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119 vealing nothing beyond a little rhonchus at the base of the chest, and there being no trace of diphtheria, a careful search was made for typhoid spots, but without success. This search was subsequently repeated daily, and with the greatest possible care; but no rose-coloured spots were found from this date onwards. There was also a total absence of diarrhoea, abdominal tenderness, or tympanitis-indeed, some constipation had to be overcome. As days passed on, the nocturnal delirium, the day drowsiness, and other cere- bral signs gradually faded. The descent of the tempera- ture line was similarly gradual. iVIorning remissions con- tinued ; and the average evening exacerbation decreased till a standard, a degree above the normal, was attained on the twenty-second day of the disease. The temperature trace thus obtained constituted a very valuable testimony as to the nature of the illness. Nevertheless, a perfectly normal level was not reached; and, after five days of an uncertain state, the evening limit was observed to touch 1002° F. The same occurred on the ensuing evening, and by the next morning the thermometer gave us 104 1’. Simultaneously with this, the pulse shot up first to 120, then to 160. The former suffused, heavy look returned. She complained of intense headache, was very restless, and had some vomiting. The skin was for the second time covered with a deep ery- thematous blush, which again spared the extremities. This time there was an absence of sore-throat. The tongue at once became brown and dry, with vividly red edges. The urine contained no albumen. After forty-eight hours the rash had vanished; but the high rate of pulse and tem- perature, the dry tongue, vomiting, delirium, and restless- ness continued. To these, wakefulness and general hyper- sesthesia were added. After this state of things had lasted for five days-i. e., on the thirty-seventh day of disease,- the albuminuria recurred. The lungs began to fill with loose rales, and the pulse to fail in power. She died on the fortieth day of illness-the twelfth from the relapse. During the last seven days of illness the average temperature was 1050 F., the day and night variations not exceeding a degree. On a post-mortem examination, numerous ulcers were found in the lower portion of the ileum. Some of these ulcers were free, and looked healthy; others were covered with yellow sloughs, for the most part on the point of sepa- rating. Nowhere was there any tendency to perforation. The spleen was large, weighing twelve ounces. The liver was very fatty. The kidneys were healthy. The lungs were generally cedematous, and one contained a small kernel of imperfect pneumonia. No other morbid change worth noticing was observed. Dr. Duffin remarks :-This case, then, was one of relapsing typhoid, but with an absence of almost all the great cha- racters which usually indicate this disease. Accepting the data given by the patient, there can be no question as to the total absence of rose spots, at least from the twelfth day onwards. The care*also with which the skin was examined on admission renders it very doubtful if any existed at that date. The absence throughout of diarrhaea, abdominal ten- derness, tympanitis, and gurgling in the iliac fossa is espe- cially remarkable in such a conjuncture. The presence of a deep erythematous blush over the face and trunk, both during the initial attack and during the relapse, is also un- usual. Being coupled at the outset with some slight sore- throat and glandular enlargement, and associated with such exceptionally severe nervous and thermometric signs for so early a period in typhoid fever, it was natural to suspect the presence of scarlatina, the more so as decided desquamation followed. Still the appearance of an erythematous blush in early typhoid is not so uncommon but that most men have observed it. Dr. Duffin has also on one other occasion seen the co-existence of sore-throat and erythematous rash; but in that instance, as the erythema fell, rcse-coloured spots ap- peared. The return of the erythema with the relapse, and the absence of sore-throat on that occasion, quite preclude the idea of the co-existence of scarlatina and typhoid. Of the signs of positive diagnostic value, the thermometer seems to have supplied the best evidence; the gradual descent of the daily maximum from the eleventh to the twenty-second day of illness was especially striking. In itself, however, it would not suffice to make the diagnosis, since Wunderlich, in his work on Temperature, has figured an almost similar curve as occurring between the same dates in a case of severe scarlet fever (fig. 34, taf. v.) The morning remissions, although, on the whole, of value, were not sufficiently steady to justify any inference. The ante- cedents probably deserved more attention than they received on admission. The insidious, gradual approach, and th& number of days occupied, especially claimed attention. The patient’s mental state was, however, such as to throw a haze over all the information with which she supplied us. POPLAR HOSPITAL. CASE OF ARACHNITIS FOLLOWING A FALL ON THE HEAD ; TREPHINING; DEATH. (Under the care of Dr. BAIN.) THE notes of the following interesting case have been supplied to us by Mr. Oliver Penfold, resident surgeon. G. C-, aged thirty-four, a shipwright, admitted April 2nd, 1869, for symptoms of brain-compression. On the 13th March last, at 11.30 P.2i., he was found in Cornhill, London, lying on his face, his head in the gutter, and his feet towards the middle of the road. He had been drinking, and it was supposed that he had run after an omnibus, which was full, and therefore did not stop when he hailed it; that he had stumbled, and had struck his head against the curbstone. He was insensible, and had a cut on the left side of the head. A policeman took him at once to Guy’s Hospital, where the wound was dressed; and in about an hour and a half he recovered his senses sufficiently to give his correct name and address. He was sent home in a cab. Two days afterwards he was seen by a surgeon, and was attended by him until the day of his admission. Dming that time he had been allowed milk and light pud- dings, but no stimulants. He kept his bed all the time, and the cut scalp seemed to be healing well till about the 26th or 27th March, when (his wife said) " it looked shiny,. and not so red as it had done." On March 27th he did not recognise properly his friends; on the 28th he had a cold shiver, was restless, and kept getting in and out of bed. When admitted (twenty days after the injury) he had a granulating wound of scalp, about the middle of the coronal suture on the left side; and at the bottom a small fissure of the parietal bone, about an inch long, was found. He was lethargic, but could be aroused sufficiently to get him to put out his tongue. There was no paralysis of sensation or of motion in the limbs. He was able to retain his urine and fseces, but for convenience the catheter was used. He was placed in bed upon a water-pillow. Beef-tea and milk diet. Ice was applied to the head, which had been already shaved; and four grains of calomel were given internally. April 3rd (twenty-first day).-Passed a restless night; complained of pain in his head. Puts his hand to his head, and moans frequently. Is very thirsty; breath "sour"; tongue dry, white, and furred; bowels confined; sensation and motion not impaired; left pupil larger than right. Lies on his right side. Pulse, morning 72., evening 95; temperature, evening, 105v5° F. 4th (twenty-second day). - Restless; still thirsty; is lethargic; pupils equal; bowels acted, the motions having a most offensive odour, and being of a light-yellow colour. (Calomel given.) Pulse, morning 70, evening 74; respira- tion 28; temperature, morning l00°, evening 104°. To take an ounce of brandy every two hours. 5th (twenty-third day).—Quiet; there is a little epiphora; no closure of the right eyelids is produced by touching the right eyeball, which is glazed over; the legs move when the soles are tickled; temperature 102v5° morning and even- ing ; pulse 82 morning and evening; tongue white, furred; a little puroin,-; involuntarily passes his urine. A grain of calomel to be given every six hours. 6th (twenty-fourth day).-Quiet, but talkative; no pain; sighs frequently; talks nonsense; recognised his wife to- day ; the right eyebrow does not move when the left does; no purging ; tougue white, furred; pulse, morning 85, even- ing 88; temperature, morning 104’75°, evening 104’25°. 7th (twenty-fifth day).-Quiet; answers questions fairly; is talkative; left conjunctiva is now ansesthetic; can only half-close his eyelids; says he can hear the ticking of a watch placed close to either ear; there are a few pustules, about as large as a split pea, on the penis and right but- tock ; abdomen tympanitic; tongue white, furred, dry; reflex movements are diminished, but not lost, in left foot. About midnight he seeded comatose and in a dying state..
