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A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

UNIVERSITY COLLEGE HOSPITAL.

CASE OF LUPUS TREATED WITHOUT CAUSTIC.

(Under the care of Dr. TILBURY FOX.)

Nulla autem est alia pro certanosoendi via, nisi quamplurimas et morborumeat dissectionum historias, turn aliorum, turn proprias collectas habere, etinter se comcarare.—MoMASNl De Sed. et Oaus. Mof5.,Iib. iv. Procemium.

THE following case (for the notes of which we are in- Idebted to Mr. W. Murrell, clinical clerk) serves to illustratetwo important points upon which great stress is laid by Dr.Tilbury Fox in the treatment of lupus. It shows, firstly, thegood results which follow attempts to subdue the diseaseby checking the hyperasmia only; and, secondly, the neces-sity of recognising the modifications of the disease producedby a pyogenic habit of body, and the advisability of admin-istering special remedies to counteract free pus-productionin conjunction with the use of local measures adopted eitherfor the destruction of the lupus neoplasm or for lesseningany undue vascularity which may exist in the diseased part.

E. A. K-, a girl aged seventeen, was admitted on the17th June, 1873. She has never followed any particularoccupation. The family history disclosed only a slight con-sumptive tendency, but the patient was never very strong.When about nine, years old she had measles, followed by"bad eyes." She has several times had abscesses formabout the neck. About five years ago she noticed a "littlewhite spot" close to and on the outer side of the lower angleof the right ala of the nose, which soon broke, and remainedfor about a year of the size of a pea. It then spread slowlyduring the following year, and for the last two years hasincreased rapidly in size. The patient has been under dif-ferent medical treatment, and various lotions, powders, andointments have been applied to the face, all of which, thepatient say a, caused the disease to spread rapidly.On admission the patient was somewhat anaemic, and

suffered occasionally from indigestion, but with this ex-

ception felt very well. The face presented an unsightlyappearance from an oval patch of lupus, which involved thewhole of the upper lip and extended upwards on each sideof the nose to within half an inch of the lower margin ofthe orbit. On a level with the lower angle of the ala ofthe nose, it extended outwards on the right side for abouttwo inches, and on the left for nearly the same distance.On the prominence of the nose it reached the lower borderof the nasal bones. Both alse were implicated, and wereabout a quarter of an inch shorter than normal, the lowerborder being extremely irregular and broken. The septumnasi was unaffected. The patch was of a dull-red colour,but in some places was covered with large yellow scabs,which readily peeled off, exposing a hard, irregular, hyper-aemio, and bleeding surface. The edges were slightly elevatedabove the surrounding tissues. There was no discharge,and no pain except when the scabs were torn off. On theright side of the lower lip, about half an inch below and tothe inner side of the angle of the mouth, was a patch ofirregular shape, about the size of the thumb-nail, resemblingin other respects that just described. About two inchesbehind the right ear was another patch similar in size andappearance to that just described. The neck on both sideswas extensively marked with the scars of old abscesses,and on the left side, a little behind the bifurcation of thecommon carotid, was an abscess, evidently chronic, aboutthe size of a threepenny piece. It was tender, and at timesdischarged freely.The view taken of the case, as might be supposed, was

that it was a lupus modified by the strumous diathesis, sothat free pus-formation was present. It was felt that ifany irritant were applied the disease would spread, andsoothing applications were accordingly used to check thehypersemia, whilst anti-strumous remedies were given tomeet the pyogenic tendency. The scabs were removed by

poulticing, and the surface was painted freely twice a daywith diluted solution of subacetate of lead, and liniment oflime was used to exclude the air. The patient took cod-liver oil, quinine and steel, and was ordered a nutritiousdiet. This treatment was continued for six weeks from thedate of admission, after which the patient was sent toEastbourne, with instructions to continue the treatmentfor a month longer, with the addition every night of aplaster made of equal parts of lead and mercury plaster,which was to be placed over the solution of lime, and re-moved on the following morning.The crusts had at this time ceased to form, the vascularity

had diminished, and the patch had become not only palerbut much thinner.At the expiration of a month the patient again presented

herself at the hospital greatly improved in personal ap-pearance, and, although she stated that Eastbourne had notsuited her, the condition of her face had steadily undergoneimprovement. On examination it was found that the diseasedpatch had almost disappeared. The surface was slightlyreddened, but with this exception there was nothing toindicate the presence of disease except slight superficialscarring. There was no contraction, no loss of subcutaneoustissue, and there were no longer any scabs. The tissuesabout the nose and mouth were perfectly soft and pliable,and there was no elevation above the surrounding skin.The patch of lupus on the lower lip, which, on admission,had been of the size of the thumb-nail, was now repre-sented by a slight redness not larger than a split-pea; soslight was the redness that till patient pointed out its ex-istence it was quite overlooked. The patch upon the neckhad undergone a similar improvement, and the abscesseswere completely healed. The change in her personal ap-pearance was indeed so marked that when patient wore athin veil, or stood at the distance of a few feet, nothingunusual could be observed in the condition of her face,with the exception of the absence of a small part of thetip of the nose.Remarks.-This case, which, in the ordinary course of

things, would have been treated with caustics, shows whatcan be done by simpler methods, directed specially againstthe hypersemia, and not against the neoplasm. Dr. Foxholds that whenever a patch of lupus is very hyperssmicand tender, and the patient is out of health, although theapplication of caustics may cure the disease in one spot, itwill only effect this by producing deep cicatrisation, andthe disease will almost inevitably spread, as happened inthis very case at the outset. This case, which had existedfor five years, made the best possible progress under thetreatment adopted, with marvellously little disfigurement.The mode in which such a local remedy as the solution ofthe subacetate of lead acts upon the lupus may be open toquestion, but most probably it is by directly constringingthe vessels and checking the vascular supply. As a con-

sequence of this the new growth is literally more or lessstarved, and as it naturally tends to undergo retrogressivechanges, it gradually disappears, as it would seem thatunder the use of the astringent the degree of its decayis greater than that of its growth. It should be noticedthat this happy result is not to be looked for in casesof severe or extensive disease, in which the growth extendsdeeply into the subjacent tissues.

ST. THOMAS’S HOSPITAL.ABSCESS CONNECTED WITH INTESTINE ; PYÆMIAK ;

OPERATION ; DEATH.

(Under the care of Dr. MURCHISON.)THE -following case; for the notes of which we are in-

debted to Mr. W. S. Greenfield, M.B., B.S., presents severalpoints of interest, although the absence of a post-mortemexamination, which could not be obtained, renders it

difficult to form any positive opinion of the nature of thecase.

’ Robert K-, aged twenty-six, a mason, was admitted onJuly 5th, 1873. His wife stated that he had been in goodhealth, though never strong, until three weeks beforeadmission, when he was seized whilst at work with severepain in the abdomen, chiefly on the left side, which com-pelled him to leave work and come home. The pain was of

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agonising character, not distinctly located. About twohours after he reached home vomiting commenced, and wasrepeated every time he took food for three or four days.The bowels, which had previously been regular, were con-fined till four days later, when opened by medicine. Thepain continued severe for two or three days, and slightlysince. He has ever since been very weak and prostrate,and has suffered from shivering, followed by heat andsweating, occurring four or five times a day for the lastfortnight. Three or four days before admission he firstobserved a small swelling in the upper part of abdomen,which was rather tender and painful; this has since in-creased and become more tender. No vomiting or retchingfor the last few days, and bowels have been open, stoolslight-coloured. No discharge of pus from bowels.

Present state.-10 r. ns. Extremely prostrate ; anxious ex-pression ; drowsy and disinclined to talk; complete anorexia;tongue dry, brown, furred, and fissured; sickly, sweetishodour of breath; frequent hiccough, which is said to havecommenced since admission. Temperature 101°; pulse 108,full and soft; respiration 32. He complains of pain andtenderness in abdomen, which is somewhat distended. On ex-amination, a circumscribed swelling, the size of a half-walnut,was found nearly in the middle line, but a little to theright, about half-way between the umbilicus and the lowerend of the sternum. It was soft, semi-elastic, non-fluctuating;very slightly diminished by firm pressure, but not reducibleeven after continued pressure. No impulse could bedetected in it on coughing. The swelling was acutelytender, and its manipulation gave him great pain; butthere was no general abdominal tenderness. No retchingor vomiting occurred after the examination. The hepaticdulness was increased, and extended downwards just to theupper margin of the tumour, over which there was imperfectresonance; some bronchitic rales audible in lungs; aharsh systolic bruit over the base of the heart, probablypericardial.As it seemed possible that the symptoms might be due to

strangulation of a small ventral hernia, after consultationwith Mr. Wagstaffe, Mr. MacCormac was sent for, who ar-rived at 2.30 A.M., and decided on exploratory operation. Onpuncturing the swelling with an aspirating trocar, a smallquantity of offensive, dirty-yellow pus, of faecal odour, wasremoved. An incision, three-quarters of an inch long inthe median line, opened the cavity of the abscess, and aboutan ounce and a half of thick pus was removed. The cavityof the abscess had ragged walls, but was surrounded by alayer of firm substance, and closely attached to the ab-dominal walls. It could not be followed further. The puscontained much granular débris, many bacteria, mostlyovoid, some fat-globules, but no faecal matter nor visibledébris of tissue. Its odour was extremely offensive. For ashort time after the operation he seemed relieved, but at4 A.M. a severe rigor occurred, and the temperature wasfound to be 1042° F., rising to 106° at 4.25, when the shiver-ing ceased. By 7 A.M. it had fallen to 1008°. Till mid-dayhe continued much the same, prostrate, with occasional hic-cough ; no tenderness over abdomen or wound. Anotherrigor occurred at 2.15, in which the temperature reached105°, and again at 11 P.M. reaching 1057°. Fifteen grainsof quinine given every four hours appeared to have no effectin checking them. i

July 7th.-Much discharge from wound, and very offen- Isive; extreme prostration; hiccough continues. Takesnourishment pretty well. Temperature varying between1026° and 104°. No distinct rigors.8th.-Appears almost moribund. The discharge from the

wound has become of bright-yellow colour, and much lessoffensive, and evidently contains matter from the small in-testine. Bowels open; motion of light-yellow colour. Noabdominal tenderness. Temperature 101° to 102°.

9th.-Temperature 102°; pulse 150; respiration 62. Noshivering. The discharge continues bright-yellow, and ap-pears to be almost identical with the milk-and-egg mixturegiven as food. About an ounce and a half escaped to-day.Is unconscious.10th.-Died at 8 30 P.M.Remarks.-It seems probable that the abscess was formed

in close connexion with the intestine, possibly as the result0f some partial obstruction or strangulation, which mayhave been followed by incomplete perforation, localisedperitonitis, and an abscess with a narrow or oblique opening

into the bowel. It is difficult to account otherwise for therapid occurrence of pysemic symptoms. The operation didnot appear in any way to accelerate death, but rather gavea temporary relief from pain; and had it been done beforethe setting in of pysemia, it would possibly have resulted incure, with a fistula opening into the small intestine.

ADDENBROOKE’S HOSPITAL, CAMBRIDGE.OVARIOTOMY ; DRAINAGE-TUBE PASSED FROM THE PERI-

TONEAL CAVITY THROUGH THE VAGINA.

(Under the care of Professor HUMPHRY.)FOR the notes of the following case we are indebted to

Mr. Robert W. Edginston, house-surgeon.E. S-, a widow, aged fifty-two, admitted Feb. 6th, 1873,

had had three children, and been the subject of ovarian dropsyfor fourteen years, during which period she had been tappedtwenty-one times. The last tapping was six weeks previousto her admission. The quantity of fluid removed on theseoccasions varied from nine to nine and a half gallons. It

was thin, albuminous, not ropy nor of high specific gravity.Each tapping was quickly recovered from, and was pro-ductive of great relief and of entire subsidence of theswelling, so that there was every reason to infer that it wasa single and simple ovarian cyst. Her health did not suffermuch, and the proposal to remove the cyst by operation,which had been rather urged in the earlier period of themalady, had not for some years been made; still the in-tervals between the tappings had decreased from sevenmonths to two months, and since the last tapping herhealth had rather failed. She felt weaker and had lessappetite, and the swelling had returned more quickly thanon former occasions, and was more burtltensome. Shetherefore requested that the attempt should now be made toremove the cyst.The abdomen was very prominent. It measured five feet

in circumference a little above the navel, and three feetfrom the ensiform cartilage to the pubes. The legs andlower part of the abdomen were very oedematous; urinescanty ; some diarrhoea and tendency to sickness. Pulse 100.The os uteri natural ; the condition of the uterus itselfcould not be further ascertained.

Feb. 7th.-As her condition did not admit of delay, theoperation of ovariotomy was commenced, under chloroform,by an incision four inches long, which was made as near tothe pubes as possible, for the purpose of avoiding the regionof the trocar punctures, where adhesions were most to beexpected. The linea alba was carefully divided, but a gushof fluid showed that the sac had been opened. The fluidwas allowed to flow away, and the sac was accordinglyemptied. It proved to be adherent to the whole of the forepart of the abdominal wall, and some difficulty was foundin tearing through the adhesions. This was, however, ulti-mately done, and the sac was removed without enlargingthe incision first made, and with very little exposure of thecontents of the abdomen. The pedicle was long. A clampwas applied. Two vessels in the pelvis bled briskly. Theseand four others on the inner surface of the abdominal wallwere tied with catgut ligatures, which were cut off close tothe knots. There was still oozing from many points intothe abdominal cavity; accordingly, the precautionary plansuggested by Dr. Marion Sims was adopted. A trocar withcanula was passed from the recto-uterine pouch of theperitoneal cavity into the vagina; a long perforateddrainage-tube was then introduced through the canula, andthe latter having been withdrawn, the tube was left, oneend being brought externally through the vagina, and theother through the lower part of the wound. The two endswere secured by being tied together. The wound was closedwith catgut sutures, and pads and bandage were placed onthe abdomen.

After the operation there was no great amount of shock,neither did the temperature at any time exceed 101°. Thelooseness of the bowels, which existed before the operation,continued for some days. During the first three days alarge quantity of sero-sanguinolent fluid passed throughthe drainage-tube. This stopped completely, and the tubewas removed on Feb. 23rd. The clamp separated onFeb. 25th. The external wound healed without trouble,