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A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

POPLAR AND STEPNEY SICK ASYLUM.AN UNUSUAL CAUSE OF EMPHYSEMA; NECROPSY; REMARKS.

(Under the care of Mr. W. H. PEARCE.)

Nulla autem est alia pro certo noscendi via, nisi quamplurirnas et mor-borurn et dtsseetionum historias, turn aliorum tum proprias collectashabere, et inter se comparare.—MORGAGNI De Sed. et Caus. Morb.,lib. iv. Procemium.

SURGICAL emphysema is usually produced by injury tothe respiratory or alimentary tracts, and of these wound ofthe former, as is well known, is by far the most commoncause. In connexion with the digestive tract, the situationsin which it has been met with are, over the abdomen afterwound of the intestine, and in the pelvic region after damageto the rectum or perforation of its wall by ulceration.Emphysema is also found in other conditions, such as woundsof a crushing or lacerating character, chiefly in the limbs,and also accompanying decomposition of parts. In the

following case a most unusual condition was found at thepost-mortem examination (q. v.), and the extravasated airhad followed the course taken by the escaped air in someinstances of injury to the root of the lung.Wm. P-, aged forty-four, was admitted in a dying state

on Monday, Oct. 25th, at 5 P.M. From the little informationthat could be gathered from the man himself or his friends,it was learned that he had always enjoyed good health andhad followed his usual employment until the previous ISaturday. He admitted being a " free drinker," and onSaturday night he had been " the worse for liquor," but, sofar as he knew, he was not injured in any way. He did notfeel well on the Sunday, and remained in bed until late inthe afternoon, when he dressed and went out for half anhour. Soon after his return he " began to swell, and hisbreathing got bad." He had urgent dyspnoea, his skin andmucous membranes being very blue, and his pulse quickand feeble. His face and neck were much swollen,especially on the left side, and on palpation this wasfound to be due to emphysema of the subcutaneousconnective tissue, which on further examination could betraced all over the trunk as low down as the hips, and forsome distance down the arms. He denied having sustainedan injury, and on careful examination by Mr. Bostock andMr. Pearce, no injury to the ribs or respiratory tract couldbe made out. The chest wall moved very little in respira-tio n, the breathing being for the most part diaphragmatic.Perc ussion elicited a resonant note all over the chest, thoughat the bases and in the axillae the note was flatter than thatobtai ned at the anterior and upper part of the lungs. Inthe fo rmer situations there was almost an entire absence ofbreath sounds on both sides in the lower half of the chest,but in the former air entered freely. The heart’s apex couldnot be made out. His breathing gradually became worse,and he died somewhat suddenly three hours and a half afteradmissior.Necropsy, forty hours after death.-The body was that of

a stoutly-built, well-nourished man, of middle age. On

opening the chest there was no fracture or other in-

jury to the chest wall, but both pleural cavities con-

tained a considerable quantity of fluid, the lower lobesof both lungs being compressed and airless. Much recentlyeffused lymph covered the surfaces of the visceral andparietal pleurae on both sides. On clearing away this, andseparating the lower part of the left lung from the peri-cardium, a collection of undigested food was found outsidethe oesophagus, occupying the posterior mediastinum andsurrounded by emphysematous connective tissue, whichcould be traced up the spine to the root of the neck. Thefood bad escaped through a ragged slit-like opening of aninch long, and situated vertically in the oesophageal wallabout an inch and a half from its lower end. Passing down-wards in the substance of the wall of the oesophagus was asinus, which connected the opening with a small circum-

scribed abscess (about the size of a hazel-nut) situated inthe wall of the stomach along the lesser curvature close to

the cardiac orifice ; this again opened into the cavity of thestomach by a smail opening, so that gas or air could passin freely from the cesophagus or stomach. A small quan-tity of pus was found in the small abscess in the stomach,but there was no sign of any in the mediastinum. Therewas no trace of ulcer in the oesophagus, the opening being amere ragged slit, with black unhealthy-looking edges, out-side which the gullet appeared healthy; but here doubtlessthe mischief must have begun and an abscess formed, thepus burrowing down and finally discharging into thestomach, the oesophageal wall giving way either at the sametime or later.Remarks by Mr. PEARCE.-As to the cause of the abscess,

the only thing that suggests itself to my mind is thelodgment of a foreign body, such as a spicule of bone ; butthere seems to have been no symptoms up to the time whenthe oesophageal wall gave way, and gas or swallowed airescaped into the mediastinal connective tissue. I did notmake out before the necropsy the considerable amount ofdouble pleuritic effusion, believing as I did that the causeof the emphysema must be due to injured lung from obscurefracture of the ribs, and that the compression was beingexercised by internal hæmorrhage.

ROYAL HOSPITAL, PORTSMOUTH.LACERATED WOUND OF THE KNEE, FOLLOWED BY TETANUS

TWENTY-TWO DAYS AFTER THE ACCIDENT; TREATMENTBY CHLORAL HYDRATE; RECOVERY ; REMARKS.

(Under the care of Mr. HENRY RUNDLE.)W. C-, aged fifteen, a healthy lad, was admitted on

Dec. 8th, 1885. Whilst holding on to the back of a cart heslipped and was dragged along the ground, sustaining alacerated wound, about four inches in length, over the leftknee. There was no fracture. The wound was washed cleanfrom gravel and dirt, and dressed with carbolised oil. Five

days after admission suppuration occurred; openings weremade, and a drainage-tube inserted for twenty-four hours.The wound was granulating healthily, when on Dec. 30thsymptoms of tetanus appeared, well-marked risus sardonicus,and seven or eight attacks of clonic spasms during theday. He swallowed with some difficulty. Breathing easy.Temperature 99°; pulse 130. He was ordered a free purgeand chloral hydrate in ten-grain doses every four hours, andremoved to a quiet and darkened part of the ward.

Jan. 1st.—Experienced great relief after medicine. Spasmsless frequent; abdominal muscles hard; wound suppurat-ing ; poultices applied. Milk, beef-tea, and juice of rawmeat to be given between the spasms.2nd.-A quiet sleep after each dose of medicine, which he

asks for to "keep off spasms." Temperature 98.2°. Threeor four spasms during the day. Complained of difficulty inpassing urine, which was relieved by hot fomentations.

3rd.--Improved. Three spasms during the day. Abdo-minal muscles still hard and contracted.During the next six days the spasms diminished both in

frequency and severity, and ceased on Jan. 9th. The chloralhydrate was continued, but less often, up to Jan. 19th.From this time the wound continued to heal, and he wasdischarged well on March 16th.Remarks by Mr. RUNDLE.-The boy being able to swallow,

although wlth difficulty, was a favourable symptom. In thetreatment of tetanus, it is essential to keep up the strengthby giving nourishment with a liberal hand, milk and juiceof raw meat being the best food. I think there can be nodoubt that the medicine aided materially in the recovery ofthe patient, for the chloral hydrate not only induced sleep,but, by diminishing the reflex irritability of the spinal cord,lessened the frequency and violence of the spasmodicattacks. The boy asked for this medicine before it becamedue, as he was afraid of the spasms recurring, and he was soconvinced of its efficiency to keep them off. The other pointsof treatment were free purgation and keeping the patientas quiet as possible, free from any cause of excitement, in-cluding light and sound. A point worth noting was the lowtemperature; once only did it reach 99°, being at othertimes normal.

MULTIPLE MELANOTIC SARCOMATA ; DEATH ; NECROPSY.(Under the care of Mr. RUNDLE.)

E. Y-, aged forty-five, was admitted on Feb. 4th, 1886.There was no history of tumours or malignant disease in thefamily. Has always been delicate. Has had eight children

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The present illness commenced six months ago, when she firstnoticed a lump like apea in the skin under the right breast. Thisgre w rapidly, but as it did not give her any pain she delayedseeking advice until a week before admission. In the rightbreast there is a semi-fluctuating, purplish tumour, movableon the thorax, the size of a large orange. The left breasthas the appearance of extravasated blood, evidently contain-ing a growth. Other small tumours, six in number, rangingin sizd from a walnut to a pea, and having the same bruisedappearance, exist over the sternum and in the abdominalwall.

Feb. llth.-The right breast was excised, and three smalltumours on the abdomen. Free haemorrhage during theoperation.16th.-Wound of small tumours healed, but that of breast

breaking down and discharging. Patient weaker and losingflesh. ,

The progress of the case was unsatisfactory. Thegranulations over the right breast became gelatinous inappearance, and the other growths increased in size, andfresh ones appeared on the abdomen. The patient sankgradually, and died from asthenia on April 20th. A micro-

scopical examination of the growth removed showed spindleand fusiform cells pigmented.

Necropsy, forty- eight hours after death (from notes by Mr.C. C. Claremont).-Body emaciated. In the situation of theright mamma is a well-defined fungating tumour, coveringan area of about six inches square, and reaching to themiddle line. The tumour at the surface is black, softened,and seems to be mainly slough. The deeper part, reachingdown to the periosteum, is white, soft, and brain-likeThe ribs are unaffected. There is a tumour in the leftmamma. Under the skin of the trunk and thighs are fourteentumours, soft, sharply defined, and some fluctuating. Dis-section shows some of them to be of the same white, softmaterial as the large tumour ; others are more or less pig-mented with black material, and some contain broken-downblood-clot. They vary from the size of a hazel-nut to thatof a walnut. Abdomen: The transverse colon,beingdistendedand translucent, exhibits several black patches the size of afinger-nail. In connexion with the omentum are four or fivetumours, more or less pigmented, and similar to the sub-cutaneous ones. The mesentery presents at least a dozen ofthese small tumours, which appear to be covered by peri-toneum ; some are free from pigment. In front of the leftkidney is a tumour the size of the fist, mottled white andblack, and containing a cavity of broken-down blood-clot;similar but smaller tumours were found at the lower end ofeach kidney. A small patch of pigment in left supra-renalcapsule. Liver and kidneys markedly fatty in appearance.Thorax: Small, partially pigmented tumour in the anteriormediastinum. Lungs emphysematous and congested pos-teriorly. Heart walls fatty: valves healthy. Skull notopened. All the tumours examined were encapsuled.CRUSH OF LEGS BY TRAM-CAR ; DOUBLE AMPUTATION BELOW

THE KNEES; RECOVERY.

(Under the care of Mr. RUNDLE.)

Henry D- aged ten, was admitted on Oct. 17th, 1886.Whilst crossing the road he was run over by a tram-car andsustained extensive compound comminuted fractures ofboth legs, the soft parts being much lacerated. On admis-sion the boy was conscious, but much collapsed. Both legswere removed at once a hand’s breadth below the knee, bycircular operation on the right and flap operation on the left.

Oct. 18th.—Restless night. Pulse 140; temperature 103°.Very sick.

19th.—Still very sick. Pulse 130; temperature 103.2°.Very restless and delirious in the night. Hypodermic injec- tion of morphia (one-sixth of a grain) at 9 P.M.

20th.-Slept fairly well. Pulse 112; temperature 100°.Retains food. Some of the stitches separated, and stumpsdischarging and inclined to slough.

26th.-Pulse 112; temperature 993°. Constitutional dis-turbance much less. Sloughs from flaps removed.From this date he went on well. The flaps were brought

together by strapping, and iodoform dusted over them, andby Nov. 30th the stumps were nearly healed.

AT an inquest held at Newport, on the 7th inst.,on the body of a woman who had died from taking a doseof liniment instead of the mixture which had been prescribedfor her, the jury returned a verdict of accidental death.

Medical Societies.MEDICAL SOCIETY OF LONDON.

Hypertrophy of Tlai;gla and Leg.—Cervical Pachymen2*n.qiti’s.-Lupus of Larynx.—Syphilis of Tongue.—Rare Syphilis ofFace.- Talipes Equinus.A CLINICAL meeting of this Society was held on Monday

last, Mr. R. Brudenell Carter, F.R.C.S., President, in the chair.Mr. BULL showed a boy with great enlargement of the

left thigh and leg, which began six months ago. There wasno evidence of tumour, phlebitis, or arterial disease. Thethigh measured two inches more in circumference than theright side. The swelling was probably due to lymphangi-ectasis. There was no evidence of chyluria or albtimiiauria.It was not a case of asymmetry. The patient had neverhad any deep-seated phlebitis or attacks of erysipelas orerythemata.-The PRESIDENT asked whether there was anydifference in the temperature of the two sides.—Mr. MAR-MADUKE SHEILD remarked that there seemed to be an

elongation of the femur. Was this so ?-Mr. J. H. MORGANconsidered with Mr. Sheild that the case was of congenitalorigin.-Dr. A. MONEY inquired for filariae sanguinishominis.-Mr. NOBLE SMITH inclined to the view that thehypertrophy was congenital.-Mr. BULL said there was nodifference in length or temperature in the two limbs.

Dr. ORD showed a specimen of Chronic HypertrophicCervical Pachymeningitis, in a footman aged twenty-six.Last Christmas (1885) he was seized with pain, stiffness ofneck, sickness, and constipation. Temperature 103°; pulse95. At another time the temperature was 101.2°; pulse 72.He had some shivering fits, which bore a resemblance toague. He had delirium at times, and was very muchweakened. Later he gained flesh and strength. In May ofthis year there was no fever, but great loss of power andwasting of muscle, and loss of sensation in the arms. The

legs were in a state of spasmodic paraplegia. Two muscleshave escaped to a large extent-the anterior part of thedeltoid, and the biceps. There was some exaggeration ofextensor tendon reflexes. Mechanical irritability of themuscles was excessive. The electrical state of the muscleswas that of the reaction of degeneration. Sensation hasimproved, and there was some improvement in the power ofthe arms and legs. A claw-shape of the hands had developedsince May. There was considerable curvature of the spine.Distressing attacks of diaphragmatic paralysis (?) hadoccurred of late. The akin of the fingers was wasted andsmooth -somewhat glossy. A gradual osteo-arthritis haddeveloped in several joints in the hand. There was no his-tory of a chill, or injury, or syphilis. He advanced this caseas an illustration of ti e hypothesis that a good many casesof chronic progressive affections of joints are dependenton altered states of nutrition of the spinal cord.-ThePRESIDENT inquired whether the optic discs were affected.-Dr. BEEVOR thought it threw some light on the localisationof groups of muscles in the spinal cord. The facts of thiscase strengthened the results of experimental observations.-Dr. A. MONEY remarked on paralysis and dilatation of pupil,associated with atrophy of interossei.-In reply, Dr. OBDsaid the optic discs were natural, the pupils were somewhatdilated, and the left larger than the right. There were noevidences of abnormality in the pulse.

Dr. ORWIN showed a case of Lupus of the Larynx in awoman, associated with the same disease of face and nose.

Dr. CoLCOTT Fox showed a case of Lupus of the Larynxassociated with lupus of the face, palate, and scalp, in a boyaged seven years. Kaposi said that autochthonous affec-tion of the larynx with lupus was unknown.-Dr. FELIXSEMON said that papillary excrescences and ulceration of the

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epiglottis were to be seen. He did not think lupus of thelarynx so rare. Chiari had collected forty cases. In perhaps5 to 8 per cent. of cases of lupus the larynx had been involved.- Mr. LENNOx BROwNE agreed with the remarks of Dr.Semon.-Dr. MoRELL MACKENZIE had noticed the stridorin Dr. Orwin’s case a month or more ago, and could nottherefore set it down to the treatment by dilatation.

Dr. ORWIN showed a specimen of Syphilitic Affection ofthe Tongue in a boy aged nine, in whom there were no otherevidences of congenital syphilis.Mr. NOBLE SMITH showed severe cases of Talipes Equinus,

in which he divided the tendo Achillis ; and rapid extension,