A CASE OF EXOMPHALOS WITH OTHER MALFORMATIONS.

442 On June 27th he again scratched himself on the endthese cases been infected by plague alone I do not think of the right thumb. When removed to the Hygeia he isuppuration would have been found in disseminated foci. had a temperatare of 105°; had a bubo in th3 left axilla IThe better class Chinese do not suffer nearly so much from without lymphangitis ; had a well-marked lymphan- plague. Their houses are slightly cleaner than those of the gitis of the right arm extending up to the level of the lower classes, and they wear shoes with the trousers tied middle of the humerus." Here there was no lymphan- tightly round the stockings, thus cutting off a large amount gitis at first in what I took to be the plague-infected arm, of infecting ground. but it was only non-apparent, as it appeared later, and Actual proof of infection from food will not be easily its intensity can be gauged by the fact that over twenty proved amongst Eastern races, and may arise from infection incisions had t3 be made in it. Professor Aoyama’s own of the animals eaten or from infection of food or vegetables statement is as follows (translated from the German) : " On which have been exposed in plague houses. Infection by June 28’;b, after having finished a dissection, I took my drinking water can only be possible where the most inmeal about half p3.st two and did not enjoy it. After the sanitary wells are allowed to exist. It will probably be meal I went upstairs, when at certain movements of the arm found that, although the infection be carried to these by it will not long survive in any well I felt a slight pain- in the leftarmpit, and on feeling with flies, mosquitoes &c., my finger I found some slightly enlarged glands present. or pool where a free access of air is possible. In the evening I felt very ill, depressed, and languid, burning hot along the whole of the back, whilst the thermometer showed normal temperature. As Mr. Kitasato and I had invited guests that evening I was present at supper. I had no appetite and felt so weak and languid that I often wished to withdraw. At half-past eleven I hurried to my room, when I found my temperature was 39’5° C. I took 1 gramme AND of quinine and slept well. Next morning I awoke and THERAPEUTICAL. noticed on the ulnar side of the left ring-finger a small, whitish-yellow blister, and thence along the back of the hand a red line. From this time I remembered nothing for A CASE OF EXOMPHALOS WITH OTHER more than two weeks.", Now on the evening of his reMALFORMATIONS. moval to the Hygeia and next morning three medical men with as good eyesight as it is possible to have examined BY WALTER M. WOODHOUSE, M.R.C.S. ENG., him and could not see a trace of lymphangitis in the arm, L.R.C.P. LOND., even when local phalangeal trouble was already evident. SENIOR ASSISTANT MEDICAL OFFICER, KENSINGTON INFIRMARY. The lymphangitis of the right arm was caused by the wound of June 27th. The question as to whether there will be A GIRL, aged twenty years, was admitted into Kensington "wound reaction"at the site of infection depends on the or of the and the material purity impurity infecting suscepti- Infirmary on Nov. 5th, 1896, suffering from syphilis. On bility and resisting power of the animal or person inoculated; examination it was found that she had mucous tubercle and in the case of Chinese, who are notoriously susceptible round the vaginal orifice and anus, besides a squamous erupto the disease and have little resisting power, it is little tion on her skin, which she stated had been there since her wonder that lymphangitis should be frequently absent seeing that they die usually from the first to the fourth day, before ninth year. The patient was thought to be in about the sixth lymphangitis, when it is to occur, has had time to make month of pregnancy. Under anti-syphilitic treatment the itself apparent. Lymphangitis may occur late in the disease mucous tubercles cleared up considerably and her general condition greatly improved. On Dec. 18th the patient had a as a sequela, and when it does it often appears in what was which Case 2 is the infected of an sudden and somewhat copius haemorrhage from the limb, example. probably An examination was immediately made and CASE 2.-Dr. Ishigami, assistant to Mr. Kitasato. I I Exami- vagina. nation (June 29th) showed the absence of any open wound the right foot of a foetus was found to be presenting. After the other foot had been brought down some difficulty was on the left hand (he had a left axillary bubo) ; but there was the mark of a small scar on one of the fingers where he said experienced owing to two soft masses which were felt, one he had scratched himself some days before....... On lying posteriorly to the abdomen and the other anteriorly to July 26th lymphangitis of left arm, treated with lead and the head. The former of these was found to be the placenta, opium." I take this as an example of what probably often and a large swelling seemingly attached to the umbilical occurred in the epidemic-inoculation by a small wound, no region ; the latter, a tumour which ruptured prior to wound reaction, no lymphangitis within the first few days, delivery, will be presently described. The mother made an but developing later if the patient survived-even this last con- uninterrupted recovery and is now to all appearances quite dition is not at all necessary. No mention of lymphangitis well. The foetus showed no sign of life ; at the same time, is made by Cerutti, who inoculated six Europeans to preserve there was no evidence of maceration. them from the plague, five of them dying. Professor Aoyama Necropsy.-The child, a female, was twelve inches in length, and his assistants were always particularly careful of their and, as far as the characteristics would permit one to judge, hands whilst examining patients in the wards, using carbolic of about from six and a half to seven months’ development. but it struck me that in the post-mortem room, Both feet presented well-marked talipes varus. There was spray, &0. ; where there was far greater danger, they were careless in a general stunted appearance, the neck being absent, and the not using some) antiseptic oil on their-hands. Although they head, which was flat at the top with a curiously sloping poswashed their hands afterwards in water and alcohol, yet terior part, appeared to spring direct from the shoulders. there would be about two hours during the sectio cadaveris The eyes were prominent and the upper lids seemed much swollen. in which they could easily get infected. Dissection proved the absence of the CASE 3.-A policeman’s wife was "admitted with sore vault of the skull, except some part of the frontal between first and second toes, right foot ; right femoral bubo bone, which was pressed back and closely approxiThe roof of and lymphangitis already suppurating." Here there was mated to the anterior part of the base. evidently a mixed infection of plague and streptococcus at the orbit was absent, leaving the eyeball uncovered on its once and suppuration was rapid. superior aspect, thus explaining the swollen appearance of These views on inoculation I have given somewhat fully, the eyes. Various foramina for vessels and nerves could as this mode of infection has been ridiculed by some plainly be discerned after the skin flaps had been dissected medical men in the Far East without having given much back. What brain matter there was was contained in a attention to the subject. The mere fact that many plague tumour before mentioned over the cervical vertebras and buboes in the groin and armpit suppurate whilst the internal posterior part of the base of the skull. There was no bony enlarged glands in the same patient do not seems to bear out matter behind the usual situation of the foramen magnum, the fact that the streptococcus infection is practically which was absent. The neural arches were deficient over stopped at the primary bubo, whilst a secondary plague the entire spinal column, leaving the spinal canal unenclosed. infection of other glands goes on. The cervical glands Still more remarkable was the arrangement of the abdominal rarely suppurated ; perhaps in inoculation by the mouth and thoracic viscera. The thorax appeared to be abnormally the streptococci had not the same chance of entering the short. From the region of the umbilicus sprang a pedunsystem. In one or two cases multiple abscesses were found, culated mass the size of a large orange, the pedicle being an From the opposite end arose the umbilical as one occasionally gets a pysemia after septicaemia ; but had inch in diameter.

Clinical Notes :

MEDICAL, SURGICAL, OBSTETRICAL,

443 It was one and a half inches. CASE OF PAPILLOMATA OF THE LARYNX IN A may be inferred that the outer coat of the mass was CHILD; RECOVERY AFTER TRACHEOTOMY. with the amnion on the since it was continuous amnion, cord. On internal examination the mass was divided BY G. HUNTER MACKENZIE, M.D. EDIN, into two unequal parts by a flat structure composed of SURGEON FOR DISEASES OF THE THROAT AND NOSE TO THE EYE, EAR, muscular tissue, no doubt diaphragm. The smaller, situated AND THROAT INFIRMARY, EDINBURGH. in the pedicle, contained-the heart with its pericardium, the lower end of the oesophagus, and the lungs. This necessarily A BOY, aged two and a half years, was sent to me at caused elongation of the trachea and bronchi. The large the the the and small Eye, E.ir, and Tnroat Infirmary on Sept. 4t.h, 1895, by stomach, large eavity-containing intestines, liver, and spleen-was lined by a continuation Dr. McCreadie of Leith. His voice had been husky from of the peritoneum. The large intestine re entered the true birth, and for a year previous to admission the vocal abdominal cavity and was continued as the rectum to the symptoms had grown appreciably worse. Latterly the reanus. The thoracic cavity was almost obliterated, containing had become and somewhat spiration noisy especially only the thymus gland. The kidneys and pelvic organs were when he had "cold," to attacks of whichimpeded, be was now very normal. subject. He bad been sivgularly free from the usual troubles Kensington. of infancy and childhood. On admission the boy was in poor general condition, the respiratory act was noisily performed, A CASE OF MALIGNANT DISEASE OF THE RECTUM; and inspiratory djspnae3. was distinctly, but not markedly, present.- He spoke in a whisper. An attempt to use the PERFORATION; DEATH; NECROPSY. laryngoscope alarmed him and induced an aggravation of BY ALONZO G. RIDER, M.B. LOND., the respiratory difficulty with spasm. He was accordingly ASSISTANT SURGEON TO THE ROYAL ALBERT HOSPITAL, DEVONPORT. chloroformed and again examined, without, however, very definite results. On Oct. 7th he had become so much worse ON Sunday morning, May 24th, 1896, I was asked to see a that tracheotomy had to be performed for the relief of the Great improvement followed and he was diswidow woman, aged sixty years, as she was in pain in her breathing. missed in about a week. abdomen. Before I reached the house, however, another The subsequent history of the patient may be briefly summedical man had been called in, as the pain had become marised. Tne tracheotomy tube was worn for seven months. much worse. I did not see the patient, but learned from During this period pieces of warty-looking growths were the patient’s daughter that she was much easier after a hypo- detached from time to time and were coughed up, usually dermic injection of morphia. Next day I was asked to see at such times as the tube was removed for cleansing purTen such pieces, the largest being of about one-half the patient, and the history obtained was as fullows. The poses. the size of a grain of rice, were detached and recovered from patient was seemingly in perfect health till Sunday morning the expectoration and secretion of the trachea and tracheal about eight o’clock, when she was taken with pan in her wound. These were found to be papillomatous in structure. abdomen, which increased rapidly in severity. (There was In June, 1896, being seven months from the date of operation no error in diet to account for this attack.) The pain and two months from the time of expectoration of the last of growth, it was determined to remove the tube and seemed to radiate from the umbilicus, where it was piece close the tracheal opening, and although for a few weeks the most severe, all over the abdomen. Vomiting set in breathing was at times greatly impeded, especially during soon after the attack; it was persistent. at first bileit gradually improved, and re-insertion of the tube was stained and afterwards brownish and offensive. It was sleep, not necessary. The toy (in January, 1897) breathed quite not fecalent. The history obtained gave two or three and about a month previously his normal voice had months alternating constipation and diarrhoea Bright freely, been heard for the first time. blood was often passed with the motions, which were .BM.!M’.—This case is recorded as an example of the frequently flattened. There had been no bladder or uterine success which attends the treatment of papillomata of the troubles. Occasionally the patient felt some dull, aching in children There is larynx by simple tracheotomy. pain over the sacrum, but with this exception be said " she abundant evidence to show that forcible removal of these had never felt better in her life till this attack commenced." or exra-laryngeal operations is There had been very little loss of flesh. The bowels were growths by intra-laryngeal to be followed by rapid and frequent recurrence. very apt easily moved by mild aperients. There was nothing definite Not only so, but in the case of the last mentioned (thyrotomy) with regard to the family history. When seen the patient being adopted an additional and serious drawback is probable was lying on her back with both legs drawn up. The features in the form of permanent injury to the voice. The disease, it were pinched ; the extremities cold and clammy. The pulse will be noted, seems to have been congenital, which is occawas 90, weak, and of low tension. The respirations were 24, the case, although moiefrequently it appears as a sionally not markedly costal. The temperature was 97 4° F. Tne of one of the
6.o,-d, the length of which

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