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CLINICAL SOCIETY OF LONDON. FRIDAY, MARCH 12TH, 1869.
462 after
CLINICAL SOCIETY OF LONDON. FRIDAY, MARCH 12TH, 1869. MR. PAGET, PRESIDENT, IN THE CHAIR. DR. DAY communicated a case of enlargement of the right lower limb, with distension of the subcutaneous lymphatics of the penis and scrotum, and occasional discharge of chylous fluid, in a child aged seven years. The enlargement was first observed when the patient was two
i
years and a half old, and was considered to be due rather to infiltration of the subcutaneous cellular tissue than to hypertrophy. In 1866 the case was seen by Mr. Paget, who pronounced that the condition of the limb was not cedema, but overgrowth, and believed that it was due to obstruction of the femoral vein, there being at that time no indication of disease of the lymphatics. Towards the end of the same year the prepuce became enlarged and indurated, and in ’, 1868 a vesicle, not surrounded with redness, appeared at ’, the edge of the frsenum other similar vesicles subsequently presenting themselves on the scrotum and on various parts of the affected limb, soon after the vesicle first formed began to discharge. Since this period the discharge has recurred at intervals in increasing quantity, the patient’s health being generally good, with the exception that each discharge is preceded by oppression and followed by more or less exhaustion. The case had been referred at the last meeting to a committee, who reported that they had directed their attention in the first place to the nature of the enlargement of the right lower limb. From comparative measurement they had concluded that the bones and muscles participated no less than the skin and cellular tissue in the overgrowth. They were further of opinion, from the examination of the patient, that the hypertrophy was intimately connected with the distended state of the lymphatics. In confirmation of this view, they referred to four previously recorded cases in which lymphorrhagia with dilated lymphatics was associated with hypertrophy of the affected part, as well as to the researches of Virchow as to true hypertrophy of the tongue, which show that in that disease the muscular overgrowth is also of lymphatic origin., A discussion followed, in which Dr. Cholmeley and Mr. Barwell expressed the opinion that the enlargement of the limb was due to excessive arterial supply, and that accordingly the proper treatment would be to apply continuous pressure to the femoral artery. Dr. Broadbent, on the other hand, agreed with Dr. Day in believing that the overgrowth was to be attributed to the detention in the affected parts of lymph, which, in common with most physiologists, he regarded, not as an excretion, but as a nutritive liquid. The PRESIDENT, after expressing his general concurrence with Dr. Broadbent, briefly related a case in which it was clear that hypertrophy of the muscles of a limb had resulted from obstruction of a vein receiving its tributaries from them. He referred in illustration to the fact in comparative anatomy that those muscles which required to cone. g., the muscles of tract strongly for short periods Right in birds-are always richly supplied with veins, the plexiform arrangement of which seems adapted to secure the sufficient detention of blood in the muscular tissue. It was the consideration of this fact that had led him, when first asked to see the case at a period when there was no indication of disease of the lymphatics, to infer that the hypertrophy might be due to venous obstruction. He thought that although there was no doubt that the disease had its origin in the condition of the lymphatics, yet there was much obscurity both as to the nature of the change they had undergone, and as to the reason why the liquid -
was
chylous.
Mr. BARWELL
reported a case of Pysemia with pneumoby himself and Sir Thomas Watson. A gentleman, thirty-nve years of age, after pain in the axilla, suffered from a small abscess in the armpit. A sudden change in his temper and manners caused fear of mental
thorax,
seen
derangement.
Pneumothorax succeeded.
Besides the ori-
ginal abscess pus collected in the knee and elsewhere. Coma supervened, and he died after fifty-five days. The pyasmia here arose from a slight cause. The sudden change of the
patient’s
tone and manner is not an isolated or unusual coMr. Barwell had seen it in many cases, so that
incidence.
an
injury,
patient’s
manner
a change in the and mental depresof pyæmia; at least,
surgical operation,
or
to sullen
moroseness
sion was, in his belief, the first sign its occurrence was of great import. After the narration of a case of Typhoid Fever by Dr. JULIUS POLLOCK, Dr. LANGDON DOWN related his case illustrative of the beneficial employment of "Pancreatine"" in the treatment of fatty alvine evacuations. After some observations by Drs. Baamler, Broadbent, and Church, Mr. GASCOYEN related a fatal case, in which, as in Dr. Down’s patient, diarrhoea, adiposa was complicated with diabetes. On dissection, it was found that there was complete atrophy of the pancreas. After a few remarks by the President relating to cases previously recorded, the Society adjourned. THE
SICK
POOR
OF
PARIS.
BY BLANCHARD JERROLD. No. II.
(Concluded from p. 432.) WE now come to the work of the medical staff. In 1865 there were 202 doctors on the home-treatment service, 204 in 1866, and 205 in 1867. Of these, 8 were exclusively engaged in receiving out-patients in the various maisons de In 1865 the average of patients for each doctor secours. was 274, 281 in 1866, and 277 in 1867. The figures are twisted many ways, in order to show the working of the system by every available light. In 1865, 203,393 Assistance doctors’ home visits were made; in 1866, 199,577; and in 1867, 189,093. In 1865 the average number of visits made by each medical man was 1048’42; in 1866, 1018’25; and in 1867, 959’86. We have even a fractional aperçu of the average daily work of the doctors. In 1865 each doctor paid 2’87 daily visits ; in 1866, 2’79visits; and in 1867 2’63 visits. The medical attention paid to each sick person is stated at three visits and the forty-sixth part of one! The consultations in the maisons de secours have increased. This increase has diminished the home treatment, and consequently effected a saving. In 1865 the number of consultations at the maisons de secours in each arrondissement was 16,209 ; and in each maison de secours 5790. In 1866 the figures were 16,705 for the arrondissement, and 5968 for each maison de secours; in 1867 the arrondissement consultations had reached an average of 17,754, and the maison de secours average was 6340. As the Central Board of the Assistance distributes money to each arrondissement just in proportion to the number of paupers on its books, so it regulates the staff of medical officers by the number of the sick poor. For instance, in the flourishing second arrondissement there were only 62& sick poor cases in 1867. These were attended by six doctors. Each doctor on an average attended 104 patients in the year, and made 597 visits. The medical staff - is not so exactly disposed as to give every Assistance doctor the same work; but the balance is kept roughly, so that none arr overworked. In the eleventh arrondissement I find the medical staff strongest, although the sick poor list is lower than that of the twentieth and nineteenth. The eleventh arrondissement employs 13 doctors in the home treatment of the sick poor, and has 3 medical men exclusively occupied with consultations at the maisons de secours; the fourth arrondissement has 14 doctors and 1 medical officer for consultations; while the twentieth arrondissement has just 12 doctors, although its sick list reached 6482 in 1867, as against the 4970 of the eleventh. In
CLINICAL SOCIETY OF LONDON. FRIDAY, MARCH 12TH, 1869. MR. PAGET, PRESIDENT, IN THE CHAIR. DR. DAY communicated a case of enlargement of the right lower limb, with distension of the subcutaneous lymphatics of the penis and scrotum, and occasional discharge of chylous fluid, in a child aged seven years. The enlargement was first observed when the patient was two
i
years and a half old, and was considered to be due rather to infiltration of the subcutaneous cellular tissue than to hypertrophy. In 1866 the case was seen by Mr. Paget, who pronounced that the condition of the limb was not cedema, but overgrowth, and believed that it was due to obstruction of the femoral vein, there being at that time no indication of disease of the lymphatics. Towards the end of the same year the prepuce became enlarged and indurated, and in ’, 1868 a vesicle, not surrounded with redness, appeared at ’, the edge of the frsenum other similar vesicles subsequently presenting themselves on the scrotum and on various parts of the affected limb, soon after the vesicle first formed began to discharge. Since this period the discharge has recurred at intervals in increasing quantity, the patient’s health being generally good, with the exception that each discharge is preceded by oppression and followed by more or less exhaustion. The case had been referred at the last meeting to a committee, who reported that they had directed their attention in the first place to the nature of the enlargement of the right lower limb. From comparative measurement they had concluded that the bones and muscles participated no less than the skin and cellular tissue in the overgrowth. They were further of opinion, from the examination of the patient, that the hypertrophy was intimately connected with the distended state of the lymphatics. In confirmation of this view, they referred to four previously recorded cases in which lymphorrhagia with dilated lymphatics was associated with hypertrophy of the affected part, as well as to the researches of Virchow as to true hypertrophy of the tongue, which show that in that disease the muscular overgrowth is also of lymphatic origin., A discussion followed, in which Dr. Cholmeley and Mr. Barwell expressed the opinion that the enlargement of the limb was due to excessive arterial supply, and that accordingly the proper treatment would be to apply continuous pressure to the femoral artery. Dr. Broadbent, on the other hand, agreed with Dr. Day in believing that the overgrowth was to be attributed to the detention in the affected parts of lymph, which, in common with most physiologists, he regarded, not as an excretion, but as a nutritive liquid. The PRESIDENT, after expressing his general concurrence with Dr. Broadbent, briefly related a case in which it was clear that hypertrophy of the muscles of a limb had resulted from obstruction of a vein receiving its tributaries from them. He referred in illustration to the fact in comparative anatomy that those muscles which required to cone. g., the muscles of tract strongly for short periods Right in birds-are always richly supplied with veins, the plexiform arrangement of which seems adapted to secure the sufficient detention of blood in the muscular tissue. It was the consideration of this fact that had led him, when first asked to see the case at a period when there was no indication of disease of the lymphatics, to infer that the hypertrophy might be due to venous obstruction. He thought that although there was no doubt that the disease had its origin in the condition of the lymphatics, yet there was much obscurity both as to the nature of the change they had undergone, and as to the reason why the liquid -
was
chylous.
Mr. BARWELL
reported a case of Pysemia with pneumoby himself and Sir Thomas Watson. A gentleman, thirty-nve years of age, after pain in the axilla, suffered from a small abscess in the armpit. A sudden change in his temper and manners caused fear of mental
thorax,
seen
derangement.
Pneumothorax succeeded.
Besides the ori-
ginal abscess pus collected in the knee and elsewhere. Coma supervened, and he died after fifty-five days. The pyasmia here arose from a slight cause. The sudden change of the
patient’s
tone and manner is not an isolated or unusual coMr. Barwell had seen it in many cases, so that
incidence.
an
injury,
patient’s
manner
a change in the and mental depresof pyæmia; at least,
surgical operation,
or
to sullen
moroseness
sion was, in his belief, the first sign its occurrence was of great import. After the narration of a case of Typhoid Fever by Dr. JULIUS POLLOCK, Dr. LANGDON DOWN related his case illustrative of the beneficial employment of "Pancreatine"" in the treatment of fatty alvine evacuations. After some observations by Drs. Baamler, Broadbent, and Church, Mr. GASCOYEN related a fatal case, in which, as in Dr. Down’s patient, diarrhoea, adiposa was complicated with diabetes. On dissection, it was found that there was complete atrophy of the pancreas. After a few remarks by the President relating to cases previously recorded, the Society adjourned. THE
SICK
POOR
OF
PARIS.
BY BLANCHARD JERROLD. No. II.
(Concluded from p. 432.) WE now come to the work of the medical staff. In 1865 there were 202 doctors on the home-treatment service, 204 in 1866, and 205 in 1867. Of these, 8 were exclusively engaged in receiving out-patients in the various maisons de In 1865 the average of patients for each doctor secours. was 274, 281 in 1866, and 277 in 1867. The figures are twisted many ways, in order to show the working of the system by every available light. In 1865, 203,393 Assistance doctors’ home visits were made; in 1866, 199,577; and in 1867, 189,093. In 1865 the average number of visits made by each medical man was 1048’42; in 1866, 1018’25; and in 1867, 959’86. We have even a fractional aperçu of the average daily work of the doctors. In 1865 each doctor paid 2’87 daily visits ; in 1866, 2’79visits; and in 1867 2’63 visits. The medical attention paid to each sick person is stated at three visits and the forty-sixth part of one! The consultations in the maisons de secours have increased. This increase has diminished the home treatment, and consequently effected a saving. In 1865 the number of consultations at the maisons de secours in each arrondissement was 16,209 ; and in each maison de secours 5790. In 1866 the figures were 16,705 for the arrondissement, and 5968 for each maison de secours; in 1867 the arrondissement consultations had reached an average of 17,754, and the maison de secours average was 6340. As the Central Board of the Assistance distributes money to each arrondissement just in proportion to the number of paupers on its books, so it regulates the staff of medical officers by the number of the sick poor. For instance, in the flourishing second arrondissement there were only 62& sick poor cases in 1867. These were attended by six doctors. Each doctor on an average attended 104 patients in the year, and made 597 visits. The medical staff - is not so exactly disposed as to give every Assistance doctor the same work; but the balance is kept roughly, so that none arr overworked. In the eleventh arrondissement I find the medical staff strongest, although the sick poor list is lower than that of the twentieth and nineteenth. The eleventh arrondissement employs 13 doctors in the home treatment of the sick poor, and has 3 medical men exclusively occupied with consultations at the maisons de secours; the fourth arrondissement has 14 doctors and 1 medical officer for consultations; while the twentieth arrondissement has just 12 doctors, although its sick list reached 6482 in 1867, as against the 4970 of the eleventh. In