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A NOTE ON THE CHARACTER OF THE CEREBRAL CEREBRO-SPINAL FLUID IN A CASE OF GENERAL PARALYSIS.
275 abdomen
on
examination
were
normal, urine specific gravity two methods of active and passive congestion of the
limb are combined a summation effect is produced. The increased vascularity of the periphery of the limb following this operation is seen by the increased volume of the plantar, dorsalis pedis, and popliteal pulses, and the line of demarcation which rapidly forms at the advancing edge of the mojst gangrenous patch. This vascularisation of the part should go far in making possible more conservative treatment in the form of low amputations. Low amputations would seem to be preferable to non-operative measures, such as allowing the part slowly to slough off-because of the increased strain thrown upon the subject by the suppuration (lowering both the local and general resistance to the disease). Larger doses of insulin will be required to keep him sugar-free, and they may fail to control the sugar output altogether. Also from economic reasons the time factor is, in some cases, a not inconsiderable one, and convalescence is very much shortened by amputation.
sugar, albumin a trace. Treatment.-The foot was at once placed in a radiant heat bath, and insulin, units 20, was given. The subsequent clinical history of the case is very similar to that of the an operation preceding one. On the day following admission was performed on the left foot; the artery and vein were
1005, reaction acid,
exposed by a longitudinal incision over Hunter’s canal. A periarterial sympathectomy was performed with ligature of the femoral vein. Following the operation the dorsalis pedis, plantar, and popliteal pulses were all temporarily exaggerated in volume on the side operated upon, and a line of demarcation rapidly formed at the edge of the gangrenous area. On the tenth day after operation, at the man’s own request, in order that he could carry on with his business as soon as possible, an attempt was made to shorten the period of his stay jn hospital. A Syme’s amputation was performed. The wound healed by first intention, and the patient was discharged with a very good, clean, and serviceable stump 14 days later. The urine remained sugar-free with 10 units of insulin daily. Discussion.
Conclusion.
There is good reason to believe that this combined operation of ligature of the femoral vein with sympathectomy of the artery is an improvement on either of these measures used by itself. One has only to examine the hard, "gritty," calcareous walls of the blood-vessels in a case of diabetes of some years’ duration to realise that, even when denuded of all vaso-constrictor fibres, the power of dilatation of the vessel distal to the site of operation must of necessity be impaired, owing to the mechanical obstacle caused by the degeneration of muscular tissues. Vasodilatation does occur after this operation-of that there is not the least doubt-and a form of active congestion of the limb is thus produced. It is to this active congestion that the good effects of the treatment are attributed. Ligature of the vein produces a similar hyperaemia by passive congestion. When these
The method adopted in the treatment of diabetic gangrene as illustrated by two cases was briefly as follows : 1. A very short preliminary course of insulin with radiant heat was given, in order to render the patient more fit for the operation to follow. The This was followed by (2) early operation. operation of choice was a combined method of periarterial sympathectomy of the femoral artery in Hunter’s canal, with ligature of the femoral vein. This was thought to be preferable to either operation by itself, as the amount of hyperaemia produced, on which the success of the operation depends, was correspondingly greater. (3) After an interval of ten days or a fortnight, low amputation (a Syme’s) was performed in the second case as a time-saving measure to ensure more rapid convalescence.
I I
Clinical and
character when withdrawn by cisternal puncture is It is unlikely, however, that many common. have had an opportunity of examining the fluid in a case of syphilis of the nervous system, in the state in which it lies in the ventricles of the brain, and a recent experience in hospital practice may be of interest. The patient was infected about the age of 17. He began to develop signs of general paralysis early in 1927, at the age of 41, when he had been elsewhere under treatment for
Laboratory Notes.
fairly
A NOTE ON THE CHARACTER OF THE
CEREBRAL
CEREBRO-SPINAL
FLUID
IN A CASE OF GENERAL PARALYSIS.
BY
HILDRED
CARLILL, M.D. CAMB.,
PHYSICIAN TO WEST END HOSPITAL FOR NERVOUS
tabes
dorsalis, intravenous and oral, for four years. His and lumbar cerebro-spinal fluid had given completely positive tests for syphilis in 1923, and gave them again on
DISEASES;
serum
AND
W. E. CARNEGIE DICKSON, M.D., B.SC., F.R.C.P. EDIN.,
admission in 1927. Four combined treatments of salvarsan and salvarsanised serum were given ; on the three last I occasions the serum was run into the right and left cerebral lateral ventricles alternately through a needle passed a hole drilled in the skull.1 i
PATHOLOGIST TO THE HOSPITAL.
ithrough
KNOWLEDGE of the character of the cerebro-spinal fluid withdrawn by lumbar puncture, in health andI 1 Sir J. Purves-Stewart : THE LANCET, 1925, ii., 1159; Hildred Carlill: THE LANCET, 1926, ii., 1212. disease, is now almost universal. Knowledge of
itsI
Table of Results.
S. L., small lymphocytes. P. L., plasma cells. E. C., endothelial cells. P., polymorphs. The upper limit of inhibition of haemolysis was not tested in the first specimen of each. M.H.D. =minimum haemolytie dose of complement which hsemolyses 1 c.cm. 5 per cent. sensitised sheep’s red blood corpuscles. t Sugar was not tested for quantitatively, a 1 : 10 dilution of Fehling’s solution, with an equal amount of cerebro-spinal fluid, giving almost complete reduction, as in most normal cerebro-spinal fluids. *
276 We are not concerned here to defend or otherwise the rationale of treatment by salvarsanised serum. We merely wish to draw attention to the character of the ventricular, as compared with the lumbar, cerebro-spinal fluid ; they were withdrawn simultaneously except on the first of the three occasions. From the table of results given above it will be seen that the first specimens of ventricular and lumbar fluid were obtained on different dates. The results suggested that the investigation of fluids obtained simultaneously would be of considerable interest. A point of interest in connexion with the Wassermann reaction was that, with the ventricular fluids, the haemolysis tailed off over a considerable number of tubes-there was no free complement in the fluid itself-there being a trace of haemolysis even in the earlier tubes, whereas with the lumbar fluids the point between inhibition and haemolysis was sharply defined. Incidentally, in none of the fluids was any blood present, nor were spirochaetes detected in any of them. ,
FATAL
CASE
OF
By
A. H. D.
given, however, by those present was most suggestive. I was called to see him in the evening. He was in a deep stupor and could not be aroused. He did not recognise me. His extremities were again extremely cold and clammy but the pulse was good, regular in rate and rhythm, and about 100. He was retaining his feeds and the diarrhcea had much improved. In the early hours of the morning of July 17th his respirations became very rapid, and he rapidly went downhill and died.
FOOD
POISONING,
WITH DELAYED NERVOUS SYMPTOMS.
HON. SURGEON AND
and was unable to retain a mixture of bismuth salicylate. The diarrhoea had subsided to a large extent, but he was inclined to get out of bed and his mental state was not as alert as it had been previously. There was a suspicion of a slight delirium. He had also complained of dimness of vision and of transient diplopia and there had been a suspicion of slight ptosis. I now saw him again late on Friday, and suspected from these nervous symptoms that the infection had been by Bacillus botulinus. As, however, the onset of nervous symptoms had been so long delayed it was felt that the use of antitoxin was not likely to be of any value. A marked feature at this stage was the coldness and clamminess of his limbs in marked contrast to his pulse which was full and regular and about 90 in rate. Early on Saturday morning, July 16th, he had what his attendants thought was a convulsion. When seen by his doctor he was stuperose and not convulsed. The description
SMITH, M.C., M.B., CH.B. EDIN., RADIOLOGIST,
LLANELLY GENERAL HOSPITAL.
THE following are notes on a case of poisoning attributable to food. The patient, a commercial traveller, aged 53, was first seen by Dr. Hugh John, of Llangennech, on July 12th, 1927, about noon. He stated he had always enjoyed good health and gave the following history of his illness. On July 10th, while out camping with his wife and daughter and three friends, he had a meal about 8 P.M. and ate heartily of a veal and ham pie. All the other members of the party except his wife ate the pie, but his daughter ate only a very small portion. The daughter did no develop symptoms, but all the others, including the wife who did not eat the pie, developed gastro-enteritis. The food eaten by the party on the Sunday, with the exception of the pie, was prepared by the wife. At 2 A.M. on July llth one of his friends was taken ill with diarrhoea and vomiting ; another had similar symptoms at 8 A.M., and another at 2 P.M. His wife was taken ill on Tuesday ; her symptoms seem to have been mainly those of gastritis and she was up and about on Friday. The daughter ;’, did not develop symptoms. The patient left his home by the 9.10 train on the morning of July llth seemingly quite fit. He arrived at his destination at 10 P.M. and then complained of feeling unwell. His symptoms seem to have been at that time those of malaise, and he went to bed. In the early hours of the next morning he developed severe diarrhoea and vomiting and was seen by Dr. John about noon. At this time he complained of severe diarrhcea and vomiting and of thirst, On physical and gave the history already recorded. The pulse examination nothing untoward was found. was full and regular and the rate was under 100, the temperature was 102 ° F’. The motions were extremely frequent, greyish in colour, and watery in consistence, They contained no blood or slime. Vomiting and retching was very marked, and the vomit consisted of what he had just taken. Dr. John gave him a gr.pil. morph. and advised abstinence from all food, recommending the patient to take sips of water. The symptoms up to this time were those of a severe gastro-enteritis. The next day, July 13th, the gastro-enteritis was still very marked but the temperature had fallen to normal. On that night Dr. John asked me to see the case. At that time the patient complained of abdominal discomfort and of exhaustion and thirst. The vomiting and retching were still very severe and the movements of the bowel almost continuous. The temperature was normal and the pulserate about 90. The pulse was regular in rate and rhythm and surprisingly good for a patient who had had such severe symptoms and persistent dehydration. He was alert mentally and answered questions readily and clearly and at this time there was not the slightest suggestion of any involvement of the nervous system. He was unable to retain anything given by mouth so morphia, gr. , was given hypodermically, and those in charge of him were advised to give him brandy 3ss. in water every two hours and albumin water. By the morning of July 14th he had improved somewhat and by Friday, the 15th, he was able to keep his feeds down for a longer time. He still, however, suffered from retching
The interesting feature in this case is the delayed onset of recognisable nervous symptoms in contrast to a fairly rapid onset of classical symptoms of gastroenteritis. It was only after five days that evidence of involvement of the nervous system appeared. In view of the statement that antitoxin has definite value if injected within a few hours of the ingestion of contaminated food, antitoxin was not given. I now wonder whether antitoxin treatment might not have been advantageous even if given late on in the disease. A further interesting feature in this case was the regular and full pulse contrasting with the clamminess and coldness of the limbs so suggestive of collapse. The illness of his wife, who had not eaten the pie, is
peculiar.
-
TWO CASES OF
ACUTE HÆMORRHAGIC PANCREATITIS. BY J. D.
DHRUV, M.S. BOMBAY, F.R.C.S. ENG.,
SURGEON, JAMSETJI JIJJBHOY HOSPITAL, BOMBAY.
THE
following
cases
have
interesting
features.
CASE I.-A man, aged 45, complained of dull pain in the epigastrium for the previous four days. The severity of the pain had forced him to take to his bed on the last two days, and for three days there had been severe constipation. On examination there was marked tenderness and rigidity in the epigastrium. The tongue was moist and clean; the temperature was 101’F.. and the pulse-rate 120. As influenza was prevalent he was labelled " abdominal influenza." Next day the temperature was 102°, and the pulse-rate 110, but the patient said he was feeling better, though he looked anxious. On the seventh day the pulserate rose to 140 and the temperature to 104°. The pain became more severe and the patient died. At autopsy patches of fat necrosis were found in the omentum and areas of softening and necrosis in the pancreatic tissue. CASE 2.-A stout male, aged 40, for a week had continuous dull aching pain in the hollow of the stomach, not related to taking food, though it was worse between 3 and 5 P.M. It did not interfere with his sleep and for five days he continued to attend to his work. Then he took to his bed, and when I saw him seven days from the onset he was acutely ill and had an anxious look. There was rigidity and tenderness in the region of the stomach. On question he admitted that he had had a similar attack two years before, which had subsided after a week’s treatment in bed. Since then he had suffered off and on from flatulent dyspepsia. A tentative diagnosis of perforated gastric ulcer or acute cholecystitis was made. The patient’s friends refused to allow abdominal exploration, and he was kept under observation. He was placed in Fowler’s position, and the diet was restricted to small sips of water. An enema was given without result. The tongue was clean and moist. On the third day after admission he became worse; the temperature was 102F and the pulse-rate 120. In the evening, however, the bowels were opened spontaneously; he felt better ; the temperature fell to 985° and the pulse1 Price’s Text-book of the Practice of Medicine, p. 375.
on
examination
were
normal, urine specific gravity two methods of active and passive congestion of the
limb are combined a summation effect is produced. The increased vascularity of the periphery of the limb following this operation is seen by the increased volume of the plantar, dorsalis pedis, and popliteal pulses, and the line of demarcation which rapidly forms at the advancing edge of the mojst gangrenous patch. This vascularisation of the part should go far in making possible more conservative treatment in the form of low amputations. Low amputations would seem to be preferable to non-operative measures, such as allowing the part slowly to slough off-because of the increased strain thrown upon the subject by the suppuration (lowering both the local and general resistance to the disease). Larger doses of insulin will be required to keep him sugar-free, and they may fail to control the sugar output altogether. Also from economic reasons the time factor is, in some cases, a not inconsiderable one, and convalescence is very much shortened by amputation.
sugar, albumin a trace. Treatment.-The foot was at once placed in a radiant heat bath, and insulin, units 20, was given. The subsequent clinical history of the case is very similar to that of the an operation preceding one. On the day following admission was performed on the left foot; the artery and vein were
1005, reaction acid,
exposed by a longitudinal incision over Hunter’s canal. A periarterial sympathectomy was performed with ligature of the femoral vein. Following the operation the dorsalis pedis, plantar, and popliteal pulses were all temporarily exaggerated in volume on the side operated upon, and a line of demarcation rapidly formed at the edge of the gangrenous area. On the tenth day after operation, at the man’s own request, in order that he could carry on with his business as soon as possible, an attempt was made to shorten the period of his stay jn hospital. A Syme’s amputation was performed. The wound healed by first intention, and the patient was discharged with a very good, clean, and serviceable stump 14 days later. The urine remained sugar-free with 10 units of insulin daily. Discussion.
Conclusion.
There is good reason to believe that this combined operation of ligature of the femoral vein with sympathectomy of the artery is an improvement on either of these measures used by itself. One has only to examine the hard, "gritty," calcareous walls of the blood-vessels in a case of diabetes of some years’ duration to realise that, even when denuded of all vaso-constrictor fibres, the power of dilatation of the vessel distal to the site of operation must of necessity be impaired, owing to the mechanical obstacle caused by the degeneration of muscular tissues. Vasodilatation does occur after this operation-of that there is not the least doubt-and a form of active congestion of the limb is thus produced. It is to this active congestion that the good effects of the treatment are attributed. Ligature of the vein produces a similar hyperaemia by passive congestion. When these
The method adopted in the treatment of diabetic gangrene as illustrated by two cases was briefly as follows : 1. A very short preliminary course of insulin with radiant heat was given, in order to render the patient more fit for the operation to follow. The This was followed by (2) early operation. operation of choice was a combined method of periarterial sympathectomy of the femoral artery in Hunter’s canal, with ligature of the femoral vein. This was thought to be preferable to either operation by itself, as the amount of hyperaemia produced, on which the success of the operation depends, was correspondingly greater. (3) After an interval of ten days or a fortnight, low amputation (a Syme’s) was performed in the second case as a time-saving measure to ensure more rapid convalescence.
I I
Clinical and
character when withdrawn by cisternal puncture is It is unlikely, however, that many common. have had an opportunity of examining the fluid in a case of syphilis of the nervous system, in the state in which it lies in the ventricles of the brain, and a recent experience in hospital practice may be of interest. The patient was infected about the age of 17. He began to develop signs of general paralysis early in 1927, at the age of 41, when he had been elsewhere under treatment for
Laboratory Notes.
fairly
A NOTE ON THE CHARACTER OF THE
CEREBRAL
CEREBRO-SPINAL
FLUID
IN A CASE OF GENERAL PARALYSIS.
BY
HILDRED
CARLILL, M.D. CAMB.,
PHYSICIAN TO WEST END HOSPITAL FOR NERVOUS
tabes
dorsalis, intravenous and oral, for four years. His and lumbar cerebro-spinal fluid had given completely positive tests for syphilis in 1923, and gave them again on
DISEASES;
serum
AND
W. E. CARNEGIE DICKSON, M.D., B.SC., F.R.C.P. EDIN.,
admission in 1927. Four combined treatments of salvarsan and salvarsanised serum were given ; on the three last I occasions the serum was run into the right and left cerebral lateral ventricles alternately through a needle passed a hole drilled in the skull.1 i
PATHOLOGIST TO THE HOSPITAL.
ithrough
KNOWLEDGE of the character of the cerebro-spinal fluid withdrawn by lumbar puncture, in health andI 1 Sir J. Purves-Stewart : THE LANCET, 1925, ii., 1159; Hildred Carlill: THE LANCET, 1926, ii., 1212. disease, is now almost universal. Knowledge of
itsI
Table of Results.
S. L., small lymphocytes. P. L., plasma cells. E. C., endothelial cells. P., polymorphs. The upper limit of inhibition of haemolysis was not tested in the first specimen of each. M.H.D. =minimum haemolytie dose of complement which hsemolyses 1 c.cm. 5 per cent. sensitised sheep’s red blood corpuscles. t Sugar was not tested for quantitatively, a 1 : 10 dilution of Fehling’s solution, with an equal amount of cerebro-spinal fluid, giving almost complete reduction, as in most normal cerebro-spinal fluids. *
276 We are not concerned here to defend or otherwise the rationale of treatment by salvarsanised serum. We merely wish to draw attention to the character of the ventricular, as compared with the lumbar, cerebro-spinal fluid ; they were withdrawn simultaneously except on the first of the three occasions. From the table of results given above it will be seen that the first specimens of ventricular and lumbar fluid were obtained on different dates. The results suggested that the investigation of fluids obtained simultaneously would be of considerable interest. A point of interest in connexion with the Wassermann reaction was that, with the ventricular fluids, the haemolysis tailed off over a considerable number of tubes-there was no free complement in the fluid itself-there being a trace of haemolysis even in the earlier tubes, whereas with the lumbar fluids the point between inhibition and haemolysis was sharply defined. Incidentally, in none of the fluids was any blood present, nor were spirochaetes detected in any of them. ,
FATAL
CASE
OF
By
A. H. D.
given, however, by those present was most suggestive. I was called to see him in the evening. He was in a deep stupor and could not be aroused. He did not recognise me. His extremities were again extremely cold and clammy but the pulse was good, regular in rate and rhythm, and about 100. He was retaining his feeds and the diarrhcea had much improved. In the early hours of the morning of July 17th his respirations became very rapid, and he rapidly went downhill and died.
FOOD
POISONING,
WITH DELAYED NERVOUS SYMPTOMS.
HON. SURGEON AND
and was unable to retain a mixture of bismuth salicylate. The diarrhoea had subsided to a large extent, but he was inclined to get out of bed and his mental state was not as alert as it had been previously. There was a suspicion of a slight delirium. He had also complained of dimness of vision and of transient diplopia and there had been a suspicion of slight ptosis. I now saw him again late on Friday, and suspected from these nervous symptoms that the infection had been by Bacillus botulinus. As, however, the onset of nervous symptoms had been so long delayed it was felt that the use of antitoxin was not likely to be of any value. A marked feature at this stage was the coldness and clamminess of his limbs in marked contrast to his pulse which was full and regular and about 90 in rate. Early on Saturday morning, July 16th, he had what his attendants thought was a convulsion. When seen by his doctor he was stuperose and not convulsed. The description
SMITH, M.C., M.B., CH.B. EDIN., RADIOLOGIST,
LLANELLY GENERAL HOSPITAL.
THE following are notes on a case of poisoning attributable to food. The patient, a commercial traveller, aged 53, was first seen by Dr. Hugh John, of Llangennech, on July 12th, 1927, about noon. He stated he had always enjoyed good health and gave the following history of his illness. On July 10th, while out camping with his wife and daughter and three friends, he had a meal about 8 P.M. and ate heartily of a veal and ham pie. All the other members of the party except his wife ate the pie, but his daughter ate only a very small portion. The daughter did no develop symptoms, but all the others, including the wife who did not eat the pie, developed gastro-enteritis. The food eaten by the party on the Sunday, with the exception of the pie, was prepared by the wife. At 2 A.M. on July llth one of his friends was taken ill with diarrhoea and vomiting ; another had similar symptoms at 8 A.M., and another at 2 P.M. His wife was taken ill on Tuesday ; her symptoms seem to have been mainly those of gastritis and she was up and about on Friday. The daughter ;’, did not develop symptoms. The patient left his home by the 9.10 train on the morning of July llth seemingly quite fit. He arrived at his destination at 10 P.M. and then complained of feeling unwell. His symptoms seem to have been at that time those of malaise, and he went to bed. In the early hours of the next morning he developed severe diarrhoea and vomiting and was seen by Dr. John about noon. At this time he complained of severe diarrhcea and vomiting and of thirst, On physical and gave the history already recorded. The pulse examination nothing untoward was found. was full and regular and the rate was under 100, the temperature was 102 ° F’. The motions were extremely frequent, greyish in colour, and watery in consistence, They contained no blood or slime. Vomiting and retching was very marked, and the vomit consisted of what he had just taken. Dr. John gave him a gr.pil. morph. and advised abstinence from all food, recommending the patient to take sips of water. The symptoms up to this time were those of a severe gastro-enteritis. The next day, July 13th, the gastro-enteritis was still very marked but the temperature had fallen to normal. On that night Dr. John asked me to see the case. At that time the patient complained of abdominal discomfort and of exhaustion and thirst. The vomiting and retching were still very severe and the movements of the bowel almost continuous. The temperature was normal and the pulserate about 90. The pulse was regular in rate and rhythm and surprisingly good for a patient who had had such severe symptoms and persistent dehydration. He was alert mentally and answered questions readily and clearly and at this time there was not the slightest suggestion of any involvement of the nervous system. He was unable to retain anything given by mouth so morphia, gr. , was given hypodermically, and those in charge of him were advised to give him brandy 3ss. in water every two hours and albumin water. By the morning of July 14th he had improved somewhat and by Friday, the 15th, he was able to keep his feeds down for a longer time. He still, however, suffered from retching
The interesting feature in this case is the delayed onset of recognisable nervous symptoms in contrast to a fairly rapid onset of classical symptoms of gastroenteritis. It was only after five days that evidence of involvement of the nervous system appeared. In view of the statement that antitoxin has definite value if injected within a few hours of the ingestion of contaminated food, antitoxin was not given. I now wonder whether antitoxin treatment might not have been advantageous even if given late on in the disease. A further interesting feature in this case was the regular and full pulse contrasting with the clamminess and coldness of the limbs so suggestive of collapse. The illness of his wife, who had not eaten the pie, is
peculiar.
-
TWO CASES OF
ACUTE HÆMORRHAGIC PANCREATITIS. BY J. D.
DHRUV, M.S. BOMBAY, F.R.C.S. ENG.,
SURGEON, JAMSETJI JIJJBHOY HOSPITAL, BOMBAY.
THE
following
cases
have
interesting
features.
CASE I.-A man, aged 45, complained of dull pain in the epigastrium for the previous four days. The severity of the pain had forced him to take to his bed on the last two days, and for three days there had been severe constipation. On examination there was marked tenderness and rigidity in the epigastrium. The tongue was moist and clean; the temperature was 101’F.. and the pulse-rate 120. As influenza was prevalent he was labelled " abdominal influenza." Next day the temperature was 102°, and the pulse-rate 110, but the patient said he was feeling better, though he looked anxious. On the seventh day the pulserate rose to 140 and the temperature to 104°. The pain became more severe and the patient died. At autopsy patches of fat necrosis were found in the omentum and areas of softening and necrosis in the pancreatic tissue. CASE 2.-A stout male, aged 40, for a week had continuous dull aching pain in the hollow of the stomach, not related to taking food, though it was worse between 3 and 5 P.M. It did not interfere with his sleep and for five days he continued to attend to his work. Then he took to his bed, and when I saw him seven days from the onset he was acutely ill and had an anxious look. There was rigidity and tenderness in the region of the stomach. On question he admitted that he had had a similar attack two years before, which had subsided after a week’s treatment in bed. Since then he had suffered off and on from flatulent dyspepsia. A tentative diagnosis of perforated gastric ulcer or acute cholecystitis was made. The patient’s friends refused to allow abdominal exploration, and he was kept under observation. He was placed in Fowler’s position, and the diet was restricted to small sips of water. An enema was given without result. The tongue was clean and moist. On the third day after admission he became worse; the temperature was 102F and the pulse-rate 120. In the evening, however, the bowels were opened spontaneously; he felt better ; the temperature fell to 985° and the pulse1 Price’s Text-book of the Practice of Medicine, p. 375.