572

few instances of vascular obstruction recorded under the iname of arteritis obliterans." It may be of interest if in 1connexion with these three cases 1 call attention to a 1fourth case, which was under my care during the autumn of ]1885 at St. Bartholomew’s Hospital, and was shown by card Iat the Clinical Society in November of that year.l In mypatient, as in Dr. Radden’s and Mr. Gould’s, there was nohistory of syphilis or alcoholism, and no cause could beassigned. The right arm was also the extremity affected, Iand the disease spread from below upwards, whilst thepatient was under observation, reaching as high as an inchbelow the clavicle. Further, there was the same indurated,tender, and pulseless condition of the radial, ulnar, brachial,and lower portion of the axillary arteries, and the sub-clavian artery formed an aneurysmal-like swelling, thesize of a small hen’s egg. The swelling could beemptied by pressure, and there was no bruit heard init. The hand and forearm were cold, and the tips ofthe fingers cold and bloodless. There was no swelling ofthe hand or forearm, and no engorgement of the superficialveins of any part of the limb. The pain in the hand andforearm was intense, and the disease, after lasting for severalmonths, subsided spontaneously. So far the four cases maybe said to be absolutely identical. In my case, however, afaint pulsation was ultimately detected in the affectedvessels, and no gangrene occurred, as in two of Dr. Hadden’scases. The fingers, moreover, were flexed and rigid, andany attempt to straighten them caused the most intensepain. Another point of difference lay in the fact that thedilatation of the subclavian artery varied from day to day,and even at times from hour to hour. One day or hour itwas the size of a small hen’s egg and pulsated violently;the next, no perceptible difference between it and the leftsubclavian vessel could be detected. Further, after theacuteness of the symptoms had worn off, slight pulsationcould on some days be felt in the radial, whilst on othersthere was no trace of such even on the most careful search.During the time he was under observation the right lobe ofthe thyroid became enlarged.

I fully agree with Dr. Hadden that the etiology andpathology of this curious and most interesting affection callfor further investigation. For my own part, 1 cannot helpthinking that it will be found to depend upon some nervelesion. The absence of the signs of inflammation exceptpain; the diurnal and at times hourly variations in the size of,and character of the pulsation in, the subclavian artery; thefact that the pulse could at times be felt in the affectedarteries, whilst at other times it was absent; the enlargementof the thyroid gland; and the great pain not only along thecourse of the vessels, but on attempting to move the fingersand on making pressure on the back of the hand-are some ofthe chief reasons which I think support such a view. Maynot the disease be of the nature of a peripheral neuritisinvolving chiefly the nerves supplying the vessels, ratherthan an inflammation of the vessels themselves? Thisquestion, I think, can hardly be answered till an opportunityof making a post-mortem examination has occurred.

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

ST. MARY’S HOSPITAL.A CASE OF TRAUMATIC HYDRO-PYO-PNEUMOTRORAX, WITH

GANGRENE OF LUNG; RECOVERY; REMARKS.

(Under the care of Mr. PAGE.)

Nulla autem est alia pro certo noscendi via, nisi quamplurimas et mor-borum et dissectionum historias, turn aliorum turn proprias collectaehabere, et inter se compa.ra.re.—MoR&A&Nl De Sed. et Caus. Morb.,lib. iv. Procemium. -

As Mr. Page states in his remarks on this interesting case,the escape of air into the pleura is uncommon as a compli-cation of fracture of the ribs, its escape into the subcutaneoustissues being much more commonly met with. The way in

which it was here produced accounts to a certain extent forits presence in so young a subject, pneumothorax as an

1 See Clin. Soc. Trans., vol. xix.

immediate consequence of fracture of the ribs being ex-tremely rare in children. The clinical history proves clearlythe pathology of the case, and the separation of a localisedpatch of gangrenous lung must be remembered in the futureas a possible, secondary cause of pneumothorax.

A. S-, aged thirteen, was admitted on July 27th, 1887,having been run over by a cart, which was said to containthree or four hundredweight of iron. lIe was in a state ofcollapse, and the direction of the wheel which passed overhim was shown by a broad band of contusion, reaching fromjust above the left nipple upwards across the front of thechest, and ending over the sternal end of the right clavicle.At this point the bone was broken. There was no certainevidence of any fracture of rib, no haemoptysis, nor anyspecial indication, either on auscultation or percussion, thatthe lung itself had been injured, but there was very obviousdifficulty in breathing.On the following day the boy had rallied from the

collapse; but his general condition pointed to some gravethoracic lesion, and he complained of a great deal of pain inthe left submammary region. It was further noted thatthe right chest moved much more freely than the left inbreathing, and that the abdomen, though somewhat hardand tender, yet nevertheless distinctly moved. Respirationswere 84 in the minute, and his countenance evinced thegreatest anxiety and distress. Nothing, however, wasto be made out by percussion or auscultation, and itwas thought just possible that his difficulty in breathingmight be due to undetected fracture of a left rib, andto the severe muscular bruising which the chest wallhad sustained. In this opinion Mr. Page was supportedby Dr. Phillips. His temperature in the evening hadrisen to 102’G". He had vomited twice, and the vomit con-tained blood, which had in all probability come originallyfrom the lung. Next day (the 29th) the morning andevening respirations were 108 and 60; pulse 108 and 120;temperature 101° and 1020. The left side of the chest wassomewhat dull on percussion, and a slight pleuritic rub wasdetected just outside the nipple. On the 30th he was ratherbetter; the respirations had fallen to 60 and 52, the pulse to120 and 102, but the temperature was slightly higher. Hisanxiety was markedly less. The 31st also saw improvementin many respects, and on Aug. 1st the respirations weredown to 52 and 44. The dulness on the left side, however,had now decidedly increased, vocal fremitus and breathsounds were gone, and on Aug. 2nd the apex beat of theheart was noted as being in the fourth right space, one inchfrom the sternum. The pulse was 130, respirations 44 and48, and the temperature 9U’8° and 99’60 in the morning and

I evening respectively. It may here be remarked that thedifficulty in breathing rendered it impossible to apply any

, means for keeping the broken clavicle in position.There being no question as to the presence of fluid in the

left pleura, Mr. Crowle on Aug. 3rd withdrew by aspirationtwenty ounces of sanguineous serum. The temperature rosein the evening to 103°. On Aug. 4th, 5th, and 6th he was de-cidedly better, and on the last of these days his respirationhad fallen to 20 in the minute. He was, however, very muchtroubled with cough, especially on the afternoon of the 7th,when it suddenly became much worse. The house surgeonimmediately requested Dr. Cheadle, who was in the house,to see him, and he on examining discovered that there waspneumothorax on the left side. The pleural cavity nowcontained both air and fluid, the latter reaching as high asthe sixth rib. During the next few days there was markedamphoric breathing, though in himself he was manifestlyrather better, and was able to take food well. The heartstill lay to the right of the sternum. This new feature nowarose in the case, that on Aug. 9th there was much purulentexpectoration. On the 10th this was noted as being thickand yellowish-green in colour, and on the llth and 12th ithad begun to have a distinctly offensive smell. On the13th the smell of it was so much worse, and his generalcondition was so decidedly going back (he was not ableto eat and was obviously very ill), that Dr Lees wascalled in consultation to see him. He fully agreed inthinking that there was a collection of decomposed pus inthe pleural cavity, associated in all probability with somegangrene of lung, and that the right thing to do was tolay open the pleura. This was accordingly done at onceby Mr. Crowle, who inserted a large tube in the fifthleft interspace, in the mid-axillary line. The pus evacuatedto the amount of several ounces, was very offensive. The

boy now began to improve at once. Pus discharged freely

573

from the side, and day by day became less and less offensiveuntil it was free from small. Temperature and respirationalike fell, and he was eating and sleeping well. On the18th there was a discharge of some six or seven ounces ofpus, and with it came a solid leathery substance of ashycolour, which when laid out was about the size of threepostage stamps, and on microscopical examination wasproved to be a piece of pleura with lung tissue attached.From this time onwards both local and general conditionsrapidly improved. The tube was finally removed on

Sept. 9th. On the llth he sat up. On the 21st therewas distinct evidence of lung expansion on the left side,and the apex of the heart was two inches below andto the right of the left nipple. He left the hospital onSept.23rd.

Dr. Lees again examined the patient on Nov. 5tb, when ’,the circumference of the right chest just below the nipple-line was 121 in., that of the left 112 in. The left chestwas a little flattened, both above and below the nipple.Resonance was good down to one finger’s breadth below thescar of the incision, and down to the angle of the scapulabehind. Below these points the percussion note was dull.In ordinary respiration the breath sounds could be fairlyheard as far as the nipple, while on deep inspiration theywere audible as far as an inch below the angle of thescapula. Recovery seems to-day to be complete, and theboy looks and feels perfectly well. (The patient was shownat the Harveian Society on March 15th.)Remarks by Mr. PAGE.-I have thought this case worthy

of being brought forward, not alone because it is an admirableinstance of the reparative powers of youth, but also, andmore especially, because it is an example of one of the moreuncommon ways in which pneumothorax may be the resultof injury. Escape of air into the pleural cavity, in con-sequence of injury, is usually an immediate or very earlyphenomenon; but even then it is one of the rarest forms ofsurgical lesion. We are all familiar with the chest-wallemphysema which sometimes follows fracture of rib, and itmust have struck many of us as remarkable that in such cases,where the presence of emphysema has removed all doubt asto injury of both visceral and parietal layers of the pleura,there has been no escape of air into the pleural cavity, norany collapse of lung. Emphysema after fracture is, indeed,very common; pneumothorax very rare. We owe toDr. Samuel West an explanation which seems to accountsatisfactorily for this paradox. The question occupied alarge share of his Bradshaw Lecture on Pneumothorax lastAugust, and it will be remembered that he therein set him-self to expound this hitherto unexplained phenomenon.Dr. West referred to a series of carefully designed experi-ments, whereby he proved that the pleural surfaceswere kept in apposition, not, as had been thought, byatmospheric pressure, but by a force which for want of abetter term, nor using the term in too technical a sense, heventured to call " cohesion," a force of no small power, andone not easily overcome. His observations established the" existence of a force between the pleural surfaces much inexcess of the elasticity of the lungs, and sufficient there-fore to maintain the lungs in apposition with the wallsof the thorax, even when air has free access to thepleural cavity"; and he goes on to say that " pneumothoraxcan no longer be regarded as a condition to which thereis an inherent tendency in the healthy body, but, on thecontrary, as a condition brought about by the forcibleseparation of the pleural surfaces." It is exactly analogousto the emphysema of the subcutaneous tissue of the chestwall, distension of which may be caused by a force muchless than that required to separate the’layers of the pleura.This chest-wall emphysema may therefore in reality be a pro-tection against pneumothorax, the air making its way inactive expiration in the direction of least resistance beneath theskin rather than between the pleural layers. We see, there-fore, that it is only in exceptional cases that injury to thewall of the thorax is likely to be of such a nature as thereand then to separate the pleural surfaces, to overcome thecohesion of the pleural layers, and prepare a way for theforcible expiration of air into the pleural cavity when thevisceral pleura has been wounded at the same time by anin-driven rib or ruptured by the violence of some contusionor blow. Profuse haemorrhage may likewise act in thesame manner. A case of this kind, which has alreadybeen published, came under my care a few years ago.I saw the accident. A healthy young man fell from acart in front of the wheel, which crushed against, if

it did not actually pass on to, his chest. From hisappearance I think that pneumothorax probably occurredimme iat6ly, but examination was impossible on the road-side. At. any rate, there was pneumothorax with collapseof lung within two hours of the accident, when he reachedthe hospital, and when relief was promptly given by use ofthe aspirator, which withdrew both air and blood from thepleura. In the present case, however, the pneumothorax arosein a wholly different manner. A severe contusion caused aportion of lung and overlying pleura to slough, and airwas forced through the opening thus made into the pleuralcavity, the serous surfaces having been already separated,and the force of cohesion having been already overcomeby the effusion of fluid from traumatic pleurisy.Another point of interest in the case is the spontaneousdisappearance of all fetor in the pleural pus after drainingthe pleura-a result, indeed, such as is usually seen in casesof the kind. Washing out the pleural cavity is not freefrom danger, and is quite unnecessary ; and it is well toremember that free drainage and perfect evacuation of thefluid may alone suffice to get rid of fetor and bring about aperfectly healthy condition of the purulent discharge.

LEEDS GENERAL INFIRMARY.LARGE HYDATID TUMOUR OF LIVER CONTAINING VERY

NUMEROUS SECONDARY CYSTS; INCISION; RECOVERY;REMARKS.

(Under the care of Dr CHURTON and Mr MAYO ROBSON)

P. W-, aged nineteen, a leather dresser, was admittedon Sept. 9th, 1887, for pain and swelling in the abdomen,with some prostration. Temperature 1012°. The abdo-minal swelling was continuous with the liver; it extendedto the right groin and two inches to the left of the middleline. There was a feeling of fluctuation on palpation, andof resilience on percussion. The liver dulness in frontextended an inch higher than is normal. No gross diseasein other organs. He said he had had a short illness whenwith his militia regiment at Halifax two months pre-viously, but felt quite well until a fortnight ago, whenhe had headache. About a week afterwards he noticedthe tumour; some twelve months before, however, hehad noticed some enlargement of the abdomen, but muchless than at present. The pain began five days pre-viously to admission. During the last six days the tumourhad much increased in size.The foregoing account is taken from notes by Dr. Wardrop.

Griffith, then resident medical officer, who summoned Dr.Churton to see the patient on the evening of his admission.The tumour was aspirated at once, but when two ounces of-clear fluid had been drawn the outflow ceased, a shock being.given to the needle as of something striking it. The fluidwas that of a hydatid cyst. Next evening the patientstemperature was 103°. On Sept. llth, therefore, Mr. Mayo.Robson was asked to see him, with a view to operation; andupon his agreeing that the case was suitable and urgent, hekindly proceeded to operate without delay. It then became-apparent that the cessation of the flow during aspirationwas due to the fact that the secondary cyst punctured hadbeen emptied, and that the shock to the needle was caused,by one of these multitudinous cysts impinging upon it..The precise reason for the pyrexia and prostration did not.appear; there was no suppuration; no peritonitis. Nervetension, with pressure upon and displacement of neigh-bouring tissues and organs, may perhaps have been thecause; the growth of the tumour had recently been,it was said, very quick. A description of the operationis furnished by Mr. H. A. Smith, then Mr. Robson’s housesurgeon.Under chloroform and with the usual antiseptic pre-

cautions, the skin having been thoroughly cleansed withturpentine, Mr. Robson made an incision through the outerside of the right rectus muscle about three inches below thecostal margin. The tissues were carefully divided on adirector. The peritoneum having been opened, the cyst wasexposed. An aspirator needle was plunged in, sponges beingpacked round to prevent any fluid passing into the peri-toneal cavity. The needle quickly becoming blocked, anovarian trocar was tried, but the fluid began quickly toescape, so the cyst was incised for about half an inch ormore with a scalpel, and its margins held up with clips.Sponges prevented any escape into the abdominal cavity.Pellucid globular cysts began to pour out from the tumour;