14

temperature was quite normal. He remained in hospital fornearly three weeks, and with careful dieting and completerest, the urgent symptoms above-mentioned abated, thetumour became less apparent, the urine regained its naturalappearance, and the mucus disappeared. He went out athis own request on September 23rd to attend once a weekas an out patient. He was readmitted on Nov. 15th, 1882.Although the vomiting had not returned, and the pain wasmuch less, the tumour had increased in size and had ex-tended a couple of inches below the umbilicus. Its con-nexions were still a mystery, and even under ether nothingfurther was made out. While under the influence of theanaesthetic the long fine needle of a small syringe wasplunged to a depth of about three inches into the tumour,and about a drachm of dark-brownish viscid fluid withdrawn.This fluid was highly albuminous, but gave no reactionswith any of the usual tests for bile; microscopically itshowed large numbers of broken-down blood-cells, granulesof colouring matter, and some larger and more perfectnucleated cells of an epithelial type, but the most carefulsearch failed to reveal anything in the shape of a hooklet.On November 30th the tumour was aspirated at a point

about three inches above the umbilicus, and thirty-twoounces of a fluid exactly similar to that described abovewere withdrawn; viewed en masse, it had a greenish tinge.Great relief followed the operation, and the tumour becameless prominent and tense, although it by no means entirelydisappeared.On December 13tb, as the tumour had nearly regained its

former dimensions, it was again aspirated an inch below theseat of the former operation, and fifty-one ounces of thesame dark-coloured fluid were withdrawn. After this secondoperation it was noticed that the right side of the tumourhad diminished to a much greater extent than the left;so on the 16th another aspiration was performed, thepoint selected being about an inch and a half to the left ofthe second puncture. Thirty-two ounces of fluid were with-drawn, resembling in all respects that previously obtained.Immediately after the third aspiration the tumour collapsed,and could only be made out as an indefinite feeling of re-sistance on deep pressure in the epigastric region, as it didnot subsequently increase in size, and the patient’s generalhealth was greatly improved. He was discharged on

Dec. 26th. 1882.After his discharge he was seen at irregular intervals as an

out-patient, and up to the beginning of March of the presentyear remained free from pain and vomiting, the tumourgradually reappearing. About the 14th of that month hehad a sudden and severe attack of abdominal pain andvomiting; this was followed by diarrhoea, the motions beingquite black and loose. From that date, the patient said,the tumour has entirely disappeared, and when seen onMay llth there were certainly no signs of anything likea tumour to be made out in any part of the abdomen ;and, except for an occasional feeling of biliousness, hesays that he has been perfectly well ever since March.Remarks.-The cyst in this case seems to have been com-

posed of at least two cavities, probably communicating, butnot freely. The sudden disappearance of the tumour, as ifby communication with the bowel, is remarkable; andalthough one can hardly expect that this disappearance willbe permanent, still, from the fact that the tumour is now,after the lapse of two months, quite imperceptible, one isalmost led to hope that such may be the case. In everyother respect it resembles closely the first of the cases citedby Dr. Briatowe in his "Clinical Remarks on AbdominalSanguineous Cysts," reported in THE LANCET of May 5th.The case cannot be said to be complete ; and the subsequent history of the patient will, as far as possible, be carefullywatched ; but even in its present incomplete form it presentsso many points of interest that it is not, perhaps, unworthyof record.

____________

ST. VINCENT’S HOSPITAL, DUBLIN.A FATAL CASE OF UNCOMPLICATED ACUTE RHEUMATISM ;

REMARKS.

(Under the care of Dr. QUINLAN.)

FOR the following notes we are indebted to Mr. Kenna,house-surgeon :-Kate C-, aged twenty-two, single, of delicate appear-

ance, was admitted on Friday, May llth, suffering fromacute articular rheumatism. She had been ailing for seven

)r days; no previous attack. Both wrists, both elbows, andte the left knee were swollen and immovable, and very pain’

ful ; tongue yellowish white; copious acid perspiration; n(]

cardiac lesion ; no subcutaneous nodules. Temperaturett 103 .8° F. ; pulse 120. Ordered fifty-grain doses of salicin ink milk, commencing at noon; alsoaquarterof agrainof morphia,2. hypodermically. At 6.30 P.M. she had taken six doses ;s the pain of joints was not so severe; temperature 100.8° ;L- pulse 112. Ordered the salicin every second hour if noti- asleep.g May 12th, 9.30 A.M.: Articular pain completely gone;e slept a few hours during the day ; temperature 100 ’5°;6s pulse 120. Ordered sixty grains of salicin every second hourr, until evening. 6.30 P.M.: A little articular pain; tempera-

ture 101°; pulse 120; the patient restless. Ordered as sleeping draught containing chloral and bromide of potas-it sium. To continue the salicin every second hour.-13th,s 9.30 A.M. : Slept well during the night ; articular pain gone;;t heart normal; temperature 1006°; pulse 128. To continuel salicin.-14th, 9.30 A.M.: Slept without a draught; free

from pain ; heart normal; she is, however, feverish and un-t comfortable ; intellect quite clear ; temperature 100°;o pulse 116. To continue salicin. 6.30 P.M.: Temperaturee 102 8°; pulse 112. At 11.30 P.M. the patient suddenly!. became delirious and violent. The temperature rose verye much; but, as she had to be kept in her bed by the efforts ofy three persons, it could not be exactly ascertained. She died

about a minute before midnight.s Remarks by Dr. QUINLAN.—Having recently put forthe some very successful cases of acute rheumatism treated bye large and frequent doses of salicin, I feel it incumbent toi publish this, the first of a large ’number of them in whichr the result was unfavourable. The very high admission; temperature, and the frequent temperature exacerbations,e marked this case from the beginning as one of those virulentf ones that used to be the dread of physicians and an oppro-- brium to medicine. I am almost inclined to regret that,. with this knowledge before me, I did not begin with sixty-, grain hourly doses, and adhere to them until the tempera-- ture was decisively lowered and the disease evidently sub-1 dued. Probably, however, in so virulent a case the result1 might have been the same. It is remarkable that, althoughi the temperature heightened again and again, the influence of

the drug in relieving the articular pain was immediate andi complete. Something also might have been done by blister-t ing the epigastrium, a procedure which often does good inr severe cases, and that quite irrespective of cardiac complica-; tion. The fatal issue does not in the least shake my con-L fidence in salicin. It shows, however, that we have some-; thing yet to learn about the exact method of using it, and, that we do not yet always administer it with sufficient

boldness.

Medical Societies.EPIDEMIOLOGICAL SOCIETY.

Outbreak of Cholera in Egypt.AT a meeting of the above Society on Wednesday, July

4th, Dr. J. M. Caningham, Sanitary Commissioner withthe Government of India, read a paper on the " SanitaryLessons of Indian Epidemics." The President of the Society,Dr. George Buchanan, F.R.S., introduced the subject by thefollowing memoranda concerning cholera :-

’ 1. Narrative.-Cholera reached Europe by way of Egyptfor the first time in 1865. Before that date, its course fromAsia had been through the Russian Empire. At the firstappearance of cholera in Europe, over forty years ago, itbegan in Great Britain fifteen months after its introductionto Europe. At its second appearance, it began with us inEngland after about the same interval. Its third appear-ance does not admit of comparison with the others. At thefourth appearance of cholera in Europe, when it came by wayof Egypt, it was epidemic in the Hedjaz in May; it appearedat Alexandria on June 2nd ; was at Malta, Smyrna, andConstantinople before the end of that month; and appearedin Spain and Italy and at Marseilles during July.Spreading somewhat widely in Europe during the nexttwo months, it was at Southampton on September 17th,and on Nov. 3rd it was witnessed at New York. In the

15

spring of 1866, cholera acquired an increased diffusiveness ;and by June had attacked many places in the UnitedKingdom, but hardly any cases occurred in London untilJuly. [The Suez Canal was opened in November, 1869.]Extension of cholera from Northern Arabia was next

threatened in 1871 ; and the disease prevailed to a smallextent in Europe during 1872 and 1873. Since that date, ithas occurred several times among the pilgrims to the Holyplaces, but has not established itself in Egypt, nor has itprevailed in Europe. Cholera is now at Damietta, a placewith some 30,000 inhabitants, about six miles from themouth of one of the branches of the Nile. The way of itsarrival thither cannot be stated. Damietta is not on anyhigh road from Asia ; and the towns above Damietta on theNde are not known to have been affected before this town.No cholera is known of at Suez, nor in the course of theCanal, though from Port Said an occasional death is nowbeing reported. In the ten days ending last Saturday, about500 deaths from cholera occurred at Damietta ; on July lstthere were 140; on the 2nd, 130; and on the 3rd, yesterday,there were 110 deaths. The disease now exists at Mansourah,higher up the same branch of the Nile, and cases are appearingin other towns situated on the railwavs of the Delta.

2. Expctatid;:=’ijh,- I have been asked, may cholera’be expected to travel through Europe to England ? how longafter its present manifestations in Egypt ? Evidently nomedical data exist for an answer to the question. We doact understand all the conditions for the diffusion of thedisease. But we in England do firmly believe, what manyof our Indian friends would deny, that cholera is influencedin its spread by human intercourse. We do not affirm thatit passes from person to person as small-pox or typhus does ;but we believe that it extends much after the fashion withwhich we are familiar in the case of enteric fever, by meansof the discharges from the sick, particularly if those dis-charges are received into foul cesspools and drains, or if theyobtain admission into drinking water; and human inter-course is one of the conditions for the spread of cholera insuch fashion as this. If we now, for the sake of hypothesis,suppose other conditions for diffusion of cholera to be to-daywhat they were in 1865, we may inquire how far the condi-tions of human intercourse have altered in such wise as toaffect the probable dissemination and rate of transmission ofcholera in and about Europe. In reply, let it be rememberedthat, though Egypt has doubtless incurred repeated riskfrom her communications with the Hedjaz, there is no.evidence that even Egypt has been subjected to dan-ger from cholera, at any time, through her directmaritime communications with more Eastern countries;let it be remembered that the Suez Canal has now been-open for more than thirteen years ; and let it furtherbe noted that the present outbreak of cholera in Egyptis not on the line of traffic between Asia and Europe ;and it will appear improbable, I think, that the use of thenew highway will affect the course of cholera towards Franceand England. Still, it is not to be supposed that 1883 will- .fiud us in every respect under the same conditions of humanintercourse as 1865; and it is possible that some of thechanged conditions may be such as to affect the opportunitiesfor the migration of cholera. But, plainly, they are notworth speculating about, in view of our complete uncertaintywhether those conditions for the diffusion of cholera whichare independent of human intercourse are or are not to bethe same in 1883 as in 1865.

3. Precautions.-" Quarantine," meaning by the word asystem which professes to prevent the entry into a countryof persons coming from another country until assurance isattained that no infection can be introduced by those persons,is not now regarded as capable of fulfilling its pretensions ;and its least failure to exclude infection is seen to make thewhole system irrational ; its cost and its vexations unjusti-fiable. Accordingly, England, which long ago abandonedthe system as of any avail against cholera, has now the con-sent 6f most European nations (as expressed by their dele-gates to the Vienna Conference of 1874) in preferring for thedefence of her ports another system which, under the name.of " medical inspection," aims at obtaining the seclusion ofactually infected persons, and the disinfection of ships andof articles that may have received infection from the sick.The details of this system, as formulated for practical appli-cation in the ports and waters of England, are set forth inan Order of the Local Government Board of July 17th, 1873.Provision is there made for the detention of ships at appointedplaces ; for the visiting and medical examination of ships

and passengers ; for the removal to hospital of personssuffering from cholera or suspected cholera, and for theirdetention there ; for the speedy burial of the dead ; for thedisinfection or destruction of clothing and bedding ; and forthe purification of the ship and of articles therein. Thisorder is at present operative. From a statement by EarlGranville last night, I learn that it is proposed to reissuethe order, though without change in essentials. It repre-sents the system upon which we rely, in preference to qua-rantine, for the protection of our shores. For the last tenyears the country has been thus prepared for the invasion ofcholera, and the fact of this preparedness should be known.We have reason to hope that if cholera should enter Englandit will find fewer opportunities for doing mischief than atprevious invasions. We are generally better provided with

: defences against a disease which spreads as cholera can. spread. Some further precautions for use at the moment; will doubtless be requisite ; but it will be on our permanent; sanitary works and procedure that we shall with most con-, fidence rely.

ACADEMY OF MEDICINE IN IRELAND.

Spontaneous Dislocation of the Hip.-Spinal Injury andMuscular Atrophy.

AT a meeting of the Surgical Section held on March 9th,Mr. KENDAL FRANKS read a communication on Spon-taneous Dislocation of the Hip, illustrated by two caseswhich he had himself observed, and of which casts wereexhibited. A child, aged five, was admitted into the Ade-laide Hospital in January last. She had been confined tobed since the summer of 1882, suffering from "acute disease ofthe left hip-joint." The acetabulum had chiefly suffered, andthe head of the femur had probably passed partially throughit, and in that position anchylosis had taken place. Anabscess which had formed burst into the vagina, and healedup. The limb remained permanently fixed in a semi-flexedposition, abducted and rotated outwards. The child hadbeen chiefly lying on this side, the right leg flexed, ad-ducted, and rotated outwards, so that the knee lay behindthe knee of the diseased limb. In August last, as she wasbeing turned in bed by the nurse, a remarkable protu.berance was seen behind the right anterior superior spine ofthe ilium. The child was questioned about it, but could notgive any account of how it occurred. It gave rise to no pain.This protuberance was caused by the great trochanter, thehead of the right femur having slipped out of its socket, andbeing easily felt on the dorsum of the ilium. No alterationin the parts has since taken place. The second case illus-trated a dislocation of the hip, taking place during an attackof acute rheumatism. A girl, aged fifteen, was admittedinto the Adelaide Hospital on Oct. 10th last, suffering fromnecrosis of the left tibia. She presented a well-marked dis-location of the right femur on to the dorsum of the ilium,the limb being shortened to the extent of 3 in. In May,1879, she had an attack of acute rheumatism, from whichshe completely recovered. In the following February-thatis, two years ago-she was attacked again with the samedisease, which kept her in bed for ten weeks. The righthip-joint and the right shoulder were the parts chieflyaffected. To alleviate the pain pillows were placed underthe hip and knees. When she tried to get out of bed afterthe disease had subsided, she found the right limb consider-ably shortened, so that she could only reach the ground withthe ball of the foot. The right hip was deformed, and shenow presents all the characteristic signs of a well-markeddislocation. The head and neck of the bone can be easilyidentified in their new position, and feel quite smooth andhealthy.-Mr. STOKES instanced a remarkable case formerlyunder his care in the Richmond Hospital, in which a fallwas apparently the exciting cause. The patient fell downstairs, sustaining a very severe injury, but he did not applyfor advice till a fortnight had elapsed, when it was found hehad sustained a dislocation on the dorsum of the ilium, whichwas, with very little difficulty, reduced by manipulation. Nextday, dislocation again occurred, and was reduced; but luxa-tion recurred three or four days in succession. He suggestedin explanation that the fracture of the rim of the acetabulumhad taken place originally, and a portion of the bone wasdriven away from its normal situation at the time theluxation recurred.—Mr. BEXXETT thought that too much

importance was attached to the term "spontaneous." All