DOUBLE PHLEGMASIA FOLLOWED BY GANGRENE OF THE RIGHT FOOT.

995 therapeutic effects in diseases due to perverted nutrition. If the latter affections are of nervous origin and are due to imperfect transmission of the nervous influence it is permissible to suggest that electric oscillations act by reestablishing in the nerve a contiguity which had become insnf5cient. The same writer has recently shown that continuous currents of a sufficient electro-motive force produce dn discontinuous conductors the same effects as discharges ,at a distance. It would be interesting, he suggests, to - Jnquire if the mode of action of continuous currents in ,diseases of the nervous system where they have proved useful presents features similar to those which occur in discontinuous conductors. It is not claimed by M. Branly that anything more than a mere analogy has been shown, but ilie thinks it possible that such considerations may prove a useful guide in determining the modality in which elec;tricity is to be employed in a given case, and perhaps furnish 1ihe electro-therapeutist with a good working hypothesis. So far it is evident that such speculations fall very far abort of this. AH that can be claimed is to have made out a case for further inquiry. Such a line of investigation has already been foreshadowed in an article by me which was published in THE LANCET, May 4th, 1895, and in which the following sentence occurs: "It seems even conceivable that other histological arrangements-e.g., those merve fibrils which conduct yet only touch and do not I anastomose, those motor nerve endings which are only ini contact with the sarcous substance ; indeed, any conducting arrangement in the animal body which may be classed as a I bad contact’-may constitute the physiological analogue of what would be electrically known as a coherer.’" ]aeans&eld-street,

W.

Clinical Notes: MEDICAL, SURGICAL, OBSTETRICAL,

AND

THERAPEUTICAL. NOTE ON A CASE OF HYDATID OF THE GALLBLADDER. BY FREDERICK PAGE, M.D. EDIN., M.R.C.S. ENG., SURGEON TO THE NEWCASTLE-UPON-TYNE ROYAL

INFIRMARY.

EARLY last December a man between fifty and sixty years f age was sent to me for surgical treatment by Mr. Martin of Darlington with the following history. For the last five years the patient, who up to that time had always had - excellent health, suffered from occasional attacks of pain in ’tha epigastric region accompanied by vomiting-« bilious .attacka," as he called them. Last summer these attacks became more severe and occurred more frequently. About October he began to lose flesh and the pain and vomiting were almost continuously present. On Nov. 24th he was examined by Mr. Martin, who found a tumour of some size connected with the under surface of the liver which he took to be the ’dilated gall-bladder. He was sent to me early in December. ’On Dec. 9th the abdomen was opened in the right Some aemilsnar line and the gall-bladder was exposed. twelve ounces of clear colourless fluid were drawn off by aspiration and a stone searched for in the cystic duct. None was found and the gall-bladder was incised. Through the ancision a collapsed hydatid cyst at once protruded. This

piece. No bile escaped. The the gall-bladder was then sutured to the skin and the abdominal wound was closed. For eleven days the temperature continued to be normal and all went well, a good deal of clear fluid escaping from the gallbladder quite unstained by bile. On the 23rd the temperature rose to 1020 F. and there was an unpleasant mell about the dressings. On examining the sinus into the gall-bladder its orifice was found to be plugged - firmly by a piece of decomposed hydatid cyst, upon the removal of which a considerable quantity of bile escaped. from this time till the middle of February bile continued to flow, at first so copiously that it was necessary to change the saturated dressings twice and sometimes three times daily. On Jan. 12th the patient was allowed to return to his home at Darlington very much improved and rapidly regaining his was

removed, but

not in one

margin of the incision into

health and strength. now quite well. In this case the

The sinus closed in

February.

He is

gall-bladder was occupied by a single hydatid cyst containing no daughter cysts. A portion of the cyst extending into the cystic duct had evidently not been removed at the time of operation. When this retained portion separated and became lodged in the sinus bile flowed into and distended the gall-bladder, by this time considerably reduced in size, escaping through the sinus as soon as its plugged orifice was freed. Newcastle-upon-Tyne.

DOUBLE PHLEGMASIA FOLLOWED BY GANGRENE OF THE RIGHT FOOT. BY THOMAS

FISHER, M.R.C.S ENG., L.S.A.,

MEDICAL OFFICER OF HEALTH Or GARSTANG.

A WOMAN, aged forty-four years, was confined of her fifteenth child on Nov. 26th, 1895. The confinement was very quick, the child being born on my arrival, but there was a retained placenta with severe post-partum hemorrhage, the patient being in a very collapsed condition ; there were great pallor, some delirium with dilated pupils, rapid breathing, and scarcely perceptible pulse. I dropped the head and raised the limbs, administered stimulants which were swallowed with difficulty, applied ammonia to the nostrils, and injected brandy subcutaneously. The condition of the patient was so serious that I did not deem it advisable to explore the uterus per vaginam until some restoration had taken place, but I simply directed my attention to external expresThe effect of the treatsion and injected ergotin. ment in about an hour’s time was to restore the patient somewhat and I determined on removal of the placenta. Upon vaginal examination I found marked hourglass contraction of the uterus. After careful manipulation I removed the placenta, carefully following the contraction of the uterus with the left hand on the abdomen. The condition of the patient continued very grave, but there was no further heamorrhage. Brandy and beaten egg-and-milk which were given were returned by the patient. Up to the third day the patient remained extremely exhausted, with a subnormal temperature and pulse. On the fourth day some tenderness of the abdomen was complained of and also some pain in the groins; there was offensive diarrhoea and the temperature was 103° F. Up to the eighth day these symptoms continued and both limbs began to show the ordinary signs of phlegmasia, the right limb more markedly, it being very tense and shining with marked tenderness along the femoral and saphenous veins; the lymphatics were also very visibly irritated. The constitutional symptoms were those of marked " adynamia," the pulse being from 120 to 130, with tongue dry and brown, thirst and some delirium, offensive diarrhoea and lochial discharge, the temperature varying from 102° to 104°. On the twelfth day the right limb presented several bullas and there was distinct oedema, the foot below the ankle being of an ashen-red colour and the toes blue. The general sensibility of the limb was lessened but more especially in the foot. Up to the twentieth day the condition of the patient was exceedingly grave, but nourishment

and stimulants, with quinine, were freely taken and the offensive diarrhoea began to subside, the limb became less swollen, and there was an evident line of demarcation at the base of the toes. Both limbs during this period were elevated, wrapped in cotton wool and dressed with boracic powder. For the next thiee weeks the patient remained very weak; gradually the symptoms of fever subsided, the offensive diarrhoea stopped, and the condition of the patient was much improved and more hopeful. I now decided on removal of the toes, the operation being successful and the wound healing well. The foot was still slightly oedematons ; this The patient was soon about on was in January, 1896. crutches and was in a short period of time able to attend to some of her household duties. In February, 1897, some tenderness and swelling appeared under the surface of the metatarsal bone of the big toe; this being opened up there was evident necrosis. Early in March with the assistance of Dr. G. Gibson this portion of diseased bone was successfully removed. In March, 1898, the condition of the foot was still cedematous, the blood-vessels

996 evidently being unequal to their work, but the patient is now and struck the right buttock a hand’s breadth behind able to perform the greater part of her household duties. the top of the great trochanter against the corner of a Remarks.-This case is interesting, particularly showing table. Soon after this she noticed a small, moveable, the very grave conditions through which a patient may pass nnt-like tumour at the seat of the blow; it had never and yet recover, and it would tend to show the connexion of disappeared but had steadily grown. Lately its growth post-partum haemorrhage with phlegmasia. In a large had been more rapid than at first. It caused a "dragging majority of cases of phlegmasia which have come under my pain" and backache and was especially painful when pressure notice it has been associated with post-partum hsemoirhage. was put upon it in sitting. On examination, to the eye ther I might incidentally mention that this patient had had hour- was nothing but a slight puckering of the skin which looked glass contraction of the uterus three times and that she had also somewhat bluish and congested. Palpation showed a borne two children with double hate lip.. very hard firm tumour rounded in outline ; it measured twa inches in diameter. It was flattened or even cupped on the Garstang. surface and was adherent to the skin, more particularly at the centre where the skin was also puckered ; but it was VENESECTION IN APOPLEXY. moveable on the deeper parts. It did not seem to be encap. BY COLIN CAMPBELL, M.R. C.S. ENG., L.R.C.P. IREL. suled yet it was very sharply circumscribed and the edge

The shape of the tumour was very similar to was rounded. satisfactory result following venesection will that of an old " cupped " blood-clot preserved in spirit; orla magnified red blood corpuscle. On one side of the swelling perhaps justify my recording the following case. Oa Feb. 2ad, 1898, at 5 P.[., I was called to see a man, were two small nodules which were connected with it ; they The mass was clearly moveable over were equally hard. aged sixty-five years, who had been found insensible, ten the but laterally it moved with tha maximus, gluteus minutes before, in his sitting-room. It was at once evident subcutaneous fat. The was diagnosed as a fibroma swelling he had a serious that apoplectic seizure. He was breathing or fibro-sarcoma ; but many other opinions were expressed stertorously, his pupils were unevenly contracted (the right as to its nature who saw it. those Among tho by was smaller than the left), the eyeballs oscillated, his left "old csematoma," "sebaceous arm lay motionless, whilst his right arm moved in short diagnoses were "scirrhus," "gumma," and" bursa." The growth was removed spasmodic jerks. Violent cardiac action was evident cyst," with its outstanding nodules and the skin over it; it reached and without the two or three snirts through baring chest and without a stethoscope a loud mitral systolic as deeply as, but did not involve the fascia over, the gluteus maximus. The wound healed by primary union and the murmur was easily heard. Without delay I opened the left median basilic vein about one-third of an inch. patient left the hospital in December, 1897. On section the as by scraping a Almost immediately a violent convulsion occurred (during tumour cut like the hardest scirrhus, and was obtained, the resemblance was even closer; milky juice the convulsion the blood "spurted" quite three feet), and after the convulsion, as the blood flowed in full stream, one but microscopical examination showed that the tumour was noticed the respirations becoming quieter, the stertor dis- composed chiefly of white fibrous tissue, freely studded with numerous tuberculous giant cell systems. appearing, and the big swollen veins of the neck (very Rewiarks by Mr. GOLDING - BIRD.-I think the correct evident at first) assuming a normal appearance. Then came of the formation of this swelling is as follows. a deep sigh and as over thirty ounces had been drawn I explanation As a result of the injury there was a subcutaneous laceraclosed the vein. A deep sleep followed and in four hours he of tissue with slight baemorrhage; the torn tissue awoke, conscious. The recovery of the patient has since tion and became cheloid and at some time or cicatrised been uninterrupted and it is worthy of note that the cardiac of the other process the new tissue became inoculated mother The patient’s murmur has for the time disappeared. with the tubercle bacillus. The cheloid or fibrous thickendied from apoplexy at the age of fifty-six years and a sister involved the subcutaneous tissue, while the skin over it, ing age of fifty-eight years. THE very

,

atSaddleworth. the

retained its normal condition except that it was adherent. We are so little acquainted with the etiology of scar cheloid that I may mention a case which appears to point towards a possible special poison (? microbic) as giving rise to cheloid. In the spring of 1896 I saw an English officer, twenty-five years of age, who had been wounded in the OF service of the British Central Africa Administration in the neighbourhood of Zomba. He had received two musket slng8 in the right arm, the lower passing through and smashing the lower fourth of the humerus, the upper passing through BRITISH AND FOREIGN. the soft parts near the insertion of the deltoid. He has been attended by the resident surgeon, Dr. Wordsworth Nulla antem est alia pro oerto noseendi via, nisi qnamplnrirnas et Poole, but fifteen hours elapsed before the wound could morbornm et dissectionum historias, tum aliorum turn proprias In less than a month three collectas habere, et inter se oomparare.—MoBQAQNi De Sed. et Ca1L8. be antiseptically dressed. of the wounds had healed ; the fourth had almost closed. dtorb., lib. iv. Prooemium. He then returned to England and I saw him in March, 1896. The wounds were all healed and the arm was perGUY’S HOSPITAL. fectly sound and useful, but each scar had developed a thick A CASE OF CHELOID. and characteristic cheloid, in each case of nearly the size of a walnut. About a year before I saw this case Dr. Poole (Under the care of Mr. GOLDING-BIRD) I MARKED cases of cheloid are always worthy of being had written to me as follows : There is a peculiarity about the natives all their wounds turn to cheloid here ; nearly recorded as being likely to assist us in arriving at a more when and they make use of this peculiarity by heal, they exact knowledge of its etiology. Many writers are of opinion cutting their faces for tribal marks or from an that in America negroes are especially liable to this diseasel idea of beauty, and the wounds leave wheals and The fact that it is unsightly lumps." The fact of the officer wounded in and the idea seems well founded. is wounds in common very suggestive of its the same district developing cheloid is at least sugseptic especially of the influence of environment. In another case being in one way or another microbic in origin, but it may gestive care a cheloid developed, although the wound under The my distinction occur after certainly aseptic operations. often made between " idiopathicand "scar"cheloid is healed by first intention, and it was never in any way septic. The patient was a schoolboy, twelve years old, probably quite artificial, the idiopathic variety developing and in February, 1895, I operated on him for torticollis from some small unnoticed scar. The condition was first by the open method, dividing the sterno-mastoid at its lower described by Alibert, and is often called by his name. A married woman, forty-five years of age, was admitted end. The skin wound was united carefully and a sealed" into Guy’s Hospital in November, 1897. She was in iodoform and collodion dressing was applied; When the appearance a particularly fresh-looking and healthy dressing was removed on the third day on account of discountry-woman. There was no history of syphilis. Both comfort the area (H in. by 2 in.) covered by the dressing her parents had died from "consumption," but her twowas blistered. Boracic acid ointment was then used and children were perfectly healthy. In Jane, 1896, she fell within a month evident thickening of the skin and subcutaneous tissue had developed. This went on to the forma. 1 J. F. Binnie, St. Louis Clinique, September, 1894. tion of a characteristic cheloid like an ivory plaque with

A Mirror

HOSPITAL

PRACTICE,

-