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the opening gradually closed, and would remain -no tubercle bacilli, no signs of echinococcus, so for a few days and then burst out afresh. but starch granules, yeast cells, and what apThe swelling remained much the same in size, peared to be partially-digested food. I must and the patient went home at the end of a say that I was at a loss for a diagnosis, and the month and eventually died ; Dr. Borthwick girl returned home, and Dr. Davies told me a telling me that the swelling increased in size few weeks later that he was certain that it must before her death. No post-mortem was obtained. be pulmonary tuberculosis, but since reading

The third case is not altogether a certain Robson and Moynihan I have come to the condiagnosis, and it only struck me what was its clusion that it is a case of gastric fistulæ opening nature whilst writing this paper. I will give it into the right lung. for what it is worth.

In the first case, there can be very little Miss O., æt. 18, sent to me by Dr. Davies, of doubt but that the patient had a gastric ulcer, Yorketown, on September 27th, 1901, com- which ruptured during the night of April 26th,

, plaining of a bad cough, more especially at 1899, during a violent attack of vomiting ; and nights when lying down, the cough having been instead of the patient dying in a short time, present about two months. During this time adhesions formed, and a subphrenic abscess the patient had been losing flesh, but had never followed. It is almost impossible to say coughed up any blood or hydatids, and had not whether the perforation in this case occurred suffered from night sweats. She was a very on the anterior or posterior surface of the anamic girl, but fairly well nourished. Her stomach ; but I am inclined to think it was on breathing was short, and on examination there the former, not only from the acute collapse was found to be dulness on the right side, from and abdominal pain which occurred, but from the hepatic region up to the right nipple, and the condition found at the operation. Proextending round to the angle of the scapula bably what happened is this : a perforation took behind. There were a few crepitations in front, place on the night of April 26th, but not with tubular breathing below and to the left of enough to flood the peritoneal cavity; adhethe right nipple. The breathing in the axilla sions formed between the great omentum and and posteriorly was almost inaudible, and the the anterior abdominal wall and liver ; the vocal resonance and fremitus absent in these contents then made their way up on the left situations. The heart's apex beat could not be side of the falciform ligament of the liver, and localised. Her heart's sounds were normal, formed the peculiar cavity my finger went into. and her urine was free from albumen and sugar. This cavity at times must have been full of gas

She was admitted to the private hospital, and at others full of fluid from the varying and on the night of her admission her tempera- dulness and hyperesonance. So much was this ture was 103° F. Next morning she had the case that I thought Dr. Poulton would coughed up

about half a pint of what looked think I had turned my physical signs topsylike frothy expectoration on the surface, with turvy, for whenever I had found the side dull a creamy material below. Dr. J. C. Verco saw in the morning he found it hyper-resonant in the patient with me in the afternoon, and we the afternoon. I presume when we turned the both thought that the physical signs pointed to patient on the right side the escaped contents a hydatid cyst on the convex surface of the right of the stomach began to digest her internal lobe of the liver, and we decided to explore organs, whatever may have formed the right with an aspirating needle, and drew off about wall of the cavity giving rise to the dull pain. 6 ozs. of ordinary serous fluid from the posterior This was always relieved by allowing the conaxillary line, but this made no difference to the tents to escape on turning the patient on to her physical signs in front. I had the expectora- back or left side. The attack of parotitis tion examined, and the report said no signs of coming on in the case is of interest, especially hydatid, no tubercle bacilli; but there were when considered in connection with Stephen

; plenty of yeast cells and starch granules and Paget's paper on this condition following abdebris. After aspiration the temperature kept | dominal injuries, and bears out what he says down, but the physical signs remained the about the inflammation of the parotid occurring game, and the patient returned home. She came in other abdominal injuries than those conto see me again on December 10th, and the nected with the pelvic viscera. physical signs were still the same with the ex- The second case is an example of idiopathic ception of an enlarged gland in the right supra- gastric fistulæ. This condition is extremely clavicular fossa, which made me suspect a new Murchison could only find 25 such cases growth in the lungs. I had the expectoration extending over three centuries.

From the age again examined, and the report came back again of the patient one would expect the ulcer to



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have been malignant in origin, but of this I am forehead, and particularly over the left temuncertain. There was the history of the two poral region. There are frequent hot flushes years' illness, with the slowly growing swelling of the face, followed by cold, clammy sensations ; and the pultaceous mass, which

also giddy sensations, with a feeling as if she markedly non-vascular, and did not appear is going to fall forwards. Locomotion is difto be malignant. The idea I formed at ficult, and a very short walk is followed by the time, and which I still believe to be the great breathlessness and palpitation, her correct one, was that a rupture of a gastric nervous equilibrium being upset over most ulcer took place slowly on the posterior wall of trivial matters. When she “catches a cold,” the stomach into the lesser omental cavity, and the pain in the chest is so severe that she that this cavity became filled with a kind of cannot sleep on its account. Standing for any lymph, which gradually suppurated, became length of time causes severe pain in the ankles adherent to the neighbourhood of the umbilicus and knees (which don't swell); this also and perforated here. What struck both Dr. prevents sleep. Poulton and myself was the amount of lateral Since both her sister and self were employed movement that could

that could be obtained, and by my parents before they were married, I also the localised swelling which could be have been able to notice the excessive developso plainly mapped out by the finger in the ment of adipose tissue more carefully than had swelling and the hand outside. Of course the I not known her so long. At that time she condition may have originated in a malignant was a very thin girl, and her sister was almost ulcer, and yet the material our fingers went twice as stout; so that by contrasting the into might have been lymph, lowly organised present measurements of their two bodies the and breaking down.

increase will be self-evident. With regard to the third case, I would rather

sister, Mrs. M., say no more here, as probably future develop

multipara. ments may make matters clearer; but my


Right. present idea is that it is a case of duodenal

12" 12" 10"

10" ulcer, which has formed & retroperitoneal Forearm

9;" 95" 8" abscess, and this has passed upwards, through Chest (over breasts) 41"


34" or behind the diaphragm, and after entering

Buttocks the right pleura has burst into the right lung.


191" [Read before the South Australian Branch, British Medical Associa. Legs

13," tion, March, 1902.)

Across shoulders

15 Across buttocks


16" ADIPOSIS DOLOROSA (DERCUM'S DISEASE). All the above measurements (except the last By E. Angas Johnson, M.D., MR.C.S., Assistant two) were taken around the middle of the parts

affected. Physician to the Adelaide Hospital.

On Examination.—A very stout woman,

with a slow, waddling gait (which Professor MRS. H., æt. 32, nullipara, who was born in Watson very aptly terms an ambulatory lipoma). and has never been out of this colony, consulted | The hair is normal, the face is not affected, and me in November, 1901, for her "stoutness, looks small comparatively. The eyes are normal, which she said was attended with great pain, the sight unaffected. The thyroid gland especially at menstruation.

The menses are is normal so far as it can be felt. The regular, but scanty, and last only two to three Chest : The walls are infiltrated; the mammæ days.

are very large, soft and doughy; the lungs Previous History.—Always strong and well. normal; the heart, the sounds are weakly Influenza two winters ago. No history of heard, but

detected. The syphilis, alcohol, rheumatism, or traumatism. temperature is

normal, the pulse 96. Thirteen years ago was married, and at that The Abdomen : The abdominal walls are time she weighed 7 st. 9 lb. Eight years ago very much infiltrated, so that whilst in the she noticed that her stomach was getting larger, recumbent position big folds of fat are produced. and very tender on pressure (the pain being This is tender on manipulation or slight squeezcompared to that of a bruise). Then the hips, ing, the pain, as already noted, is likened to chest, arms, and legs got bigger. Pains of a that which follows a bruise, the skin bruising neuralgic nature under the left shoulder, which on very slightly squeezing it. Urine: The have been worse since the influenza ; also quantity not increased; specific gravity, 1010; neuralgic pains on crown of head, across the no albumen, no sugar, no deposit. Per


20" 41"

60" 23" 16" 15"



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Vaginam : Professor Watson said the vagina tion, and then with Condy's Auid, and subwas small, and the uterus infantile. The cutaneous injection of one pint of saline solution Extremities : The hands and feet are normal, was administered. Hypodermic injection of except for a slight fulness of the thenar, hypo- strychnine to grain every three hours ; hypothenar, and plantar eminences. The reflexes dermic of morphia to of a grain on one night, are normal. There are no enlarged veins or and later a mixture of bismuth sub-carbonate abnormal tenderness over the big nerve trunks. and soda bicarbonate completed the treatment No muscular wasting can be detected. The adopted, and which resulted in rapid conheadache, vertigo, palpitation, and sleepless- valescence and cure. ness are intensified at menstruation.

The child was re-admitted on October 23rd, 15th February1902.—The weight is 1901, in practically the same state as when 13 st. 7 lb.

admitted on July 3rd ; this illness also ensuing Treatment. —Slight massage, combined with upon his having some meat for the first thyroid tabloids, which will both be gradually time since his first attack. The symptoms were increased.

practically the same, but though similar treat5th March, 1902.- Patient has not been ment was adopted, he never rallied, and died weighed since, but the affected areas already 30 hours after admission. seein firmer to the touch (and not so doughy). A post mortem examination was made by

Although morphia is condemned, it was the Dr. Cleland a few hours after death. The only drug that relieved the severe neuralgic stomach and intestines presented no macroscopic pains which preceded her last menstrual attack signs of any disease. The liver was slightly one week ago. Professor Watson very kindly softer than normal, and showed some fatty saw this patient in consultation with me, and change on microscopic examination. The confirmed the diagnosis.

kidneys were pale, but otherwise showed no Unfortunately, the patient won't allow a gross change in structures, but the epithelium of photograph to be taken of her, but from a the tubules showed considerable fatty degenerapicture in the Medical Review, Vol. III., page tion. All other organs of the body, including 676, a fair idea of her appearance can be got, the nervous system, appeared perfectly normal. Mrs. H. being about twice as fat, the hips Cultures were taken from the spleen, which being very prominent.

grew on agar in twenty-four hours as dense,

white spherical colonies, consisting of a bacillus CLINICAL AND PATHOLOGICAL

staining somewhat irregularly and faintly with

methylene blue, and sometimes slightly curved. NOTES.

From the liver two colonies only, of a similar

but stouter bacillus, were ined. An Obscure Case.

The points of interest in the case

1. The very severe gastric symptoms, without A MALE child, aged 7 years, was admitted to corresponding post mortem appearances of Prince Alfred Hospital, Sydney, on July 3rd, inflammation of the gastric mucosa. 2. The 1901, with a history of six days' illness with total absence of post mortem appearances of vomiting and abdominal pain, attributed by his gross pathological changes. 3 The readiness parents to his having eaten some meat. He with which the symptoms cleared up in the had always been delicate, suffering from “weak first attack under lavage of the stomach and digestion," and was said to have had “ erysipelas saline injection, as opposed to the utter failure of the head and inflammation of the brain two of the same treatment on the second occasion. years previously. On admission he was in an 4. The trivial nature of the supposed cause, and extremely collapsed condition, extremities cold, absence of any other known atiological factors. semi-conscious, pulse barely perceptible, respira- 5. The fact that the attacks might have passed tive sighing, and temperature sub-normal; for cerebral disturbances, while the large size tongue dry and furred, abdomen retracted of the head and the doubtful history of inflamand hard, and marked tenderness over the mation of the brain would have supported the epigastrium and left hypochondrium was pre- theory, whereas the post mortem examination sent. The bowels were constipated. There revealed a very large, but, macroscopically at no squint or indication of cranial nerve

any rate, a perfectly healthy brain. involvement. The vomiting was urgent, and

C. BICKERTON BLACKBURN, M.B, Ch.M., nutrient enemata were not retained. The temperature only reached 101° on one occasion.

Medical Superintendent The stomach was washed out with saline solu

Prince Alfred Hospital, Sydney.


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MIRROR OF HOSPITAL PRACTICE tapped. Ten pints of clear fluid withdrawn IN AUSTRALASIA.

(specific gravity 1004, acid, heavy cloud albumin, no T.B.). Spleen could now be felt 1} in.

below costal margin. Liver margin smooth, PRINCE ALFRED HOSPITAL, regular, firm and sharp at level of costal margin. SYDNEY.

December 10th, 1901.Paracentesis abdoCASE OF CIRRHOSIS OF THE LIVER IN A Child. minis again performed. Fifteen pints of fluid

drawn off. (Under the Care of Dr. Scor-Skirving.)

December 15th, 1901.-Eleven pints withReported by A, H. MACINTOSH, M.B, CH.M., drawn.

House Physician ; and J. B. CLELAND, January 2nd 1902.-Laparotomy performed. M.B., CH.M., Resident Pathologist.

Five pints of fluid let out. Peritoneum healthy.

Nothing to be made out. Drainage tube left E.S., female, cet. 12 years, was admitted to in. Patient became very restless ; later bePrince Alfred Hospital

, Sydney, November came delirious, and on January 6th, 1902, 23rd, 1901, complaining of swelling of abdo- sank into a state of coma and died.

She had noticed the abdomen gradually Before death she emitted several times a becoming more and more prominent for the short sharp cry like that of meningitis, the last nine months, but the swelling had increased respirations became very slow (about ten å much more rapidly lately. She had never had minute), and the pulse remarkably quick. The any abdominal pain and only very occasional temperature lay between 98:4° and 100°. irregular vomiting. Bowels were constipate:) Post-mortem Examination, Jan. 7th, 1902.and the appetite poor. She had been getting The bodily nutrition was good, but the subgradually weaker. She had no cough, nor any cutaneous fat deficient; rigor mortis was passing swelling of feet or legs.

off. The lungs were congested at their bases ; Past History.She never had scarlet fever, here and there were some small purple blood and never had alcohol given her in any form. extravasations. The heart weighed 8 oz. ; its She never suffered from an illness which might valves and coronary vessels were healthy ; have required alcohol, and was not accustomed some petechiæ and vibices appeared under the to take spices or condiments.

visceral pericardium, and a few smaller ones in Family History. -Good, no phthisis. Brother the parietal pericardium ; the blood in the said to have an enlarged liver. Parents teeto- vessels was fluid. The liver weighed 30 oz. ; tallers and very plain-living people.

it was uniformly contracted with some small Present State.- Patient is ænemic ; no s'gn: bossy projections in places; the surface was of of icterus. Face full and puffy.

a pale whitish colour; the consistence exceedDigestive System.-Appetite poor. Tongue ingly tough ; on section, thick bands of pale highly furred. Bowels constipated-no pain on pinkish or white fibrous tissue invaded the whole defecation. Abdomen uniformly distended, organ isolating numerous small yellow lobules tense, umbilicus everted. Superficial veins or groups of lobules which projected markedly very prominent. Well-marked fluid thrill. above it; in some places this fibrous tissue was Extensive dulness in flanks and lower part of alone left; the capsule of the liver was not abdomen, varying with position of patient; appreciably thickened.

position of patient; appreciably thickened. Microscopically, the not to be felt on palpation.

liver presented the typical appearance of a Liver Dulness. — From fifth rib in nipple line multilobular cirrhosis ; the portal systems were and sixth rib in axilla.

surrounded by a very great increase in the Heart.-Apex beat in fourth space in nipple connective tissues, this being in general fibrous, line. Sounds clear.

though in places more cellular ; the larger Lungs.--Impaired percussion note at bases. branches of the portal veins traversing these Crepitant notes at both bases, but clear areas were held widely dilated by the dense elsewhere.

fibrous nature of their walls, which prevented Urine is acid, one-eighth albumin, and con- any contraction ; the contour of numerous bile tains granular casts. Some ædema of feet and ducts could also be seen in this stroma, occupylegs.

ing positions formerly taken by hepatic cells; Subsequent Examination of the Urine.-The rounded isolated hepatic lobules could be seen amount always scanty, never more than 25 in various stages of diminution, almost to ounces in 24 hours-- usually less. Specific obliteration, though their remaining cells exgravity varied between 1015 and 1030 ; only hibited no great fatty changes. The gall bladder twice contained albumin, then only a trace. was contracted, small, and thickened.

The November 27th, 1901.-The abdomen was spleen was large, firm, and weighed 11 oz. ; it


1 was dark red in colour, and showed prominent REVIEWS AND NOTICES OF BOOKS. Malpighian bodies ; under the microscope, there was no decided increase in its stroma, but the rounded cells of the lymphoid tissues were


E. Giles, M.D., B.Sc., F.R.C.S., etc. ; Su on to noticeably prominent. The pancreas was very the Out-patients, Chelsea Hospital for Women ; firm; microscopically appeared an increase in

Gynæcologist to the Tottenham Hospital, etc. its interacinous stroma consisting chiefly of Crown 8vo., 28. 6d. net. London : Bailliére, rounded and spindled cells which tended here Tindall and Cox, Sydney : L, Bruck. and there to enter between the peripheral cells The writer of this monograph aims at presenting a

and of the acini so as to separate and isolate them; concise and practical exposition of normal

diseased menstruation. Within the space of 100 pages, in the centres of some acini, collections of small

he has successfully carried out his object. Too fre. rounded or irregular or spindle-shaped cells quently brochures of this kind are a weak and could be seen.

The kidneys were deeply con- unsatisfying dilution of the standard treatises. In gested ; the capsules peeled; the left weighed the present case this cannot be charged, and Dr. Giles

has done his work so well that the larger treatise which 5 oz., the right 6 oz ; there was a scattered

he promises on the same subject will be expected with infiltration of small rounded cells in the stroma interest. between the tubes, and in the Malpighian

About one-third of the volume is given to a con. capsules, but this was not very marked; the sideration of the physiology of menstruation. Its renal cells were granular and their nuclei indis

anatomical and physiological characteristics, and its

relation to the “estrus » in animals in the light of tinct. The suprarenals were unaffected; the Heape's investigations are discussed ; next we have an stomach showed some slight old slaty pigmenta- account of its clinical characters, and chapters on its tion; the intestines were healthy; the peritoneum relation to conception, ovulation, and pregnancy, and

on the menopause. was not thickened ; it was discoloured and of a

The disorders of menstruation receive fuller atten. greenish hue (p. m. changes) close to the supra- tion, and they are treated simply and clearly, in a pubic wound. The brain exhibited no changes. manner th will make this little book practically The urine removed p. m. contained a few blood

useful to the practitioner. Dr. Giles emphasises the

fact that these disorders are but symptoms, suggesting cells, an occasional blood or hyaline cast, and

a cause to be investigated, " and not separate diseases, many bladder cells, but no crystals.

for the cure of which an empiric therapeutic formula The following attempts at establishing the suffices.” collateral circulation were noticeable. The To the practitioner of medicine the subject is one of vein accompanying the phrenic nerve

every day interest, and this little book can be recommended for perusal as being, though its scope

is enlarged, the veins in the falciform ligament of circumscribed, both scientific and practical. the liver were marked, as were all the retro

A.W.M. peritoneal veins which connected with small veins running into the mesentery; a deep OBSTETRIC AND GYNECOLOGIC NURSING. By E. P.

Davis, A.M., M.D., Professor of Obstetrics in purple varicose condition of veins connected

Jefferson Medical College and Philadelphia Polythe mesentery, binding down the cæcum and clinic. Illustrated. Philadelphia and London : adjacent parts with the deep pelvic veins and W. B. Saunders and Co., 1901. Melbourne ; Jas. those around the iliac bone.

Little. Price, 9s. Remarks.—The following points may be

This book, which was prepared for the Training The youth of the patient'; the Schools of the Jefferson and Philadelphia Hospitals, in entire absence of alcoholic history either instruction as to the various duties of the obstetric and

both of which the author teaches, is designed to furnish personal or parental; the rapid re-accumulation gynecologic nurse. Obstetric nursing demands some of fluid after tapping; and the fact that though knowledge of natural pregnancy, and of the signs of this had to be repeated several times chronic accidents and diseases which may occur during preg. peritonitis was quite absent; the presence of

nancy. It also requires knowiedge and experience in the

care of the patients during the labour, and her complete pancreatic as well as hepatic cirrhosis ; the recovery, with the needs of the child. Gynecologic sudden supervention of auto-intoxication symp- nursing requires special instruction and nursing, and a toms (from defective hepatic action) shortly thorough knowledge and drill in asepsis and antisepsis

are absolutely indispensable. This bok will be found after exploratory laparatomy and draining,

to supply in a clear and concise manner all the details which supervention may be merely a coincidence necessary to enable any fairly educated woman to · or directly due either to the loss of fluid by become proficient in these branches of nursing, prodraining with increased absorption in

vided that she receive at the same time proper practical

training. Fortunately the days of “Sairey Gamp" are sequence from the alimentary canal, thus nearly past, and women are beginning to fully recognise increasing the work of the liver cells, or to the necessity of having properly trained nurses the reparative changes and increased metabolism attend to them in their accouchments. The work is originating in the area of the wound; and the very freely illustrated, and can be safely recommended history of liver enlargement in the patient's deals with.

as a text-book for the two branches of nursing that it brother.



dwelt upon.




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