CASE OF MALIGNANT PERIOSTITIS AND PYÆMIA WITHOUT EX

TERNAL WOUND.-M. P., æt. 15, was admitted to hospital on 12th November, 1882, complaining of pain and swelling over the left hip, with inability to move the left leg. The patient was in a state of high fever when admitted to the surgical wards, and had been equally so for two days previously in Ward IX, where she was first received as a medical case.

She cannot give any cause for her illness, but says that while at her work, which was that of carrying heavy pieces of clay at a brickfield, she was constantly in the habit of resting her hand on her left hip and bringing weight to bear on that part. Nine days before admission she was suddenly seized with severe pain in the left gluteal region, and this increased so much as to prohibit at first walking, and latterly even movement of the limb.

On examination, which could not be made complete owing to the patient's feverish and excitable state, it was found that pain was distinct over the left hip, and also, though less acutely, in the right knee joint. On careful manipulation over the left gluteal region, deep fluctuation was made out. Gentle passive movement of the limb did not cause so much pain as direct pressure over the swollen area. When gentle rotation of the leg was practised, the head of the bone moved in the joint easily, and without any roughness or grating. The girl herself was much emaciated, the lips were pale and the cheeks white.

On the following day she continued much in the same state (except that swelling over the hip was more pronounced, and fluctuation more distinct) till the afternoon, when she complained of pain in the side and difficulty of breathing. There was great thirst and high fever, the temperature being above 103°. On auscultation loud friction was heard all over the chest, and also in the cardiac area. Jacket poultices were applied and quinine administered, but the symptoms did not abate.

Next day the swelling had increased over the hip and in the left iliac region, and in both situations fluctuation could now be distinctly felt. On consultation, it was deemed unwise to open the abscess in the critical condition of the patient. Friction was as general and as loud as before, and the breathing laboured and shallow. Temperature still above 103°. During forenoon she had been conscious, but so weak as to be unable to speak; towards afternoon, however, delirium set in, and she died about three P.M.

The post-mortem examination was made by Dr. Coats, of which the following is a note. The body is emaciated; and

on the skin there are a few scattered petechial spots and pustules. The heart is normal in size, but in its wall a pale area is found which may be an abscess. There is a considerable quantity of fluid in the pericardial sac.

The lungs contain a large number of metastatic abscesses, but mostly of small size. The areas affected are always distinctly demarcated and have generally a pale colour, but sometimes they are red in the central parts and pale peripherally.

The kidneys present a number of very minute white spots. The left is enlarged, weighing 6 oz.; the right weighs only 4 oz. The liver is somewhat enlarged, weighing 3 lbs., and only two small white spots are discovered in it. No abscesses are discovered in the spleen. The broad ligament in the neighbourhood of the left iliac fossa is thickened and somewhat adherent, but no purulent exudation is noticed.

The left wing of the iliac bone is denuded of periosteum, both in its external and internal surfaces, and in each case there is a considerable cavity filled with pus. The pus also infiltrates largely the connective tissue on the left side of the pelvis, especially in the posterior parts, but it does not extend higher than the level of the first lumbar vertebra. No pus is discovered in any of the veins, although the infiltration of the connective tissue is such as to render it impossible to state whether any of the finer veins contain pus or not.

MEETINGS OF SOCIETIES.

GLASGOW MEDICO-CHIRURGICAL SOCIETY.

SESSION 1882-83.

MEETING IV.-12TH JANUARY, 1883.

DR. ALEXANDER ROBERTSON in the Chair.

DR. A. SCOTT, Tollcross, was elected a member.

DR. JAMES WHITSON read (1) CASE OF ADENOID SARCOMA OF THE MAMMA, and showed microscopic sections of the tumour. Lantern slides from these were shown on a screen, and a communication was read from Mr. Adolf Schulze, who made the

photo-micrographs, detailing the methods adopted in their production. (2) CASE OF COMPOUND FRACTURE OF THE CLAVICLE; and (3) CASE OF RADICAL CURE OF HERNIA. In the two last

cases the patients were shown.

Dr. Macewen said that he had never seen a tumour of the kind of such enormous size as that exhibited. The results of the operation had been most excellent. In regard to the second case he had never seen a compound fracture of the clavicle. The result of the operation had been very good, with comparatively little thickening. The operation performed in the third case had been pretty frequently resorted to within the last four or five years. Mr. Wood, who has performed the operation many times, admitted that there was a tendency to the return of the hernia. In one case he (Dr. Macewen) had operated on, the hernia was double, and the tissues extremely lax. The ring was not distinct; the abdominal walls were so lax that the whole hand could be introduced through the opening. After a couple of operations he got the parts into a condition that a belt could be worn. In Dr. Whitson's case there was some impulse on coughing, and he would advise that a belt should be used, as the connective tissue was apt to stretch. To Mr. Schulze they were greatly indebted for the photo-micrographs exhibited. For teaching purposes they had great advantages over microscopic specimens.

Mr. Maylard said that the case was not one of adenoid sarcoma, but of adeno-sarcoma. In reference to the last case of hernia, the use of the wire would be apt to set up a good deal of irritation, and would interfere with the process of healing. In the present case it would be wise to wear a belt.

Dr. Barlow said that it appeared to him very doubtful policy to leave the wire to eat its way out, as suggested by Dr. Whitson. The process of "eating out" would be a very slow one; and in view of the fact that the wire got loosened it could be easily removed. The case of hernia exhibited showed a slight impulse, and it would be premature to pronounce it cured.

Dr. Hugh Thomson said that a very excellent splint for fractures of the humerus was that which used to be known as croix de fer. Its effect in pressing back the shoulder was such as no other apparatus could bring about. In the ordinary bandages for keeping back the shoulder it was forgotten that, where the clavicle was broken, the pole or stay which threw the shoulder back was absent; and that the effect of directly pressing it back was the very reverse, that is, to throw it out. Dr. Newman described the tumour of the breast in its patho

logical aspects as a typical adeno-sarcoma, and through all its parts of the same character.

Dr. Whitson, in reply to what had been said by Dr. Barlow, said that in regard to the removal of the wire in the clavicle case, it was a question whether, from the very considerable force necessary for its removal, it was better to leave it to work its way out than to run the risk of refracturing the bone.

MEETING V.-2ND FEBRUARY, 1883.

DR. GAIRNDER, President, in the Chair.

MR. W. H. S. WALKER, Sick Children's Hospital, was elected a member.

DR. WOOD SMITH read NOTES OF A CASE OF CATALEPSY, and showed the patient.

The President said that no doubt many of those present had for the first time that evening seen a case of catalepsy. In the course of a long experience he had himself met a good number of cases which, in one or more points, approached the peculiarities of catalepsy; but he had never seen a perfectly typical case, as this was. If the condition in which the patient at present was came to be prolonged, probably a lunatic asylum would be a more proper place for him than a general hospital. In regard to former cases not so treated, it was strongly impressed on his mind that some of them had been allowed to die of starvation. In an asylum the risk of this termination of the case was greatly diminished.

Dr. Alexander Robertson said that in a pretty extensive experience of nervous diseases he had never seen a case resembling the present. The condition generally corresponded to that of those cases seen in asylums, and classed as melancholia with stupor," or "acute dementia." There was the same complete abeyance of intellectual activity as in acute dementia. In the latter there was often a general torpor of the mental powers, coldness and blueness of the extremities, and sometimes a want of sensibility in regard to position-the patient standing in the same position for a considerable period. One essential point of difference between acute dementia and catalepsy was the plastic rigidity exhibited in the latter. The causation of both conditions was much the same-strong religious excitement being sometimes a factor in the causation

In

of melancholia with stupor. In regard to intensity of expression there was a resemblance between the two conditions. In cases of melancholia there seemed to be present an overpowering delusion-the person perhaps believing that he was acting under the direct commands of the Deity. Dr. Smith remarked that, on being pricked, no bleeding followed in this case. this fact there appeared to lie a valuable suggestion as to treatment. It was evident that there existed some contraction of the arterioles and of the capillary vessels. This indicated an affection of the nerves, connected with the circulatory system; and might there not exist a similar condition of the nervous system generally? Might there not be a state of contraction of the small vessels supplying the nervous centres? and if there were, their function would be materially interfered with. In convulsions from bleeding there was a deficiency of blood supply to the nerve centres; and in epilepsy the same condition existed. But instead of a tonic contraction they might suppose that the condition in this case was gradual. This would produce a certain rigidity of the muscular system, and the small arteries would be diminished in calibre. This indication seemed to suggest for treatment some agent fitted to relax these vessels. Possibly the exhibition of the nitrite of amyl by inhalation might have a good effect, as its action in many cases was to relax the small vessels. But if the case continued for much longer time, undoubtedly a lunatic asylum was the proper place for the patient.

Dr. Finlayson said that he had seen several cases which more or less nearly approached to catalepsy, in connection with hysterical attacks. But before this case he had seen only one marked case of typical catalepsy. It was in the Edinburgh Royal Infirmary; and he only saw it casually. In that case that of a woman-the cataleptic seizure came on suddenly, and then suddenly passed off. In the course of the short time that he was present, she had three separate attacks. During the attacks she was insensible, and her limbs could be placed and would remain in any position, even one in which, under ordinary conditions, she could not have remained but for the shortest period. In a short time the spasm relaxed, and she woke up to her ordinary state. In the present case the condition was of a chronic character, and did not pass on into attacks of an acute kind. Then, again, in this condition this man was capable of undertaking and executing movements when ordered to do so. The remaining point of peculiarity in this case was the sex of the patient. Catalepsy in a man was certainly very uncommon.