298

possible and then strapping it into position with strips ofplaster. Next, the ruptured muscles were treated in thesame manner and the parts brought as near as possibletogether. Then the limb was flexed sufficiently to be com-fortable, fixed on a back splint and swung from a cradle.When this was completed the space between the bone andthe torn muscles was about half an inch. This apparatuswas kept in position for three weeks, when I restrapped thejoint, still finding the parts in good position. This strappingwas allowed to remain a fortnight, when I dispensed withthe splints and put the joint up in plaster-of-Paris. Thiswas left on for a month and then I ordered him a leather knee-

eap, which he has worn since. The loss in length of tendonis three-quarters of an inch. The patient has retired frombusiness and is able to take long walks of eight or ten milesa day, with just the slighest halt in his gait. He is able towalk without his knee-cap, but does not feel quite safe.The predisposing cause of this accident seems to have beenexcessive use of the muscles of the thigh for pushingin the drawers in connexion with his occupation, causinghypertrophy of the muscles and bones of the knee and,later, degeneration of the muscles. The left knee was oneinch more in circumference than its fellow. This is the onlyinstance in which I have seen this particular form ofoccupation deformity, and I consider the accident worthrecording on account of its rarity.West End, Hampstead, N.W.

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

MIDDLESEX HOSPITAL.CASE OF DIFFUSE, RADICULAR LYMPHAITGIECTASIS AND

LYMPHOMA AFTER A LYMPHATIC ABSCESS, THESEQUEL OF VARIOLA.

(Under the care of Mr. HULKE.)

Nulls autem est alia pro certo noscendi via, nisi quamplurimas et mor-oorum at dissectionum historias, turn aliorum tum proprias collectashabere, c’t, inter se comparare.—MORGAGNI De Sed. et Caus. Morb.,fib. iv. Proœmium. ————

THE circumstance last mentioned in the report, coupledwith [" resemblance found between the little tegumentalbodies from which the discharge issued and some of the

small cutaneous nodules occurring in lymph scrotum, endemicin certain Oriental countries, appeared to Mr. Hulke to justifythe inference that the little bodies on the upper part of thethigh in the present case were also connected with the

lymphatic system. He did not suggest their absolute identityand pointed out that in lymph scrotum some of the nodules areformed by varices of the larger lymph vessels, whereas inthis case some of the little tegumental bodies appeared, atleast in their earlier stages, to be small masses of lymphoidtissue The associated diffuse swelling of the thigh appearedto find s. natural explanation in the supposition that it was dueto increased formation of lymphatic tissue, a diffuse lymphomacombined with dilatation of the lymphatic radicles, andperhaps at the seat of the former abscess, with extasia ofsome of the larger lymph vessels-an idea which found somesupport in the elongated forms of some of the quasi-fatpellets in this situation. This abscess seemed to constitutethe starting-point of the disorder. The appearance of thescar left by it clearly disproved the abscess having beenperiosteal or osteal ; it formed as the patient was recoveringfrom variola, and its occurrence as a sequel of the suppurativephase of a widely diffused dermatitis is strongly suggestivethat if, was a lymphatic abscess. Should this be conceded heconsidered that we are yet without a satisfactory explana-tion why in this instance damage, perhaps amounting todestruction of one or more lymphatic glands and of the

lymphatic, tracts connected with them, should have given riseto such widespread peripheral disorder in the lymphaticsystem of the limb. It must be conceded that the greatinfrequcncy of such disorder, as the result of destructive

lymphadenitis, offers strong ground to doubt in the presentcase the notion of a direct causal relation between the

abscess and the disorders in the limb which followed it. He

pointed out an analogy, which would not, however, hethought, bear being pressed too closely, was ofEered in eachdivision of the blood-vascular system. Usually (the largestvessels in each excepted) a localised injury of an artery orvein produces very limited effects ; but exceptionally a

very limited injury to a minor artery may originate a pro-cess occasioning a cirsoid condition, ultimately involvinga considerable segment of the arterial system, and

occasionally a similar process, starting as the effect of injuryof a veinlet, may be seen to overrun the whole venous systemof a limb. In connexion with treatment, it was instructiveto observe the progressive decrease in number and sizeand the complete disappearance of most of the littlelymphoid tegumental up-growths on the inner side of thethigh :after a few weeks’ rest in bed, with protection fromchafing against the other thigh. Uniform, gentle compressionof the thigh by a well-fitting elastic stocking was found torelieve the aching which had previously been occasioned bystanding and by work. This palliative measure appeared tobe all that the condition permitted.A well-grown, healthy-looking brunette, aged eighteen,

her face slightly marked by variola, in domestic service, wasreceived into the Bird Ward on Nov. 24th, 1892, for asupposed tumour with pain in the thigh. No distinct tumourwas, however, present, but the entire right thigh, particularlyits upper half, was obviously enlarged. Its girth at thedistance of four finger-breadths above the patella was foundto be 42’5 centimetres, and at the distance of 15 centimetresbelow the anterior superior iliac spine-where the thigh wasstoutest-the girth was 53 centimetres. The correspondinggirths of the other thigh were 39 and 49 centimetres respec-tively. The swelling was greatest in the upper part of theadductor region, where it was very conspicuous when thestrongly abducted thigh rested on its outer side upon thebed. Over this prominent part the skin was beset withnumerous little eminences of very peculiar appearance.Some were broadly sessile, and the size of most of theseranged from that of a pin’s head to that of a No. 6 shot ;but a few were larger, attaining a diameter of five milli-metres, and these were minutely nodular, a configurationsuggestive of their formation by aggregation and blendingof several of the smaller eminences. All these little noduleshad a slightly translucent aspect; to the touch they seemedsolid, but when pricked there exuded from them a small dropof colourless liquid. Scattered amongst these and about asnumerous were other bodies, flaccid and shrivelled, pro-jecting more from the general surface, having a lengthof from three to five millimetres and a basal diameter of fromone to two millimetres. At the free end of a few of these aminute stigma was just discernible with the unaided eye, andstill better seen with a pocket magnifier ; this seemed tomark the spot where a rupture had occurred. The circum-stance of the association of the two kinds of little bodies andthe appearance of those last described were taken to indicatethat the latter represented a later phase of the former. The

lymphatic glands in both groins were slightly increased in size,those in the right groin being somewhat the larger, but in otherrespects they did not seem abnormal. The manifest enlarge-ment of the thigh appeared to be due to the presence of a largerquantity of subcutaneous tissue. This, when an attempt wasmade to pinch it up with a fold of skin, felt less suppleand less elastic than that of the left limb. This was certainlynot occasioned by cedema, for of such there was not a trace,but seemed to be referable to the larger quantity of tissue.In the upper part of the adductor region was just discerniblea faint scar, which the girl said marked the seat of an abscess,and beneath and around this the pellets of subcutaneous fatwere somewhat coarser than elsewhere, and they were alsoless mobile on one another.The account the patient gave of the affection of her thigh was

remarkable, and in respect of a very characteristic sign itwas quite spontaneous. She said that, with the singleexception of an attack of small-pox when she was

nine years old, she had not had any illness-and herappearance conformed with her statement of excellent health.She had not been vaccinated, her parents objecting. She hadsmall-pox in her ninth year, and when she was recoveringfrom the attack a large abscess formed in the upper part ofher right thigh ; it burst and in a short time closed. Soonafter this occurrence her thigh began to swell. The swellingbecame larger when she stood much and when she worked ;and it decreased when she rested in bed. Working andstanding made her thigh ache, but when resting in bed the

299

thigh was quite easy. About two years before the date ofher coming to the hospital the little bodies above describedfirst appeared ; they troubled her much by." milking "-theyburst and a discharge like watered milk oozed from them andwetted her dress.

CHILDREN’S INFIRMARY, LIVERPOOL.CASE OF SCARLET FEVER WITH PURPURA.

(Under the care of Mr. R. W. MURRAY.)WITH regard to the following case Mr. G. E. Clemons,

senior house surgeon (to whom we are also indebted for thenotes), writes :-Beyond passing reference in Fagge nothingis said in the ordinary English text-books on the subjectof purpura after scarlet fever. Eustace Smith, Ashby andWright, Collie and others are silent on the subject. Henoch, I

however, mentions the manifestation of a hoemorrhagicdiathesis as a sequela of scarlet fever, but of eight casesall began in the third or fourth week after the eruptionand all terminated favourably. In discussing the etiology ’,of purpura fulminans,2 he also states that a fatal case ofthis occurred one week and a half after a slight attack ofacailet fever. Dr. Collie, in THE LANCET3 and in the"Archives of Pediatrics,"4 reports a case of purpurafulminans three weeks after an attack of scarlet fever.

Unfortunately, in this case of J. 0-, it was not possibleto trace distinctly the source of infection. There had beenno scarlet fever in the ward for some time previously ; therewas none at his home or in the neighbouring houses. Therewas, however, an epidemic of small-pox at Warrington whichds only a short distance from, and in constant communicationwith, Ditton, the town in which he lived. This togetherwith the symptoms, and in the light of Dr. Gee’s statement,mturally made one suspect hsemorrhagic small-pox. Dr. Gee5 5

says : "Scarlatina hasmorrhagica is so rare that the’occurrence of a passive hemorrhage from several mucousmembranes at once might make one with justice suspend thediagnosis of scarlet fever until the notion of possibly havingto do with variolous roseola was discarded. I have knownvariola basmorrhagica to be mistaken for scarlatina hasmor-Thagica and the truth not to appear until, in the course oftime, those who had dealings with the case were themselvesattacked with small-pox." That variola hsemorrhagica,’however, was rightly discarded would, I think, appear fromthe following facts : (1) There never was any true small-pox.eruption, the child’s illness lasting for thirteen days ; (2) theTash was typically that of scarlet fever ; (3) desquamation’commenced between the seventh and eighth days ; (4) noperson attending upon the child contracted small-pox.

J, 0-, aged two years, was admitted into the infirmaryon Oct. 10th, 1892, for the radical cure of an inguinal hernia.He was a fresh-coloured boy and apparently in good health,- except for slight bronchitis. His family history was good.There was no history of haemophilia, and he had had noserious previous illness. On account of the bronchitis the

.operation was deferred for some ten days. He had one ortwo occasional rises of temperature in the evening during’that time, but for four days before the operation the tempe-rature had been normal. He had eaten and slept well andthe motions and urine were normal. On the morning ofOct. 20th the operation, which lasted some thirtyminutes, was performed ; it presented no special diffl-oulty. The child had no after-sickness and suffered

apparently little from shock. The following morninghis temperature was 101°, but except for this feverishness11e seemed fairly well. The temperature, however, keptelevated, and on the third day after the operation it was stillhigher (1014° F.). He was restless and uneasy. The tonguewas coated and furred ; the tonsils and fauces were congested ;’the glands at the angle of the jaw were swollen and a

diffused punctiform red rash appeared over the upper part ofthe chest, legs and back. The wound was dressed ; it lookedquite healthy and healing. He was transferred to thefever ward. On the 24th he vomited five times and haddiarrhoga. The rash had spread and become much more pro-nounced. The temperature was 104’2° ; the pulse beat andrespiration were rapid ; the urine was highly concentrated,- canty and albuminous. On the 29th the urine became

1 Diseases of Children, vol. ii., p. 231. 2 Vol. ii., p. 380.3 THE LANCET, March 21st, 1891. 4 July, 1891.

5 Reynolds’ System of Medicine, p. 165.

intensely bloodstained and much blood was passed per rectum.This continued till his death, which occurred on Nov. 3rd.During his illness he developed petechise generally over the

body. There were subconjunctival hsamorrhages and bleedingfrom the gums, nose and stomach, and two large sub-cutaneous hemorrhages, one in the right parotid region, theother into the site of the wound. He became very pale, thecorpuscles scarcely being 2,000,000 per centimetre, and theproportion of red to white about normal. The urine containedred blood-corpuscles, leucocytes, and epithelial, blood andhyaline casts. Peeling of the skin commenced on the 30th.The first sound of the heart was replaced by a soft systolicmurmur. He had a short, hacking cough and some consolida-tion towards the apex of the right lung. The retinae were

extremely pale, but no other change was noted on ophthal-moscopic examination. Before death he had a slight con-vulsion, chiefly left sided.Necropsy.-The waxy pallor of the body generally con-

trasted with the haemorrhages in the situations abovedescribed. The right lung was consolidated at the apex(hsemorrhage and pneumonia around it). There was somecongestion at both bases. There were several petechias underthe epicardium, but there was no endocarditis. Numeroushaemorrhages existed under the serous coating of the bowels.The stomach contained altered blood, and many points ofhaemorrhage were visible beneath the mucous membrane.Several small ulcers were seen on the sites of older hagmor-rhages. The kidneys to the naked eye before section appearednormal, the capsule being non-adherent ; but on section thecalyces on both sides were filled with blood ; both the cortexand medulla were congested. The spleen was congested andthere were many hasmorrhages in its substance. There was no

hasmorrhage in the membranes, substance or cavities of thebrain. Beyond the haemorrhages into the substance of theorgans and the congestion and cloudy swelling of the kidneysmicroscopic examination revealed nothing noteworthy.

Medical Societies.PATHOLOGICAL SOCIETY OF LONDON.

Melanotic Carcinoma of Skin. -Foreign Body in Hernial Sac.-Intra-auricular Cardiac Polypus.-Heart mith CongenitalMalformations.-S’arcomato2cs Growth in ffsophagus asso-ciated with Sarcomatous Growths in Bone.-.Ale7v Gromthin Descending Colon.-Carcinoma of Lung in a Cow.-Rupture of Heart.AN ordinary meeting of this Society was held on Tuesday,

Feb. 7th, Sir George M. Humphry, President, in the chair.Mr. J. HUTCHIXSON, jun., exhibited specimens from two

cases of Melanotic Growths of the Skin, demonstrating theirnature to be carcinoma and not sarcoma. In one case thetumour commenced in the thigh, in the other the heel. Thecells of the malignant growth were arranged in alveolar form,and were distinctly derived from the rete mucosum. In one

specimen cell-nests were fairly abundant, and were some-times deeply pigmented. The cells were, as a rule, muchsmaller and possessed less distinct outlines than those usuallymet with in the down growths of skin epithelioma, and it isprobable that many of the examples of supposed melanoticsarcoma are really carcinomatous. Sections at the edge ofthe tumour are necessary to decide the point. Probablymelanotic sarcoma and cancer are equally malignant in

causing deposits in the lymphatic glands. Allusion wasmade to the remarkable difference as to this in cases ofmelanosis, one case being quoted of melanotic sarcoma of the

orbit, which, after incomplete removal, continued to dischargeblack material for six years. At the end of this time thepatient was in good health without evidence of secondarydeposit.-Dr. NORMAN MOORE considered Mr. Hutchinson’sremarks as to the duration of symptoms important, andadduced two other cases in his own experience in which theyhad extended over a period of at least three years. Heremarked upon the uncertainty as to the exact origin, inrelation to the foetal layers, of those cases which commenced

, in the eye.

,

Mr. J HUTCHINSON, jun., also showed the Sac of a FemoralHernia, the neck of which was perforated by a strong fish-bonewhich had evidently passed through the intestinal wall andthrough Gimbernat’s ligament. The fish-bone had irritated