cases of scrofula showed noincrease of phosphates.

Hospital Reports.MANCHESTER ROYAL INFIRMARY.

CASES OF INJURY TO THE HEAD.

Reported by W. D. EMMETT, M.R.C.S.E., formerly Clinical Clerk toW. J. WILSON, Esq., Manchester Royal Infirmary.

CASE l.-J ohn Al-, aged twenty-five; admitted Oct. 12th;had fallen from the third story of a factory upon some timber.He was taken up in an insensible condition, and (as is gene-rally the case in the country in all similar accidents) was im-mediately bled. When brought to the Infirmary the pulsewas scarcely perceptible ; skin quite cold; pupils almost, fixed,and slightly dilated; there was bleeding from the right ear.He was immediately placed in a warm bed; reaction came onin a few hours, when his head was shaved, and cold lotionconstantly applied. The left tibia and fibula, which werealso fractured, were subjected to the usual treatment.Up to the 15th he continued in an insensible condition,

passing his faeces in bed; pulse full; skin hot and dry. Orderedturpentine enema, blister to the nape of the neck,and calomeland antimony every four hours. Under this treatment hegradually improved, and on the 20th all the most urgentsymptoms had disappeared. The pulse still continued full,and there was a constant tendency to headaeh, if the bowelsbecame in the least costive. On the 24th he was rather restless.To continue the powders,and take a draught of house-medicine.

Oct. 26th.-More tranquil and sensible; the leg in good posi.tion; but when dressed, showing no sign of the reparative process27th.-Confused and drowsy; face flushed; pulse full and

soft; bowels open.Nov. 2nd.--Symptoms as above; continued in spite of the

usual treatment. Ordered an antimonial every two hours; tobe cupped; cold lotion and blister applied.4th.-Pulse slow and soft; bowels free; the leg has made

no progress; there does not seem to be any callus thrown out.8th.-Bowels again costive; face flushed; pulse full; skin

hot. To take house-medicine immediately.9th.-Slept well; all bad symptoms abated as soon as the

bowels were purged.11th.—Had alittle more pain in the head. To be purged again.14th.—No more pain in the head, but occasionally giddy;

the leg now for the first time shows the deposit of callus.20th.-Continues well.25th.-Leg put up in starch bandage. He had been now

several days free from headach. He was cautioned as to hismode of living, and discharged.

Dec. 12th.—Presented himself for examination. The legis now quite sound, and he has continued free from all headaffections. Cured.

____

EXTENSIVE FRACTURE OF THE BASE OF THE SKULL.

CASE 2.-G. H ,aged about twenty-five; admitted Nov .10.He was s-tiffering from symptoms of concussion, caused, it wasthought, by having fallen from a wall. It was not known howlong the accident had happened, nor indeed the exact natureof it, as it occurred during the night, it was believed, whileattempting to commit a felony. On admission, the surface ofthe body was cold; pulse slow and laboured; pupils acted; hecould be easily roused to answer questions, and had walkedinto the accident-room with the assistance of a policeman.He was taken to bed, and as it was not clear what was the exactnature of the injury, it was judged advisable to wait for symptoms.

Nov. 11th.—Feels much better, and able to answer questionsreadily; says that he was attacked by some men, who ill-treated him; bowels have been freely opened; pulse ratherfuller,but very soft and compressible. Ordered cold lotion to thehead; to take calomel and antimony every four hours.

12th.-Complains of a little pain in the head; there is apurulent discharge from the right ear. To have six leechesto each temple; continue the pills. Pulse as before; pupilsnatural, but rather sluggish. To have an enema.13th.-Pain in the head increased; face flushed; pulse full.

To be cupped on the back of the neck; a blister applied.-Evening: Felt relieved; pulse very soft and compressible.

14th.—Discharge continues from the ear; complains of in-tense pain in the head. To have twelve more leeches appliedto the temples; continue the pills.-Seven P.M.: Roused vvilidifficulty; pulse soft; skin moist; bowels open; passes hisurine.-Eleven P.M.: Quite insensible; pupils fixed; pulse verysoft and compressible.15th.-Nine A.M.: Total insensibility, though his legs are

drawn up, on tickling his feet. He continued in mnch :hesame way, the pulse alternating every two or three hours

225

at one time slow and labouring, and again full and bounding.- At six P.-4. it was proposed to try the effect of venesection,attending to the pulse at the same time. An ounce or so

being drawn, the pulse seemed stronger, but quickly becamesoft. The breathing was affected. There was little further

change, until about nine P.3I., when he suddenly expired.Post-mortem &xe’nM’K6[<n’K.&mdash;On removing the scalp, no frac-

ture could be perceived, nor any very great marks of violence.The head being opened as usual, a very large clot of bloodwas seen between the anterior inferior angle of the rightparietal and the squamous portion of the temporal, about oneounce and a half in weight.; the dura mater was separated,for a considerable extent, from the skull, and the right hemi-sphere of the brain flattened to an amazing extent; the duramater on the left side presented over the entire surface abluish tint; on cutting through this, the brain was found tobe covered with fluid effused blood. The meninges did notappear to be inflamed, though discoloured with blood; therewas no effusion of serum; the ventricles were empty; thesubstance of the brain, on being sliced, presented no appearance worthy of note. On entirely removing the brain andcoverings, a fracture was found extending from the middle ofthe parietal, through the angle and the temporal. Thepetrous portion was comminuted over the internal ear, andthese portions were easily removed by the finger. From thispoint the fracture extended in one direction, through thesphenoid and frontal, as far as the foramen c&aelig;cum; in theother, through the right side of the foramen magnum. Therewas no effusion of blood or serum in these positions, therebeing merely a dark line, tracing the line of fracture.

CASE 3.- -, admitted Jan. 18th, eleven P.M., with slightsymptoms of concussion. The lad had been knocked down;he had a severe contusion on the left cheek; the left eye wasquite closed; the right pupil acted well; pulse indicatednosevereinjury; he was, however, sent to bed, and cold lotion applied.19th.-Ten A.M.: On going round the wards I was surprised

to find the lad up and dressed, standing by his bed. He com-

plained of no pain, said he felt perfectly well, and wished toleave the hospital. The tongue was clean, pulse tranquil,skin cool, and pupil acting naturally: I, however, ordered himbed, and to continue the cold lotion, also to take a draughtrof house medicine. He continued free from pain during theday, and at night seemed pretty well.

20th.&mdash;About seven A.M., without having previouslyexhi-bited any alteration, he suddenly leaped out of bed and com-menced shouting; considerable force was required to hold him.The pulse was quick, skin hot, eye suffused; the right pupilstill acted, the other could not be seen. He was ordered totake a calomel and antimony bolus immediately, to be bled, ablister applied, cupped, and an enema administered. In a fewhours, despite this treatment, he died.At the post-mortem examination, a fracture was found, ex-

tending through the left orbital plate, and over the seat ofthis fracture there was considerable extravasation of blood.No other appearances worthy of note were discovered. I wasprevented from taking further notes of this case, as I was suf-fering from a dissection wound.

CASE 4.-Bridget -, aged about forty-eight; admitted asa home-patient, Oct. 18th. When first visited, she complainedof drowsiness and headach, appeared very stupid; pulse slow,skin cool, bowels costive; said she had been ailing a few days,but going about her work in the factory. Ordered to take anaperient mixture, and to report progress in the morning: thisshe, or rather, her friends, neglected to do.On the 19th, when I called, she was in a state of complete

coma; both pupils dilated, eyes glassy, mouth open, and teethencrusted; the tongue dry and brackish. The husband wouldgive no account of his wife: a neighbour, however, informed methat she had had a severe fall, down thirteen steps, on theback of her head, about ten days previously; that she had beenstunned for a short time from it, but a little whisky had sether all right again. She had followed her usual occupation,as stated. The case now assumed a serious aspect. Her headwas immediately shaved, and a blister applied; also one downthe spine; mustard poultice to each leg; to have a turpentineenema directly; calomel and sugar to be washed down thethroat with a little hot brandy-and-water. Afternoon andevening: Little alteration; perhaps the skin is a little warmer.Continue remedies; repeat enema.

20th.&mdash;In the same deep coma; pupils fixed and dilated;breathing very slow; pulse slow; skin clammy. Mr. Roycenow saw the case with me, and we thought it advisable tc

order decoction of cinchona, with carbonate of ammonia;blister to the back of the neck, and repeat enema, with beef-tea ; to continue the calomel.-Evening: To continue as before.21st.-Shows more signs of vitality; moved her eyelids

several times; otherwise much as before. Continue remedies.To have blisters behind each ear.22nd.-Breathing regular and deep; skin warmer; teeth

cleaner; eyes less glassy; pupils still fixed; has, all along,passed her urine unconsciously. To have enemas of beef-teatwice a day; swallows her medicines more easily.

23rd.-Pupils scarcely affected by a candle. Blisters toeach temple, and behind the ears. Repeat turpentine enema;continue calomel and mixture.

24th.-Pupils beginning to act, though very sluggish; othersymptoms also rather more favourable.26th.-Turns her head on my entering the room, but does

not seem to know or recognise any one; apparently endeavoursto speak, but ineffectually; pupils more active, though ex-cessively dilated. At times the husband thinks she squints.To take the mercury three times a day; beef-tea and gruelenemas as before; a blister to the occiput, and the back ofthe neck.

30th.--Pupils less dilated; bowels regular; tongue moist;pulse quiet; skin warm. Repeat blister to back of neck.Nov. 4th.-Has had blisters repeated to her temples and

ears; seems much annoyed at the blisters, but unable to speak,though she evidently tries hard; appears quite conscious, andpupils tolerably active. From this period she gradually im-proved. The bladder regained its power, and about six weeksafterwards, she surprised me by walking into the out-patients’room, nearly a mile from her own home. She still clipped herwords, and there was certainly a slight difference in the eyes,though scarcely amounting to strabismus. Three months,afterwards she experienced no ill effects.Remarks.-I am inclined to consider the first case as com-

plicated with fracture of the base, not alone from the symp-toms presented in this case, and the bleeding from the ear,but also from comparing it with many others which I havehad the opportunity of examining after death. It will beseen that bleeding was had recourse to very sparingly; infact, I think the first bleeding had very nearly rendered himhors de combat. It is possible it might have been beneficialafterwards, but as purgatives answered every object, (combinedwith enemas,) it was thought preferable to avoid that re-action which, more or less, always follows venesection. I amdecidedly of the opinion, that recovery after this very seriousinjury is not so rare as is generally imagined. However, thismust of course be received as each may think, pro or con.The second case is very interesting, inasmuch as it shows

how extensive may be the injury received, and how compara-tively slight the symptoms may be. Your readers will pro-bably be as well able to account for the various symptoms andpost-mortem appearances as myself. In fact, I confess Icannot satisfactorily account to myself for the immense clot,which, judging from its appearance, I should say had beeneffused and coagulated at the same period-i. e., that therehad not been a partial effusion in the first instance, andanother subsequently. May not the opinion be entertained,that it proceeded from rupture of the lacerated internalcarotid?-for from the comminuted state of the surrounding

canal, I think it must have been. Suppuration from the ear,. in these cases, is a very dangerous symptom. However, the, injury was so great that no treatment could have availed; and, it is only surprising he should have survived so long.

The third case tells us strikingly how guarded we ought tobe in forming our prognosis in cases where the head has beeninjured. I can recal to my mind many cases, not only in the

. provinces, but also in town, where the symptoms have beenattributed to intoxication; and the patient, in many instances,has been dragged to the police office, and locked up; death,

, as might be expected, generally following, and in more thanone instance, I recollect, from collapse. Indeed, most expe-

L rienced writers and practical men are well aware of the diffi-, culty of discriminating between some cases of injury to the, head and the different stages of intoxication. In this case, itt was never imagined he had been drinking.IThe fourth case shows how persevering and energetic we

ought to be in cases where the injury or disease is evidentlyvery great. I think there can be but very little doubt re-1 garding the nature of this case. The indications were plain,. and they were undoubtedly most assiduously fulfilled. It is

true there was neglect in the first instance, and gross igno-rance displayed by the relatives. The case may perhaps beserviceable in more ways than one. With permission, perhaps

I may resume the subject at a future period.