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201 Leeches were applied to the hip, and a bracket long outside splint put on. Further investigation elicited the fact that twelve months ago he had lost a horse from influenza and running from the nose." After the horse was killed, the man himself had severe colds in the head, accompanied by an offensive discharge from the nose, and expectoration of a large quantity of very offensive phlegm. He had also lost two horses this year from "glanders." The last died two months ago, after which the stable was turned out by the sanitary authorities. He had had no sore of any kind about the hand or face. July 20th.—About 9 o’clock yesterday morning he be- came delirious and very restless, continuing so all day. This morning the pulse is 132, and there is a marked eruption of pustules scattered over the chest, arms, face, and neck, most marked on the back of the shoulders. The spots begin as pimples, which develop into pustules, the base of which is inflamed and elevated. As they i increase in size the inflammation around the base extends, and they have a tendency to irregular outlines, and in some parts coalesce; they are not umbilicated. There is no discharge from the nose. Last night he was noticed to hawk and spit about the floor, as if trying to get rid of a viscid mucus which in small quantity was clinging to his tongue and gums. This symptom continued at intervals until the day before death. 21st.—Has had a fairly good night and slept for three hours, but was delirious. Says that he is better, but looks anxious, and there is some nervous twitching about the lips when he speaks, and slight subsultus tendinum of the forearms. Pulse 164; respiration 52. Tongue covered with a white fur and rather dry. He complains of some pain across the abdomen over the region nf the stomach, where there is tenderness; there is much tympanitic distension. Bowels acted once; very offensive motion. The swelling of the thigh is less. The pustules have increased over the face, nek, hands, and arms; there are some on the fingers. The smaller spots are shotty in character. There is a little running from the eyes, but none from the nose. He is taking uve grains of quinine in milk every four hours, and is to have six ounces of brandy, eggs, milk, and ice. 22nd.-The patient died at 4 A.M. During the last hour or two he was unable to expectorate, and this caused con- siderable increase of the dyspnoea from which he had been suffering. The eruption covered the whole body. There was some diarrhoea during the night, with offensive motions. The temperature continued high throughout, not falling below 100.8° (8 A.M., 19th); it was usually lowest at noon, being generally about 102.4° at that time, but would rise to 105° two hours later, and always ex- ceeded 104° some time during the day, but with no regu- larity ; a short time before death it rose to 105’20. He had profuse sweating on the 19th, but there was no repetition of the rigor. On the 21st Mr. Hull, the house-surgeon, examined some secretion from one of the pustules; this was stained with methyl violet and washed with dilute acetic acid. Under a strong microscope, one of the slides examined showed the presence of bacilli of well-marked character resembling those found in tuberculosis. The post-mortem examination was made by Dr. Sharkey ten hours after death. The body presented the appearance of well-made and somewhat thin man. The skin in general- body, face, arms, and to a less extent the legs-was covered with a vesicular eruption. On the neck and face several of the vesicles had burst and left scabs of a dark-brown colour, thin, and with a depressed centre. The vesicles varied from a pin’s head in size to six times that size. A very frequent appearance was that of a purplish area of skin, not thickened, supporting a large vesicle (such as is seen in herpes), which had in its immediate neighbourhood several smaller vesicles. The contents of all the vesicles were opaque, and white in colour. None could be seen in the nostrils or mouth. The left tonsil had been the seat of former ulceration, which had left a largish, clean-cut, superficial depres- sion. The right was ulcerated, and presented a slightly granular surface, covered with pus. On the soft palate, close by the uvula, was a small ulcer. The larynx and trachea presented no ulcers, &c., except a very minute one, which was situated on the anterior wall of the trachea, below the larynx. The bronchi were inflamed, and sometimes a small caseous nodule presented itself in their mucous membrane. The right lung was adherent by old adhesions to the chest wall. Both lungs were studded thickly with caseous-looking nodules, varying in size from the smallest visible points to about the size of a large hazel-nut. They were irregular in shape, with sharply defined outline, and the lung tissue around was deeply congested, but not solid. The nodules themselves were solid and greenish-white. When they were situated deeply beneath the pleura, the latter was very deeply injected, and the nodules appeared white, with a deep-red border. The right hip-joint contained synovial fluid, a little opaque. The spleell was large and soft. The liver was large, pale, and a little harder than natural. The rest of the organs, including the intestines, were healthy. YORK COUNTY HOSPITAL. MALIGNANT DISEASE OF THE MOUTH ; EXCISION OF THE FLOOR OF THE MOUTH AND PART OF THE LOWER JAW; RECOVERY. (Under the care of Mr. JALLAND.) WILLLIAM N-—, aged fifty-eight, a blacksmith, admitted March 16th, discharged May 2nd, 1885. A brother of the patient died at the age of fifty-five from recurrence of glands in neck after removal of cancerous tongue. Had had no illness till the present. Has lived freely. Accustomed to smoke not less than a quarter of a pound of tobacco a week out of clay pipes. Fifteen months ago noticed the inner surface of left cheek was sore constantly; attributed it to excessive smoking. The sore never healed. Twelve months ago the above-mentioned sore began to spread back- wards towards the lower molars, thence into the floor of the mouth, till one month before admission the ulceration had extended to the frænum linguae, and the present tumour began to develop. On admission he appeared a healthy, well-nourished man; no signs of cachexia. On the inner surface of the body of the jaw was seen a somewhat rounded tumour (the size of a pigeon’s egg divided longitudinally), dense and elastic in consistence; a portion of its surface was ulcerated, and more deeply so posteriorly in the situation of the second bicuspid and molars (which got loose and were extracted by the patient himself, about six months ago). In the socket of the left central incisor (which he pulled out two weeks ago) was a mass of granulations. The outer surface of the bone seemed fairly smooth. The remaining teeth (second incisor, canine, and first bicuspid) on the left side all moved on pressure and apparently carried a portion of the alveolus with them. On the right side the growth extended to the level of the second bicuspid, and posteriorly and on the left side nearly to the angle of the jaw. Slight and occasional pain. Salivation somewhat interfered with articulation. The tumour, being supposed to be epitheliomatous, Mr. Jalland on March 17th proceeded to remove it. The patient was first placed under the influence of chloroform, but took it badly, his pulse failing, so the A. E. C. mixture was sub- stituted. Being anaesthetised, an incision was made through the lip to the right of the median line about the level of the canine, the lip being completely divided from above downwards, an incision carried backwards along the lower border of the bone on the left side to about the level of the third molar, and on the right for about an inch and a half to the right of the lip incision. All bleeding vessels were secured as they were divided. Thejawwasnow sawn through on each side of the growth, and, being grasped by the fingers, the knife was carried from behind forwards through the soft parts beneath the tongue, thus detaching the mass. At this stage, before the wound was sewn up, a stout piece of silk was passed through the tongue, the ends being held by the anaesthetist. Scarcely had this been done when the patient ceased breathing, rapidly becoming cyanosed, his pulse remaining full and good. The tongue being forcibly drawn forwards, breathing recommenced. The lip wound was brought together by three hare-lip pins, and the wounds on each side sutured. While this was being done stoppage in respiration again occurred, the patient not being fully under the influence of the aneasthetic at this stage, and he had a partial respiratory convulsion. Pulling the tongue forwards by means of the silk cord not availing, a finger was passed down to the root of it and the hyoid pressed forcibly forwards, respiration at once returning. A drainage-tube was placed in the wound, and a dressing of salicylic wool over all. The patient was placed in bed and kept in a sitting posture, with the tongue ligature strapped to the cheek ready for an emergency. There was E2 2
