A CASE OF NEGLECTED SHOULDER PRESENTATION.

CLINICAL NOTES.

foregoing substances the acidic group 002H moderates the physiological effect of the active groups and when this group is replaced in formula V. by the group COH one arrives at cinnamaldehyde, the active principle of cinnamon oil, and this substance has been employed instead of cinnamic acid. Its use, however, demands some care and when injected subcutaneously it was found to be somewhat painful. The metal copper is probably one which merits a more extended trial in therapeutics ; and cuprocitrol (copper cinnamate) has had some limited application. Copper oleate Cu (CH3 7 CHCH. [CH2]’ , -C02)2 has been employed by Dr. Drage in certain skin troubles of a cancerous nature. In both cases one has the combination of the active metal copper and an organic complex containing an ethylene linking. The exploitation of the rare earths in the manufacture of incandescent mantles has led to the production on a large scale of pure thorium and cerium salts, and as the earlier pharmacological experiments carried out with these bases were probably made on specimens of very doubtful purity it would be of interest to subject the modern preparations to a fresh examination from this standpoint. That some revision is desirable is evident from the conflicting statements which have been made on this subject. It was formerly supposed that cerium was more active physiologically than thorium, but it has since been stated that thorium is more effective than cerium. The only cerous compound hitherto employed to any extent in medicine is cerous oxalate, but a series of cerium compounds suitable for therapeutic application has recently been described by the writer and Mr. E. Cahen1 and a corresponding set of thorium compounds has been obtained by the writer and Dr. Martindale. The action of the cerium salts may be referred to the tendency which this metal has of existing in several states of combina. tion. In the case of thorium the habit of combination h constant, but the compounds of this element are more or less radio-active, and this factor may have some influence ir determining their physiological action. Many other example: might be adduced in which other elements such as bismuth mercury, zinc, silver, &c., are advantageously employed ir combination with various organic complexes, and it i; certain that further extensions of this principle will increasE the number of trustworthy drugs at the disposal of th< In the

(carboxyl)

1369

There was no sign of any caseation, neither were the cervical The brain, the and inguinal glands markedly enlarged. heart, the kidneys, the liver, and the spleen were all normal. There were ecchymoses on the surface of the lungs, which otherwise were healthy. The stomach and the intestines showed no signs of gastro-enteritis or of any congestion, but all the lymphoid glands in the walls were very prominent and stood out from the surface of the gut. The tonsils were moderately enlarged and adenoids were present. Rickets, syphilis, and tuberculosis could all be excluded and by all outward appearances the child would seem to have been very healthy. Osler’s" System of Medicine," Vol. IV., gives the normal weight of the thymus gland as from 7 to 10 grammes and considers hyperplasia to be present when 15 grammes are reached. Since this particular gland weighed 28 and was associated with a very definite grammes lymphatic enlargement, I think it is quite fair to class the case as one of thymic death and not to consider the convulsion " the primary cause of death but as something entirely dependent on the hyperplastic condition of the thymus and lymphatic glands. Palmer’s Green, N. A CASE OF NEGLECTED

SHOULDER

PRESENTATION. BY M. J.

PIERCE, L.R.C.P., L.R.C.S., L.M. IREL.

may interest the readers of THE LANCET, rarity outside maternity institutions, but because of the locality in which it took place, and consequently the difficulties in connexion with it. I am at present acting as locum tenent for the medical officer of No. 3 Dispensary District of the Galway union (Arran Islands), and on the night of Oct. 10th at about 11.30 P.M. I received an urgent telegram from the midwife in the south island, Innishere, to come at once to a difficult midwifery case as the woman was in danger. The distance was nine miles and it was blowing a gale at the time, and as no boat would venture out it was impossible to get there that night. On the next morning, although the gale had not abated much, in response to another urgent telegram stating that the presentation was transverse, I obtained a fishing physician. boat called a I I hooker " to take me to the island (for which, by the way, I had to guarantee payment of 30s. out of my own pocket and chance getting it back from the guardians). I was accompanied by the curate of the parish whose services AND had also been requested. We arrived safely, though we had been nearly swamped several times. On examination of the THERAPEUTICAL. patient I found that the membranes had ruptured and that the right arm was protruding. The patient, a multipara, A CASE OF "THYMIC DEATH." aged 38 years, strong and healthy-looking and accustomed BY M. STEWART SMITH, M.B., B.S. LOND., M.R.C.S. ENG., to an active outdoor life, had been in labour for 24 hours, and there was a history of previous difficult pregnancies. CLINICAL ASSISTANT AT THE EVELINA HOSPITAL FOR SICK CHILDREN. The position could be easily made out on abdominal palpation. The os was sufficiently dilated to enable me THE number of recorded cases of " thymic death " are to pass my hand into the uterus to try to rectify matters by few that it is perhaps right that the following case should bec converting it into a breech. The child, however, was so recorded. f firmly wedged into the pelvis that I found it impossible to The patient, a boy aged eight months, had been suddenly aalter the position, and desisted owing to fear of rupturing seized while in his mother’s arms with what was termed atthe uterus. Evisceration was plainly indicated, so I wired for convulsive fit, in which the lips became blue and ther nearest Dr. Francis of Lettermore Dispensary, my colleague, extremities cold. There was just time to get a hot bathIwho at great personal risk and after a seven hours’ voyage ready and to place the child therein before death took place.owing c to the terrible weather, very kindly came to my No history of any previous illness was obtainable. Indeed, aassistance. On his arrival the child was, of course, dead the baby had not been seen by any medical man since birth ;zand the mother was dying from exhaustion. In the meanneither had he suffered from"convulsions,"although bottle-ttime, I had the only treatment which seemed feasible adopted fed on cow’s milk and barley water. -viz., to keep the uterus quiet with one-grain opium A post-mortem examination showed that the body was thatttabloids and to keep up the strength with milk and a little of a well nourished and developed child showing no signs of1 In deference to the wishes of the patient’s friends brandy. any external injury. On removing the ribs and the sternumiwe proceeded with the operation. The surroundings werea greatly enlarged thymus gland was exposed. This con-a very small room with the usual insanitary accompaniments, sisted of two large lobes, each two and a half inches in length,a candle for light, and improvised instruments sterilised in a which completely covered the trachea. From the upper The whole affair lasted two hours and was potato pot. part of each lobe a prolongation extended posteriorly. successful as far as the operation went but our entirely the two lobes and their prolongations very nearly encircled patient died 12 hours later. Chloroform was the onlyanaesthe trachea. The weight of the gland was one ouncethetic which we had and this had to be alternated with (28 grammes). The lymphatic glands of the thoracic and brandy 1 owing to the extreme weakness of the pulse. abdominal cavities were all greatly enlarged, especially those Had the operation been performed a day or two earlier I of the latter which formed a solid mass in the mesentery. think the patient might have been saved, but the utter of the situation where help cannot be promptly hopelessness 1 Transactions of the Chemical Society, 1907, p. 475, and Pharma- obtained is also, I think, only too painfully evident. ceutical Journal, April, 1907. T 3 THE

following

not alone because of its

_________

Clinical Notes :

MEDICAL, SURGICAL, OBSTETRICAL,

sot

i

Thus i

ROYAL SOCIETY OF MEDICINE : SECTION OF DISEASE IN CHILDREN.

1370

Medical Societies. ROYAL SOCIETY OF MEDICINE. SECTION OF DISEASE IN CHILDREN. apparently cczscd by Ascaris Lwnbriooides.Cyanosis RetGnC2.-L’xhibit207L ofS]peci)i?ens and Cases. THE first meeting of the newly constituted section for the Study of Disease in Children was held on Oct. 23rd, Dr. G. CARPENTER being in the chair. The minutes of the last meeting of the Society for the Study of Disease in Children, at which it was resolved that the society should be dissolved and should become a section of the Royal Society of Medicine, were read and confirmed. Dr. Carpenter announced that a dinner would be held by the section on Nov. 5th at the Cafe Royal to commemorate the eight years of usefulness of the old society and to wish it success in its new sphere of activity. Dr. Carpenter then presented to the meeting the final volume of the society’s

Toaeae1llia

reports. Dr. F. W. HIGGS read a paper on a case of Toxaemia caused by Ascaris Lumbricoides, which was discussed by Dr. CARPENTER, Dr. C. W. CHAPMAN, Dr. J. PORTER PARKINSON, Dr. E. CAUTLEY, Dr. F. J. POYNTON, Dr. R. H. MILLER, and Dr. E. I. SPRIGGS. Three cases of Congenital Morbus Cordis were shown by Dr. CHAPMAN, Dr. PARKINSON, and Dr. HIGGS.-Dr. CARPENTER referred to the changes in the fundus oculi in cases of congenital heart disease. Mr. SYDNEY STEPHENSON described the condition of Cyanosis Retinas and said that it had led to the successful diagnosis of congenital heart disease when no murmur could be heard.-Dr. DAN MACKENZIE spoke of the submucous structures in the naso-pharynx in such cases.-Dr. SPRIGGS referred to analogous cases in which the arms and legs were

apparently

blue but no cardiac lesions could be found.-Dr. POYNTON, Dr. J. FAWCETT, Dr. L. G. GUTHRIE, and Dr. F. PARKES WEBER discussed the nature of the lesion in the cases shown. The following specimens and cases were shown :Dr. CAUTLEY and Dr. MILLER exhibited a Cranium and Shoulder Girdle from a case of Cleido-cranial Dysostosis.Dr. CARPENTER, Dr. CAUTLEY, Dr. SPRIGGS, and Mr. DUNCAN C. L. FITZWILLIAMS discussed the specimen, the latter suggesting that what was thought to be a rudimentary clavicle was a coracoid bone. Dr. J. WALTER CARR : A case of Enlarged Spleen. Dr. PoYNTON and Mr. W. M. JEFFREYS: A Case of PostBasic Meningitis treated by Intraspinal Injections of Ruppel’s Serum ; Recovery.-Dr. J. A. TORRENS referred to six and Dr. SPRIGGS to two cases treated by this serum without avail. Dr. CAUTLEY : (1) Dextrocardia; and (2) Prolonged Pyrexia of Uncertain Causation. Mr. FITZWILLIAMS: Congenital Syphilis with Enlargement of the Long Bones. Dr. CARPENTER: Two cases of with Changes in the Fundus Oculi.

Microcephalic Idiocy

HUNTERIAN SOCIETY. BOII/e Causes of Death ditring Anæsthesia. A MEETING of this society was held on Oct. 28th, Dr. ARTHUR T. DAVIES, the President, being in the chair. Dr. R. J. PROBYN-WILLIAMS read a paper on Some of the Causes of Death during Anæsthesia, other than the direct effect of the anæsthetic. He mentioned fear as a possible cause in the early stage before the abolition of consciousness, and quoted a recent case of a boy aged nine years whose tonsils and adenoids were to have been removed under chloroform but who died before any anaesthetic had been dropped on the mask. Various ways in which asphyxia may be produced were described and cases in which death had been caused by the inspiration of vomited matter, by portions of a malignant growth, and by pus from an empyema on one side of the chest entering the bronchus of the sound side, thus drowning the patient. Dr. Probyn-Williams then related cases in

which the heart’s action had been stopped by embolism and by the rupture of an aneurysm into the pericardium, and discussed the sudden heart failure which occurs when a large empyema is rapidly emptied. Shock, hæmorrhage, both sudden and gradual, and cerebral hæmorrhage were mentioned as causes of death, and also a case of sudden death during anaesthesia in which the necropsy showed the " typical signs of the status lymphaticus." He drew the following conclusions : (1) That when death occurs during anaesthesia it is not by any means always due to the effect of the anæsthetic ; (2) that a careful post-mortem examination should always be made ; and (3) that a coroner’s jury is not always the best means of determining the amount of blame which should be attributed to the anaesthetic. Dr. THEODORE FISHER referred to some of the pathological aspects of cases of deaths under anaesthetics. He said that they could be divided into three classes : (1) cases of death in no sense due to the anæsthetic, such as those in which blood and pus entered the air passages ; (2) cases in part due to the anaesthetic, that is where some condition predisposing to sudden death was present; and (3) cases due wholly to poisoning by the anaesthetic. The second class he considered to be the largest. The morbid conditions present favouring the harmful effects of the anmsthetic might be either in the lungs or the heart. Even tenacious muco-pus in the air passages might predispose to death. It was suggested that where death immediately followed a forcible inspiration and the postmortem examination showed the presence of universal pleural adhesions, these adhesions might favour inhibition of the heart by preventing the lungs from advancing over the heart and thus preserving it from the influence exerted by the sudden and unusual change in intra-thoracic pressure. Of heart ! affections which predisposed to death there was much misunderstanding with regard to the fatty heart. A fatty heart could not be described as one variety of chronic cardiac disease. Fatty changes in the heart’s wall were not uncommonly found in fibroid disease of the heart, but this disease frequently caused sudden death in people who had had no indications of cardiac weakness. Most cases of death under anaesthetics, in which fatty heart was described as present, considered to be so described in consequence of error of were observation or of judgment. The"status lymphaticus" was also referred to and the opinion was expressed that such a condition existed and predisposed to death under anaesthetics. Dr. STANLEY B. ATKINSON said that the legal interest of this discussion appeared from the fact that coroners considered that such deaths were from unnatural causes and should therefore be inquired into by an inquest jury. The jury, under the direction of the coroner, might probe deeply into the circumstances and discover signs of negligent treatment by the medical adviser, which discovery might lead to criminal proceedings against him or stimulate a solicitor representing the family of the deceased to commerce an action for damages as the result of the unfortunate fatality. The point, then, at issue would be, Who was legally responsible for the death ? If a competent surgeon retained the services of a competent anaesthetist and nothing extraordinary in the mode of proceeding occurred there would be no gro md for legal proceedings. Even where some slight blame was possible the medical man would receive the benefit of the doubt if he could show that he acted with reasonable care and skill and did not exhibit wilful neglect. Anyone, qualified or lay, might administer anæsthetics as the law now stood. In the case of the former the law assumed that he knew the methods approved and in use ; in the case of the latter he might be called upon to show that he had an adequate skill in, and knowledge of, the procedure. Where a surgeon engaged the services of an unregistered man he would have to bear the blame if anything went wrong ; if he retained a registered practitioner the latter would be prima facie responsible for his own acts, particularly so as in this country a class of specialists in this department existed in the larger towns. When the sweeping assertion was made in the press and before juries that all deaths under anaesthetics were preventable deaths the corollary was that it might go hardly with an unfortunate practitioner in the coroner’s court or beyond. At present no such proceedings had in fact arisen ; the results of the public inquiries had been beneficial from the points of view both of education in technique and of allaying the public fear which was probable if such misfortunes were hushed up and hidden from reasonable investigation. In any case, whenever a post-mortem examination was ordered by