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MIRROR OF HOSPITAL PRACTICE
PRINCE ALFRED HOSPITAL,
CASE OF CIRRHOSIS OF THE LIVER IN A CHILD.
E.S., female, cet. 12 years, was admitted to Prince Alfred Hospital, Sydney, November 23rd, 1901, complaining of swelling of abdomen. She had noticed the abdomen gradually becoming more and more prominent for the last nine months, but the swelling had increased much more rapidly lately. She had never had any abdominal pain and only very occasional irregular vomiting. Bowels were constipated and the appetite poor. She had been getting gradually weaker. She had no cough, nor any swelling of feet or legs.
Past History. She never had scarlet fever, and never had alcohol given her in any form. She never suffered from an illness which might have required alcohol, and was not accustomed to take spices or condiments.
Family History. Good, no phthisis. Brother said to have an enlarged liver. Parents teetotallers and very plain-living people. Present State.-Patient is enemic; no sign of icterus. Face full and puffy.
Digestive System.-Appetite poor. Tongue highly furred. Bowels constipated-no pain on defecation. Abdomen uniformly distended, tense, umbilicus everted. Superficial veins very prominent. Well-marked fluid thrill. Extensive dulness in flanks and lower part of abdomen, varying with position of patient; not to be felt on palpation.
Liver Dulness. From fifth rib in nipple line and sixth rib in axilla.
Heart.-Apex beat in fourth space in nipple line. Sounds clear.
Lungs.-Impaired percussion note at bases. Crepitant notes at both both bases, but clear
Urine is acid, one-eighth albumin, and contains granular casts. Some oedema of feet and legs.
Subsequent Examination of the Urine.-The amount always scanty, never more than 25 ounces in 24 hours--usually less. Specific gravity varied between 1015 and 1030; only twice contained albumin, then only a trace.
November 27th, 1901.-The abdomen was
tapped. Ten pints of clear fluid withdrawn (specific gravity 1004, acid, heavy cloud albumin, no T.B.). Spleen could now be felt lin. below costal margin. Liver margin smooth, regular, firm and sharp at level of costal margin.
December 10th, 1901.-Paracentesis abdominis again performed. Fifteen pints of fluid drawn off.
December 15th, 1901.-Eleven pints withdrawn.
January 2nd 1902.-Laparotomy performed. Five pints of fluid let out. Peritoneum healthy. Nothing to be made out. Drainage tube left in. Patient became very restless; later became delirious, and on January 6th, 1902, sank into a state of coma and died.
Before death she emitted several times a short sharp cry like that of meningitis, the respirations became very slow (about ten minute), and the pulse remarkably quick. The temperature lay between 98.4° and 100°.
Post-mortem Examination, Jan. 7th, 1902.— The bodily nutrition was good, but the subcutaneous fat deficient; rigor mortis was passing off. The lungs were congested at their bases; here and there were some small purple blood extravasations. The heart weighed 8 oz.; its valves and coronary vessels were healthy; some petechiae and vibices appeared under the visceral pericardium, and a few smaller ones in the parietal pericardium; the blood in the vessels was fluid. The liver weighed 30 oz. ; it was uniformly contracted with some small bossy projections in places; the surface was of a pale whitish colour; the consistence exceedingly tough; on section, thick bands of pale pinkish or white fibrous tissue invaded the whole organ isolating numerous small yellow lobules or groups of lobules which projected markedly above it; in some places this fibrous tissue was alone left; the capsule of the liver was not appreciably thickened. Microscopically, the liver presented the typical appearance of a multilobular cirrhosis; the portal systems were surrounded by a very great increase in the connective tissues, this being in general fibrous, though in places more cellular; the larger branches of the portal veins traversing these areas were held widely dilated by the dense fibrous nature of their walls, which prevented any contraction; the contour of numerous bile ducts could also be seen in this stroma, occupying positions formerly taken by hepatic cells; rounded isolated hepatic lobules could be seen in various stages of diminution, almost to obliteration, though their remaining cells exhibited no great fatty changes. The gall bladder was contracted, small, and thickened. spleen was large, firm, and weighed 11 oz. ; it
was dark red in colour, and showed prominent Malpighian bodies; under the microscope, there was no decided increase in its stroma, but the rounded cells of the lymphoid tissues were noticeably prominent. The pancreas was very firm; microscopically appeared an increase in its interacinous stroma consisting chiefly of rounded and spindled cells which tended here and there to enter between the peripheral cells of the acini so as to separate and isolate them; in the centres of some acini, collections of small rounded or irregular or spindle-shaped cells could be seen. The kidneys were deeply congested; the capsules peeled; the left weighed 5 oz., the right 6 oz ; there was a scattered infiltration of small rounded cells in the stroma between the tubes, and in the Malpighian capsules, but this was not very marked; the renal cells were granular and their nuclei indistinct. The suprarenals were unaffected; the stomach showed some slight old slaty pigmentation; the intestines were healthy; the peritoneum was not thickened; it was discoloured and of a greenish hue (p. m. changes) close to the suprapubic wound. The brain exhibited no changes. The urine removed p. m. contained a few blood cells, an occasional blood or hyaline cast, and many bladder cells, but no crystals.
The following attempts at establishing the collateral circulation were noticeable. The vein accompanying the phrenic nerve enlarged, the veins in the falciform ligament of the liver were marked, as were all the retroperitoneal veins which connected with small veins running into the mesentery; a deep purple varicose condition of veins connected the mesentery, binding down the cœcum and adjacent parts with the deep pelvic veins and those around the iliac bone.
Remarks. The following points may be dwelt upon. The youth of the patient; the entire absence of alcoholic history either personal or parental; the rapid re-accumulation of fluid after tapping; and the fact that though this had to be repeated several times chronic peritonitis was quite absent; the presence of pancreatic as well as hepatic cirrhosis; the sudden supervention of auto-intoxication symptoms (from defective hepatic action) shortly after exploratory laparatomy and draining, which supervention may be merely a coincidence or directly due either to the loss of fluid by draining with increased absorption in consequence from the alimentary canal, thus increasing the work of the liver cells, or to the reparative changes and increased metabolism originating in the area of the wound; and the history of liver enlargement in the patient's brother.
REVIEWS AND NOTICES OF BOOKS,
AND ITS DISORDERS. By Arthur E. Giles, M. D., B.SC., F. R.C.S., etc.; Surgeon to the Out-patients, Chelsea Hospital for Women ; Gynecologist to the Tottenham Hospital, etc. Crown 8vo., 2s. 6d. net. London Bailliére, Tindall and Cox, Sydney: L. Bruck.
The writer of this monograph aims at presenting a concise and practical exposition of normal and diseased menstruation. Within the space of 100 pages, he has successfully carried out his object. Too fre quently brochures of this kind are a weak and unsatisfying dilution of the standard treatises. In the present case this cannot be charged, and Dr. Giles has done his work so well that the larger treatise which he promises on the same subject will be expected with interest.
About one-third of the volume is given to a consideration of the physiology of menstruation. Its anatomical and physiological characteristics, and its relation to the "estrus" in animals in the light of Heape's investigations are discussed; next we have an account of its clinical characters, and chapters on its relation to conception, ovulation, and pregnancy, and on the menopause.
The disorders of menstruation receive fuller atten
tion, and they are treated simply and clearly, in a manner that will make this little book practically useful to the practitioner. Dr. Giles emphasises the fact that these disorders are but symptoms, suggesting a cause to be investigated, "and not separate diseases, for the cure of which an empiric therapeutic formula suffices."
To the practitioner of medicine the subject is one of every day interest, and this little book can be recommended for perusal as being, though its scope is circumscribed, both scientific and practical.
OBSTETRIC AND GYNECOLOGIC NURSING. By E. P.
Davis, A.M., M.D., Professor of Obstetrics in
This book, which was prepared for the Training Schools of the Jefferson and Philadelphia Hospitals, in both of which the author teaches, is designed to furnish instruction as to the various duties of the obstetric and gynecologic nurse. Obstetric nursing demands some knowledge of natural pregnancy, and of the signs of accidents and diseases which may occur during pregnancy. It also requires knowledge and experience in the care of the patients during the labour, and her complete recovery, with the needs of the child. Gynecologic nursing requires special instruction and nursing, and a thorough knowledge and drill in asepsis and antisepsis to supply in a clear and concise manner all the details are absolutely indispensable. This bok will be found necessary to enable any fairly educated woman to become proficient in these branches of nursing, provided that she receive at the same time proper practical nearly past, and women are beginning to fully recognise training. Fortunately the days of "Sairey Gamp" are the necessity of having properly trained nurses attend to them in their accouchments. The work is
very freely illustrated, and can be safely recommended as a text-book for the two branches of nursing that it deals with.
A TEXT-BOOK OF THE PRACTICE OF MEDICINE. streptococci, eponymic; tables of diseases, operations,
By Dr. Hermann Eichborst, Professor of Special signs and symptoms, stains, tests, methods of treatment, Pathology and Therapeutics, and Director of the Medical Clinic in the University of Zurich. The author has sought a middle course between the Authorised translation from the German. Edited large, unwieldy lexicon and the abridged student's by Augustus A. Eshner, M.D., Professor of Clini- dictionary, avoiding the disadvantages of both. Special cal Medicine in the Philadelphia Policlinic, &c. attention has been paid to the wording of definitions, Philadelphia and London : W. B. Saunders and with the intention of making them clear, concise, and Co. Melbourne: Jas. Little. 2 vols. Price, yet sufficiently complete. The important features of £1 109.
pronunciation and derivations have received careful This is a translation from the German of Professor attention. The illustrations have been chosen for their Eichhorst's " Practice of Medicine," which, the author
value in aiding the text rather than for their artistic says in the preface, was written at special request as
value. The work has been admirably designed and an elementary text-book for students.
carried out, and the type is so arranged and varied Not much criticism need be directed to the book that the eye is not confused and wearied in scanning a itself, though one cannot help being struck with its in- page in scarch of the required information. equality. One of its best features is an excellent The Dictionary is a valuable addition to a library, account of the different modes of investigation of the and it is certain to be popular with the profession. functions of the stomach. The author gives a full account of the processes for ascertaining the atsorptive SEXUAL INVERSION. By Havelock Ellis, L.S.A. power, the motor activity, and the digestive power of England. Sold only to physicians, lawyers, the stomach. This is given much more fully than in advanced teachers, and scientists. Philadelphia, any English text-book of the same class, and is un- Pa. : F. A. Davis Co. doubtedly of real practical value. On the other hand, This work deals with a subject which may be of the account given of " Appendicitis” is confused and some interest to alienists and of some assistance to unsatisfactory. The author really believes in an oc- medical jurists, and that is about all that can be said casional primary typhlitis, as apart from an appen- of it. A record of a number of cases of sexual dicitis. Although he is not alone in his belief, it is inversion in the two sexes, with a description of their contrary to all recent pathological experience, which experiences in various abnormal ways of gratifying the is derived chiefly from the examination of specimeos sexual appetite is not edifying reading to any pureobtained from the operating theatre, and not the post- minded person, whether he be a physician or lawyer, mortem room. The treatment recommended is anti- or scientist. To speak if such a work as "scientific quated, to say the least ; e.g. (we quote the exact
is, in our opinion, to use a misnomer. words) : “An ice-bag that is not too heavy should be applied over the right iliac fossa. When the acute in.
A BRIEF MANUAL OF PRESCRIPTION WRITING IN flammatory manifestations have subsided, and the
LATIN OR EsGLISH FOR THE USE OF PHYSICIANS, exudate has been well circumscribed, the ice-bag should
PHARMACISTS, AND MEDICAL AND PHARMACAL be replaced by a hot cataplasm, which will better
STUDENTS. By M. L. Neff, A.M., M.D., Cedar favour the absorption of pus.
Severe pain will frequently be relieved speedily by the application of
Rapids, la. Philadelphia, Pa. : F. A. Davis Co. from 6 to 10 leeches. Treatment with opium should be
The first part of this small work is devoted to a brief persisted in till all pain in the right iliac fossa has dis
account of Latin grammar, sufficient to enable one appeared, even if many weeks should be required.” unfamiliar with the language to write an intelligible One can hardly believe that such treatment should be and correct Latin prescription. As every medical recommended in a modern text-book. Perhaps no
student is, or ought to be, familiar with the rudiments more dangerous advice could be given to a student. of Latin, we fail to see the use of this part of the book. In the same way the author does not recommend the The remaining portions of the work, which are antitoxine treatment of diphtheria with absolute con
devoted to a description of the method of prescription fidence ; he recommends that 1,000 units be injected writing, with illustrations of model prescriptions, immediately, and 1,000 more next day, in a severe tables of doses and incompatibles, are useful, and He does not seem aware of the great value, and
should tend to keep up the art of prescription writing, even necessity, of giving much larger doses.
which, with the great increase in these days of tabloids Evidently the book cannot be recommended as a and "elegant preparations,” we fear is fast decaying. text-book for students.
With regard to the translation, it is fairly well DEATH FROM TETANUS.—The death of Mrs. done ; the English is always clear, and German idioms
Emily Pearson, who died recently in the Melbourne are, as a rule, absent. The illustrations are not nume- Hospital from the effects of an injury to her hand, rous, and are poorly executed ; the majority are of was inquired into at the Morgue by Dr. Cole, very little help to the text,
Acting City Coroner. The evidence of deceased's
husband was that on the 13th ultimo his wife, while THE AMERICAN ILLUSTRATED MEDICAL DICTIONARY.
climbing over a neighbouring fence after a tablecloth, By W. A. N. Dorland, A.M., M.D. Second slipped and hung suspended on a nail which had entered edition, revised, large octavo, nearly 800 pages, her hand. The flesh eventually gave way and released bound in flexible leather. Price, 226. 6d. Phila
her, and as she fell a piece of paling entered the delphia and London : W. B. Saunders and Co., I wound. She went to Dr. Reid, who dressed the wound, 1901 ; Melbourne : J. Little.
and attended deceased every day. On the 20th, This is a complete dictionary of the terms employed deceased complained of pains and a peculiar feeling in medicine, surgery, dentistry, pharmacy, chemistry, around her jaw. Deceased was sent to the Melbourne and all the kind red branches; containing also much | Hospital, where her case was diagnosed as a severe collateral information of an encyclopædic character ; form of tetanus. Dr. Bondin evidenced that deceased also new and elaborate tables of arteries, muscles, died from that disease. A verdict of death from Derves, veins, etc. ; of bacilli, bacteria, micrococci, tetanus was returned.
Branch. But we shall certainly wage war MEDICAL GAZETTE. upon a society which is political in aim, but
tries to carefully disguise this fact under the SYDNEY, 2IST APRIL, 1902.
masquerade of a medical benefit society. In
so doing we do no injury to a single individual THE POLICY OF THE NEW SOUTH
who is deserving of the help and consideration WALES BRANCH OF THE BRITISH
of medical men.
We are acting also in the MEDICAL ASSOCIATION.
best interests of the legitimate friendly societies,
whose field for recruiting new members is being In the excellent address delivered at the damaged by the invasion of the Australian Annual Meeting of the New South Wales Natives' Association, which appears to threaten, Branch of the British Medical Association, by judging by the figures put forth by the officials the retiring President, Dr. FOREMAN, we had of that organisation, to destroy their progress
, laid down in clear and emphatic language the and efficiency. past policy of the Branch, and some good
We are glad to know that some of the advice as to our future action. We hope that
officers of these Orders in Sydney and other bis sanguine expectation will be realised, and
centres are alive to this fact, and regard that by the end of the year we shall have
the Australian Natives' Association with no enrolled in our membership all the members of the profession in the State who are eligible for friendly eye, in spite of the efforts of the
officials to impress upon them and the public membership
that the sole aim and object of the British We are passing through troublous times, and Medical Association is to deal a death blow we need to emphasize again the importance of to all friendly societies. The President of unanimity of action in preventing encroach- the United Friendly Societies' Association was ments upon our rights as professional men and recently reported to have said that “they citizens. Our policy is a defensive one, and not had had no trouble with their doctors until offensive ; we seek to act not in the interest of the advent of the Australian Natives' Associaany one section or clique, but in the interests tion”; so that to be consistent he must of the profession throughout Australasia.
regard this association as a thorn in their Dr. FOREMAN has put very clearly the case sides rather than the bosom friend that the we have against the Australian Natives' Asso-i officials would have them believe them to ciation, and no policy of compromise or be. We know, further, that if the Council
, , mediation be tolerated. We have no of the New South Wales Branch of the war to wage against the legitimate friendly British Medical Association had only taken societies; we have always recognised the im- the bait held out to them by the Ausmense influence for good they exert upon the tralian Natives' Association, the friendly industrial population, and the great assistance societies would have found themselves actively they are to a large section of the profession, opposed by the Australian Natives' Association. and any action which would tend to destroy Now, having failed to secure the benefits they the usefulness of these societies, or to
want from us, the Australian Natives' Associathem up” (to use the language which has been tion seeks an alliance with the friendly societies put into our mouths by the officials of the of an offensive nature against us. But we are Australian Natives' Association), would be mistaken if the latter will not see that such an strenuously opposed by the Council of this I alliance is not in their own interests, and that
they will act wisely in not taking up the 'factor can reasonably be assigned to the two cudgels for a rival association, and precipitating forms of disease. No theory of perversion of an unnecessary quarrel with the profession. nutrition of the tissue or loss of federal control
will, surely, explain the cancerous cachexia, THE DISCUSSION ON CANCER. which so strongly suggests a poisoning of the
tissues by the products of the growth of some The discussion on cancer at the recent Inter- parasite, or the introduction into the system of colonial Congress at Hobart seems, on the
some foreign substance; and further, we think whole, to have been disappointing. With all that on no other hypothesis can the occasional due deference to Professor Allen, we think that spontaneous disappearance of the disease be nothing has been gained by it, and no new explained.
explained. But we must await the results of facts bearing on the etiology, pathology or
further experimental and clinical investigation, treatment of the disease have been forthcoming and hope that much good will ensue from the We regret that the suggestion made in the large amount of attention and research now editorial in our January issue was not acted being given to this subject by the pathologists upon, and a Collective Investigation Committee of Europe and America. appointed to collect evidence and report to a
Many points of interest in Professor Allen's subsequent Congress.
address were not touched upon by subsequent Professor Allen's introductory address, of speakers, and the discussion practically resolved which we give an abstract in another column, of the question. Dr. Verco's statistics of the
itself into a series of papers on various aspects
. was the result of an immense amount of labour in
disease in South Australia are very interesting, collating statistics, and dealt with the subject and the fact brought out by him—that women from various points of view; but we must confess
in South Australia are relatively less frequently our inability to accept his conclusions in toto.
attacked by the disease-is ditlicult of explanaHis inference that the increase in cancer
tion. largely only an apparent one because of the relative increase in the potential
THE MONTH. patients, is not borne out by Mr. Coghlan's
The Victorian Sanatorium for Consumpstatistics for this State, and cannot be taken to
tives. explain the relatively larger increase in cancer The Victorian Sanatorium for Consumptives in England in recent years. While, of has now been in existence for eleven years, and course, the parasitic theory so far lacks actual it is a matter for regret that this institution, demonstrative proof, we think that the ten
which appears to be doing such excellent work,
and which is always full to overflowing with dency of recent investigations, as well as a patients, should lack widespread support from study of the clinical history and course of the community. The patients spend the summer cancer patients all point strongly in favour of in the sanatorium at Mount Macedon, and the
winter at Echuca. During the last summer this theory. On no other hypothesis can all season at Mount Macedon, the average weight the facts be harmonised, and here we would gained by each patient was a stone. Accomremark that in speaking of "Cancer,"
modation is provided for fifty patients, and over
fifty more who have been medically certified as should restrict our attention to carcinoma
suitable cases are awaiting admission. During as distinct from "
The two forms of the year, owing to great increase in the demand malignant tumour are distinct in their mode of for admission, temporary additions in the shape
of tents were used to accommodate twenty-two development, their age incidence, and mode of
more patients; but the committee having secondary dissemination, and no one etiological recently received a donation of £2,300 from a