510

I communicated, and to many of my professional brethren here, who conferred with me and gave me their assistance,including Dr. J. Ward Cousins, Dr. Axford, Messrs. Morley,Pike, and Mudeley, and my colleague, Mr. W. Mark Atkin-son, who has seen the case with me almost daily.Sonthsea.

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

GUY’S HOSPITAL.EXOPHTHALMIC GOITRE; HEART DISEASE; JAUNDICE;

DEATH.

(Under the care of Dr. HABERSHON.)

Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborumet dissectionum historias, tum aliorum, tum proprias collectas habere, etinter se comparare.-MORGAGNI De Sed. et Caus. Jfof&., lib. iv. Proceminm.

THE following case, for the notes of which we are indebtedto Mr. W. Ernest Dring, is of considerable interest; but,as usually happens in exophthalmic goitre, death resultedrather from the complications than from the original dis-ease, so that it is difficult to determine the relations existingbetween the early and the late symptoms observed duringlife and the lesions found after death. The commencementof the disease in the following case appears to have datedfrom an attack of rheumatic fever, which probably inflictedsome damage on the heart; but even this heart mischiefcannot be regarded as an efficient cause of the exophthalmicgoitre, for in other instances the enlargement of the thyroidgland and the prominence of the eyeballs have been knownto precede the heart affection, and in many cases there isno organic disease of the heart at all. Another pointworthy of note in the subjoined case is the existence ofwell-marked jaundice without any apparent hepatic lesionadequate to account for it.Rebecca S-, aged twenty, was admitted Nov. 5th, 1873,

and gave the following history. Four years ago she was an

in-patient, with a slight attack of doubtful rheumatic fever.All her relations are healthy. Just before her admissionshe noticed her eyes became prominent, and during herstay in the hospital she fancied they got worse. Afterleaving, and especially during the last two years and a half,she has had giddiness, pain in her head and in the left side,the eyeballs have throbbed and ached, and she has sufferedfrom dyspnoea on exertion.When seen on her admission in November last her face

was flushed, the eyeballs were prominent, the throat slightlyenlarged, and there was pain below and to the outer side ofthe left nipple. She had palpitation on slight exertion;throbbing in neck and eyeballs. The heart’s impulse washeaving and strong; apex-beat between the fifth and sixthribs; had a systolic mitral bruit (loud). Pulse 132; tem-perature 98 6°.

Digitalis was ordered, which seemed to quiet the pulsesomewhat, though it varied from 99 to 160 until Jan. 15th,when it was found that her temperature suddenly went upto 102.3° F. After this it was almost always above normal,and sometimes even as high as 103° F. On Feb. 9th the

conjunctivæ became yellow, and on the 12th some choreicmovements were noticed. Jaundice became much increasedbefore death, which took place on the 19th while she ap-peared to be sleeping, though unable to close her eyes.At the autopsy it was found that the complexion was as

much jaundiced as in many cases of actual atrophy of liver,and there was moderate dropsy of both legs. The duramater and sinuses were bile-stained; brain was quite colour-less and healthy, and weighed 47 oz. Nothing could bemade out of the eyes to account for the exophthalmos whichstill existed. The thyroid body was not much enlarged, itstissue being lax, and made up of loose homogeneous glisten-ing substance held together by loose connective tissue.

There was acute pleurisy of the right base. The base of theright lung was also inflamed, its tissue airless, and allowedof the escape of much yellow bile-stained serum on section.The larynx was healthy. The heart weighed 14 oz. Thepericardium was acutely inflamed, both surfaces beingcovered with a shaggy membrane, and its cavity containinga good deal of fluid. The inflammation did not anywherepenetrate into the muscular substance of the heart. Therewas a single granulation on the tricuspid valve. The pul-monary artery was nearly as thick as the aorta ; no athe-roma. There was a row of very soft reddish recent granu-lations on the auricular surface of the mitral, and a slightvegetation on the posterior semilunar valve of theaorta. These appeared to be quite recent. With themwas evidence of old disease of the mitral, for thelower edge of the valve was decidedly thickened and thelower chordse also; the very lowest of the chordæ seemedto be stretched, so that the edge of the valve could be in-verted into the auricle. The right musculus papillarishad a considerable patch of fibroid degeneration at itsapex; the left none. The stomach was considerablyreddened and lined with mucus, as was also the duodenum,though this was redder. The mucus in the latter was quitefree from bile, even below the ductus communis choledochus.Lower down in the small intestine there was a smallquantity of dark-brown fceoal matter, which might haveowed its colour to the bile. On pressing the gall-bladder,bile of a deep-yellow colour flowed down into the duodenum;the mouth of the duct was reddened, but this condition didnot extend to the duct itself, which was free from swelling,and bile-stained in its whole surface. The liver weighedseventy-four ounces; it was of a bright-yellow colour,anaemic, and in no way nutmegged. The spleen was veryhard, had no embolic patches; weight seven ounces anda half. Kidneys both hard, jaundiced, but apparentlyhealthy; weight fourteen ounces.

MIDDLESEX HOSPITAL.CASES ILLUSTRATING THE OPEN TREATMENT

OF WOUNDS.

(Under the care of Mr. DE MORGAN.)THE following cases, for the notes of which we are in-

debted to Mr. H. Hammond Smith, house-surgeon, illustratethe open treatment of wounds, as recommended by Pro-fessor Humphry. Although the plan has been tried in asufficiently large number of cases to prove its efficiency, itis impossible to disregard a serious objection which at-oncesuggests itself, and the importance of which was exemplifiedin two of the subjoined cases-namely, the danger of inter-mediary and secondary haemorrhage from the want of suffi-cient support to the divided vessels of the wound. Therecan be no doubt that strappings and bandages afford con-siderable support to the vessels undergoing the processesof repair, and thereby materially lessen the chances of

haemorrhage. Whether the absence of the support to theflaps of the wound and to the vessels will prove an insuper-able objection to the open treatment of wounds remains tobe shown by future experience. Otherwise the plan is

worthy of adoption from its simplicity and its cleanliness.CASE 1.-Rebecca P-, aged sixteen, was admitted, on

August 28th, into Queen ward, suffering from strumous dis-ease of the left knee-joint.On Dec. lOth, the disease having resisted all treatment,

the leg was amputated, by Teale’s method, in the middle ofthe thigh. The stump was dressed with carbolised oil, andfirmly bandaged.

Dec. 11th.-Patient in no pain; dressings removed; thewound well washed, and the stump then laid on a pillowcovered with oakum, and lightly covered with dry cottonwool.

l6th,-Patient has gone on improving. No dressing hasbeen applied up to the present date, when, after using thebed-pan, a severe attack of secondary hsemorrbage came on.The flaps were opened, and everything appeared healthy;no bleeding vessel could be seen, but there was generaloozing from all parts of the two flaps. The wound waswashed out with a solution of ergotine (1 in 6). The edgeswere then drawn together with strapping, and the woundstill left open.