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PAPERS ON SKIN DISEASES.
297 the corpus striatum region consequent on degradation of its tissues-unilateral spasm-in contrast and in comparison with its total loss of equilibration, as by actual breaking up of structure-viz., unilateral palsy. Then, as I think, unilateral spasm
is a good starting-point for the clinical grouping of temporary disorders of speech, sight, and smell, just as unilateral palsy is for continued loss of speech, amaurosis, and anosmia. Partial fits—which, when they precede a full seizure, are often called auræ—are symptoms of very great interest to those working at unilateral convulsive seizures. They are, doubtless, the outward local signs of the first local changes inside. They most frequently occur in the hand, less frequently in one side of the face or one half of the tongue, and least frequently in the leg. Patients, the subjects of the aura, often keep off their fits by a ligature, by rubbing the part, or by some sort of disturbance of it. At the Hospital for the Epileptic and Paralysed, a few days ago, a single woman, thirty-four years of age, described to me partial fits of an unusual kind, and of interest in relation with several subjects in this paper. Her eyes, she said, would " suddenly fix to the left," her head turn to the left, and the arm of the same side would begin next to shake. She did not know whether the face was distorted, but the left side of the nose had sometimes felt as if drawn down. There was no loss of sensibility, nor even giddiness, and the leg had at no time been affected, and she had only had two attacks in which the arm had become involved as mentioned. A little worry, she said, would bring on an attack. A unilateral convulsion sometimes leaves other continued conditions of the muscles of the arm and leg, besides more or less loss of power. The limbs that have suffered most in the fit now and then become the subjects of irregular movements, very like those seen in children who haveunilateral chorea. And it is most important to pay attention to such phenomena, for we should study each disordered movement in reference to the other departures from muscular health which occur in
like chilblains is common; it occurs in in winter, and is connected with loss of hair, The erythema of urticaria is very easily diagnosed: a slight &c. scratching with the nail will produce a wheal. Papules, pale and firm, on the inner aspect of the limbs, with a thickened dull state of skin, constitute lichen; with dark apices (coagulated blood), if in a slight degree and on the arms and anterior aspect of the trunk, as a complication of scabies and of strophulus (pruriginosus) in children; to a marked extent seen in prurigo, accompanied mostly by an inelastic state of skin and the " broad" papules formed by an exaggeration of the little areas enclosed by the natural furrows of the skin: intermingled with vesicles and pustules in scabies; soft and red, and in children with erythema, strophulus; flat and reddish, collected together in little parcels, though discrete, lichen ruber; aggregated and confluent, lichen circumscriptus; formed about the hair follicles, lichen pilaris, pityriasis pilaris, lichen scrofulosus, and the lichen of phthisis. The most common mistake, that of confounding lichen and scabies, is at once avoided by observing the multiform aspect of the latter and the uniform character of the former. Those eruptions in which vesicles and pustules occur are eminently by the occurrence of secretion; and this at once divides diseases into twogreat classes: in the one class, where secretion or discharge occurs, crusts form ; in the other, crusts are entirely absent. Ulcerative diseases are easily recognised. The character of the secretion affords most reliable information. If there be serosity, with crusts, it is intertrigo; if thin, few, flimsy, light-coloured crusts form, and the discharge stiffen linen, it is eczema ; if the crusts be a little thicker and in little circular patches, herpes or vesicular scabies. Sero-purulent, with slight yellow crusts, eczema impetiginodes; or if stuck on and flattened, impetigo contagiosa; purulent, forming thick crusts of a yellow colour, becoming more or less
todes
an
erythema
summer as
this region. Bedford-place, Russell-square, Feb. 1867.
well
as
distinguished
dark, ecthyma, furunculus, purulent scabies, impetigo sycosiforme, impetigo scabida, sycosis; and if cockle-shaped, rupia of course. Sanious, rupia and ecthyma cachecticum. Fatty, acne sebacea, seborrhcea capillitti, seborrhœa, sebaceous ichthvosis (legs.
Hœmorrhagic. hæmidrosis. &e. scales from crusts : scales are altered epithelial cells. Redness with scales, lasting on to chronicity, we see in tinea circinata, erythema circinatum, and herpes iris. Scales, as a primary formation, if partial, in lepra ; if general, ichthyosis. Tubercula are (1) homologous, as in keloid and elephantiasis. Keloid never ulcerates, and occurs about cicatrices and the chest; it is white and hard, with a few vessels coursing over it, with claw-like processes produced by contraction of the hypertrophous growth. Other forms of disease need not be mentioned, save molluscum, which consists either of an increase of the fibro-cellular tissue of the derma, including the pilous follicles, or of enlarged and recognisably distended sebaceous sacs. (2) Heterologous, followed by ulceration ; and of these there are four diseases somewhat alike, some characters of which have already been given :Cancer (epithelioma). Solitary, flat, hard, and tender. Scabs slight. When ulceration sets in the glands enlarge. There is much infiltration of tissues around the ulcer, which is papillated, dirty-greyish, ichorous, or semi-scabbed, with hard, everted, and undermined edges. Epithelial elements may be seen by the microscope. Rodent ulcer begins as a small, pale, pretty soft tubercle, of very slow growth, almost painless, giving rise to an ulcer, without glandular enlargement, presenting a clear surface, not papillary, without ichor, but with hard, sinuous, non-everted, and non-undermined edges. Lupus has at its base an erythema that looks like searing ; then upon this arise dullish-red, softish, round, gelatinouslooking tubercles, forming patches of various extent. Thin adherent crusts form. There is no pain. The course is indolent. The edges of the patches are inflammatory, rounded, and raised, but not everted. There is always a tendency to repair, and cicatrices form, accompanied by distinct loss of substance. Syphilis. Tubercles commence as papules ; they become hard, large, and flattish, but not so flat as those of lupus ; they are dull-red at first, then coppery, and disposed in circles, or serpiginous, covered by thick dark scales. There is an ulcerating and a non-ulcerating form, the ulceration being often serpiginous and misnvmed "lupus."Syphilitic tubercles often occur about the face. The ulceration is dirty, ashy grey, sloughy, and ichorous, the edges sharply cut and everted, surrounded by tubercles of a copper tint. With regard to parasitic diseases, no difficulty ought to
We
PAPERS
ON
BY TILBURY PHYSICIAN TO ST.
SKIN
DISEASES.
FOX, M.D., M.R.C.P.,
JOHN’S
HOSPITAL FOR SKIN DISEASES.
No. I. DIAGNOSTIC
MEMORANDA—(Continued.) and their characters.—Maculæ : (1) pigmentaryEruptions,
freckles, moles, the melasma. about the nipples in pregnancy, vitiligoidea (sebaceous ?) ; (2) parasitic—chloasma, often confounded, when the microscope is not used, with (3) syphilitic stains ; (4) hæmorrhagic—persistent, and irremovable by pressure. Erythema : There is no need to particularise that of the acute specific diseases. Mistakes generally occur with roseola, which is confounded with erythema papulatum and rubeola; but it is never accompanied by distinct catarrh; is rose-coloured at first, gradually getting duller; non-crescentic,
occurring in circular patches from half an inch to an inch in diameter; not on the face; whilst it is often partial. In acute diseases erythema oftentimes occurs about the arms and limbs, rheumatism. Ordinary erythema is of a darker a bluish tinge at its edge, and is not so well defined-i. e., is more diffuse. Erythema may also arise from friction; from tension, as in œdema; from medicinal substances, as henbane, arsenic, belladonna, copaiba; and after operations, when it is often pygemic. The erythema of erysipelas is accompanied by tension, shining, smarting, and swelling. E. scarlatiniforme presents all the characters, as the rash, of scarlatina, but without its general or throat symptoms or the peculiar appearance of the tongue. The rash is seen about the neck, the flexures of the joints, and the trunk; it lasts five or six days, and is often evanescent for a time. The rosalia of authors—Rubeola notha, or Rubellaholds the same relation to rubeola that E. scarlatiniforme does to scarlet fever; that is to say, there is an absence of the general symptoms, whilst the eruption is similar. In all these cases of acute febrile erythemata desquamation is observed. In every instance the redness disappears or is removable by pressure, unlike that of purpura or pellagra. In lupus erythema-
as
in cholera
or
hue than roseola; it has
regards
distinguish
298
adds :
’’ There appeared, notwithstanding this defect, to be arise now that the microscope is at hand. Nevertheless, favus The patient breathed very and impetigo are confounded with lepra, eczema, and tinea sufficient respiratory power. tonsurans, notwithstanding the cupped-crust favi of the former forcibly in his dyspnœa, and in auscultating him the moveand the dry nibbled patches of the latter, in which the epithe- ments of the chest appeared just as in an ordinary double The stomach was thought to be, as it was found, lial cells and hairs are literally eaten away by the fungus, when this is in abundance. Chloasma, with its itching and very high up, but nothing unusual attracted Mr. Archer’s ordesquamation, is very frequently indeed mistaken for syphi- my attention; the left side of the chest certainly moved freely, litic maculas. Sycosis is often non-parasitic ; in this case, the and the patient often lay on his right side." damaged split-up hairs will be absent, whilst the disease travels St. Bartholomew’s Hospital, Jan. 1867. up into the whiskers. There are three agencies that need a special word of comment- the use of flannel, scratching, and gravitation; but these must be reserved for another occasion. The condensed sketch I have given may help the student in the out-patient’s room and the in his busy practice, and pave the way OF THE PRACTICE OF for some remarks on individual diseases.
pneumonia.
A Mirror
practitioner
Sackville-street, Feb.
1867.
MEDICINE AND SURGERY IN THE
ON ABNORMAL CONDITIONS OF THE
HOSPITALS OF LONDON.
DIAPHRAGM. BY F. HOWARD MARSH, F.R.C.S.
PHYSICIANS and pathologists are alike indebted to Mr. Callender for his paper on "Fatty Degeneration of the Diaphragm," which appeared in THE LANCET of January 12th. His cases prove that the disease, which, though no doubt known to some observers, had not been well described, can be
by very rare; and they point out what is really the cause of death in certain obscure cases which have hitherto been reckoned as instances of heart disease. The following case, which Mr. Paget has kindly given me leave to publish, may stand as a supplement to those of Mr. Callender. It is not exactly like his, for the diaphragm was not altered by fatty degeneration, but was, as Mr. Paget believed, defective in its original development; but the patient’s symptoms, and the manner of his death, were very similar to those noted by Mr. Callender; and the case serves to keep attention fixed on the very important fact that the diaphragm may, either by congenital defect, or, much more commonly, through subsequent disease, so fail in its action as to lead, sooner or later, to rapid death. On September 20th, 1851, Mr. Archer, who was then housesurgeon, admitted into St. Bartholomew’s Hospital a man who said that just before his master was going to strike him, and, in a fright, he jumped back, and felt something "give way" in his chest. He was faint and depressed, and it was thought he might have burst an aneurism. He complained also of pain in the left side of his chest, but his symptoms were obscure, and he was left to rest. In the evening he had dyspnœa, and a cough, which he had before, was aggravated. He was found next day to have double pneumonia, and with this, and with increasing dyspnoea, two days later he died. In the examination after death Mr. Paget found that the greater part of the lower lobe of the right lung, and the lower half of the upper lobe of the left lung, were completely solidin well-marked red hepatisation. Obsolete tubercles existed in the upper part of the right lung, but, with these exceptions, his organs appeared of normal structure. The condition of the diaphragm, however, was remarkable. Its left half was arched up to the third intercostal space, and the stomach, which was extremely large, was pushed up so high as to be nearly concealed by the left ribs; the liver lying below, and in front of it. The right side of the diaphragm appeared normal. On closer examination, the left side of the diaphragm In was seen to be almost wholly wanting in muscular fibres. the left crus, which was about half as large as natural, there were bundles of pale, muscular fibres, but in the rest of the left side there were only just so many of these that, on holding the diaphragm to the light, a few pale, pinkish lines could be seen radiating from its central tendon to its outer border. These were just visible enough for saying that muscular fibres were not wholly wanting. On the right side all appeared normal. No defect of symmetry was found either among the intercostal muscles or in any other part. Mr. Paget remarks in a note on the case that the defect of the diaphragm was probably a congenital one, for there was no apparent abnormality of structure; the pleura and peritoneum lay in contact, but were healthy in texture, and with no fat or other degenerate substance between them. And he
se
Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborum, et dissectionum historias, turn aliorum, tumproprias collectas habere, et inter comparare.—MORGAGNI De Sed. et Caus. JMof&., lib. iv. Procemium.
MIDDLESEX HOSPITAL. A CASE IN WHICH A COMMON SEWING-NEEDLE CAUSED DEATH BY HÆMORRHAGE FROM THE AORTA INTO THE PERICARDIUM.
no means
was held on the 16th ult. on the body of a named Maria Thompson, aged forty, who died under the following very remarkable circumstances :It appears that the deceased, who was a woman of intemperate habits, went to bed on the night of the llth apparently in good health. At three o’clock on the following morning, however, a female who slept in the bed with deceased was awakened by hearing her make a peculiar " groaning noise," though at the same time she was quite unconscious. She was aroused, and after being taken out of bed and having a cup of tea she revived. A short time afterwards she became faint, and was seized with diarrhœa and vomiting; and remained very much in this condition, sometimes being a little betterand then again becoming worse, until about a quarter to ten A.M., when she was brought to the hospital in a cab. She was immediately admitted, and seen by Mr. A. Waymouth, the resident medical officer, who at once pronounced her to bedead. Death had taken place whilst she was being conveyed to the hospital. Mr. Waymouth has obliged us with notes. At the post-mortem examination, the pericardium, on being. opened, was found to be full of blood-clots ; and on the hand of the operator being introduced into its cavity, the forefingerIt was pricked by some foreign body, which was removed. proved to be a sewing-needle, without an eye, in a very blackened and roughened state, and about two inches in length. From its appearance, it had probably been in the body for a considerable time. On the heart and great vesselsbeing examined, three spots of ecchymosis, each about the size of a threepenny-piece, were found on the anterior wall of theascending portion of the arch of the aorta ; and on that vessel being opened, two punctures were found on its inner surface, corresponding with two of the spots of ecchymosis. These were situated, one about a quarter and the other about threequarters of an inch above the aortic valves; so that the point of the needle had evidently passed through the coats of the artery about a quarter of an inch above the semilunar valves, had passed out again about a quarter of an inch higher up, and had finally lodged itself in the outer coat of the artery near that part where the left carotid is given off, being just within the reflection of the pericardium. The points are indicated in the accompanying rough diagram, which we sketched from the preparation. At 1 the needle had apparently first pierced the aorta, emerging at 2, to bury itself again in the coats of the vessel at 3. Just above this last the reflection of the pericardium is meant to be represented. Death in this instance had doubtless been caused by the heart’s action being arrested, consequent on the pericardium having become full of blood from the gradual oozing which had taken place from the punctures in the aorta. How came the needle in this position ? It must, it would appear, have been by one of two modes : it must have been swallowed, or have been
AN
inquest
woman
is a good starting-point for the clinical grouping of temporary disorders of speech, sight, and smell, just as unilateral palsy is for continued loss of speech, amaurosis, and anosmia. Partial fits—which, when they precede a full seizure, are often called auræ—are symptoms of very great interest to those working at unilateral convulsive seizures. They are, doubtless, the outward local signs of the first local changes inside. They most frequently occur in the hand, less frequently in one side of the face or one half of the tongue, and least frequently in the leg. Patients, the subjects of the aura, often keep off their fits by a ligature, by rubbing the part, or by some sort of disturbance of it. At the Hospital for the Epileptic and Paralysed, a few days ago, a single woman, thirty-four years of age, described to me partial fits of an unusual kind, and of interest in relation with several subjects in this paper. Her eyes, she said, would " suddenly fix to the left," her head turn to the left, and the arm of the same side would begin next to shake. She did not know whether the face was distorted, but the left side of the nose had sometimes felt as if drawn down. There was no loss of sensibility, nor even giddiness, and the leg had at no time been affected, and she had only had two attacks in which the arm had become involved as mentioned. A little worry, she said, would bring on an attack. A unilateral convulsion sometimes leaves other continued conditions of the muscles of the arm and leg, besides more or less loss of power. The limbs that have suffered most in the fit now and then become the subjects of irregular movements, very like those seen in children who haveunilateral chorea. And it is most important to pay attention to such phenomena, for we should study each disordered movement in reference to the other departures from muscular health which occur in
like chilblains is common; it occurs in in winter, and is connected with loss of hair, The erythema of urticaria is very easily diagnosed: a slight &c. scratching with the nail will produce a wheal. Papules, pale and firm, on the inner aspect of the limbs, with a thickened dull state of skin, constitute lichen; with dark apices (coagulated blood), if in a slight degree and on the arms and anterior aspect of the trunk, as a complication of scabies and of strophulus (pruriginosus) in children; to a marked extent seen in prurigo, accompanied mostly by an inelastic state of skin and the " broad" papules formed by an exaggeration of the little areas enclosed by the natural furrows of the skin: intermingled with vesicles and pustules in scabies; soft and red, and in children with erythema, strophulus; flat and reddish, collected together in little parcels, though discrete, lichen ruber; aggregated and confluent, lichen circumscriptus; formed about the hair follicles, lichen pilaris, pityriasis pilaris, lichen scrofulosus, and the lichen of phthisis. The most common mistake, that of confounding lichen and scabies, is at once avoided by observing the multiform aspect of the latter and the uniform character of the former. Those eruptions in which vesicles and pustules occur are eminently by the occurrence of secretion; and this at once divides diseases into twogreat classes: in the one class, where secretion or discharge occurs, crusts form ; in the other, crusts are entirely absent. Ulcerative diseases are easily recognised. The character of the secretion affords most reliable information. If there be serosity, with crusts, it is intertrigo; if thin, few, flimsy, light-coloured crusts form, and the discharge stiffen linen, it is eczema ; if the crusts be a little thicker and in little circular patches, herpes or vesicular scabies. Sero-purulent, with slight yellow crusts, eczema impetiginodes; or if stuck on and flattened, impetigo contagiosa; purulent, forming thick crusts of a yellow colour, becoming more or less
todes
an
erythema
summer as
this region. Bedford-place, Russell-square, Feb. 1867.
well
as
distinguished
dark, ecthyma, furunculus, purulent scabies, impetigo sycosiforme, impetigo scabida, sycosis; and if cockle-shaped, rupia of course. Sanious, rupia and ecthyma cachecticum. Fatty, acne sebacea, seborrhcea capillitti, seborrhœa, sebaceous ichthvosis (legs.
Hœmorrhagic. hæmidrosis. &e. scales from crusts : scales are altered epithelial cells. Redness with scales, lasting on to chronicity, we see in tinea circinata, erythema circinatum, and herpes iris. Scales, as a primary formation, if partial, in lepra ; if general, ichthyosis. Tubercula are (1) homologous, as in keloid and elephantiasis. Keloid never ulcerates, and occurs about cicatrices and the chest; it is white and hard, with a few vessels coursing over it, with claw-like processes produced by contraction of the hypertrophous growth. Other forms of disease need not be mentioned, save molluscum, which consists either of an increase of the fibro-cellular tissue of the derma, including the pilous follicles, or of enlarged and recognisably distended sebaceous sacs. (2) Heterologous, followed by ulceration ; and of these there are four diseases somewhat alike, some characters of which have already been given :Cancer (epithelioma). Solitary, flat, hard, and tender. Scabs slight. When ulceration sets in the glands enlarge. There is much infiltration of tissues around the ulcer, which is papillated, dirty-greyish, ichorous, or semi-scabbed, with hard, everted, and undermined edges. Epithelial elements may be seen by the microscope. Rodent ulcer begins as a small, pale, pretty soft tubercle, of very slow growth, almost painless, giving rise to an ulcer, without glandular enlargement, presenting a clear surface, not papillary, without ichor, but with hard, sinuous, non-everted, and non-undermined edges. Lupus has at its base an erythema that looks like searing ; then upon this arise dullish-red, softish, round, gelatinouslooking tubercles, forming patches of various extent. Thin adherent crusts form. There is no pain. The course is indolent. The edges of the patches are inflammatory, rounded, and raised, but not everted. There is always a tendency to repair, and cicatrices form, accompanied by distinct loss of substance. Syphilis. Tubercles commence as papules ; they become hard, large, and flattish, but not so flat as those of lupus ; they are dull-red at first, then coppery, and disposed in circles, or serpiginous, covered by thick dark scales. There is an ulcerating and a non-ulcerating form, the ulceration being often serpiginous and misnvmed "lupus."Syphilitic tubercles often occur about the face. The ulceration is dirty, ashy grey, sloughy, and ichorous, the edges sharply cut and everted, surrounded by tubercles of a copper tint. With regard to parasitic diseases, no difficulty ought to
We
PAPERS
ON
BY TILBURY PHYSICIAN TO ST.
SKIN
DISEASES.
FOX, M.D., M.R.C.P.,
JOHN’S
HOSPITAL FOR SKIN DISEASES.
No. I. DIAGNOSTIC
MEMORANDA—(Continued.) and their characters.—Maculæ : (1) pigmentaryEruptions,
freckles, moles, the melasma. about the nipples in pregnancy, vitiligoidea (sebaceous ?) ; (2) parasitic—chloasma, often confounded, when the microscope is not used, with (3) syphilitic stains ; (4) hæmorrhagic—persistent, and irremovable by pressure. Erythema : There is no need to particularise that of the acute specific diseases. Mistakes generally occur with roseola, which is confounded with erythema papulatum and rubeola; but it is never accompanied by distinct catarrh; is rose-coloured at first, gradually getting duller; non-crescentic,
occurring in circular patches from half an inch to an inch in diameter; not on the face; whilst it is often partial. In acute diseases erythema oftentimes occurs about the arms and limbs, rheumatism. Ordinary erythema is of a darker a bluish tinge at its edge, and is not so well defined-i. e., is more diffuse. Erythema may also arise from friction; from tension, as in œdema; from medicinal substances, as henbane, arsenic, belladonna, copaiba; and after operations, when it is often pygemic. The erythema of erysipelas is accompanied by tension, shining, smarting, and swelling. E. scarlatiniforme presents all the characters, as the rash, of scarlatina, but without its general or throat symptoms or the peculiar appearance of the tongue. The rash is seen about the neck, the flexures of the joints, and the trunk; it lasts five or six days, and is often evanescent for a time. The rosalia of authors—Rubeola notha, or Rubellaholds the same relation to rubeola that E. scarlatiniforme does to scarlet fever; that is to say, there is an absence of the general symptoms, whilst the eruption is similar. In all these cases of acute febrile erythemata desquamation is observed. In every instance the redness disappears or is removable by pressure, unlike that of purpura or pellagra. In lupus erythema-
as
in cholera
or
hue than roseola; it has
regards
distinguish
298
adds :
’’ There appeared, notwithstanding this defect, to be arise now that the microscope is at hand. Nevertheless, favus The patient breathed very and impetigo are confounded with lepra, eczema, and tinea sufficient respiratory power. tonsurans, notwithstanding the cupped-crust favi of the former forcibly in his dyspnœa, and in auscultating him the moveand the dry nibbled patches of the latter, in which the epithe- ments of the chest appeared just as in an ordinary double The stomach was thought to be, as it was found, lial cells and hairs are literally eaten away by the fungus, when this is in abundance. Chloasma, with its itching and very high up, but nothing unusual attracted Mr. Archer’s ordesquamation, is very frequently indeed mistaken for syphi- my attention; the left side of the chest certainly moved freely, litic maculas. Sycosis is often non-parasitic ; in this case, the and the patient often lay on his right side." damaged split-up hairs will be absent, whilst the disease travels St. Bartholomew’s Hospital, Jan. 1867. up into the whiskers. There are three agencies that need a special word of comment- the use of flannel, scratching, and gravitation; but these must be reserved for another occasion. The condensed sketch I have given may help the student in the out-patient’s room and the in his busy practice, and pave the way OF THE PRACTICE OF for some remarks on individual diseases.
pneumonia.
A Mirror
practitioner
Sackville-street, Feb.
1867.
MEDICINE AND SURGERY IN THE
ON ABNORMAL CONDITIONS OF THE
HOSPITALS OF LONDON.
DIAPHRAGM. BY F. HOWARD MARSH, F.R.C.S.
PHYSICIANS and pathologists are alike indebted to Mr. Callender for his paper on "Fatty Degeneration of the Diaphragm," which appeared in THE LANCET of January 12th. His cases prove that the disease, which, though no doubt known to some observers, had not been well described, can be
by very rare; and they point out what is really the cause of death in certain obscure cases which have hitherto been reckoned as instances of heart disease. The following case, which Mr. Paget has kindly given me leave to publish, may stand as a supplement to those of Mr. Callender. It is not exactly like his, for the diaphragm was not altered by fatty degeneration, but was, as Mr. Paget believed, defective in its original development; but the patient’s symptoms, and the manner of his death, were very similar to those noted by Mr. Callender; and the case serves to keep attention fixed on the very important fact that the diaphragm may, either by congenital defect, or, much more commonly, through subsequent disease, so fail in its action as to lead, sooner or later, to rapid death. On September 20th, 1851, Mr. Archer, who was then housesurgeon, admitted into St. Bartholomew’s Hospital a man who said that just before his master was going to strike him, and, in a fright, he jumped back, and felt something "give way" in his chest. He was faint and depressed, and it was thought he might have burst an aneurism. He complained also of pain in the left side of his chest, but his symptoms were obscure, and he was left to rest. In the evening he had dyspnœa, and a cough, which he had before, was aggravated. He was found next day to have double pneumonia, and with this, and with increasing dyspnoea, two days later he died. In the examination after death Mr. Paget found that the greater part of the lower lobe of the right lung, and the lower half of the upper lobe of the left lung, were completely solidin well-marked red hepatisation. Obsolete tubercles existed in the upper part of the right lung, but, with these exceptions, his organs appeared of normal structure. The condition of the diaphragm, however, was remarkable. Its left half was arched up to the third intercostal space, and the stomach, which was extremely large, was pushed up so high as to be nearly concealed by the left ribs; the liver lying below, and in front of it. The right side of the diaphragm appeared normal. On closer examination, the left side of the diaphragm In was seen to be almost wholly wanting in muscular fibres. the left crus, which was about half as large as natural, there were bundles of pale, muscular fibres, but in the rest of the left side there were only just so many of these that, on holding the diaphragm to the light, a few pale, pinkish lines could be seen radiating from its central tendon to its outer border. These were just visible enough for saying that muscular fibres were not wholly wanting. On the right side all appeared normal. No defect of symmetry was found either among the intercostal muscles or in any other part. Mr. Paget remarks in a note on the case that the defect of the diaphragm was probably a congenital one, for there was no apparent abnormality of structure; the pleura and peritoneum lay in contact, but were healthy in texture, and with no fat or other degenerate substance between them. And he
se
Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborum, et dissectionum historias, turn aliorum, tumproprias collectas habere, et inter comparare.—MORGAGNI De Sed. et Caus. JMof&., lib. iv. Procemium.
MIDDLESEX HOSPITAL. A CASE IN WHICH A COMMON SEWING-NEEDLE CAUSED DEATH BY HÆMORRHAGE FROM THE AORTA INTO THE PERICARDIUM.
no means
was held on the 16th ult. on the body of a named Maria Thompson, aged forty, who died under the following very remarkable circumstances :It appears that the deceased, who was a woman of intemperate habits, went to bed on the night of the llth apparently in good health. At three o’clock on the following morning, however, a female who slept in the bed with deceased was awakened by hearing her make a peculiar " groaning noise," though at the same time she was quite unconscious. She was aroused, and after being taken out of bed and having a cup of tea she revived. A short time afterwards she became faint, and was seized with diarrhœa and vomiting; and remained very much in this condition, sometimes being a little betterand then again becoming worse, until about a quarter to ten A.M., when she was brought to the hospital in a cab. She was immediately admitted, and seen by Mr. A. Waymouth, the resident medical officer, who at once pronounced her to bedead. Death had taken place whilst she was being conveyed to the hospital. Mr. Waymouth has obliged us with notes. At the post-mortem examination, the pericardium, on being. opened, was found to be full of blood-clots ; and on the hand of the operator being introduced into its cavity, the forefingerIt was pricked by some foreign body, which was removed. proved to be a sewing-needle, without an eye, in a very blackened and roughened state, and about two inches in length. From its appearance, it had probably been in the body for a considerable time. On the heart and great vesselsbeing examined, three spots of ecchymosis, each about the size of a threepenny-piece, were found on the anterior wall of theascending portion of the arch of the aorta ; and on that vessel being opened, two punctures were found on its inner surface, corresponding with two of the spots of ecchymosis. These were situated, one about a quarter and the other about threequarters of an inch above the aortic valves; so that the point of the needle had evidently passed through the coats of the artery about a quarter of an inch above the semilunar valves, had passed out again about a quarter of an inch higher up, and had finally lodged itself in the outer coat of the artery near that part where the left carotid is given off, being just within the reflection of the pericardium. The points are indicated in the accompanying rough diagram, which we sketched from the preparation. At 1 the needle had apparently first pierced the aorta, emerging at 2, to bury itself again in the coats of the vessel at 3. Just above this last the reflection of the pericardium is meant to be represented. Death in this instance had doubtless been caused by the heart’s action being arrested, consequent on the pericardium having become full of blood from the gradual oozing which had taken place from the punctures in the aorta. How came the needle in this position ? It must, it would appear, have been by one of two modes : it must have been swallowed, or have been
AN
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woman