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ŒDEMA OF THE GROIN IN ACUTE PERITONITIS.
210
VAPOUR BATHS IN THE TREATMENT OF BRONCHIECTASIS.
GUAIACOL
BY G. HEARN
PARRY, M.B., C.M. EDIN.,
SENIOR RESIDENT MEDICAL OFFICER TO THE ROYAL NATIONAL HOSPITAL FOR CONSUMPTION AND DISEASES OF THE CHEST, VENTNOR.
the fcetor returned to the expectoration, the quantity of which was not diminished. On the 12th Dr. Coghill prescribed vapour baths of guaiacol which were given daily till the patient left the hospital, the duration of the bath being gradually increased from 10 to 60 minutes, as shown in the following table :-
indebted to the late Dr. Sinclair Coghill (formerly physician to the Royal National Hospital for Consumption and Diseases of the Chest), in whose block at the hospital the patient was treated, for permission to publish details of the following case of bronchiectasis which rapidly improved after treatment by vapour baths of guaiacol, when baths of commercial creasote as advocated by other authorities had had to be abandoned on account of the unfavourable results
J
AM
senior
produced. ’ The patient, a woman, 27 years of age, was admitted to the hospital on Jan. 9th, 1399, complaining of severe cough, foul expectoration, and loss of appetite. The illness was of about eight years’ duration and appeared to have originated from bronchitis following upon influenza. She had been an in-patient of the hospital in 1894, 1895, and 1897, and had improved slightly under the administration of cod-liver oil and guaiacol. During her last residence in the hospital she was treated in addition by hypodermic injections of guaiacol and strychnine with some beneficial results. On her re-admission, on Jan. 9th, 1899, the patient stated that in the preceding November she was troubled with a tight feeling at the base of the left lung and that her cough became more frequent and more paroxysmal. Soon afterwards, after a severe fit of coughing, she expectorated about a pint of dark-green matter which her mother said smelt very badly, although she herself, she said, did not notice its foul odour. These bouts of coughing had since continued and they were always relieved by the expulsion of large quantities of similar matter. The appetite had gradually been getting worse and she was losing weight. On examination the usual physical signs of a bronchiectatic cavity were detected in the left infrascapular region. With the’exception of slight dulness on percussion over the left apex anteriorly no abnormal physical signs were detected elsewhere. The fingers of both hands were markedly clubbed. The fcetor of the breath was marked, so much so that her society was shunned by the other occupants of the sittingroom allotted to her in the hospital and, as she herself stated, her condition was a source of misery to herself and all around her. The character of the expectoration wasI typical of bronchiectasis. On standing three layers could be distinctly made out. The uppermost layer was brownish in colour and thin and frothy, the middle layer was a light greenish fluid, and the lowest layer was a thick, turbid, and purulent mass. On microscopic examination this lowest layer was found to contain debris of connective tissue and many staphylococci. A few of Dittrich’s plugs were observed but no tubercle bacilli. The reaction was faintly acid. For the first month of her stay at the hospital she was treated by hypodermic injections of guaiacol and strychnine and constantly used Coghill’s dry inhaler moistened with encalyptol, chloroform, and guaiacol. The sputum during Intra-tracheal this period averaged 55 ounceg per week. injections of oil of eucalyptus, castor-oil, and balsam of Peru There was no improvement in the symwere also tried. ptoms, but on the contrary she lost weight and the factor of the breath became more pronounced. On seven occasions between Feb. 3rd and Feb. 15th the evening temperature ranged between 100° and 101’6°F. The remainder of the story can best be told by reference to the case-book, from which the following are abstracts. The expectoration during the week ended Feb. 14th weighed 55 ounces. On the 15th a vapour bath of commercial creasote was given for 10 minutes. These vapour baths of commercial creasote were given daily with an intermission of three days till the 25th. The patient was much exhausted after them and had to be kept in bed for the remainder of the day and she failed to get used to them. Her general appearance gradually got worse, her appetite fell off altogether, and a condition of acute bronchitis was set up. On nine occasions between the 15th and the 26th the evening temperature ranged between 100 2° and 102’40. On the 26th the hypodermic injections of guaiacol and strychnine were renewed. The patient’s temperature and general appearance improved during the week ended March 3rd, but
On the 19th she felt much better in every way and had much less discomfort during the bath ; her appetite had improved, and her breath was almost odourless. The evening temperature ranged between 99° and 1014° from Feb. 26th to March 26th. On March 27th it fell to normal and remained so with one exception (on March 30th) when it rose to 101°. The quantity of the expectoration gradually decreased and the patient began to regain the weight she had lost. She leftthe hospital on April 14th. Ventnor.
ŒDEMA OF THE GROIN IN ACUTE PERITONITIS. BY E. WHARMBY BATTLE, M.R.C.S. ENG., L.R.C.P. LOND., JUNIOR
HOUSE SURGEON TO THE WARRINGTON INFIRMARY; HOUSE SURGEON TO THE MANCHESTER ROYAL INFIRMARY.
LATE
IN THE LANCET of March 27th, 1897, Mr. W. H. Battle recorded a case of acute peritonitis in which a curious oedematous condition of the groins was present as a symptom before death. A post-mortem examination of this case showed considerable subperitoneal oedema extending along both inguinal canals into the scrotum, and acute peritonitis characterised by much recent lymph formation and adhesions mainly affecting the pelvic peritoneum. On the condition of the subperitoneum in this and also in a second case in which, however, no cedema of the groins was noticed Mr. Battle bases the suggestion that the latter is due to an " escape of some of the fluid (subperitoneal) along the inguinal canals into the groin and to a less extent into the scrotum." Two fatal cases of acute peritonitis have recently come under my notice in the Warrington Infirmary in which cedema of both groins was a marked, though late, symptom and remained a prominent feature for some time after death. Apparently the condition is not a common one, and until the appearance of the article referred to, if seen, was unrecorded. I am not aware of any further instance having been noticed in surgical literature. For permission to publish the following cases I am indebted to the kindness of Dr. A. E. Fox and Mr. C. E. Richmond respectively. CASE l.-On Sept>. 29th, 1896, a man, aged 49 years, walked into the accident-room of the Warrington Infirmary. He stated that a week previously after a meal of mutton chops he was seized with abdominal pain, sickness, and diarrhoea. On the second day the last-named symptom abated, the pain and vomiting, however, persisting, and at times being very intense. Difficulty in micturition had been an additional trouble during that day and on the previous day. The general appearance of the man was bad ; he was cyanosed, cold, and evidently in great distress. Once in bed, warmth and stimulants temporarily improved his condition. He then complained of no special pain. He had a typical abdominal facies, with a dry and brown tongue. The pulse was small, quick, and feeble. At short intervals the patient vomited small quantities of a foul-smelling, coffee- ground -11 ke fluid. The abdomen was moderately distended, generally tympanitic and tender. In both groins there was a localised symmetrical oedema extending into the flanks and upwards on to the lower part of the abdominal walls to the extent of a hand’s breadth above Poupart’s
211
ligament.
This oedema terminated
upwards
as
well
as i
How the
spread
of
inflammatory
action to the
groins
downwards in a definite margin raised above the level occurs is at present a matter of uncertainty. The crural of the neighbouring, apparently uninvolved, parts. The canal may be excluded, lying as it does outside the junction
upper limit was roughly concave. The overlying skin was dusky red tint, pitting on pressure. The scrotum and penis were normal. A catheter was passed and the urine obtained was barely a teaspoonful in amount and apparently normal. Rapid collapse negatived operation and the patient of a
of the
It is difficult to imagine the scrotum uninvolved in an acute cellulitis reaching the remaining thigh by the inguinal canal. On the other hand, there is a strong probability that extension might occur through the lower part of the abdominal walls by way of the loose areolar tissue in the inter-tendinous and inter-muscular two fascia;.
died 12 hours after admission. The diagnosis in this case obscure; the appearance and extent of the cedema spaces. Analysis of the conditions common to the above cases and pointed to an acute peritonitis of a very virulent type. At the necropsy, which was made five hours after death, to that of Mr. W. H. Battle shows-1. Symptoms of acute the abdomen was found to be greatly distended. The con- peritonitis with those of inflammatory oedema extending to dition and extent of the oedema were unaltered. After open- both groins, the flanks, and in one case to the lower part the abdominal walls. 2. Limitation of the inflammatory ing the abdominal cavity a portion of very dilated bowel presented in the wound. This proved to be the cascum process to, or a greater intensity in, the pelvic portion of the enlarged to an enormous size. It extended from the right peritoneum. In Mr. Battle’s case it affected mainly the flank upwards and to the left across the abdomen, pelvis and was limited above to those parts of the general occupying the umbilical and leftt hypochondriacal cavity in the neighbourhood of the cascum and the sigmoid regions. At its junction with the remainder of flexure. In Case 1 given above there was general peritonitis, the large intestine it was twisted, and this twisted but the pelvis and the parts around the cascum were those portion was bent at an acute angle on the rest of most involved. The peritonitis in Case 2 was most acute in the gut. Round this part a loop of small intestine had the region of the fractured ilium; the right fossa contained wound itself so tightly that it was impossible to say whether a distinct collection of pus. 3. All three cases (that* the kinking of the bowel or the constriction by the loop of recorded by Mr. W. H. Battle and the two cases here small intentine was the primary condition. There was described) were fatal. Four days after the onset of acute general peritonitis which was especially marked in the pelvis. abdominal symptoms was the duration in Mr. Battle’s case. Here, as well as around the site of the obstruction, there The time cannot be definitely stated in the first of the were much recent adhesion and lymph formation. The above two cases. The man roughly dated the commencedilated cascum contained a thin, black, foul-smelling fluid in ment of his illness at a week previously to admission. which were found numerous large fish bones and (presumably) His condition did not become urgent until two days pieces of mutton-bone. One of the former measured an inch later from his own account. The oedema, was noticed in length; a piece of mutton-bone was three-quarters of an soon after admission, 12 hours after which he died. The inch across. The remaining large intestine was empty and patient in the second case was brought to hospital immecollapsed. The small gut was distended and contained a diately after the accident and lived only 52 hours. The brownish feculent fluid. degree of inflammatory disturbance was quite proportionate CASE 2.-This was the case of a man, aged 39 years, to the rapid fatality though abdominal shock is an element who was crushed beneath a heavy weight. He was admitted not to be overlooked in this case. In all the cedema seemed in the early morning of March 24th, 1899, suffering con- to foreshadow a condition of peritonitis of a septic and pecusiderably from shock. There was a fracture of the pelvis. liarly malignant type and one in which any operative interThe urine, drawn by a catheter, was normal. His condition ference would have had a very limited chance of success. was very grave from the onset. On the second day abdoWarrington. minal symptoms were noticed; some distension appeared, with dulness in the right flank. There were pain and tenderness. The bowels were opened once. No vomiting occurred. THE POSSIBILITY OF THE SUCCESSFUL Death took place 52 hours after the accident. OUTDOOR TREATMENT OF TUBERCUThe post-mortem examination showed the abdomen to be a Both were distended. occupied by symLOSIS IN LONDON: groins slightly metrical oedema reaching into the flanks and similar to that AN ILLUSTRATIVE CASE. noticed in Case 1 with the exception that there was no osdema of the abdominal walls. The scrotum and penis were BY DAVID SOMMERVILLE, M.D.R.U.I. normal. On opening the abdomen marked peritonitis was found in the right flank, the intestines being matted together A MAN, aged 21 years, a native of Germany, was sent to with large flakes of yellowish lymph. This condition was intensified in the pelvis and especially in the right iliac fossa London to acquire English and a knowledge of office work in where there was a collection of purulent fluid. No injury of an English business house. He had suffered from lung the abdominal organs was found. The line of fracture in the trouble, which would seem to have been tuberculosis, several pelvis ran across the right iliac fossa and the left pubic rami. years before, and he had always had a " weak chest," and The softened condition of the parts made a search for wounds of the peritoneum in the region of the fracture well-nigh his "throat gave him trouble." When I first saw him heimpossible. The extent and symmetry of the oedema point said that he had had a "cold" for about three months and to its limitation in a downward direction by the blending of that he had just returned from Brighton where he had hoped the deep layer of the superficial abdominal fascia with the to throw it off. At this date-the first week in April, 1899fascia lata. On each side by a tongue-shaped area it he was emaciated and and to the most casual observer weak descended well outside the femoral ring into the thigh for appeared quite ill. On examination his chest was found to some foar or five inches, and crossing the limb by a convex border rounded it below the anterior superior iliac spine. present typical signs of pulmonary tuberculosis. The supraIn neither of the above cases was there any fluid in the sub- clavicular and infra-clavicular regions were quite hollow on peritoneum and in both there was absence of cedema about both sides, but more so on the right. The vesicular murmur at, the external genitals. The osdema in Case 1 was the more the right apex was replaced by fine rales and signs of conextensive, involving the lower part of the abdominal walls. solidation were apparent for some little distance downwards It was probably also of longer duration. Tenderness was and inwards from the middle point of the clavicle on this present though merged in that generally present over the side. BtUes were not heard at the left apex, but inspiration whole abdomen, and as a symptom it was obscured by the was ill-defined and was of the " cog-wheelvariety. collapsed state of the patient. Redness of the skin also Expiration was much prolonged. The sputum was nummular existed, as was noticed in the case recorded by Mr. W. H. and streaked with blood; a bacteriological examination Battle. These three symptoms-viz., an oedema marked by revealed numerous tubercle bacilli and there was marked tenderness and redness of the overlying skin-suggest a haemoptysis. The pharynx presented a congested and distinct cellulitic process and evidence an acute inflammatory swollen appearance, the dusky red colour being relieved change rather than a passive exudation of fluid from sub- here and there by paler patches. The larynx partook of this peritoneal effusion above. Case 2 being of traumatic origin congestion to a considerable degree, especially in the neigh, it might possibly be urged that the cedema resulted from the bourhood of the arytenoid folds and the mucous membrane general injury, but the line of the fracture and the around the posterior ends of the vocal cords. When it is added that an elevation of temperature was found in the symmetry of the oedema negative such an assumption. was
of
VAPOUR BATHS IN THE TREATMENT OF BRONCHIECTASIS.
GUAIACOL
BY G. HEARN
PARRY, M.B., C.M. EDIN.,
SENIOR RESIDENT MEDICAL OFFICER TO THE ROYAL NATIONAL HOSPITAL FOR CONSUMPTION AND DISEASES OF THE CHEST, VENTNOR.
the fcetor returned to the expectoration, the quantity of which was not diminished. On the 12th Dr. Coghill prescribed vapour baths of guaiacol which were given daily till the patient left the hospital, the duration of the bath being gradually increased from 10 to 60 minutes, as shown in the following table :-
indebted to the late Dr. Sinclair Coghill (formerly physician to the Royal National Hospital for Consumption and Diseases of the Chest), in whose block at the hospital the patient was treated, for permission to publish details of the following case of bronchiectasis which rapidly improved after treatment by vapour baths of guaiacol, when baths of commercial creasote as advocated by other authorities had had to be abandoned on account of the unfavourable results
J
AM
senior
produced. ’ The patient, a woman, 27 years of age, was admitted to the hospital on Jan. 9th, 1399, complaining of severe cough, foul expectoration, and loss of appetite. The illness was of about eight years’ duration and appeared to have originated from bronchitis following upon influenza. She had been an in-patient of the hospital in 1894, 1895, and 1897, and had improved slightly under the administration of cod-liver oil and guaiacol. During her last residence in the hospital she was treated in addition by hypodermic injections of guaiacol and strychnine with some beneficial results. On her re-admission, on Jan. 9th, 1899, the patient stated that in the preceding November she was troubled with a tight feeling at the base of the left lung and that her cough became more frequent and more paroxysmal. Soon afterwards, after a severe fit of coughing, she expectorated about a pint of dark-green matter which her mother said smelt very badly, although she herself, she said, did not notice its foul odour. These bouts of coughing had since continued and they were always relieved by the expulsion of large quantities of similar matter. The appetite had gradually been getting worse and she was losing weight. On examination the usual physical signs of a bronchiectatic cavity were detected in the left infrascapular region. With the’exception of slight dulness on percussion over the left apex anteriorly no abnormal physical signs were detected elsewhere. The fingers of both hands were markedly clubbed. The fcetor of the breath was marked, so much so that her society was shunned by the other occupants of the sittingroom allotted to her in the hospital and, as she herself stated, her condition was a source of misery to herself and all around her. The character of the expectoration wasI typical of bronchiectasis. On standing three layers could be distinctly made out. The uppermost layer was brownish in colour and thin and frothy, the middle layer was a light greenish fluid, and the lowest layer was a thick, turbid, and purulent mass. On microscopic examination this lowest layer was found to contain debris of connective tissue and many staphylococci. A few of Dittrich’s plugs were observed but no tubercle bacilli. The reaction was faintly acid. For the first month of her stay at the hospital she was treated by hypodermic injections of guaiacol and strychnine and constantly used Coghill’s dry inhaler moistened with encalyptol, chloroform, and guaiacol. The sputum during Intra-tracheal this period averaged 55 ounceg per week. injections of oil of eucalyptus, castor-oil, and balsam of Peru There was no improvement in the symwere also tried. ptoms, but on the contrary she lost weight and the factor of the breath became more pronounced. On seven occasions between Feb. 3rd and Feb. 15th the evening temperature ranged between 100° and 101’6°F. The remainder of the story can best be told by reference to the case-book, from which the following are abstracts. The expectoration during the week ended Feb. 14th weighed 55 ounces. On the 15th a vapour bath of commercial creasote was given for 10 minutes. These vapour baths of commercial creasote were given daily with an intermission of three days till the 25th. The patient was much exhausted after them and had to be kept in bed for the remainder of the day and she failed to get used to them. Her general appearance gradually got worse, her appetite fell off altogether, and a condition of acute bronchitis was set up. On nine occasions between the 15th and the 26th the evening temperature ranged between 100 2° and 102’40. On the 26th the hypodermic injections of guaiacol and strychnine were renewed. The patient’s temperature and general appearance improved during the week ended March 3rd, but
On the 19th she felt much better in every way and had much less discomfort during the bath ; her appetite had improved, and her breath was almost odourless. The evening temperature ranged between 99° and 1014° from Feb. 26th to March 26th. On March 27th it fell to normal and remained so with one exception (on March 30th) when it rose to 101°. The quantity of the expectoration gradually decreased and the patient began to regain the weight she had lost. She leftthe hospital on April 14th. Ventnor.
ŒDEMA OF THE GROIN IN ACUTE PERITONITIS. BY E. WHARMBY BATTLE, M.R.C.S. ENG., L.R.C.P. LOND., JUNIOR
HOUSE SURGEON TO THE WARRINGTON INFIRMARY; HOUSE SURGEON TO THE MANCHESTER ROYAL INFIRMARY.
LATE
IN THE LANCET of March 27th, 1897, Mr. W. H. Battle recorded a case of acute peritonitis in which a curious oedematous condition of the groins was present as a symptom before death. A post-mortem examination of this case showed considerable subperitoneal oedema extending along both inguinal canals into the scrotum, and acute peritonitis characterised by much recent lymph formation and adhesions mainly affecting the pelvic peritoneum. On the condition of the subperitoneum in this and also in a second case in which, however, no cedema of the groins was noticed Mr. Battle bases the suggestion that the latter is due to an " escape of some of the fluid (subperitoneal) along the inguinal canals into the groin and to a less extent into the scrotum." Two fatal cases of acute peritonitis have recently come under my notice in the Warrington Infirmary in which cedema of both groins was a marked, though late, symptom and remained a prominent feature for some time after death. Apparently the condition is not a common one, and until the appearance of the article referred to, if seen, was unrecorded. I am not aware of any further instance having been noticed in surgical literature. For permission to publish the following cases I am indebted to the kindness of Dr. A. E. Fox and Mr. C. E. Richmond respectively. CASE l.-On Sept>. 29th, 1896, a man, aged 49 years, walked into the accident-room of the Warrington Infirmary. He stated that a week previously after a meal of mutton chops he was seized with abdominal pain, sickness, and diarrhoea. On the second day the last-named symptom abated, the pain and vomiting, however, persisting, and at times being very intense. Difficulty in micturition had been an additional trouble during that day and on the previous day. The general appearance of the man was bad ; he was cyanosed, cold, and evidently in great distress. Once in bed, warmth and stimulants temporarily improved his condition. He then complained of no special pain. He had a typical abdominal facies, with a dry and brown tongue. The pulse was small, quick, and feeble. At short intervals the patient vomited small quantities of a foul-smelling, coffee- ground -11 ke fluid. The abdomen was moderately distended, generally tympanitic and tender. In both groins there was a localised symmetrical oedema extending into the flanks and upwards on to the lower part of the abdominal walls to the extent of a hand’s breadth above Poupart’s
211
ligament.
This oedema terminated
upwards
as
well
as i
How the
spread
of
inflammatory
action to the
groins
downwards in a definite margin raised above the level occurs is at present a matter of uncertainty. The crural of the neighbouring, apparently uninvolved, parts. The canal may be excluded, lying as it does outside the junction
upper limit was roughly concave. The overlying skin was dusky red tint, pitting on pressure. The scrotum and penis were normal. A catheter was passed and the urine obtained was barely a teaspoonful in amount and apparently normal. Rapid collapse negatived operation and the patient of a
of the
It is difficult to imagine the scrotum uninvolved in an acute cellulitis reaching the remaining thigh by the inguinal canal. On the other hand, there is a strong probability that extension might occur through the lower part of the abdominal walls by way of the loose areolar tissue in the inter-tendinous and inter-muscular two fascia;.
died 12 hours after admission. The diagnosis in this case obscure; the appearance and extent of the cedema spaces. Analysis of the conditions common to the above cases and pointed to an acute peritonitis of a very virulent type. At the necropsy, which was made five hours after death, to that of Mr. W. H. Battle shows-1. Symptoms of acute the abdomen was found to be greatly distended. The con- peritonitis with those of inflammatory oedema extending to dition and extent of the oedema were unaltered. After open- both groins, the flanks, and in one case to the lower part the abdominal walls. 2. Limitation of the inflammatory ing the abdominal cavity a portion of very dilated bowel presented in the wound. This proved to be the cascum process to, or a greater intensity in, the pelvic portion of the enlarged to an enormous size. It extended from the right peritoneum. In Mr. Battle’s case it affected mainly the flank upwards and to the left across the abdomen, pelvis and was limited above to those parts of the general occupying the umbilical and leftt hypochondriacal cavity in the neighbourhood of the cascum and the sigmoid regions. At its junction with the remainder of flexure. In Case 1 given above there was general peritonitis, the large intestine it was twisted, and this twisted but the pelvis and the parts around the cascum were those portion was bent at an acute angle on the rest of most involved. The peritonitis in Case 2 was most acute in the gut. Round this part a loop of small intestine had the region of the fractured ilium; the right fossa contained wound itself so tightly that it was impossible to say whether a distinct collection of pus. 3. All three cases (that* the kinking of the bowel or the constriction by the loop of recorded by Mr. W. H. Battle and the two cases here small intentine was the primary condition. There was described) were fatal. Four days after the onset of acute general peritonitis which was especially marked in the pelvis. abdominal symptoms was the duration in Mr. Battle’s case. Here, as well as around the site of the obstruction, there The time cannot be definitely stated in the first of the were much recent adhesion and lymph formation. The above two cases. The man roughly dated the commencedilated cascum contained a thin, black, foul-smelling fluid in ment of his illness at a week previously to admission. which were found numerous large fish bones and (presumably) His condition did not become urgent until two days pieces of mutton-bone. One of the former measured an inch later from his own account. The oedema, was noticed in length; a piece of mutton-bone was three-quarters of an soon after admission, 12 hours after which he died. The inch across. The remaining large intestine was empty and patient in the second case was brought to hospital immecollapsed. The small gut was distended and contained a diately after the accident and lived only 52 hours. The brownish feculent fluid. degree of inflammatory disturbance was quite proportionate CASE 2.-This was the case of a man, aged 39 years, to the rapid fatality though abdominal shock is an element who was crushed beneath a heavy weight. He was admitted not to be overlooked in this case. In all the cedema seemed in the early morning of March 24th, 1899, suffering con- to foreshadow a condition of peritonitis of a septic and pecusiderably from shock. There was a fracture of the pelvis. liarly malignant type and one in which any operative interThe urine, drawn by a catheter, was normal. His condition ference would have had a very limited chance of success. was very grave from the onset. On the second day abdoWarrington. minal symptoms were noticed; some distension appeared, with dulness in the right flank. There were pain and tenderness. The bowels were opened once. No vomiting occurred. THE POSSIBILITY OF THE SUCCESSFUL Death took place 52 hours after the accident. OUTDOOR TREATMENT OF TUBERCUThe post-mortem examination showed the abdomen to be a Both were distended. occupied by symLOSIS IN LONDON: groins slightly metrical oedema reaching into the flanks and similar to that AN ILLUSTRATIVE CASE. noticed in Case 1 with the exception that there was no osdema of the abdominal walls. The scrotum and penis were BY DAVID SOMMERVILLE, M.D.R.U.I. normal. On opening the abdomen marked peritonitis was found in the right flank, the intestines being matted together A MAN, aged 21 years, a native of Germany, was sent to with large flakes of yellowish lymph. This condition was intensified in the pelvis and especially in the right iliac fossa London to acquire English and a knowledge of office work in where there was a collection of purulent fluid. No injury of an English business house. He had suffered from lung the abdominal organs was found. The line of fracture in the trouble, which would seem to have been tuberculosis, several pelvis ran across the right iliac fossa and the left pubic rami. years before, and he had always had a " weak chest," and The softened condition of the parts made a search for wounds of the peritoneum in the region of the fracture well-nigh his "throat gave him trouble." When I first saw him heimpossible. The extent and symmetry of the oedema point said that he had had a "cold" for about three months and to its limitation in a downward direction by the blending of that he had just returned from Brighton where he had hoped the deep layer of the superficial abdominal fascia with the to throw it off. At this date-the first week in April, 1899fascia lata. On each side by a tongue-shaped area it he was emaciated and and to the most casual observer weak descended well outside the femoral ring into the thigh for appeared quite ill. On examination his chest was found to some foar or five inches, and crossing the limb by a convex border rounded it below the anterior superior iliac spine. present typical signs of pulmonary tuberculosis. The supraIn neither of the above cases was there any fluid in the sub- clavicular and infra-clavicular regions were quite hollow on peritoneum and in both there was absence of cedema about both sides, but more so on the right. The vesicular murmur at, the external genitals. The osdema in Case 1 was the more the right apex was replaced by fine rales and signs of conextensive, involving the lower part of the abdominal walls. solidation were apparent for some little distance downwards It was probably also of longer duration. Tenderness was and inwards from the middle point of the clavicle on this present though merged in that generally present over the side. BtUes were not heard at the left apex, but inspiration whole abdomen, and as a symptom it was obscured by the was ill-defined and was of the " cog-wheelvariety. collapsed state of the patient. Redness of the skin also Expiration was much prolonged. The sputum was nummular existed, as was noticed in the case recorded by Mr. W. H. and streaked with blood; a bacteriological examination Battle. These three symptoms-viz., an oedema marked by revealed numerous tubercle bacilli and there was marked tenderness and redness of the overlying skin-suggest a haemoptysis. The pharynx presented a congested and distinct cellulitic process and evidence an acute inflammatory swollen appearance, the dusky red colour being relieved change rather than a passive exudation of fluid from sub- here and there by paler patches. The larynx partook of this peritoneal effusion above. Case 2 being of traumatic origin congestion to a considerable degree, especially in the neigh, it might possibly be urged that the cedema resulted from the bourhood of the arytenoid folds and the mucous membrane general injury, but the line of the fracture and the around the posterior ends of the vocal cords. When it is added that an elevation of temperature was found in the symmetry of the oedema negative such an assumption. was
of