769

appeared; the patient was made quite comfortable. The re-

spiration fell to 36, and the pulse to 100. She slept thatnight, and lay on either side indifferently. The right chest-wall, which before the operation was three inches largerthan the left one, at once fell to normal girth, and respira-tion was re-established, though very feebly in parts, overthe entire right side. The dyspnoea never returned, and thepatient from this day forward presented no outward appear-ance of danger. The temperature, however, attained a re-markable height, mounting up to 104°, and even 105.8°, andthis it maintained, with some slight variations, for twelvedays. After that it fell to 100°, and thence gradually to thenormal standard. Fresh fluid was subsequently effused,but the quantity was trifling. Gradually respiration becamere-established, the percussion - note became clearer, andthe general condition improved. She left hospital in August.The pulse and respiration were a little above normal. Theright lung was natural on percussion in front ; the lowerpart of the right side behind presented a modified dulness,while the upper half of the same side exhibited a moremodified tonelessness. The respiration was natural over theentire chest in front, but feeble over the right side behind.A process of contraction of the right side had gone on thewhole time, and this now left this side an inch and a half ’,smaller than the corresponding one.

It is highly probable that the woman’s life was saved bythe operation. The subsequent tediousness of the case, and,above, all the contraction of the side, offer some discrepanciesto the views of Trousseau, who held out the opposite resultsas one argument in favour of thoracentesis.

HÔPITAL DE LA PITIÉ, PARIS.FRACTURE OF THE SKULL ; RAPID DEATH ; SUGAR AND

ALBUMEN IN URINE; SUBMENINGEAL HÆMORRHAGE;HÆMORRHAGE INTO THE BULB AND INTO THE PRO-

TUBERANCE.

(Under the care of Professor VERNEUIL.)

THE following case, the notes of which were taken byMons. Paul Redard, house-surgeon, is interesting from morethan one point of view : first, as a corroboration of certainopinions advanced by M. Duret in a recent work; and,secondly, from the rapidity with which death occurred.

X., thirty-five years of age, mason, fell off the top of aladder at the height of a second-floor window. He was apowerfully built man, and, as it was ascertained from hisrelatives, had never been ill previously. It was impossibleto learn how the fall had taken place, and what portion ofthe head had struck the ground. He was immediatelypicked up after the accident, placed upon a litter, and carriedto the hospital. A few minutes after the fall breathingstopped, and when he reached the wards of ProfessorVerneuil he had already expired. Three hours after deathrigor mortis was hardly perceptible. There did not appearto be any fracture of the limbs, of the thorax, or of thevertebral column. There was no subconjunctival hæmor-rhage, nor was there any trickling of blood or serosity by theears. There were traces of haemorrhage by the nasal fossae.There was no wound of the scalp ; the left temporal region,however, was tumefied, and presented a purple colouring.With the help of the catheter, a small quantity of urine wasdrawn off. By means of heat and nitric acid an albuminousprecipitate was deposited, and by the admixture of some ofFehling’s solution a large quantity of sugar was shown toexist. The result of the examination of the urine gave riseto the suspicion of the possibility of the existence of a frac-ture of the skull with concussion of the bulb.Necropsy, twenty-four hours after death.—Rigor mortis

well marked. After the incision of the pericranium, a col-lection of blood was found in the left temporal fossa. Thetemporal muscle was triturated and converted into a blackpulpy substance. There was a fissure in the bone of theleft temporal fossa, extending upwards towards the frontalbone. When the superior portion of the skull was uplifted,a slight collection of blood was found under the dura materat the point corresponding to the left temporal bone. Atthe point corresponding to the fissure, which was probablywhere the shock had been sustained, the pia mater was dottedwith traces of haemorrhage. On the right side there washaemorrhage under the pia mater, occupying almost all thesurface of the hemisphere, with slight hæmorrhagic points.At the base was submeningeal haemorrhage, chiefly situated

at the bulb and at the protuberance. Upon section the1"1was no trace of haemorrhage in the lateral ventricles or iithe third ventricle. Slight dotted haemorrhage was founin the protuberance, and a small haemorrhagic focus abouthe size of a pea on the floor of the fourth ventricle, and 01each side of the median line two other foci. The hsemorrhagic focus on the right side was about the size of a smal

pea, and seemed to correspond to the point which i:described as containing the origins of the pneumogastri.nerves. On the left side the extravasation of blood wa:situated about three centimetres from the median lineThere were no traces of haemorrhage in the cerebellum no:in the superior portion of the medulla. The right lung wafmarkedly congested with dark blood. There was sub.pleural haemorrhage of about twelve centimetres in length;about the middle of the right lung. In the pleura was som(black blood coagulated. The left lung was less coagulated,There was subpericardic haemorrhage on the anterior factof the heart. The heart otherwise was healthy. Live]slightly congested. The kidneys were tolerably congested,especially the right one.

Remarks.—This case showed us haemorrhagic lesions othe meningeal membranes at the base and on the hemi.spheres at the point where the shock took effect, and at thepoint diametrically opposite to it, as mentioned by M. Duret,after concussions, and which are probably determined by theshock of the cephalo-rachidien fluid. It showed also lesionsof the fourth ventricle, thus explaining the reason of therapid death ; as also the presence of albumen and sugar inthe urine, and the congestion and haemorrhage in the differ-ent viscera. The lesions of the fourth ventricle are deter-mined by the sudden impulsion given to the cephalo-rachidien fluid, as M. Duret has shown..

M. Redard has already twice observed the presence ofsugar and albumen in the urine of patients with fracture ofthe skull. This case of surgical injury might be comparedto those of medical shock (cerebral haemorrhage) whereglycosuria and albuminuria are found temporarily ac.

companied by visceral congestions. M. Redard, whileintern in the service of M. Ollivier, saw many cases ofcerebral haemorrhage where glycosuria and albuminuria hadexisted during life, associated with congested viscera.

Medical Societies.ROYAL MEDICAL & CHIRURGICAL SOCIETY.

Thyrotomy for Removal of Membrane Occluding Larynx.-Tracheotomy in Membranous Laryngitis.

THE ordinary meeting of this Society was held on the26th inst., Dr. Charles West, President, in the chair. Two

papers were read, one recounting the details of a case ofthyrotomy for the removal of a cicatricial membrane ob-literating the larynx, by Dr. Semon, and the other dealinggenerally with the subject of tracheotomy in membranouslaryngitis, by Mr. R. W. Parker, a paper which gave riseto an extended discussion, the meeting being prolonged forthe purpose. Mr. Parker especially urged careful localtreatment of the larynx and trachea during and after theoperation.The first paper read was that on a case of Thyrotomy for

the Removal of a Membrane completely Obliterating theLarynx, by Dr. FELIX SEMON. The patient had attemptedto cut his throat, and as the wound healed, it was found

necessary to perform tracheotomy. The voice graduallybecame diminished, and laryngoscopically a tough densemembrane was found occluding the larynx between the falsevocal cords, with evidence of anchylosis of the left arytenoidcartilage. The operation was undertaken to remove thismembrane, and was the third case on record in which

thyrotomy had been practised for such a purpose. A modi-fication of Trendlenberg’s tampon was employed to plug thetrachea. The author urged great caution in the administra-tion of chloroform through the tampon-cannula, the liabilityto asphyxia being greater than when inhaled in the ordinary