A its/ralian Medical 7ournal
NOVEMBER' 20, 18 9 5.
TWO CASES OF TUBERCULAR OSTEO–MYELITIS.
By R. A. STIRLING, M.B., Ch. B. Meib.
The shaft of the long bones is generally exempt from tuber- cular disease,.the anatomical conditions in the neighbourhood of epiphyses in young persons favouring the deposit of, the microbes.
All writers admit the rarity of the epiphyseal line being crossed by the invading hosts ; and as two such cases have recently come under my care at the hospital, they are thought worthy of record, especially as so serious a complication necessitates the last grim remedy of the surgeon—amputation. Both patients were ad- mitted within a few days of each other, and so far as I can learn, these are the only instances in our records.
That of a boy, mt. 8 years, was admitted. September 14, 1895.
He had been under the care of a surgeon in the country, and was by him recommended to me. His mother dated the symptoms to a fall from a cart six weeks previously. The left leg, on admis- sion, was swollen from the knee to the hip-joint, and there were marks of incisions, from which pus still oozed at various points of the limb. The knee-joint was flexed, somewhat swollen, especially at the posterior part, there being evidence of a pus accumulation in the popliteal space, and the joint showed the usual deformity of subluxation of the tibia backwards.
On September 17, I made an exploratory incision in the posterior part of the limb, into the popliteal space, and found the lower part of the femur devoid of periosteum ; pus had also dissected the periosteum from the bone for the space of several inches, and had passed into the joint through the posterior liga- ment, and burrowed down past the heads of the tibia. The femur felt roughened, and the separation of the shaft from the epiphysis was very complete, an interval of about an inch of carious crumbling debris filling up the gap. Although the case looked a hopeless one as far as saving the limb was concerned, I was loth to amputate, and the boy, being a sturdy country lad in robust health otherwise, I tried lavage, drainage, and plugging with iodoform gauze.
VOL. XVII. No. 11. KK
For a few days things went well, but the discharges becoming foul and the temperature rising, on October 2 I again made a thorough examination of the joint, and found amputation necessary.
The patient made an uneventful recovery, and was discharged with a good stump on November 13.
Was admitted September 17, 1895, complaining of pain and swelling in her left knee, which came on spontaneously about three weeks before. She had previously been quite strong and healthy, lived in Gippsland, and was, although looking pale and weak, without much constitutional disturbance at first, the temperature being normal and the pulse rate only moderately quickened. The knee-joint was much swollen, and the lower part of the thigh was also tender and more enlarged than its fellow, but the case looked like an ordinary tubercular knee-joint, except on careful examination, when it could be seen that the displacement backwards of the limb, and the mobility on lateral motion was more pronounced than mere softening and straining of ligaments could give.
October 10.—The patient being much on the decline, very anaemic, worn out with pain, with rising temperature, and other symptoms of septic infection, was anaesthetised, the joint opened by the usual anterior incision for resection, and found to be apparently but slightly involved ; the supra-patellar bursa showing unmistakable evidence of tubercular disease, and some slight erosion of the cartilages and granulation tissue on the lateral aspects of the synovial membrane being noted. Posteriorly the same invasion of the joint, from epiphyseal inflammation, as in the previous case was apparent, and the shaft of the femur presented the appearances of diffuse tuberculous osteo-myelitis, combined with suppurative osteo-myelitis. For high up in the deeper structures of the middle third of the thigh, running along the linea aspera, close to the bone, and stripping the periosteum, was a collection of pus, with liquefied cheesy debris in it. The lower end of the shaft was ragged. After amputation as high as the bone disease, the affected soft parts were curetted and much caseous and shreddy material dislodged. She made an excellent recovery, and left the hospital on November 11.
I am indebted to Dr. Tymms, my House Surgeon, for many of the notes of these cases.
482 Australian Medical Journal. Nov. 20, 1895
Nov. 20, 1895 Exhibits. 483
Webitai (Soria)) of Vittoria.
ORDINARY MONTHLY MEETING.
W EDNESDAY, NOVEMBER 13, 1895.
(Hall of the Society, 8 p.m.)
The President, Dr. ROTHWELL ADAM, occupied the chair, and twenty-one members were present.
One gentleman was nominated for membership.
(1) Dr KENT HUGHES showed a case of Complete Anterior Obstruc- tion in both Nares in an adult wt. 20. The lower part of the nose was large and well-developed, but the bridge was flattened and depressed, resembling the bridge of " congenital syphilis." Upon inspection, there was seen to be in both nares a cicatricial adhesion, binding the outer wall firmly to the septum. On cutting through the adhesion in the left nostril, it was found to be thin below, but above it was of firmer consistence, and extended for about half an inch. A short length of soft rubber catheter (No. 8) was passed through the incision, and secured by a piece of silk and adhesive plaster to the cheek. In two days this was found to be quite loose in the nostril, and was replaced by a No. 10, which was again changed in two days for a No. 13. The anterior portion of the inferior turbinate, which could be seen with some difficulty after the first incision, was of a diminutive size, but quickly increased, and was now (fourteen days after the first incision) about four times as large.
The girl is an orphan, and no definite history can be obtained.
She herself asserts that she was born with it, and a very old friend of her father, who lived near them when she was a baby, also states that she was born with it, but he has no recollection of any difficulty about rearing the child, and does not know whether it was breast-fed or spoon-fed. At five years of age the girl states that she was taken to a well-known medical man in this city, who told them that nothing could be done then for the condition, as the child was too delicate.
The case was kindly sent to me by Dr. Herman Lawrence, whom she consulted for " loss of voice." She was then suffering from chronic laryngitis, and had " lost her voice " for about three months. This was the third occasion upon which she had "lost her voice."
484 Australian Medical Journal. Nov. 20, 1895 Her complexion is sallow ; eyes prominent ; mouth always wide open ; teeth small, but no appearance of " pegging;" no traces of any scars at the angle of the mouth, in fact, no other definite signs of " congenital syphilis," with the exception of the nose. The case that Dr. A. J. Wood has just shown, however, may be taken as a guide, and seems to be quite analogous in every way.
-So much has been written about the chest in nasal obstruction, that it is interesting to note that in this patient in whom the obstruction has been complete, certainly from the age of five, and probably from the first year of life-- it is absolutely flat, and presents no sign of recession.
I have omitted to state that the posterior nares are normal.
(2) A case of Growth on the Cornea in a patient tet. 70. The growth was papillomatous and very vascular ; it stretched from near the inner canthus across the pupil, being about the size of a small broad bean. At the upper and outer quadrant of the cornea, there was an opaque smooth growth, raised slightly above the level of the cornea. The patient said that, three months ago, he could see well with the eye, and did not notice anything there.
(3) A case of Severe Flat-foot in a boy of 14.—When this boy first presented himself, the arch of the foot was represented by a convexity, caused by the head of the astragalus projecting down- wards and inwards. No restoration was possible without complete narcosis, so the boy was put under the influence of chloroform, the foot well wrenched, and put up in an over-corrected position in plaster, and left for a month ; this had to be repeated four times
—twice would have been sufficient, but the boy was careless, and did not attend regularly, so the good effects of the first two wrenchings were lost. The foot was then ready for the boot devised by Mr. Walsham for these severe cases; it consists of a properly made boot, with straight inner edge and low heel, with an outside leg iron up to the knee, free joint at the ankle and calf piece, and a strong rubber band attached to the outer edge of sole, which passes across the sole to the inner side of the foot, and is attached to the calf piece. In this boot, he can walk and stand quite comfortably.
Dr. A. JEFFREYS WOOD showed a male Infant with Occlusion of both Nostrils, and read the following notes :-
A. H., aged 12 weeks, was strong and well at birth. He could not take the breast at first, but when the frenum of the tongue
Nov. 20, 1895 Exhibits. 485 was cut, he was able to suck well. When three days old, he began to snuffle, and a watery discharge began to appear from both nos- trils ; crusts then formed, which had to be removed to permit him to breathe through his nose. At nine weeks old,. his nasal breath- ing became very much obstructed, and he was unable to take the breast or the bottle, and had to be fed with a spoon._ The'right nostril then stopped discharging, and four days later, the discharge from the left nostril also stopped.
On October 29, when the child was 10 weeks old, the nose was found to be completely obstructed in both nares. The obstruction seemed to.be the result of the outer wall of the nostril having be- come attached to the septum at the anterior extremity of the inferior turbinate. With a strong reflected light, absolutely no trace of an aperture could be seen in either nostril. An attempt was made to force a blunt silver , probe through the obstruction on the right side, but the probe bent with the force used, and did not break down the barrier ; on the left Side, however, the passage of the probe was effected by means of considerable force, and was followed by bleeding.
Under chloroform, a tenotome was introduced along the floor of each of the Dares, and the obstruction was freely incised, and a plug of iodoform gauze introduced into each passage. This was removed a few hours later, and two small pieces of drainage tube inserted instead. The passages were well dilated daily for a week with Spencer Wells' forceps, and now have a feather smeared with unguent. hydrarg. passed down three times a day. The result in the right nostril is excellent, but the left nostril will want a little more incising. At 7 weeks old, the child was brought to the Children's Hospital, suffering from a specific rash on the buttocks, as well as the specific rhinitis. The nostrils were certainly quite patent at birth, as evidenced by the freedom with which the child took the breast ; the severe form of rhinitis, which lasted for nearly seven weeks without any mercurial treatment, evidently lead to the occlusion of both nostrils at about the tenth week.
Our patient is the first child ; the mother has not had any mis- carriages, and is apparently free from any specific manifestations.
A mercurial binder was applied when he was seven weeks old, and is still being worn. The extremely atrophic condition of the body is due to the difficulty which he experienced in taking his food ; but for the last three days he has been taking the breast splen- didly, and is certainly beginning to put on flesh. I have not seen
486 Australian Medical Journal. Nov. 20, 1895
any case of congenital syphilis previously that presented this com- plication, and can readily imagine that, as a rule, these children would die if the obstruction was not relieved, or very great care was taken with spoon-feeding.
Dr. W. Animisox Woon showed a case of Actinomycosis in a man. The lesion was situated behind the left ear.
The PRESIDENT then declared a Special Meeting to consider the resolutions of the delegates concerning the elections at the Melbourne Hospital.
At the request of the President, Dr. BARRETT reported that the conference of delegates of the three Medical Societies had passed the following resolutions, which they presented to the members of the Medical Society for criticism :—
" (1) That the present system of election of honorary medical officers of the Melbourne Hospital is unsatisfactory.
" (2) Suggested reforms--(a) That an age tenure is desirable, and that the retiring age be 60 years. It is sub- mitted for the consideration of the Societies whether it is, or is not, desirable to fix a time tenure of 25 years for members of the in-patient staff. (These proposals not to apply to members at present on the senior staff). (b) That the candidates for vacancies on the senior staff be selected from the junior staff.
" (3) That all vacancies in the honorary medical offices be filled by election at the hands of life governors, and subscribers who have subscribed a total sum of £3 at any time or times during the four years preceding an election.
" (4) In the event of these resolutions being endorsed by the Society, the conference of delegates be empowered to take such action as it may deem necessary to give effect to them."
In explanation, Dr. BARRETT said that the age tenure had been decided upon inasmuch as it embodied a definite principle, namely, the security of tenure to men who were properly elected, and who did their work efficiently. The principle of an age tenure had been practically adopted in all the important hospitals in Europe.
It was adopted in the making of all important appointments in which it was felt that security of tenure was necessary if the best
Nov. 20, 1893 Special Meeting. 487 development of the individual was to be obtained. An alternative proposal before the Conference was the fixation of longer terms of office than those at present existing, say ten years in each case.
All the evils of the present system must remain, but the present indiscriminate scramble for office would take place every ten years instead of every four years. As against the age tenure, it was urged that men might become incompetent, negligent, or fossilised, and in that case it was desirable to remove them. It would not be difficult to devise machinery for meeting such an objection, but such a danger was much more apparent than real. On the other hand, it was urged that the appointment of men for ten years would give the electors an opportunity of removing a negligent or careless officer. As a matter of fact, however, the election every four years had notably failed to produce that result, and if the argument held good, there was no reason why the election should take place so infrequently as every four years. If the sole object of frequent election was to remove undesirable officers, the election might be made annual, as in the case of one of the large suburban hospitals in Melbourne, where the officers were renewed by the Committee from year to year. Certain important consequences followed from the adoption of an age tenure when conjoined with subsequent resolution. The resolution carried at the Conference—that for the future, senior medical officers should be elected from the junior staff, coupled with the adoption of the age tenure—meant a complete revolution in the method of election. When senior officers retired, an election would take place for the purpose of electing to the vacant position one of the junior officers, and then an election would be held to elect some one from outside to the vacant junior office.
Consequently, the whole attention of the electors would be focussed on one election for one office, and in such a case the influence of the medical profession in one direction or the other would be very great indeed. The election would be devoid of the unpleasant peculiarities which attached to a general and indis- criminate scramble for eighteen vacancies, and consequently would gradually fall more and more into a parallel with similar elections conducted in the old country. •So that, although the subscribers still elect, this alteration, namely, age tenure coupled with promotion of junior officers, would mean a complete reformation of the present objectionable system. The Conference had further suggested that all elections in future should be effected by
438 Australian' Medical Journal. Nov. 20, 189g
subscribers. In so resolving, after considerable deliberation, the Conference was influenced by the following circumstances :-
All elections, so ..far as it is aware, are conducted either by hospital committees or hospital subscribers. An electoral college is, broadly speaking, an untried method of eleCtion, and in Melbourne, at all events, hospital, surgeons seem more afraid of committees and councils than of subscribers. It is not a choice, therefore, of an ideal electoral college, but of election by committee or election by subscribers, and of the two the method of election by subscribers seems to offer, on the whole, the fewest practical difficulties. There is, further, the important circumstance to be taken into account, that the subscribers might not consent to the abrogation of any of their privileges. But since no matter what scheme is adopted, all present officers must retire at the end oi four years and a new election must take place, some method of safeguarding the just interests of present officers had to be devised, and it was suggested that no subscriber should vote who bad not subscribed at least £3 during the three years preceding the next election. By this means the " faggot " vote would be practically eliminated, since no one could afford to make a large number of votes at the heavy price of £3 per vote. Consequently, the next election would be a fair electioU at the hands of subscribers and governors, and after the next election no further general election would take place. Elections would only take place as the single vacancies occurred. Summarising, then, it would be seen that the proposals of the Conference were, to abolish the general election after the next one, to elect on an age tenure, to promote junior officers to senior vacancies, and to abolish or restrict the evil known as "the faggot vote." The scheme might not be an ideal one, it might be imperfect, but it would effect a vast improvement. It was infinitely better than the present chaotic system, and it would increase the influence of the medical profession in controlling elections in the future. It remained for members to say whether it was or was not to be adopted. He proposed that the resolutions be adopted by the Society.
Dr. MOLLISON seconded the motion.
Dr. J. P. RYAN objected to the resolutions as they stood, for the election of the honorary medical officers was still left in the hands of the subscribers, and such a mode of election, in his opinion, was radically bad. He spoke with feeling, as he had
Nov. 20, 1895 Special Meeting. 489 acted as a junior on the staff for many years, and resigned when he 'saw no reasonable prospect of ever - being - able tO' attain a position on the senior staff As Li matter of justice, the juniors might. most certainly to be elected to the vn.ancies on the senior staff.
Dr. DUNCAN said he thought it was a pity that the principles of election embodied in the measure before them were not made to apply to all the hospitals in the Colony. The methods of election in all were nearly the same as the one under discussion, but the latter stood out more prominently in attracting public attention.
Undoubtedly the method was radically bad in many respects, but whilst it was easy to criticise, the difficulty lay in formulating a scheme of a more perfect nature. That was by no .means an easy task, not even in older centres of population, where longer and wider experience could be brought to bear on it. The plan pursued in the London Hospitals had been quoted, but anyone conversant.
with these methods knew that they were by no means perfect.
Under no circumstances was it possible to devise a perfect scheme, vet the one before them was infinitely preferable, to the present state of affairs. After all, it depended largely or solely on the attitude of the subscribers. if they could be brought to see that a change was desirable, there could be no poSsible difficulty in effecting a radical alteration.
Dr. EGRYN JUNES said he agreed that the present system of election of Honorary Medical Officers to the Melbourne Hospital is unsatisfactory, but he submitted that the proposed scheme of reform leaves practically untouched the most glaringly unsatis- factory thing, viz., the method of electing the Staff; and the question arises whether it is worth while to deal with the length of tenure of office, without attacking the offensive. and degrading method of election. The next election will be carried out on the lines of the past, with only this difference—that a man elected under a vicious system will have practically a life tenure of office on the hospital Staff, for there is no provision under the scheme for the removal of an incompetent man. Perhaps the worst feature of past elections has been the creation of " faggot " votes.
It is sought now to lessen this by increasing the subscription from
£1 to £3. But if it is worth a canditate's while to spend large sums of money on a four years' tenure of office, it will be worth his while spending larger sums on a life tenure. Further, with infrequent elections, the interest of the subscribers will grow less,
490 Australian Medical Journal. Nov. 20, 1896 and the decision fall into the hands of a constituency so small as to be easily swamped by a "faggot" vote not more expensive than the present one. He urged, therefore, that unless a scheme for a
thorough reform of the method of election can be passed, it would be detrimental to the best interests of this hospital, and all other hospitals which may follow its lead, to grant a Staff elected under a bad system a life long (practically) tenure of office.
Mr. A. L. KENNY agreed with Dr. Jones that there appeared to be a tendency to cast the blame of the present unsatisfactory system of election upon the subscribers. It was wrong to do this;
the fault lay with certain members of our own profession, who in their eagerness and determination to obtain positions on the honorary staff, cast aside all feelings of what was due to their profession. He thoroughly agreed with the first resolution. He
felt considerable difficulty with regard to age tenure, preferring a
time limit, with the provision of some means of displacing incompetent men, who would be harmful to the best interests of
the hospital. He quite recognised the advisability of giving some sense of security to good men, by which they would be encouraged to do good work without being required to constantly plot for re-election at short intervals. Recently, at St. Bartholomew's Hospital, a special position had to be created in order to make Dr. Lauder Brunton a full honorary physician after some twenty- five years' work as an out-patient physician ; such a prospect, mainly due to an age tenure, would blight the hopes and embitter the career of many able men. It was a matter for general agreement, that vacancies in the senior staff should be filled from the junior staff. He did not think that resolution 3 would be accepted by the subscribers, and he felt that in any case it offered only a slight improvement. As it was understood in the resolutions that an election at the ordinary period would have to
take place in order to inaugurate the new system, it was easy to see that with eighteen positions open, and a long tenure offered, men who now spent certain sums of money for election purposes, with the prospect of having to do the same every four years, would not hesitate to spend three times that sum for the purpose of securing election to the new tenure. At such election incompetent or unsuitable men might easily be elected, and unless some means of review by re-election at certain intervals were provided, say at intervals of ten years, much harm would be done.
Dr. HOWARD was afraid that any proposal for the creation of
an electoral college would only meet with failure, for subscribers would have to forego their privileges, or a special Act of Parlia- ment would have to be passed depriving them of their present power. The medical profession would all like to see an ideal scheme of election, but under the circumstances he thought that the present regulations were certainly in the right direction, for the ordinary subscriber was only asked to select and vote for one candidate at an election, instead of being asked to elect candidates for no less than sixteen vacancies at the same time. He certainly thought that the present scheme, as proposed, ought to be accepted by the Society.
Dr. CHERRY moved that a time limit be substituted for the age limit as proposed by the Committee. He would be in favour of a maximum term of office of thirty years, subject to re-election every ten years. As some vacancies would be likely to occur on the senior staff before the expiration of the first period of ten years, the junior men-who were promoted to the in-patient staff would hold office for ten years from the time of such promotion, and hence in a short time the hospital elections would occur singly and at frequent intervals, probably at the rate of about two mem- bers every year. Six or eight of the first staff, under the new system, might have to seek re-election together at the end of the first period of ten years, but after that the elections would occur one at the time, just as in the scheme proposed by the joint Committee. He agreed with Dr. Barrett in thinking that the new constituency it was proposed to create would be to a very large extent under the control of the profession, and hence if a man did his duty during his term of office, he would be certain of re-election. For all practical purposes, therefore, this plan . would make the tenure of office as certain as was desirable. He failed to see how absolute permanency of tenure would be any guarantee for efficiency of work. On the other hand, as a man drew near the age limit, and at the same time found himself engaged in a large private practice, the possibility of . neglect of hospital work was too great to be ignored. The importance of the Melbourne Hospital depended on its connection with the Medical School, and permanency of tenure would mean that no control could be exercised over the clinical teaching. This want of control was at present the weak point of the Medical School, and every plan for the reform of the method of hospital elections should provide for the efficiency of
Nov. 20, 1896 Special Meeting. 491
492 Australian Medical Journal. Nov. 20, 1896 clinical teaching also. A young m-an might secure an out-patient position, and yet turn out a complete failure from the student's point of view ; yet under the scheme of the Committee, there was no possibility of getting rid of him till he reached the age.of 60 or 65. If his amendment were adopted, every member of the staff would 'know that his re-election depended solely on the way he did his work. He would allow any member of the junior staff to oppose a senior man who was seeking re-election, but by doing so his own seat would become vacant, and in case of failure his own re-election would be necessary.
Dr. CHERRY moved that the Committee of Delegates from the three Societies be requested to formulate a scheme based upon a time tenure.
Dr. KENNY seconded the amendment, which was lost. Dr.
Barrett's original motion, " that the Society adopt the proposals of the delegates," was then put and carried.
Iltientt aoriation offirforia fintit6.
LIST OF MEMBERS.
Abramowski, Otto L. M., M.D. Berlin, Langtree Avenue, Mildura.
Adam, George Rothwell Wilson, M.B. et Ch. M. Ed., Collins Street, Melbourne.
Anderson, Alfred V. M., M.D., B.S. Melb., Greville St., Prahran.
Anderson, Eugene W., M.D., B.S. Melb., L.R.C.S., L.R.C.P. Ed.
Burwood Road, Hawthorn.
Argyle, S. S. ; M.B., B.S., &c., Kew.
Armstrong, G. W., M.B., &c., Corryong.
Bage, Charles, M.A. ; M.D. et B.S. Melb., Toorak Road, South Yarra.
Balls-Headley, Walter, M.A. ; M.D. et C.M. Cantab., M.D. Melb., F.R.C.P. Lond., Collins Street.
Bennie, Peter Bruce, M.A.; M.D., B.S. Melb., Collins Street, Melbourne.
Black, Archibald Grant, M. B., Ch. M. Glas., Victoria St., Carlton.
Box, J. L., M.B., &c., Foot scray.
Boyd, William R., M.D., B.S. Melb., M.B.C.S. Eng., L.S.A.
Lond., Hoddle Street, Richmond.
Brett, John Talbot, M.R. C.S. Eng., L.R.C.P. Loud., Collins Street, Melbourne.
Nov. 20, 1895 Medical Defence Association. • 493 Bryant, H. W., M.B., &c., Williamstown.
Clendinnen, Frederick John, L.R.C.P. et S. et L.M. Ed., L.M.
K.Q.C.P.I., L.R.C.P. Lond., M.D. et D. Ch. Brux., Malvern Road, Hawksburn.
Cole, Frank Hobill, M.B., B.S. Melb., Lygon Street, Carlton.
Cox, James, M.D. et B.S. Melb., M.R.C.S. Eng., Collins Street.
Cuscaden, George, L.R.C.P. et S. L. Mid. Edin., Bay Street, Port Melbourne.
Davenport, Arthur Frederick, M.B. Lond., M.R.C.S. Eng., High Street, St. Kilda.
Daish, William Christian, M.D. et B.S.Melb,, Howe Crescent, South Melbourne.
Duncan, Robert B., F. R. C. S. Ed., F. F. P. S.G. , L. R. C. P. Ed., Simpson Street, Kyneton.
Dyring, Carl P. W., M.A. ; M.B. Melb., Walsh Street, Coburg.
Embley, Edward Henry, M.B. et Ch.B, Melb., Latrobe Street, Melbourne.
Embling, Herbert A., M.B., B.S. Melb., L. Mid. F.P.S. Glasgow, Power Street, Hawthorn.
Fishbourne, John William Yorke, M.B. et Ch. M. Dub., 35 Puckle Street, Moonee Ponds.
Fletcher, Arthur Augustus, M.D. et B.S. Melb., M.R.C.S. Eng., Lygon Street, Carlton.
Ford, William H., L.S.A., 115 Cecil Street, South Melbourne.
Goodall, Charles E., M.B., B.S. Melb., Carlisle Street, St. Kilda.
Hamilton, Francis G., M.R.C.S. Eng., Sydney Road, Brunswick.
Harricks, Francis Meagher, F.R.C.S.I., M.K.Q.C.P.I., Alma Road, East St. Kilda.
Harris, J. R., M.B., &c., Rutherglen.
Henry, Louis, M.D. Wu rtz. et Melb., L.R.C.P. Lond., Sydney Road, Brunswick.
Honman, Andrew, M.R.C.S. Eng., L.S.A. Lond., Nelson Parade, Williamstown.
Horne, George, M.A. ; M.B., B.S. Melb., Queen's Parade, Clifton Hill.
Howard, George T., M.D. et Ch. B. Melb., Nicholson Street, North Carlton.
Hughes, Wilfred Kent, M. R. C. S. Eng., L. R. C. P. Lond., M.B.
Lend., Collins Street, Melbourne.
Jackson, James, M.D. Lond. et Melb., M.R.C.S. Eng., Collins Street, Melbourne.
494 Australian Medical Journal. Nov. 20, 1895
Jamieson, James, M.D. Glas. et Melb., Ch. M. Glas., Collins Street, Melbourne.
Johnstone, John, M.B., Ch. M. Glas., Ferguson Street, North Williamstown.
Jordan, Thomas Furneaux, M.R.C.S. Eng., Doveton St., Ballarat.
Lawrence, Herman F., L. et L. Mid. R.C.P. et S. Ed., L.F.P.S.G., Brunswick Street, Fitzroy.
Liddle, P. H., M.B., &c., Surrey Hills.
Loosli, Robert J , M.B., B.S. Melb., Camberwell.
MacGibbon, Walter, B.A. Melb., M.D. Brussels, L. et L.M.R.C.P.
Ed., L.R.C.S. Ed., L.F.P.S. Glas., Brunswick Street, Fitzroy.
Mailer, M., M.B., &c., Rathdown Street, Carlton.
Meyer, Felix, M.B. et B.S. Melb., 169 Lygon Street, Carlton.
Miller, Joseph J., M.B. et B.S. Melb., Sydney Road, Brunswick.
Moloney, Patrick, M.B. Melb., Collins Street, Melbourne.
Moore, William, M.D., M.S. Melb., Collins Street, Melbourne.
Morrison, Reginald Herbert, M.B. et Ch.M. Edin., Toorak Road, Toorak.
Morton, Francis W. W., L.R.C.P. et S., L.M. Ed., Brunswick St., Fitzroy.
Mullen, William L., M.A. ; M.D., B.S.; LL.B. Melb., 13 Spring Street, Melbourne.
McAdam, Robert L., M.D., Ch. B. Dub., Alma Road, St. Kilda.
McCarthy, Charles Louis, M.B. et Ch. B. Melb., Paisley Street, Footscray.
Noyes, Jun , A. W. Finch, M.R.C.S. Eng., L.R.C.P. Lond., F.R.C.S. Ed , Collins Street.
Owen, Frederic James, M.D. et B.S. Melb., Brunswick Street, North Fitzroy.
Owen, William Hall, L. et L. Mid. K.Q.C.P.I., M.R.C.S. Eng., 4 Bank Street, South Melbourne.
Ramsey, John R., M.D. Glas., 241 Malvern Road, Prahran.
Rennie, G. C., M.B., &c., Collins Street, Melbourne.
Ryan, Charles Snodgrass, M.B. Ed. et Melb., Ch. M. Edin., Collins Street, Melbourne.
Ryan, T. B., M.B., &c., Michael Street, North Fitzroy.
Shanassy, Thos., L.R.C.S. et P., &c., Heywood.
Smith, C., M.D., &c., Casterton.
Snowball, William, M.B. et B.S. Melb., L.R.C.S. et L.M. Ed., L.S.A., Victoria Street, Carlton.
Stanton, Thomas, M.B. Dublin, L.R.C.S.I,, Koroit.
Nov. 20 1895 Hospital Reports. 495 Springthorpe, John William, M.A., M.D. et B.S. Melb., M.R.C.P.
Lond., Collins Street, Melbourne.
Stawell, Richard R., M.D., B.S. Melb., Collins Street.
Stirling, Robert Andrew, M.B. et B.S. Melb., L.R.C.P. et S. Ed., Lonsdale Street, Melbourne.
Syme, George Adlington, M.B., M.S. Melb., F.R.C.S. Eng., Collins Street, Melbourne.
Thomson, John R. M., M.B., B.S. Melb., Napier Street, Essendon.
Trood, C. J., M.B., &c., Prahran.
Walsh, William B., M.D. Dub. et Melb., F.R.C.S.I., 65 Cotham Road, Kew.
Wilkinson, A. M., M.B., &c., Burwood Road, Hawthorn.
Willis, T. Rupert H., M.B., B.S. Melb., Daylesford.
Wood, A. Jeffreys, M.D., B.S. Melb., Collins Street, Melbourne.
SOME UNUSUAL CASES FROM THE OUT–PATIENT ROOM.
By Dr. W. MOORE, M.D., M.S. Melb.
In the out-patient department , of a large Hospital many cases of interest come under observation, but the difficulty of keeping accurate records, at any rate at the Melbourne Hgspital, is almost insuperable. Hence it is perhaps not remarkable that cases from the out-patient department so seldom appear in the columns of the Journal. Brief and imperfect records of the following cases were kept :-
CASE I.—Fracture of the Humerus (R.) by Muscular Action.
S. B., alt. 28, a pale, puffy-faced, unhealthy-looking man, came under treatment in March 1894, suffering from a simple transverse fracture of the right humerus about its middle. He stated that he hurt his arm in throwing a cricket ball hard, against a strong wind ; his arm at once became powerless, and he has been unable to use it since. He was not an expert thrower. The fracture was directly transverse ; there was no sign of bruising about the arm. A rectangular splint was applied on the inner side of the arm, and a cardboard splint on the outer side. It gave no trouble
49.6 Australian Medical Journal. Nov. 20,1895
;svbatever,.and union was firm in six weeks, when the splint was removed, and the patient allowed to carry his arm in a sling.
This accident is not common. It may be .remembered that a neinhet of the, first Australian Eleven, who did a large share of the outfielding in England, was. unfortunate enough to fracture ,his humerus in,Sydney.soon after his .return, whilst throwing the ball in from the outfield.
CASE IL--Dermoid 'Cyst, attached to Spine of Scapula.
R., T., tnentlis,,a: healthy male child.. The mother states that about nine months ago she noticed a small lump on the child's shoulder ; it remained very small until recently ; it then increased
in size somewhat rapidly. It has never been painful.
On examination, there was noticed a lump about the size of a pigeon's egg, rounded, apparently attached to the spine of the scapula, near its centre ; it was completely free from the skin, but there was a small wart on the skin immediately over it.
On October 10, 1894, the cyst was removed ; it was found to be firmly attached to the spine of the scapula, and a small piece of the bone was removed by cutting bone forceps. The wound healed by immediate union.
Dr. Mollison examined the little growth, and pronounced it to be a dermoid cyst ; it contained hair.
CASE III.—Carcinoma of the Male Breast.
F. H., mt. 60, miner, came under observation in November 1894, suffering from a hard irregular lump in the right breast. It was not adherent to the muscles, nor was the skin infiltrated. He stated that about four months previously, he had struck himself on the right nipple with the handle of a shovel, some soreness resulted ; about two weeks ldter he noticed a small lump, which was not painful, but which has gradually increased in size.
Nov. 5, 1894.—Under chloroform, the whole breast was removed through an oval incision ; there was very little hwmorrhage. The wound was closed with horse-hair sutures ; no drainage was em- ployed. The axillary glands were not removed. Dry perchloride gauze was applied, and the patient allowed to go home.
Nov. 8.—There was considerable swelling about the wound, dark discoloration extended from the axilla to the crest of the ilium.
It was necessary to remove several sutures and wash out the blood-clot. This delayed the healing for several weeks.
Dr. Mollison examined the tumour, and pronounced it a carcinoma.
CASE IV.—Tumour of Male Breast.
A. R., vet. 22, engineer, working lately as a miner, sought advice for an enlargement of the left breast, which he had noticed recently.
There was no defined lump, but the chief enlargement was just above the nipple ; he did not remember any injury ; it was not painful.
Nov. 19, 1894.---The whole breast was removed under chloro- form, the wound was accurately sutured, and dressed with dry dressing. In a week the wound was firmly healed, and all sutures were removed. He was discharged November 29, 1894. Three months later he returned to show himself ; there was no sign of a recurrence.
Dr. Mollison examined the growth, and reported that there was marked irritation of the epithelium in the acini, many. being stuffed with cells, some of which showed a tendency to break out into the connective tissue, resembling the early stage of a malig- nant growth.
It was somewhat remarkable to have two cases of tumour of the breast in males under treatment at the same time.
HOSPITAL FOR INSANE, ARARAT.
Case of Adolescent General Paralysis of the Insane.
By W. BEATTIE SMITH, F.R.C.S. Ed., Medical Superintendent.
The increasing prevalence of general paralysis of the insane amongst the new admissions for the past two years to the various Victorian asylums demands attention, and perhaps a unique case, so far as Victorian, and to the best of my knowledge, Australian records go, will warrant special mention. It is that of an adolescent general paralytic, whose history commenced with tremors, general irritability, untidy habits, extravagant ideas, ataxic gait at the age of eighteen years. His symptoms were accurately watched, and carefully marshalled by my friend, Dr. George Palmer, of the Ararat Hospital, during the two years prior to his admission to the Ararat Asylum. He then presented the typical appearance of a case of general paralysis, and displayed the typical symptoms of muscular tremors and jerkiness, with restlessness, fumbling, quivering speech, and ataxic gait.
On further examination, there were found rigidity of frame, with spasmodic twitches, hand grasp jerky and tremulous, speech
Nov, 20,-1895 Hospital Reports. 497
498 Australian Medical Journal. Nov. 20, 1895
shaky, with facial twitchings, and arched eyebrows (the left par- ticularly) ; on being made to walk he looked down, with body bent forward and inclined to the right, with heels slightly swerving, feet thrown forwards and turning in, markedly unsteady, but safe, and with marked action of the adductors. The plantar and pal- mar reflexes were most marked on the left side ; the knee-jerk more so on the right side ; the left eyebrow more arched than the right ; the right pupil more dilated than the left, but both reacting to light ; no conjunctival irritation, except after mixed tearing and laughter. The iridal differences were constant, and iridal abnormality and old corneal changes could be excluded. Both pupils dilated equally with atropine. The ophthalmoscope reveals hyperaemia ; the. outer edge of the disc was whitened, and the
veins tortuous on the left side, the right fundus being generally hyperaemic, with a hazy disc.
Since admission, about three months ago, there has been a continuance of the symptoms, a further development of tearful- ness, with lessened irritability and muscular tenseness, lessened tactile sensibility, and commencing loss of control of sphincters, with dirty habits, and the gathering of rags, buttons, &c., but as yet without any insane decoration.
Although we have in this case a history of masturbation, of excessive tobacco-chewing and smoking, and a fall from a horse, with scalp wound, I think we can safely conclude that the case is
one of general paralysis of the insane, and as such, most interest- ing from the youth of the patient.
The family history displays nothing of interest beyond the fact that the mother has had three sets of twins in five years, blushingly remarking on enquiry that she "did not suckle the second lot." The patient was not a twin.
The progress of this case will be closely watched, and the results reported.
7'wo Cases 01 Intra-Peritoneal and One of Extra-Peritoneal Hcemorrhage— Abdominal Section—Recovery.
Under care of WM. FORBES, M.R.C.S., and JAMES A. REID, 3/I.D<.
Mrs. A., aged 30, married ten years. She has had four children
—two at seven, one at five, and one at eight months, the last of which only was born alive ; the last confinement occurred nine
Nov. 20, 1895 Hospital Reports. 499 months before the recent illness. She menstruated six weeks afterwards, since which time she has been regular every four weeks, with the exception of the last time when there was only an interval of a fortnight. Soon after this period came on, she was seized with sudden severe pain in the left iliac region (which spread all over the abdomen), sickness, and fainting. She had two more similar attacks at intervals of one week. The last attack was the most severe, and she became collapsed.
We saw her three days after the last attack, and three weeks from the commencement of the illness. She was then excessively blanched, with a quick small pulse. The discharge from the vagina had continued during the three weeks, and was still present at date of examination. She had little or no pain except when she moved in bed, but there was tenderness to touch over the left groin. The abdomen was not distended. There was no decided fluctuation to be felt, but there was an indistinct feeling as if some dense fluid was present in the peritoneum. Per vaginam, the left side felt full, and somewhat doughy.
At the operation, the peritoneal cavity contained a large quantity of dark fluid blood, and clots of different ages. A tumour, or rather a firm coagulum, the size of a small egg, was found adhering to the back of the left broad ligament in the neighbourhood of the tube and ovary. This was evidently the source of the bleeding, and the tube, ovary, and coagulum were tied off and removed.
The tube seemed to be enlarged, but not ruptured. The right ovary was then found to be cystic, and enlarged to about the size of a* large turkey egg. This, with the tube, was also removed.
The cyst contained transparent fluid. She made an uninterrupted recovery. The coagulum had all the naked eye appearances of a mole, and the tube before it was contracted by the spirit in which it was afterwards preserved, appeared swollen towards the fim- briated extremity as if an ovum might have dropped out of it at an early stage. Dr. Mollison, however, who kindly examined the specimen for us, could find no trace of foetal structures in the coagulum, nor any apparent alteration in the tube. He suggests the rupture of a varicose vein of the utero-ovarian plexus. What- ever was the origin of the case immediate operation was absolutely necessary, and we had the satisfaction of saving a useful life,
Mrs. C., aged 42, a big powerful country woman, has had eleven children, the last fourteen months ago. She had a bad
500 Australian Medical Journal. Nov. 20,1895
time at that confinement, and has not felt well since; she complained of nothing definite, but was out of health. Nine weeks ago she menstruated for the first time since her confinement, but it was only just a show. She then went five weeks when she was suddenly attacked with excruciating pain in right groin, which gradually spread over abdomen, and at about the same time her period appeared. The pain continued with little interruption for about a week, when she presented herself at the hospital.
At the time of her admission, she looked pale, but not anwmic ; temperature 100°. She complained of great pain in the right iliac region, the abdomen was moderately full, a dark bloody discharge escaped per vaginam, and the nurse on that same evening found a perfect decidua on her linen ; the uterus was slightly enlarged, was empty, and the sound passed a little over two and a half inches.
A distinct fulness was felt over the right tube, and under chloro- form this was felt as a definite tumour. There had been no syncope at any time during the illness.
Tubal fcetation was diagnosed, with possibly a slight rupture and small escape of blood. On opening the peritoneum, there was an enormous gush of black fluid blood and a few clots. A tumour, apparently of exactly the same character as that in the former case, was found adhering to the right tube, from which it had escaped through a large rent in its upper surface. The tube itself was much thickened. The tube, ovary, and coagulum were tied off and removed, and the usual peritoneal toilet completed.
She made a most excellent recovery. The pain, which had been constant, entirely disappeared immediately after the operation.
The remarkable point in this case is, that in the presence of such an enormous effusion of blood into the peritoneum, there was not the slightest tendency to fainting or collapse.
Mrs. H., aged 44, multipara ; last confinement June 4, 1894 ; menstruated regularly from that time till the beginning of April.
She missed her period in May, and in the beginning of June she was suddenly seized with severe pain in the abdomen, vomiting, and fainting. A few days later a vaginal discharge appeared, which continued until her admission to the hospital six weeks later. She was attended by a medical man, and treated for mis- carriage. She did not improve, and came under the care of Dr.
J. M. Smith, of Bairnsdale, who diagnosed a tubal fcetation, and sent her to us.
Nov. 20, 1895 Hospital Reports. .501 On her admission, she complained of great pain in the lower part of the abdomen, especially after action of the bowels. The pelvis was occupied by a dense and irregular mass, which displaced the uterus upwards, so that the os lay above and behind the pubis. A firm ring of induration surrounded the rectum, and greatly added to her sufferings when the bowels acted, as the whole mass was painful and exquisitely tender at two or three spots. The mass extended up towards the right iliac region, and to a less extent towards the left ; the uterus was slightly enlarged, but empty. Ther3 was a vaginal discharge of very dark blood without fcetor. Vomiting was very troublesome, and had been so all through the illness. The woman looked very ill, but not blanched. She had a temperature ranging between 99° and 100 °, and had troublesome perspirations when she went to sleep. A tubal fcetation, with rupture downwards into the right broad ligament was diagnosed, and it was thought that it most likely was in a state of suppuration. She was kept under observation for a few days, and as the vomiting and pain continued, and the temperature continued to rise, the abdomen was opened. A firm elastic mass occupied the right side of the pelvis, and more or less surrounded the uterus. Nothing was seen of the right ovary or tube, and it seemed as if they had been incorporated with the tumour. An exploratory puncture was made into the mass, but only a small quantity of dark fluid blood was found, and the needle felt as if it were in a mass of blood-clot. As it was evidently not suppurating it was left alone, and an explanation of the temperature, Stc., sought for elsewhere. The left ovary was cystic and acutely inflamed. The cyst gave way on the gentlest manipulation, and gave exit to a quantity of bloody serum. The tube was also very much congested. The tube and ovary were removed. Bleeding was troublesome, as owing to the facts of the parts being matted together, and the woman being badly chloro- formed, some difficulty was experienced in securing the vessels, &c.
She recovered well ; vomiting ceased ; the temperature gradually fell to normal ; the effused blood became gradually absorbed, and she writes to say that she is now perfectly well.
In this, as in Case No. I, there is no absolute certainty as to the cause of the haemorrhage, but the history and symptoms seem to point pretty conclusively to a tubal fcetation.
NOTES ON A CASE OF INTUSSUSCEPTION OF SIGMOID FLEXURE AND DESCENDING COLON, REDUCED WITHOUT OPERATION.
By ALEX. B. BENNIE, M.A., M.B., B.S. Melb.
At 10 a.m. on November 17, I was consulted by a mother about her baby girl, Ida M., wt. 5 months.
Mother states that child was in good health until 6 a.m. same morning, and suddenly, while she was changing the napkins, the baby threw herself back in her arms with a sharp cry, and from that time the crying had continued for hours, with a few minutes intervals. The baby had a motion, natural in colour and consist- ency, immediately before the cry, and had passed water at the same time ; there was no blood in the motion. The mother further states that she had given her baby (hitherto fed exclus- ively on breast milk) a cupful of cow's milk and water on the previous day ; the baby had vomited shortly after the cry, and then four or five times until I saw her.
On examination at 10 a.m. the same day, temp. 99° in groin ; breathing regular ; pulse quick, regular ; expression calm, but with the well-known look of intro-spection, or deep thought (if I might describe it as such) so indicative of discomfort in the bowels in children, then in a few minutes a troubled look came over the face, and the child cried and drew her knees up as if troubled with wind and colicky pains, in a minute or so the paroxysm passed off;
and the child was quiet ; this was repeated over and over again.
Abdomen soft, more retracted than distended ; pressure with fingers occasioned pain, evidenced by cry and drawing up of legs, and the most tender spot appeared to be in the left iliac region.
Believing the child to be troubled with the undigested curds of the cow's milk, I ordered hydrarg. creta gr. ss. and barley water, and instructed the mother to watch child, and inform me should vomiting increase or blood be passed.
At 7 p.m., same day, mother reported child worse, vomiting frequently and passing motions of pure blood, bright red in colour, with no faecal matter intermixed ; the first blood appeared at 12.30 p.m., six hours after the onset.• On examining again, I found child in pain, knees drawn up, tenesmus marked, temp. 98°, and a distinct mass could be felt in the left iliac region, extending 502 Australian Medical Journal. Nov. 20, 1835
Nov. 20, 1895 Clinical Records. 503 almost up to the level of the umbilicus, and any pressure over this mass occasioned pain. The diagnosis of intussusception was now made, and rectal injection, or rather irrigation, of one pint of warm water was twice tried, but the water only distended the rectum, and would not flow even with the buttocks raised, and with a pressure of six inch elevation of the reservoir. This pressure was maintained for fifteen minutes each time, and with the second application a few ounces, two or three, passed in, but apparently the only result was to distend the rectum, and this amount was almost immediately expelled.
As the child was straining greatly, it was left for two hours on its mother's lap, with the buttocks raised, and hot foments on the abdomen, and at ten o'clock irrigation was again tried, with an elevation of nine to twelve inches, and the child in the same position, and manipulation of the tumour tried at the same time.
The pressure was again maintained for fifteen minutes, with no result, the water would not flow ; the apex of the intussusception could be felt by the little finger per ano. A fourth attempt was more successful, for suddenly four or five ounces of water flowed in with a rush, and the same feeling that the return of a hernia produces. To make certain, another injection was given, and this flowed freely, three-fourths of a pint, and on its return, a mass of stringy, blood-stained mucus was passed, in appearance like a collection of red worms, and about an ounce and a half in quantity. This stringy mucus had, in my opinion, been formed between the middle and outer layer of the intussusception, and its liberation pointed to a reduction of the intussusception. The child. immediately after the reduction of the intussuscepted bowel took the breast, and went to sleep, slept for four hours, with no bad symptoms.
The mother was instructed to take the child to the Children's Hospital in Melbourne for observation, and operation in case of relapse, unless the child had a healthy motion before the morning.
This did not occur, and I am informed that the first healthy motion took place in the casualty room of the Children's Hospital.
The child was detained in the hospital for forty-eight hours, where she took the breast well, and was very bright. No vomiting, and only one motion occurred during this time.
I saw the child again on Wednesday, November 20, the motions were green, slimy, and curdy, and kept the child on breast milk alone, with the addition of half an ounce of barley
504 Australian Medical Journal. Nov. 20, 1895
water before each drink. The motions are improving daily, and the child to-day, Friday 22nd, appears in good health, and as lively and jolly as ever.
I would like to call attention to two or three points in this case.—(1) The cause was undoubtedly the irritation produced by the sudden inroad into the bowel ,of the thick curds formed from the cupful of cow's milk in a bowel hitherto only accustomed to mother's milk. (2) The ease with which a case of this sort may be overlooked, especially if seen a few hours after the onset, but before any thickening of the walls of the bowel had taken place, and before blood had appeared in the motions, which, in this case, was six and a half hours after onset. (3) The low temperature, falling below normal, apparently with the increase of the telescoping. In this case, could the tendency to collapse, produced by the intussusception, have counteracted the tendency to rise, produced by the inflammatory trouble, and in this way the temperature remain nearly normal ? (4) A point I consider diagnostic of reduction, and a point I have not known to have been mentioned before, 1 mean the passing of this thick, stringy, blood-stained mucus, each string about the thickness of a wax match, and one or two inches long. I would like to be informed if this has been noticed and recorded in similar cases. (5) I would like to emphasise the advantages of perseverance in irrigation, and the advisability of repeated and long-continued trials, combined with gentle manipulation of the tumour, before proceeding to operation.
TWO CASES OF OPTIC NEURITIS OCCURRING IN BROTHERS, EACH WITH CENTRAL COLOR SCOTOMATA.
By JAMES W. BARRETT, M.D. et M.S. Melb., F.R.C.S. Eng.
T. C., mt. 28, a country labourer, complained that his sight had been failing for six weeks, he had not had any illness, head- aches, or sickness, and there was no evidence of syphilis. He smoked two small plugs of tobacco per week. Examination.—
Vision in R. eye reduced to counting fingers at two feet, in L. eye to -8?-a. The fields were—right, a little contracted for white, with a large central scotoma. Blue, red, and green not recognised.
Left, white not contracted, no scotoma. Blue, a large central scotoma. Red and green not recognised. Refraction + 2 D., R.
Nov. 20, 1895 Notes on Current Dermatology. 505 and L. The optic discs were pale, and showed distinct traces of past neuritis in the shape of tortuous vessels and organised exuda- tion. After six weeks' treatment with iodide, mercury and strychnine, there was no change. Examination of the rest of the nervous system revealed.no abnormal symptoms.
F. C., the second case, was a younger brother, aet. 23, who came under observation two years and eight months later. His sight had been failing for three months. His vision was reduced in R.
eye to -eu, and Cowell 10 ; in L. eye to
A,and Cowell 12. The right field showed slight contraction for white, and a large central scotoma for red. Green was not seen.. The left field was normal for white, but showed a large relative scotoma for red. Green was not seen. The optic discs gave obvious indications of a subsiding neuritis, namely, tortuous vessels and effused lymph. He stated that he had never known what it was to be ill, and had not suffered from headaches since he was a lad at school. There was no evidence of syphilis. He smokes two plugs of tobacco a week.
Examination of the nervous system showed nothing abnormal. In both cases there was a little mental dulness, possibly associated with an uneventful country life. As far as could be ascertained, no other members of the family suffered from defective eye-sight.
Here again are two cases of neuritis, in which there is and has been no symptoms present indicating the existence of any cerebral affection.
I am indebted to Dr. 'Webster for the foregoing notes.
NOTES ON CURRENT DERMATOLOGY.
By A, W. FINCH NOYES, JUN., F.R.C.S. Ed.
Surgeon in charge of Skin Departments, Melbourne and Alfred Hospitals.
AFFECTIONS OF THE SKIN OCCURRING IN THE COURSE OF BRIGHT'S DISEASE.
Pye-Smith points out that the only cutaneous disorder hitherto generally recognised as occurring in Bright's disease, is the con- dition known as erythema leve of Willan, a superficial dermatitis occurring on the surface of dropsical skin. Besides this, he describes four other forms of dermatitis :-
(1) A " roseolous " rash occurring in chronic tubal nephritis, chiefly on the trunk, neck, arms, and thighs, seldom on the face, hands, or feet. Its distribution, its appearance when the skin is harsh and dry, and irrespective of means used to produce sweating,
506 Australian Medical Journal. Nov. 20, 1895
and the absence of sudamina, distinguishes it from a somewhat similar rash produced by natural or artificial diaphoresis.
(2) A 'vular eruption, with large discrete rather dark red pimples, seated on a dry, rough and somewhat scaly surface ; legs, arms, loins, and abdomen may be affected.
(3) A dermatitis resembling eczema, but without any pruritis or tendency to affect flexures, face, or ears.
(4) A dermatitis resembling universal exfoliative dermatitis.
All these eruptions are superficial, and leave no trace behind when they disappear. They generally occur in the late stages of renal disease, usually in the chronic tubal form, or at any stage in the course of chronic granular degeneration, with shrinking of the renal cortex.
The author is not inclined to connect these inflammations of the skin with uraemia, except by a natural coincidence ; but he would rather associate them pathologically with the retinitis, the serous inflammations, and the pulmonary oedema to which patients with Bright's disease are liable.—P. H. Pye-Smith, British Journal of Dermatology, September 1895, p. 284.
DIET IN THE ETIOLOGY AND TREATMENT OF DISEASES OF THE SKIN.
Dr. Walter Smith starts with the two propositions, that the real 'Influence of diet in the causation of skin diseases is a small one, much less than it is credited with ; and that our substantial knowledge of the subject is very limited. Fundamentally, the action of food and of drugs is to be explained upon similar general principles. But great as are the difficulties of forming a correct judgment of the mode of action of a drug, still greater are the complexities which surround questions of dietetics in the causation of cutaneous affections.
We are always, and in all places, confronted with the problem of the idiosyncrasy of the individual, which is a real and perplexing difficulty, and should make us more cautious in formulating cut- and-dry rules for the guidance of our patients' stomachs. The tendency of modern inquiries has been largely towards the more exact determination of etiological factors. Hence, we have been gradually led to minimise laying stress upon vague and indefinite conceptions, such as diatheses and the like, and of the vague causes diet is, I think, one so far as the skin is concerned. Diet may possibly influence the skin in four ways.—(1) Through the