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source; probably many others had done so, too. The over-flow pipe from the same cistern had its orifice of dischargeover a gully in the corner of a paved yard, the orifice beingparallel with the gully, and an inch or two above it. Sideby side with this pipe, and terminating at the same level,was another. This other led down from a slop sink, andconveyed the night urine from the girls’ dormitory into thedrain. These pipes had been in use for two years, as had theportion of the school wherein the disease occurred and to whichthey belonged. The drain, which was trapped below the gullyby a Doulton’s siphon, conveyed also rain water and bath-room water to the larger drain beyond, and the gully gratingwas somewhat furred with urine salts. Now, whether thestructural arrangement described had anything to do withthe scarlatina or not, it was clearly a bad one, and open tograve suspicion. The overflow pipe was therefore cut awayto half its length on March 26th, 1881, nine days from thelast case of illness, and was made to discharge itself upnn alow roof hard by, thus dissociating it from the urine-pipe,which in its turn had its extremity cut into the shape of ajug spoat. After this no case of fever happened.Owing to the circumstance that no ordinary cause of the

disease was discovered, as contagion or fomites, it seems

probable that there was some less common cause for thisseries of cases of scarlatina. If so, either it was one ofwhich I am not cognisant, or it was connected with thejuxtaposition of the two pipes. In the latter case, the over-flow pipe appears to have conveyed to the cistern, uponTobin’s principle of ventilation, air, with all that air may carry,and the chemical results of some decomposition of urine andperhaps of other fluids ; and by this contamination thewater was made equal to the production of scarlatina atuncertain intervals, depending partly upon the receptivityof those who drank of it. Arguing upon this, one’s qu’es-tion next is, What is this chemical which was conveyedfrom the urine pipe, or perhaps, but unlikely, from the corn -paratively harmless drain below? For, so far as can betold, no ordinary scarlatina germs were present, the factsappearing to favour the theory that scarlet fever may begenerated de novo.As to the case of the boy, he had no means of getting at

the water which the girls drank from, and I know of no wayin which it was probable he took scarlatina, except it be ad-mitted that his mother brought it to him. But if she did,the period of apparent incubation was of unusual length. Itmay be, however, that the poison lay in his clothing for aday or two, and so the ordinary period of incubation may nothave been transgressed. But if the boy’s mother did not bringthe disease to him, and the girls did not get it by meansof the pipes, then the facts given exemplify what isundoubtedly true sometimes, that with all the circum.stances seeming to favour a given conclusion that con-

clusion is not correct, because an important something elsehas needed recognition. Query, In the present case, is therethis something else ?" And if there is, what is it ? But ifnot, what was the seed of mischief in the water ?Kenley, Surrey.

A MirrorOF

HOSPITAL PRACTICEBRITISH AND FOREIGN.

MIDDLESEX HOSPITAL.TWO CASES OF TRAUMATIC ONE-SIDED PALSY OF

SPINAL ORIGIN.

(Under the care of Mr. HULKE.)

Nllllaalltem estalia pro certonoscendivia, nisi qnamplnrimas et morborumotdissectionam historias, tum aliorum tum proprias collectas habere, et Iinter se compMa.M.—MoMAairi De Sed. et DaUB. Morb., lib, iv. Procemium.

CASES of this kind seem to be rare. In the first case the

lower, in the second the upper limb was affected. In boththe motor palsy was of much greater intensity and of longerduration than the loss of sensation, a coincidence which mayfind its partial explanation in the greater complexity ofmotor function. The implication of both motor and sensoryfunctions would suggest a lesion of the nerve cords beyond

the junction of their motor and sensory roots, and wouldlocate in the second case the injury outside the intervertebralforamina. The widespread convulsions, however, in thiscase point to a more centrally seated injury, to an excessivestrain falling principally on the anterior roots and their

ganglionic connexions, and to a widely spreading irritation.In the first case the lesion was considered to be probablyhaemorrhage into the anterior grey cornu.CASE 1. Palsy ()f Left Lower Limb from a fall.-On

March 16th, 1882, at 11.30 A.M., a short, extremely stoutcarman, aged twenty-eight years, was received into Broderippward for injuries received a few minutes previously in a fallfrom his driving-box, in which, it was said, his loins hadstruck upon the pole or splinter-bar of the van. Whenextricated from between the horses it was found that he wasunable to stand in consequence of want of power in his leftleg. Upon examination half an hour after the accidentthere were noted absolute motor palsy of the left leg andthigh, great insensibility to tactile stimulation as high asthe knee, and absolute insensibility of the surface of thescrotum, and integument of the penis, on both sides of theselatter parts. No reflex movements could be excited in thelimb. Retention, requiring the use of the catheter, was alsoshortly afterwards observed. On the following day theanaesthesia, of the scrotum and penis had disappeared, andthat of the leg was much less. Defecation occurred withoutconsciousness of the act. Notwithstanding precautions toavoid septic infection of the bladder by the catheter, acutecystitis supervened on the third day after the injury. Urine,alkaline and bloody, was voided occasionally without con-sciousness of the occurrence, but when the catheter wasused, as the emptied bladder contracted upon it he sufferedvery great pain. This was so severe-he called it agonising-that a hypodermic injection of morphia was required dailyduring several weeks. Later, retention was replaced bystillicidium, which was not the dribbling of an overfilledviscus, but it was due to loss of tone of the sphincter vesicae;for catheterisation proved that the urine escaped per penemas quickly as it entered the bladder through the ureters.On May 15th, a few months after the accident, he had asevere gastric attack, marked by severe pain in the region ofthe stomach and vomiting. This yielded to bismuth andprussic acid. Two days afterwards acute inflammationof the left testis supervened. The left lower limbby this date had become very cedematous, the surfacewas pale, the epidermis thickened and opaque. His statevaried little from day to day, but in the course of Juneand July a marked improvement had taken place. Bythe end of the latter month he was able to flex and extendthe hip, knee, and ankle-joint through a considerable angle,and he had regained some power over the toes. The im-provement was more rapid after he was able to be dressedand wheeled about in a chair, and it was yet greater when,with the aid of crutches and supported by a couple of assist-ants, he began to try to walk. When last seen, about amonth ago, he walked with crutches only, and did not needany longer the assistance of others, and the improvement ofthe limb was so considerable as to warrant hopes of the re-covery of a useful limb. The paralysis of the sphinctervesim and unconscious defecation continued. The treat-ment consisted mainly in measures tending to maintain andimprove the nutrition of the palsied limb-e.g., shampooingand faradisation. Much care was required to avoid the for-mation of pressure sores.CASE 2 Violent general Convulsions and Motor Palsy of

t7to Lejt Upper Limb, caused by a severe Squeeze of the Neck ;Recovery. (From notes by the dresser, Mr. C. E. Faunce.)- own March 10th, 1881, a factory boy, aged sixteen, whilein the act of stooping over a rail and looking down the wellof a lift, was caught across the neck by the cage in itsdescent, and thus held imprisoned until the jambed-tightcage was lifted with a crowbar sufficiently to allow the extri-cation of his head. Insensible and violently convulsed, hewas immediately brought in a cab to the hospital. On un-dressing him it was found that he had voided urine andfseces. The convulsions soon ceased, consciousness returnedslowly, and was not completely restored until night. Theleft upper limb was comptetely paralysed as regards motion,but the sensibility of its surface was only slightly if at allimpaired. The left pupil was contracted; the left cheekand the right forearm were noticed to be slightly grazed,and the right side of the neck seemed to be a little swollen.

112

The sternal end of the left collar bone was incompletelyluxated forwards. Temperature, taken in armpit, was

subnormal (97’6°F.), and it continued so during a week. Onthe fourth day a strong volitional effort produced slightmovements of the hand and forearm. This improvementcontinued, and by December 5th, when he become an out-patient, he could execute with regularity such completeacts with the hand and forearm as were required in dressingand taking his meals. He soon after this returned to work,and when recently seen the only remaining traces of theinjury were a slight loss of bulk and slight defect ofmuscular power of the limb as compared with what hebelieved to have been its condition previously ; and the sub-luxation of the collar bone, which did not appear to causeany inconvenience.

EVELINA HOSPITAL.CASE OF RUPTURE OF THE ŒSOPHAGUS; FRACTURED BASE;

NECROPSY.

( Under the care of Mr. HOWSE.)FOR the following interesting notes we are indebted to

Dr. W. H. C. Newnham, resident medical officer.Edward B-, aged three years, was admitted on Oct.

15th, 1883. On the 15th, at 10 A.M., the child went up to abaker’s cart standing in the street, and hanging on the backthe cart tipped up. The child fell with his head on the

stones, the cart striking his forehead and chest. ’

On admission there was a very ma.11 cut on the back ofthe head, no bone exposed. There was much bruising ofthe left eyelids, bleeding from right nostril only. The childappeared drowsy but quite conscious. No paralysis, no con-vulsions, no vomiting. Pupils equal. Pulse 80, not quiteregular. Temperature 960 F. Limbs not drawn up. Inthe night the child was very sick, bringing up a largequantity of blood.

Oct. 16th.-Pulse 156. Respiration 48. Still conscious,eyelids much more ecchymosed. At 10 P.M. the child beganto have convulsive movements of both arms and legs, equalon both sides, some twitching of face also, was not drawn toeither side. Temperature 103 2°.-17th : The movementshave continued at intervals during the day. The rightpupil is much more dilated than the left. No paralysisapparent. Pulse 192 ; respiration 60.-18th : At 2 A.M. thechild died quietly. The treatment was simply to keep thechild in bed with an ice-bag applied to the head, andadministering a little milk.Necropsy, thirteen hours and a half after death.-Well-

nourished, well-developed child. Rigor mortis present;ecchymosis of both upper eyelids, chiefly left ; a smallsuperficial wound of occiput. No other external injury.Head : Meningitis, chiefly of vertex, but slightly at baseof brain; lymph becoming yellow in the sulci ; opacity ofmembranes ; changes not localised on hemispheres ; no

bruising of brain substance, or other changes ; some excessof fluid ; the left spheno-trontal suture at the outer end(where the great wing of the sphenoid articulates with thehorizontal plate of the frontal) is started, and a fissureextends forwards into the orbital plate of the frontalabout an inch and a half ; a very slight extravasationof ’blood at this fracture beneath the dura mater ; no otherfracture of skull ; slight extravasation of blood into theleft temporal muscle. Chest : No fracture of ribs or ver-tebras, or dislocation of the latter; in left pleural cavitya considerable amount of brown gelatinous matter, chiefly,if not entirely, blood-clot, abo some dark blood ; in rightpleural cavity some dark blood, less in quantity thanin left side. Lungs normal ; no rupture on pleural sur-face. Heart normal. Pericardium normal. CEsophagus:On left side, and somewhat posteriorly, is a rent about aninch and a half in length, half an inch above the cardiacorifice, the edges of which, though not ragged, are not

sharply cut, and the edges of the mucous and external coatsdo not quite correspond; it is quite unlike the hole whichwould result from post-mortem digestion; the coats of thecesophagus in the remainder of its length are normal andhealthy-looking ; no other lesion discoverable. Stomach con-tained a little blood. Kidneys, intestines, and spleen normal.Liver healthy in appearance on the surface; and extendinginto the substance are some yellow patches (gummata 1); noother evidence of hereditary syphilis.

SHEFFIELD PUBLIC HOSPITAL.INTESTINAL OBSTRUCTION ; DEATH ; REMARKS.

(Under the care of Dr. THOMAS and Mr. THORPE)FOR the following notes we are indebted to Dr. S;nclair

White, house-surgeonAlfred H-, aged twenty-seven, a silver buffer, married,

was admitted on October 25th, 1883. He gave the followinghistory: Had inguinal hernia when a child, and wore atruss until he was four years of age. Since then the herniahas not reappeared ; has been fairly healthy, and has had nodifficulty in regulating the bowels. On Oct. 20th, five daysprior to admission, he began to feel pain in the abdomen;the pain was of a "colicky" character. He could assign nocause for the pain, and had been until then in his usualhealth. On the 21st the pain was worse and the bowelswere relaxed, and he vomited for the first time. On the 2?odthe pain and vomiting continued, the vomited mattersmelt faecal ; he had one motion. From this date untiladmission the pain and vomiting continued, and his medicalattendant, Mr. Hargreaves, states it was distinctly stercora-ceous ; the bowels did not act subsequent to Oct. 22od.On admission the abdomen was moderately distended and

tympanitic all over except in the left iliac region ; here anoblong swelling could be distinctly felt; percussion over thisarea elicited a dull note, and pressure caused pain ; elsewhereover the abdomen pressure was borne without complaint.The patient volunteered the statement, that the waterrolled all over the belly until it came to the left side, whereit stopped." The inguinal canals were unduly large, but nohernia could be detected here nor in any of the situationswhere it may appear. Examination per rectum revealednothing abnormal. The patient was not suffering muchpain, nor were the features pinched ; he complainedof thirst, but the tongue was fairly clean and moist.The temperature was normal, and the pulse 96 perminute and fairly strong. He passed a considerableamount of urine, which was normal. Shortly after ad-mission, he vomited a small quantity of liquid matter ; thisdid not smell fcal, and was mostly beer, which he hadtaken prior to admission. The case was diagnosed as one offaecal impaction in the descending colon. Belladonnafomentations were applied to the abdomen, and an enemaof castor oil and gruel was thrown up the rectum through along rectal tube. The man was allowed small quantitiesof iced milk and beef-tea. The enema did not bring awayany faecal matter, but the patient seemed to improve; thevomiting ceased, and the pain subsided considerably.During the night he slept for five consecutive hours. Nextmorning he was was fairly comfortable; there had been norecurrence of the vomiting. The abdomen was softer, andthe iliac swelling had entirely disappeared ; still, no fsecalmatter had come away, although the enema had beenrepeated. The improvement was maintained until theafternoon, when the vomiting recurred, and the pulse wentup to 120 per minute ; the vomited matter soun becamestercoraceous, and the patient got rapidly worse.A consultation was held, and operative interfereoce

decided on. The patient was aneesthesised, and the abdo-minal cavity opened by means of an incision four inches inlength, at the linea alba, between the pubes and umbiiicu?.The large intestine was first examined, but was found every-where empty and natural. The small intestine was next traced,and at an inch from the ileo-cæcal junction a band was foundconstricting the ileum; this band was easily torn throughon passing the finger beneath it. The protruding portionof intestine was carefully replaced, and the wound in theabdominal wall closed by sutures. The operation was per-formed under strictly antiseptic precautions. The patientdid not rally, and died an hour after the operation was com-pleted. It may be here stated, that in the efforts made torevive him the subcutaneous injection of twenty minims ofether had a remarkable influence on the pulse, causing itfor a short time to beat much more strongly ; but the gainwas not maintained for more than a few minutes. Etherwas the anaesthetic used.Examination after death showed the bowels slightly in-

flamed and distended with gas. The constricted portionwas thickened, and its lumen narrowed but patent ; therewas some blood effused beneath the peritoneum around it.The large intestine contained no faecal matter.Remarks.-The case is one of unusual interest and shows