321

ienna, including 3585 cases of carcinoma, and found that in two only was the vermiform appendix primarily affected.

Grosvenor-street, W.

Clinical Notes :MEDICAL, SURGICAL, OBSTETRICAL, AND

THERAPEUTICAL.

A CASE OF DIPHTHERITIC PARALYSIS.

BY A. J. RICE OXLEY,, M.B. DUB.

THE following notes of a case of diphtheritic paralysisafter very slight sore-throat are so interesting and emphasiseso clearly some of the points referred to by Dr. E. F.Trevelyan in his able paper that I venture to think theymay be worth recording.A boy, aged 10 years, was brought to me some little time

ago by his father who stated that the boy could not swallowproperly, fluids returning through his nose, and that therewas something in the throat or nose causing this state ofthings. He wished to know if an operation was necessaryfor the removal of the obstruction. Two medical menhad seen the boy and one of these said he hadfound the growth and was very anxious to have the

boy anaesthetised and operated on without delay. I- elicited the fact that the boy’s sight was also so muchinterfered with that he was frequently reprimanded at schoolfor inattention when in reality he was unable properly todistinguish Sgures and writing on the blackboard. Thecharacter of his voice and the history that he had been athome for two days with slight sore-throat made me sus-

picious and on examination the palate was found to bepractically motionless. Except for this and the affectionof vision there were no other very marked symptoms of anykind. The boy, as I have stated, had returned to schooland but for the regurgitation of fluids through his nosewould probably have continued at school. Some of thehome circle were inclined to look upon the nasal regurgita-tion as a bad habit or trick, the boy’s general condition wasso good and the sore-throat had attracted so little attention.Removal from school and a course of the usual tonics curedthe paralysis and the impaired vision.Streatham.

A FOREIGN BODY IN THE ARM FOR 10 1/2 YEARS.

BY A. R. HENCHLEY, L.R.O.P.,, L.R.C.S. EDIN.,L.F.P.S. GLASG.

ACCOUNTS are so often given in the columns of themedical press of cases where foreign bodies have migratedfrom the position of entrance to some more or less remote

part of the body that the present case seems worth mention-ing. In this case the foreign body remained practically in,the same position as it entered notwithstanding the greatlapse of time and its being situated in the arm.On Dec. 26th last a young man, working as a labourer,

came to me saying that he thought he had a piece of glassin his arm that he wished removed. He said that 10½ years.ago while "playing at horses" with some boys he stumbledand fell on some broken glass. His left arm bledfreely, but healed up all right in due time and gave nofurther trouble till a few days before, when a friendhappened to pinch him just over the place and he felt asharp pricking pain. On examination of the arm I found a

stellate-shaped scar about three inches above, and slightlyexternal to, the internal condyle of the humerus, and one anda half inches internal to and on the same level as the scarwas to be felt a fairly moveable oblong body about twoinches in length. After having made the skin aseptic Isprayed it with ether and made a vertical incision three-- quarters of an inch long, and eventually got out a piece of.glass a quarter of an inch thick and about one and a

1 THE LANCET, Nov. 24th, 1900, p. 1482.

half inches long and the shape of an old-fashioned f. It wasimbedded in a considerable amount of tissue.Blagdon, Bristol.

__ ___

A PECULIAR COMPLICATION IN MIDWIFERY.

BY JAMES MORE, M.D. EDIN.

SOME little time since I was called in by a midwife to seea patient of hers who had been in strong labour all daywithout any appearance of its coming to a satisfactorytermination. The midwife informed me that there was

something unusual in the case as she could not make outthe presentation. On examination I was myself quite at aloss as to its nature. I found the lower outlet of thepassages completely blocked up by some part of the childbut what that part was I could not make out. It seemed likea spongy mass with one opening in the centre, into whichthe finger could be easily introduced. It was not themouth as the jaw was absent, nor the anus as the pelvicbones were not within reach. I determined to introduce myhand and explore, and on doing so I was surprised to find thatthe mass was indeed the breech with the foetal vagina muchswollen and congested. On delivering I found this part ofthe child very much swollen and almost black, evidentlycaused by the nurse poking her finger into the opening underthe idea that it was the os uteri-a mistake I could quiteunderstand under the circumstances and which I was on theverge of committing myself.Rothwell.

_______________

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

Nulla autem est alia pro certo noscendi via, nisi quamplurimas etmorborum et dissectionum historias, tum aliorum tum propriascollectas habere, et inter se comparare.—MORGAGNI De Sed. et Caus.Morb., lib. iv., Proœmium.

ST. MARY’S HOSPITAL.TIGHT BANDAGING ; ISCHÆMIC PARALYSIS IN

AN ADULT.1

(Under the care of Mr. EDMUND OWEN.)THE paralysis following the application of a splint has

been termed "ischæmic paralysis," on the supposition thatthe pressure on the vessels of the limb has impaired theblood-supply of the part so that the muscles have sufferedand perhaps a chronic inflammation with sclerosis of themuscles has followed. Mr. H. Littlewood attributes its merelyto contraction of the muscle in healing after being torn. Itis, however, not improbable that another factor is concernedin the production of this variety of paralysis, and this otherfactor is a neuritis of the motor nerves of the part resultingfrom the excessive pressure of the splint. In some casesone of these factors, in other cases the other, may be thechief or only cause of the palsy, but it is not improbable thatin most instances both causes act.A man, 30 years of age, a carpenter, was admitted into

St. Mary’s Hospital on March 31st, 1900. 17 months pre-viously, when working on a wall at Krugersdorp, in theTransvaal, he fell about 15 feet, and stretching out his lefthand to save himself, he " broke the outer bone" of hisforearm a few inches from the wrist. (The fracture dulyconsolidated.) He was treated by a Scotch practitionerand a Boer practitioner in consultation, who fixed the armbetween an anterior and a posterior splint which reachedfrom the bend of the elbow to the wrist. The patient saidthat the splints were bound on very tightly by three piecesof bandage which were put on through looped ends-" bowlines"—and hauled taut. He said that he com-

plained at the time that the splints were too firmlybound on, but that no notice was taken of his com-

plaint ; so he thought that such harsh treatment

1 Reported at a meeting of the Medical Society of London on Jan.28th, 1901, and the case exhibited.

2 THE LANCET, Feb. 3rd, 1900.

322

was probably in accordance with the needs of the injury. iIn four days’ time-during which he had suffered intense ’,distress-the splints were taken off, the hand being much swollen ; they were afterwards re-applied. The splints wereremoved from time to time and gentle massage was doneduring 30 days, after which the splints were entirely left off.The hand, however, remained swollen for at least twomonths, and during this time he lost the nails of his first andsecond fingers. The thumb-nail also blackened, but it didnot come off. When the swelling went down there was very little feeling in his hand, and his fingers and thumb werestiff and useless. About a fortnight after the accident twosloughs appeared-an extensive one over the outer side ofthe forearm near the elbow and a deep one- over thetuberosity of the scaphoid bone. The resulting sores tookrespectively three and four months to heal.The forearm was found to be fixed midway between

pronation and supination ; the thumb was strongly adductedwith the terminal phalanx rigidly flexed, and the-fingers werestiffly bent into the palm. On firmly flexing the wrist thefingers could be partly straightened, but the thumb wasimmoveable and the hypothenar muscles were much wasted.Faradaism gave no reaction, but galvanism set up sluggishcontractions. There was considerable anaesthesia in thehand and fingers. The outlook was most unpromising, butthe man readily accepted the suggestion that an attemptshould be made to put slack into the pronator radii teres andmost of the flexors by taking an inch out of the upper partof the radius and ulna. After this it was found that hecould get his fingers straighter and had much more power ofrotation of the forearm ; but the improvement was notmarked, so most of the tendons at the front of the wrist wereexposed by operation, split, cut, lengthened, and sutured.

In October the man was re-admitted because non-unionhad followed the operation on the bones, and as the tendonsseemed to need more slack being put into them, anotherinch was removed from the bones by the electric saw, and thefresh ends were adjusted by wire sutures. An operation wasdone for lengthening the long flexor tendon of the thumb.The limb was adjusted in a plaster-of-Paris apparatus asbefore, the wound healed perfectly well, but, as before,there was no solid union and the question is, Can anythingmore be tried for him 7 "

Remarks by Mr. OWEN.--The pathology of the case is

probably this, that the tight and long-continued compressionof the forearm kept the muscles completely starved of blood,and so injured them that a myositis supervened, which, in itsturn, was followed by an intractable fibroid degeneration ofthe tissue with permanent contracture. It was Volkmannwho first described the disease and found the name for it,ischremic (&tgr;&sgr;&khgr;&ohgr;, restrain; &agr;&tgr;µ&agr;, blood) paralysis.

I have seen a good many cases of ischaemic paralysis inchildren, but I have never previously met with an instancein an adult; and I should not be surprised to learn that noother case in an adult has been recorded, for an adult, as arule, would absolutely decline to submit to the agony of the Itight compression. In children the myositis has sometimesbeen determined by a few hours’ compression, and, ofcourse, the tighter the compression the shorter need be theperiod. My own experience of operation in these cases hasbeen most unfavourable, but my colleague, Mr. HerbertPage, was enabled to speak more hopefully in a case whichhe recorded in a valuable clinical lecture in THE LANCET ofJan. 13th, 1900, p. 83.

PARK HOSPITAL, HITHER GREEN, S.E.A CASE OF ENTERIC FEVER ; LARYNGEAL PERICHONDRITIS,

TRACHEOTOMY ; RELAPSE, PERFORATION,LAPAROTOMY ; NECROPSY.

(Under the care of Dr. A. KNYVETT GORDON, SeniorAssistant Medical Officer.)

THE value of absence of liver-dulness as an indication of

free gas in the peritoneal cavity is not so great as was at onetime thought, but the sudden appearance of this sign duringthe course of typhoid fever is necessarily of great import-ance and is very suggestive of perforation. The mortalityafter laparotomy for perforation in typhoid fever must alwaysbe high, for the patient’s general condition before the per-foration occurs is usually very bad, and the added shock ofthe perforation and of the operation is sufficient frequentlyto prove fatal even if no marked peritonitis should have

followed. Mr. J. E. Platt has collected 103 cases, and in21 of these the patients recovered.l This is a mortality ofnearly 80 per cent.A well-nourished boy, aged 15 years, was admitted to the

Park Hospital on Sept. 20th, 1900, suffering from an attackof enteric fever which was stated to have begun on

the 16th. On admission he was found to be moderatelyill: there were slight abdominal distension and enlargementof the splenic dulness, nocturnal delirium, headache, andslight diarrhoea. The temperature was 39.8° C., the respira-tions were 25, and the pulse was 110. The mouth was verydirty, the tongue and gums being covered with dried muco-purulent secretion ; there was one carious molar tooth dis-charging pus which was extracted on admission. He becameworse and his attack ran a severe course which, however,with the exception of baemorrhage from the bowel on

Sept. 28th, 29th, and 30th, did not present any specialfeatures until the morning of Oct. 15th. On thatday the respiration became stridulous and he rapidlydeveloped symptoms of laryngeal obstruction ; there were

great distress and rapidly increasing cyanosis with veryslight epigastric recession. In the afternoon, about 10hours after the onset of the stridor, a high tracheotomywas performed after injection of eucaine subcutaneously, nogeneral anzesthetic being required. A No. 5 Parker’s tubewas inserted, with complete relief of the symptoms. On thenext day it was possible to see the larynx with difficulty anda large swelling was found over the right arytenoid cartilageand ary-epiglottic fold ; it was bright red in colour and wascausing almost complete glottic obstruction. On Nov. 2ndhe was able to breathe without the tube for a short time, andthe metal tube was replaced by a rubber one which he worefor gradually decreasing periods until his death, but hisvoice did not return at all. As seen with the laryngo-scope the swelling appeared to be lessening gradually;there was no sudden discharge of pus but the sputum wasmuco-purulent throughout. The temperature, which hadbeen raised at first daily to 40° C. but had been controlledeasily by tepid sponging, began to fall on Oct. 10th andreached normal on the 15th, the pyrexia having thus lasted 28days. On Oct. 28th the temperature rose again and a relapseoccurred, the second attack being considerably milder thanthe first and presenting no features of interest untilthe afternoon of Nov. 10th, when he vomited slightly, butwas not otherwise worse. On the llth, at 10 A.M.. hebecame suddenly worse, the chief symptom being rapidityof breathing ; there was no abdominal pain at all and thetemperature, which ranged from 38° to 39° C., did not fall;there was no marked collapse, vomiting, or hiccough. On

examining the abdomen there was greatly increased disten-sion, and the liver dulness, which had been normal at noonon the preceding day, had completely disappeared; theabdomen moved very slightly, and the diaphragm was

acting; a long tube was passed per rectum as far as thesigmoid flexure, but no gas escaped.

It was thought that perforation had occurred, and as theboy, though much emaciated by his long illness, was notmoribund it was decided to open the abdomen. This wasdone at 3.30 P.M.--probably six hours after perforation-through an incision in the right linea semilunaris, chloro-form being administered through the tracheotomy tube. Inthe incision, which was four and a half inches long, thedeep epigastric artery was cut and was ligatured, bleedingbeing completely arrested. On opening the peritoneumfeetid gas escaped and a quantity of clear serous fluidwelled up, but there was no sign of pus; a coil of smallintestine presented which was brightly injected on itssurface. The appendix was felt, and on tracing theileum back a perforation was found, from which fasceswere escaping, four and a half inches from the ileo-cseoatvalve and about three inches from the presenting coil. Thisperforation was of the size of a crowquill and was

situated in an ulcer one and a half inches long and three-. quarters of an inch wide. Lembert’s sutures of flne silk, were now passed so as to invaginate the entire ulcer and the

intestine a quarter of an inch on each side, the stitchesreaching to half an inch from each end of the visiblyulcerated surface. As the boy’s condition did not admit ofa prolonged peritoneal toilette the fluid was sponged out asgently as possible and the abdomen was sewn up with silk-worm gut, a gauze drain being left at the lower angle of the

’ wound. The whole operation lasted an hour and 20 minutes

1 THE LANCET, Feb. 25th, 1899, p. 505.