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A CASE FOR DIAGNOSIS.
1270 hours in a state of delirium tremens, but passing his urine freely. He remained in the hospital for ten days until this Keomplication was over, when he wa3 discharged, passing turine normally and able to introduce a full-sized bougie for
.himself. The third and last case I shall introduce was also recently .admitted into the Royal Infirmary. It was that of a man .ged thirty-two years, who had long suffered from stricture, and had undergone some operation for it in hospital "seven years previously. The meatus of the urethra was involved in a cicatricial mass connected with the foreskin, ;and in addition there was a long fibrous subpubic contraction. He had extreme retention of urine, which had evidently been only very partially relieved by the introduction of a small catheter prior to his admission. With much -difficulty, owing to the double nature of the obstruction, I .could only succeed in passing a No. 1 metal Lister’s bougie. This was most firmly grasped. Under an anaesthetic I .nanaged to introduce the entire series. The bladder was then emptied of much offensive urine by a large catheter. The stricture at the orifice was freely divided with a probepointed bistoury. This patient rapidly, and in the course of ten days, was able to leave the .’:passing a full-sized instrument. In connexion with these cases there are some details to ’which I could refer, as I am satisfied that much of the ’.success attending them, as well as of others of a like kind which have come under notice, is due to their recognition. ’Every care was taken to prevent the occurrence of any lorin of urethral septicaemia, as indicated by the occurrence wnf rigors and fever following the performance of the operation that was selected. This consisted in the employment f local and general measures. As soon as the bladder was .-emptied with a large catheter, it was thoroughly washed ’out with a perchloride solution of 1 in 5000; three or four ’ounces of this fluid were left behind, so that the first urine - which, was spontaneously passed was largely impregnated "with this antiseptic. As a rule, no catheter is tied in, nor can I remember an instance where its subsequent introduction became necessary. Before the patient is ’sent to bed the urethra is distended with carbolic oil 1 in 20), which is well rubbed into the part where section or divulsion may have taken place. Five-grain doses of are given every four hours; in some instances boracic acid appears to have answered equally well. They seem, by sterilising the urine, to prevent Tigors and fever. For rapidly dilating very fine tight strictures, I have found Banks’s filiform bougie of great service. It is an instrument that is well known in America, but not in this
A CASE FOR DIAGNOSIS. BY FRED. J.
SMITH, M.B., M.R.C.P.,
MEDICAL REGISTRAR TO THE LONDON HOSPITAL.
By the kind permission of Dr. Warner, under whose care the patient was in hospital, and with the ready assistance of Mr. H. A. Debenham, the house physician, I am enabled to publish the following case, which I watched with the greatest interest, not unmixed with stronger feelings of
baffled
curiosity.
L. W-, aged twenty-three, a female fancy worker, was admitted to the London Hospital complaining of a dull pain in the back and abdomen. The family history was without bearing on the case, except that the father was said to have died from a tumour of the lungs. The personal history showed an entire absence of any previous illness of sufficient severity to cause her to lie up. The history of her present illness was that the pain began somewhat suddenly in the lumbar region about three weeks only before admission, and was of such severity as to cause her to faint; for this she was treated by a general practitioner. On admission the patient was seen to be a well-nourished girl; slightly ansemic; very restless in bed; complaining of severe appeared to shift from place to place, at one time in the middle of the back, and again appearingat the being of the abdomen; it was increased by lying on either side, and bv sitting or standing; the pain was of a throbbing character, likened by the patient to a "gathering."General superficial examination and palpation revealed absolutely nothing to account for the pain. An examination of the alimentary tract showed some slight digestive disturbance, with a furred tongue, discomfort after eating, with slight nausea and obstinate constipation. The heart and lungs yielded entirely negative results on examination, except for occasional dyspncea and slight pain on taking a deep breath. The patient was treated with a saline mixture, and morphia was administered hypodermically. For the next fortnight no change took place practically in her condition; the pains were occasionally a little easier, but generally got much worse at night. On May 25th a thorough vaginal examination was made by the assistant obstetric physician, who reported that the uterus was freely movable, and, in fact, that there was no abnormal or pathological condition to be detected, either per vaginam or on bimanual abdominovaginal examination; but, at the same time, he advised that a surgical opinion should be obtained as to the condition of the spire, inasmuch as the patient seemed to refer country. It is made of highly polished whalebone, on the the pain pretty consistently to that region. For some days - principle of the wedge, and can be used with great safety. after this she seemed and expressed herself as being much When completely passed through the stricture, a much better, though the notes state that she was very hysterical. ’’larger - sized ordinary catheter or bougie can usually OnJune5th the patient was again most thoroughly overhauled be made to follow easily. These instruments, of which in an attempt to arrive at some definite grounds on which to there are several sizes, have been supplied to me by Messrs. base a diagnosis. The reflexes appeared entirely normal ; the 1 iemann of New York. bladder and rectum were performing their functions in a perIt is not to be assumed that the treatment this fectly healthy manner ; passive movements of all kinds were ’
infirmary
convalesced
pain, sides which
quinine
mtty
1271 tines were full of scybala. There was no spinal meningitis, -] DISLOCATION OF THE FINGERS and the base of the skull was not affected. No deposits of BACKWARD the growth (which, on microscopical examination, was UPON THE METACARPUS. evidently sarcomatous) could be found in any visceral organ. BY WILLIAM H. BATTLE, F.R.C.S., Re7narh;s.-Cases presenting such diagnostic difficulties ASSISTANT SURGEON TO THE ROYAL FREE HOSPITAL AND TO THE must be, I think, always worthy of publication, if it were EAST LONDON HOSPITAL FOR CHILDREN. only to give isolated practitioners the comfort of knowing of is not that the collective acumen (Concluded from p. 1224.) hospital teachers always equal to finding the clue to obscure symptoms. The diagnosis of hysteria was based chiefly on the following As I have already mentioned, much attention has bees grounds. First, and perhaps foremost, the absolute failure in the past to dislocations of the first phalanx of J of the most thorough examination to detect by physicalgiven examination any morbid changes which could give rise to 1the thumb on account of the diniculiy so frequently met the pain complained of. Secondly, the manners and general with in the reduction of the backward dislocation of that, behaviour of the patient, which, though difficult to describe, bone, the reasons for which vary according to different. were precisely those usually ascribed to hysterical females. authors. I do not, however, propose to enter fully into a Thirdly, the great inconsistency in the patient’s answers as ’consideration of the arguments for and against them these, of the would one day say that to the seat pain ; e.g., she and the on the subject voluminous.’ of the in literature caused the cervical being many spine pain region percussion only, and next day, while this region was free from pain, As they have received so much consideration at the hands she would complain of the slightest touch in the dorsal of surgeons, it may be as well to briefly enumerate them in region. On the other hand, the persistent dyspeptic sym- order to see if there are any likely to cause a similar diffiptoms (of which the exceedingly obstinate constipation was culty in the case of the other metacarpo-phalangeal joints. a very marked feature), the extreme severity of the alleged In England the action of the two heads of the flexor brevis the sometimes to scream and shout pain (causing patient all night), and the progressive loss of flesh and strength pollicis in their altered relationship to the head ’of thue were certainly suggestive of some gross anatomical lesion. metacarpal bone, which they embrace as a button.hole the After weighing these considerations, it has to be button, has received and still receives the commonest admitted that no less than four physicians of recoacceptance as the cause for difficulty in reduction, the bone gnised position and ability, after a most thorough being said to tear its way through the fibrous tissue uniting examination, entirely failed to diagnose the case. the two heads of the muscle and remain fixed in its new The nervous system of the patient was examined frei position.2 Other causes may be constriction of the neck 9i£ quently, and, though found normal in most respects, the the bone between the lateral ligaments of the joint3 (the examination revealed an interesting condition of the writer in Heath’s Dictionary says they are nearly always patellar reflexes ; these were at first considerably exag- ruptured). Folding in of the anterior ligament of the joint.. gerated on either side, but about six weeks before death the and the interposition of a sesamoid bone has also been sugleft disappeared entirely, the right disappearing about a gested4 and this view has numerous supporters.5 Farabeuf, month later. on reviewing the case, This, very in his paper on backward displacement of the thumb, says: : depended on implication of the efferent nerves in the pelvic " La phalange n’est rien; les os sesamoides sont tout." Sir, cavity, though during life it was looked upon as supporting Astley Cooper ascribed it to the contraction of the six . a possible diagnosis of spinal meningitis which was at one muscles inserted into the phalanges of the thumb. The time thought of, though afterwards entirely abandoned. long flexor tendon was found causing the difficulty in reThe temperature was somewhat irregular, occasionally position by Lisfranc, Esmarch, Deville, Wadsworth, and rising to 102° and sometimes to 103°, while the evening Bryant. Others may be mentioned : the cuneiform or ( temperature was usually 100° or a little more. The chart is clubbed head of the metacarpal bone;6 the interposition of of course not by any means typical of any disease, and the sesamoid bones ;7 the constriction of the metacarpal might easily enough be read as that of a hysterical case; bone by the boundaries of the button-hole slit ;8 and the but it certainly acquires great interest when looked at from of applying sufficient force to the thumb;9’ the point of view of the post-mortem evidence, as it is an difficulty These numerous suggested conditions, to one or more of illustration of one side of a fact that must be recognised- which the difficulty in reducing these dislocations has been viz., that in suppurative diseases the temperature may be ascribed, indicate the rare opportunities afforded for fullynormal, and that in malignant disease it may be raised. investigating cases, it being very unusual for a patient toDuring the patient’s stay in hospital it was stated that two die whilst suffering from this injury. They also express months or so before the pain came on she was thrown across wide divergence of opinion as to the real obstacle or a bedstead and injured in the back. After-events lend con- obstacles those who have given to them serious siderable interest to this fact, but at the time it was deemed attention. amongst Those who have had opportunity of examining of little importance, as, in the first place, its actual occur- the exact pathology of the displacement after arthrotomy, rence seemed almost doubtful; and, secondly, the patient’s in unreduced dislocations found in the post-mortem room, statements as to the transitory effects of the accident were or in dislocations produced in the cadaver, lay great stress such as to entirely remove any suspicions that might have on the resistance ot the anterior ligament to the reduction, arisen that it was the cause of the pain. It is now, how- and there is no doubt that in a large majority of instances. ever, well known that bruises can in some way so affect the this, with its contained sesamoid bones, is the offending tissues that at the spot bruised a sarcoma begins, piobably structure. As long ago as 1837, Mr. J. Adair Laurie, due either to a morbid development of the fixed tissue cells on the subject,lO said that " the anterior ligament writing or to the activity of an included fcetal remnant on Cohnis completely torn from the metacarpal bone, and remainsheirn’s theory; and we must, I think, conclude that with attached to the and sesamoid bones in such a her accident she received what was practically her death manner that the phalanx torn ligament and sesamoid bones are blow. One question arises which is of the greatest interest. carried backwards by the phalanx and placed between Was the case distinctly organic from the commencement, or it and the bone. This state of parts is metacarpal could it be an illustration of hysteria or functional disturband rendered permanent by the contraction, aggravated ance running on in the course of time into organic mischief? of the muscles attached to the sesamoid bones and anterior I have seen in consultation one or two cases of the latter ligament, which muscles, together with the tendon of the" sequence of events, in which the after-history has been 1 See also reported to me as death from malignant trouble ; but Kelley, Dublin Journal of Med. Science, May, 1883. 2 The more probable explanation (Erichsen). Generally accepted the course and symptoms of those illnesses could hardly "Dictionary of Practical Surgery," vol. i., p. 674). Confirmed be said to be comparable with this one, and I think the (Heath’s by observations of Vidal, Malgaigne, Ballinghall (Gant, "Science and question must be left still undecided. Practice of Surgery "), and by Fabbri and Hamilton (Heath, op. cit.). failure of division of the short flexor (to ensure reducWest-street, Finsbury-circus. ’ The occasional tion), due to a difficulty in dividing all the opposing fibres (Holmes, of Surgery," vol. i., p. 988). S1LA..LL-POX IN DUNDEE.-Cases of small-pox are " 3System 4 See Erichsen, vol. i. p. 589. Dupuytren, Erichsen, Gant. Hey, 5 Pailloux, Deville, Wadsworth said to have been imported into this city by the arrival of (Gant), Michel, Laurie, Roser, B. vessels from Oran, in Algeria, where the disease is prevalent. Anger (Heath), Hueter, Michel, Leva, Blechy, Farabeuf, Polaillon, Keetley, Walsham, Bryant, and Druitt. A ship’s mate has died in the Dundee Hospital, and several Jalaguier, 6 7 8 Waitz. 9 Liston. Hey, Syine. Humphry. 10 London Medical sufferers are under treatment. Gazette, voL L, p. 95. I
all
=
likely,
.himself. The third and last case I shall introduce was also recently .admitted into the Royal Infirmary. It was that of a man .ged thirty-two years, who had long suffered from stricture, and had undergone some operation for it in hospital "seven years previously. The meatus of the urethra was involved in a cicatricial mass connected with the foreskin, ;and in addition there was a long fibrous subpubic contraction. He had extreme retention of urine, which had evidently been only very partially relieved by the introduction of a small catheter prior to his admission. With much -difficulty, owing to the double nature of the obstruction, I .could only succeed in passing a No. 1 metal Lister’s bougie. This was most firmly grasped. Under an anaesthetic I .nanaged to introduce the entire series. The bladder was then emptied of much offensive urine by a large catheter. The stricture at the orifice was freely divided with a probepointed bistoury. This patient rapidly, and in the course of ten days, was able to leave the .’:passing a full-sized instrument. In connexion with these cases there are some details to ’which I could refer, as I am satisfied that much of the ’.success attending them, as well as of others of a like kind which have come under notice, is due to their recognition. ’Every care was taken to prevent the occurrence of any lorin of urethral septicaemia, as indicated by the occurrence wnf rigors and fever following the performance of the operation that was selected. This consisted in the employment f local and general measures. As soon as the bladder was .-emptied with a large catheter, it was thoroughly washed ’out with a perchloride solution of 1 in 5000; three or four ’ounces of this fluid were left behind, so that the first urine - which, was spontaneously passed was largely impregnated "with this antiseptic. As a rule, no catheter is tied in, nor can I remember an instance where its subsequent introduction became necessary. Before the patient is ’sent to bed the urethra is distended with carbolic oil 1 in 20), which is well rubbed into the part where section or divulsion may have taken place. Five-grain doses of are given every four hours; in some instances boracic acid appears to have answered equally well. They seem, by sterilising the urine, to prevent Tigors and fever. For rapidly dilating very fine tight strictures, I have found Banks’s filiform bougie of great service. It is an instrument that is well known in America, but not in this
A CASE FOR DIAGNOSIS. BY FRED. J.
SMITH, M.B., M.R.C.P.,
MEDICAL REGISTRAR TO THE LONDON HOSPITAL.
By the kind permission of Dr. Warner, under whose care the patient was in hospital, and with the ready assistance of Mr. H. A. Debenham, the house physician, I am enabled to publish the following case, which I watched with the greatest interest, not unmixed with stronger feelings of
baffled
curiosity.
L. W-, aged twenty-three, a female fancy worker, was admitted to the London Hospital complaining of a dull pain in the back and abdomen. The family history was without bearing on the case, except that the father was said to have died from a tumour of the lungs. The personal history showed an entire absence of any previous illness of sufficient severity to cause her to lie up. The history of her present illness was that the pain began somewhat suddenly in the lumbar region about three weeks only before admission, and was of such severity as to cause her to faint; for this she was treated by a general practitioner. On admission the patient was seen to be a well-nourished girl; slightly ansemic; very restless in bed; complaining of severe appeared to shift from place to place, at one time in the middle of the back, and again appearingat the being of the abdomen; it was increased by lying on either side, and bv sitting or standing; the pain was of a throbbing character, likened by the patient to a "gathering."General superficial examination and palpation revealed absolutely nothing to account for the pain. An examination of the alimentary tract showed some slight digestive disturbance, with a furred tongue, discomfort after eating, with slight nausea and obstinate constipation. The heart and lungs yielded entirely negative results on examination, except for occasional dyspncea and slight pain on taking a deep breath. The patient was treated with a saline mixture, and morphia was administered hypodermically. For the next fortnight no change took place practically in her condition; the pains were occasionally a little easier, but generally got much worse at night. On May 25th a thorough vaginal examination was made by the assistant obstetric physician, who reported that the uterus was freely movable, and, in fact, that there was no abnormal or pathological condition to be detected, either per vaginam or on bimanual abdominovaginal examination; but, at the same time, he advised that a surgical opinion should be obtained as to the condition of the spire, inasmuch as the patient seemed to refer country. It is made of highly polished whalebone, on the the pain pretty consistently to that region. For some days - principle of the wedge, and can be used with great safety. after this she seemed and expressed herself as being much When completely passed through the stricture, a much better, though the notes state that she was very hysterical. ’’larger - sized ordinary catheter or bougie can usually OnJune5th the patient was again most thoroughly overhauled be made to follow easily. These instruments, of which in an attempt to arrive at some definite grounds on which to there are several sizes, have been supplied to me by Messrs. base a diagnosis. The reflexes appeared entirely normal ; the 1 iemann of New York. bladder and rectum were performing their functions in a perIt is not to be assumed that the treatment this fectly healthy manner ; passive movements of all kinds were ’
infirmary
convalesced
pain, sides which
quinine
mtty
1271 tines were full of scybala. There was no spinal meningitis, -] DISLOCATION OF THE FINGERS and the base of the skull was not affected. No deposits of BACKWARD the growth (which, on microscopical examination, was UPON THE METACARPUS. evidently sarcomatous) could be found in any visceral organ. BY WILLIAM H. BATTLE, F.R.C.S., Re7narh;s.-Cases presenting such diagnostic difficulties ASSISTANT SURGEON TO THE ROYAL FREE HOSPITAL AND TO THE must be, I think, always worthy of publication, if it were EAST LONDON HOSPITAL FOR CHILDREN. only to give isolated practitioners the comfort of knowing of is not that the collective acumen (Concluded from p. 1224.) hospital teachers always equal to finding the clue to obscure symptoms. The diagnosis of hysteria was based chiefly on the following As I have already mentioned, much attention has bees grounds. First, and perhaps foremost, the absolute failure in the past to dislocations of the first phalanx of J of the most thorough examination to detect by physicalgiven examination any morbid changes which could give rise to 1the thumb on account of the diniculiy so frequently met the pain complained of. Secondly, the manners and general with in the reduction of the backward dislocation of that, behaviour of the patient, which, though difficult to describe, bone, the reasons for which vary according to different. were precisely those usually ascribed to hysterical females. authors. I do not, however, propose to enter fully into a Thirdly, the great inconsistency in the patient’s answers as ’consideration of the arguments for and against them these, of the would one day say that to the seat pain ; e.g., she and the on the subject voluminous.’ of the in literature caused the cervical being many spine pain region percussion only, and next day, while this region was free from pain, As they have received so much consideration at the hands she would complain of the slightest touch in the dorsal of surgeons, it may be as well to briefly enumerate them in region. On the other hand, the persistent dyspeptic sym- order to see if there are any likely to cause a similar diffiptoms (of which the exceedingly obstinate constipation was culty in the case of the other metacarpo-phalangeal joints. a very marked feature), the extreme severity of the alleged In England the action of the two heads of the flexor brevis the sometimes to scream and shout pain (causing patient all night), and the progressive loss of flesh and strength pollicis in their altered relationship to the head ’of thue were certainly suggestive of some gross anatomical lesion. metacarpal bone, which they embrace as a button.hole the After weighing these considerations, it has to be button, has received and still receives the commonest admitted that no less than four physicians of recoacceptance as the cause for difficulty in reduction, the bone gnised position and ability, after a most thorough being said to tear its way through the fibrous tissue uniting examination, entirely failed to diagnose the case. the two heads of the muscle and remain fixed in its new The nervous system of the patient was examined frei position.2 Other causes may be constriction of the neck 9i£ quently, and, though found normal in most respects, the the bone between the lateral ligaments of the joint3 (the examination revealed an interesting condition of the writer in Heath’s Dictionary says they are nearly always patellar reflexes ; these were at first considerably exag- ruptured). Folding in of the anterior ligament of the joint.. gerated on either side, but about six weeks before death the and the interposition of a sesamoid bone has also been sugleft disappeared entirely, the right disappearing about a gested4 and this view has numerous supporters.5 Farabeuf, month later. on reviewing the case, This, very in his paper on backward displacement of the thumb, says: : depended on implication of the efferent nerves in the pelvic " La phalange n’est rien; les os sesamoides sont tout." Sir, cavity, though during life it was looked upon as supporting Astley Cooper ascribed it to the contraction of the six . a possible diagnosis of spinal meningitis which was at one muscles inserted into the phalanges of the thumb. The time thought of, though afterwards entirely abandoned. long flexor tendon was found causing the difficulty in reThe temperature was somewhat irregular, occasionally position by Lisfranc, Esmarch, Deville, Wadsworth, and rising to 102° and sometimes to 103°, while the evening Bryant. Others may be mentioned : the cuneiform or ( temperature was usually 100° or a little more. The chart is clubbed head of the metacarpal bone;6 the interposition of of course not by any means typical of any disease, and the sesamoid bones ;7 the constriction of the metacarpal might easily enough be read as that of a hysterical case; bone by the boundaries of the button-hole slit ;8 and the but it certainly acquires great interest when looked at from of applying sufficient force to the thumb;9’ the point of view of the post-mortem evidence, as it is an difficulty These numerous suggested conditions, to one or more of illustration of one side of a fact that must be recognised- which the difficulty in reducing these dislocations has been viz., that in suppurative diseases the temperature may be ascribed, indicate the rare opportunities afforded for fullynormal, and that in malignant disease it may be raised. investigating cases, it being very unusual for a patient toDuring the patient’s stay in hospital it was stated that two die whilst suffering from this injury. They also express months or so before the pain came on she was thrown across wide divergence of opinion as to the real obstacle or a bedstead and injured in the back. After-events lend con- obstacles those who have given to them serious siderable interest to this fact, but at the time it was deemed attention. amongst Those who have had opportunity of examining of little importance, as, in the first place, its actual occur- the exact pathology of the displacement after arthrotomy, rence seemed almost doubtful; and, secondly, the patient’s in unreduced dislocations found in the post-mortem room, statements as to the transitory effects of the accident were or in dislocations produced in the cadaver, lay great stress such as to entirely remove any suspicions that might have on the resistance ot the anterior ligament to the reduction, arisen that it was the cause of the pain. It is now, how- and there is no doubt that in a large majority of instances. ever, well known that bruises can in some way so affect the this, with its contained sesamoid bones, is the offending tissues that at the spot bruised a sarcoma begins, piobably structure. As long ago as 1837, Mr. J. Adair Laurie, due either to a morbid development of the fixed tissue cells on the subject,lO said that " the anterior ligament writing or to the activity of an included fcetal remnant on Cohnis completely torn from the metacarpal bone, and remainsheirn’s theory; and we must, I think, conclude that with attached to the and sesamoid bones in such a her accident she received what was practically her death manner that the phalanx torn ligament and sesamoid bones are blow. One question arises which is of the greatest interest. carried backwards by the phalanx and placed between Was the case distinctly organic from the commencement, or it and the bone. This state of parts is metacarpal could it be an illustration of hysteria or functional disturband rendered permanent by the contraction, aggravated ance running on in the course of time into organic mischief? of the muscles attached to the sesamoid bones and anterior I have seen in consultation one or two cases of the latter ligament, which muscles, together with the tendon of the" sequence of events, in which the after-history has been 1 See also reported to me as death from malignant trouble ; but Kelley, Dublin Journal of Med. Science, May, 1883. 2 The more probable explanation (Erichsen). Generally accepted the course and symptoms of those illnesses could hardly "Dictionary of Practical Surgery," vol. i., p. 674). Confirmed be said to be comparable with this one, and I think the (Heath’s by observations of Vidal, Malgaigne, Ballinghall (Gant, "Science and question must be left still undecided. Practice of Surgery "), and by Fabbri and Hamilton (Heath, op. cit.). failure of division of the short flexor (to ensure reducWest-street, Finsbury-circus. ’ The occasional tion), due to a difficulty in dividing all the opposing fibres (Holmes, of Surgery," vol. i., p. 988). S1LA..LL-POX IN DUNDEE.-Cases of small-pox are " 3System 4 See Erichsen, vol. i. p. 589. Dupuytren, Erichsen, Gant. Hey, 5 Pailloux, Deville, Wadsworth said to have been imported into this city by the arrival of (Gant), Michel, Laurie, Roser, B. vessels from Oran, in Algeria, where the disease is prevalent. Anger (Heath), Hueter, Michel, Leva, Blechy, Farabeuf, Polaillon, Keetley, Walsham, Bryant, and Druitt. A ship’s mate has died in the Dundee Hospital, and several Jalaguier, 6 7 8 Waitz. 9 Liston. Hey, Syine. Humphry. 10 London Medical sufferers are under treatment. Gazette, voL L, p. 95. I
all
=
likely,