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the bones of the leg, ligation of the femoral

The boy works on a farm, and though he artery, division of the nerves, etc., were tires rather easily, has never been seriously ill. mentioned. For some years, until he was It has been suggested that it might be of about eighteen, the deformity increased, but syphilitic origin. His parents are very quiet the mother thinks it is now stationary; she, farmers, who, from extreme youth, have always at least, has not had to increase the size of his resided in a rural township, where it would be stockings since that period. almost impossible to find a case of syphilis in a generation. They never visit towns or cities, and I should feel safe in saying that if syphilis is a factor in the case it was contracted as far back as the grand parents of the patient.

You see the state of the limb to-day. The enlargement has extended up the thigh. The femur is nearly two inches longer than its fellow. The circumference above the knee is four inches greater than that of the right, while the circumference at the ankle is 13 inches greater than that of its fellow (the right leg, 8, left, 21 inches.) This size (at the ankle) would be increased, were he to keep

long on his feet, and night's rest.

DISCUSSION.-Dr. A. A. Riddel remarked that he had probably seen as many cases of elephantiasis as any other member of the Society. It was much more prevalent in hot than in cold climates. To him it seemed that the case exhibited by Dr. Harrison lacked some of the principal features such as the thickened, hard, rugose, and anæsthetic skin-of true elephantiasis. He had never seen or heard of a case in which such increase of the length of some of the long bones as was here present had been observed.

Dr. Hamilton said that it did not at all correspond with the few cases of elephantiasis he had observed. In all of these the limb was of almost wooden hardness, while here there was the feeling of a soft doughy bag. What is elephantiasis? It consists chiefly in hyper trophy of connective tissue, and was of fibrou nature and consistence, the very opposite of that presented here. Besides anything like | elephantiasis could not from its nature disapdiminished after his pear on simple elevation of the limb as this was stated to do to a considerable extent.

[graphic]

In the cut you will observe the right foot rests on some books. These, though they do not bring it to a level, are 5 (five and seven-eighths) inches high. The femur is bowed, so as to take nearly, or quite an inch off its length. It is increased in size and altered in shape, the spine at the shin entirely absent. The skin is soft, and with the tissues it covers, has a soft, flabby feel. The hairs on the affected parts are very much elongated, the skin in places dark coloured, and the inguinal glands on both sides greatly enlarged. The eyes are rather prominent, and show a large amount of peculiarly white and glistening sclerotic.

This favored the view that the lesion was in the softer parts. If the child must be named something he would have it christened Lymphangeioma, or an enlargement consisting mainly in dilatation of the lymph channels-a clinical entity concerning which the literature was scanty, and the only thing written of late was by Dr. Busey, of Washington, who had written* a small work on the congenital forms. He thought its general symptoms, history, and behaviour upon elevation corresponded with this view.

* Dr. Busey's case lxxxvii, was strikingly like the one presented. See cut in American Journal of Obstetrics for January 1878, p. 99.

Dr. Oldright remarked that there was an elongation of the bone, and that the most prominent feature was not a hyperplasia of the areolar tissue such as we have in elephan

tiasis.

Dr. Teskey looked upon the case as one of elephantiasis. Although it lacked many of the conditions generally found in that disease, yet those which were absent were chiefly the acces sory rather than the essential ones, as, for example, the warty growths of the skin; while those conditions which are essential to that disease, e. g. the progressive hypertrophy of the cellular tissue, were present to a marked degree.

Dr. Temple had considerable experience of elephantiasis in India, but could not reconcile the peculiar conditions presented by this case with what he had before observed. The rapid emptying of the limb by elevation was not characteristic of elephantiasis. The sensation impressed upon the fingers by these tissues was also entirely different.

Dr. Graham did not think that the case was one of elephantiasis. He considered the condition of the bones to be one of hypertrophy, perhaps caused by some trophic nerve lesion and the same might be said of the connective tissue.

There was also present a peculiar condition of the lymphatics which he could not explain. He had observed the same condition present in a patient under his care in the Toronto General Hospital, in whom the thigh had the same feeling resembling a bag of worms. This might be caused by enlarged lymphatic ducts.

Dr. Sheard said that he regarded the case as one of elephantiasis, admitting that there was not so much hardness as is usually found in elephantiasis. He remembered three cases where the softening was as marked as in this one, and yet hardening occurred subsequently. As to the pathology of elephantiasis it was known to be mainly modified nutrition and he could easily understand how that, where there was a change in nutrition producing hyperplasia of the fibrous connective tissue elements, there could also be produced at the same time an increase in the bony tissue leading to lengthening

of the limb. He would suggest that the elastic bandage be tried, believing that the artificial pressure supplied by the elastic band would, in a measure, supply the lost vascular tone, diminish the amount of blood sent to the parts and hence arrest the hypertrophy. He had seen a somewhat similar case in an (East) Indian lad treated in this way with most satisfactory

results.

Dr. Cameron would hesitate to call the condition elephantiasis, although at a distance it resembled it very closely. Upon manipulation, however, a very different impression was conveyed. He pointed out the greatly enlarged inguinal glands, and admitted a condition of lymphangiectasis but could not regard this as the cause of the elongation of the limb since the lymph channels on the opposite side and especially the glands were almost equally enlarged and had not produced a similar condition of the corresponding limb. He was rather inclined to regard it as a result of trophic nerve lesion analogous to the unilateral hypertrophy of the face, so well described by Jonathan Hutchinson, and others, the counterpart of the more common unilateral atrophy. This view he thought received corroboration from the presence of certain pigmentary patches on that buttock and on the inside of the leg of the affected side. With reference to palliative treatment, he thought the suggestion of the rubber bandage to be certainly a good one. But with regard to more radical relief of the condition, he thought the time had gone by for anything short of a serious operation. Had the sciatic nerve been stretched or divided in the early history of the case it might have proved of service, as had been shown by Morton, of Philadelphia. As it was, two operations only suggested themselves as applicable, viz:-Osteectomy, such as MacEwan, of Glasgow, would probably practise, or amputation.

Dr. Osler said, that notwithstanding the somewhat unusual flabbiness and softness of the tissues to the touch he would incline to regard it as elephantiasis. This consisted, undoubtedly, in hyperplasia of the skin and subcutaneous connective tissue, and he could conceive of an hypertrophy of the bone resulting from the same causes.

LIVING EXAMPLE OF LYMPHATIC DISEASE. We select the following as companion with Dr. Hamilton's case. - ED.]

ment.

Mr. Walter Whitehead, at Manchester Medical Society, (reported in British Medical Journal), showed a female patient, aged 15, suffering from lymphatic oedema and giant-growth of her left leg. The symmetry of her two legs had been maintained up to the age of twelve, when she commenced working in a factory as a "half-timer." She then noticed for the first time that the left leg gradually became larger. The swelling in creased during the day, but subsided very considerably during the night. The development became more marked, when she extended the hours of attendance at the mill. No accident nor injury could be remembered, and there was an entire absence of pain from the commenceThere had never been any inflammation nor hyperplastic changes in the integuments, nor any impairment of sensibility or muscular power in the limb. At the age of fourteen, a lymphatic fistula opened above the inner condyle, and periodically discharged about half a pint of fluid in the twenty-four hours. The leg ultimately acquired an increase of about three inches more than the right, measuring from ankle to hip; from patella to malleolus, it exceeded the right by one inch; and the foot was three-quarters of an inch longer than its fellow. Elevation of the leg and continued elastic pressure caused all the swelling to disappear; to return, however, when these measures were relaxed. The skin of the leg was uniformly pale, firm, and elastic, with the exception of a small area just above the outer malleolus, where there was a slight hardness of skin, superficial œdema, and pitting. There was no manifest impediment to the venous circulation, or apparent glandular induration. From the foregoing, he regarded the case as one of those where probably some congenital structural defects in the lymphatic trunks remain indefinitely passive in the absence of any immoderate influence, but which, when overtaxed mechanically, break down. He believed that it was one of a class recognized under the generic term of elephantiasis, but characterized by the deep rather than the superficial lymphatics being at fault, and where the lymphatic

trunks were in a condition of dilatation, and with incompetent valves; and where, probably, there was also a consecutive dilated condition of the lymph-spaces.

ANEURISM OF SUBCLAVIAN COMPRESSED BY ADHESIVE STRAPS AND ELASTIC BANDAGE.

BY DR. COBURN, OSHAWA. [Reported before the Ontario Medical Association.] MR. PRESIDENT,-Since entering the hall this evening I have learned that my name appears upon the Programme for a paper upon the subject of "Aneurisms." Evidently there has been some misunderstanding upon the matter, as it was not my intention to submit a paper, but to present a patient, and I had hoped, in accordance with the arrangements I had made, to have been able to bring the patient

before the Association at this session, but for some reason, which I cannot at present explain, the patient did not meet me at the station this afternoon, on my way here, as I expected he would. I hope, however, to see him arrive by While the early morning train to-morrow. making this explanation I may as well, perhaps, give a brief history of the case, and, at the same time make some allusion to the plan of treatment.

The wife of the patient referred to called at my office on the 25th of March last, and stated that her husband had not been feeling very well for some time, that he experienced more or less pain in the right shoulder and in the upper part of the right arm, that he did not eat nor rest as well as he usually had done, that a few days before her visit he had accidently observed a "lump," as large as a hen's egg, near the side of the neck, in the hollow below the shirt band, that the lump was not to say painful or very hard, that it was not discolored, and for the reasons mentioned did not appear like & gathering. As the patient's work was urgent, and he was engaged every day, and thinking I might decide to prescribe without making a was detailed visit, the history of the case somewhat minutely, more particularly the The kind of work her points first mentioned. husband was engaged at, the location of the lump and its physical peculiarities, suggested

that, in order to a proper comprehension of the
case, a visit was necessary. I accordingly saw
the patient that evening, and heard from him a
recapitulation of the history given by his wife.
The "lump" I found to be situated over the
second part of the right subclavian, in the
angle or fossa at the side and lower part of the
neck.
It was nearly oval--the base pointed
downwards, forwards, and outwards. Its
greatest measure, from base to apex, over its
convexity, I found to be two and a half inches,
its oblique measure two and a quarter inches,
and its shortest one and three-quarter inches.
Its pulsations and murmurs were synchronous
with the cardiac systole, and the reflex pulse-
wave was toward the mesial line and upwards.
Not having a hypodermic syringe with me at
this visit, I was unable to determine the nature
of the contents of the lump, which had been so
very well described to me, consequently I
decided to make a second visit at an early date.
I accordingly saw the patient again two days
later, and after going over the case once more,
I made the hypodermic test, and found that the
lump contained arterial blood. I then decided
to make an effort towards reduction by
compression. The mode adopted has been by
adhesive straps drawn tightly over a firm,
closely-fitting compress. Finding these did not
accomplish all that was desired, graduated
pressure has been affected recently, by an
elastic band applied over the straps. What
degree of success has been secured you will be
better able to determine upon personal examina

tion of the patient.

When first examined the pulsations of the sac were somewhat diffused, and difficult to trace, but after a time, as it became smaller, they were more easily detected, and the bruit much more distinctly heard. The diagnosis was aneurism of the thyroid axis, at or about the origin of the transversalis colli and, supra-scapular arteries, involving, as nearly as could be determined, both these branches. The aneurism was caused doubtless by prolonged severe muscular exertion in the use of a heavy hammer. The adhesive straps were removed at intervals of from two to three weeks, and fresh ones applied. Improvement was specially noticeable atter the application of the elastic band, and at present (August 6th) I am glad to be able to report almost complete obliteration

of the sac.

Selections: Medicine.

THE USE OF LOCAL REMEDIES IN
THE TREATMENT OF DIPHTHERIA.

WE recently asked a certain number of phy-
sicians, whose experience on the subject seemed
especially to entitle them to speak, to favour us
with their opinion on the advisability of using
local remedies in diphtheria, and to state what
The subject is one
drug they preferred to use.
which is to be discussed at the approaching
meeting of the International Medical Congress ;
and we trust that the paragraphs which here
follow may stimulate the interest of our readers
in what will, no doubt, be a most interesting
debate. There are many difficulties surround-
ing the subject, and one of these has been forci-
bly put by Dr. OCTAVIUS STURGES, who writes
thus:

of the value of local remedies in diphtheria. "I have never been able to convince myself In cases that have been cccurring lately, there has been so large a proportion of recoveries, especially after tracheotomy, that the question of treatment, local or otherwise, or any comparison between the results now and two years ago, or, still more, eighteen years ago, is hedged about with difficulty. My personal belief is, that the great safety in diphtheria is early tracheotomy; and the important question, awaiting authoritative statement, in reference to the disease, the precise clinical signs which give the proper signal for the operation."

There

Sir William Jenner, who published (now many years ago) a small monograph on the disease, advised the use of local remedies, preferring nitrate of silver for this purpose. are still many who adhere to this plan, and for these Dr. EDWARD WOAKES may be allowed to speak. He says:

During an experience of diphtheria in one locality, where the disease was rife, dating from 1860 to 1876, and which included some four or five distinct outbreaks of the disease, I invariably used topical remedies. I do not recall a single fatal case in which the following plan was adopted, providing the larynx and airpassages proper escaped-though nearly every instance in which those organs were implicated

ended fatally. The disease presented itself in two forms the catarrhal and the membranous, though a tendency was observed for the former to pass into the latter, especially in the late stages of the disease. In the catarrhal type, I contented myself with syringing the nasal passages, and swabbing the fauces with a strong solution of chlorinated soda, repeated very frequently, every hour or two. In the membra nous phase, I adopted the local application of nitrate of silver, almost invariably in the solid form. This I use very freely, stirring it into, and, if possible, under the exuded mass, completely breaking up the latter, so as to reach the diseased surface beneath. In very bad cases, I have made this application as often as three times in one day, so as to keep pace with the renewal and extension of the patches. In addition, I give repeated mouth and nose washes of chlorine or permanganate, in order at once to disinfect and get rid of débris. The form of query does not embrace internal treatment; but, as I always push perchloride of iron to the limit of toleration, the passage of it over the diseased mucous tract must, in some degree, be regarded as a topical application. Up to the present time, I have met with no treatment that offers greater advantages than the above, and its severity may be mitigated by the concomitant local application of morphia in powder, by means of the insufflator; and I confess, at the risk of appearing obsolete, to a preference for that method which has so often stood me in good stead."

Professor MCCALL ANDERSON, on the other hand writes to us, that "he is entirely opposed to the use of caustics and other strong applications in cases of diphtheria, as being injurious as well as increasing the distress of the patient." But, he adds, that "he has great faith in the local application of carbolic acid, of the strength of two or three grains to the ounce of water, and to which one drachm of glycerine has been added. This may be used in the shape of spray; or a large mouthful may be taken frequently, and allowed to lie for a short time at the back of the throat without gargling."

Dr. ROBERT CORY also expresses a similar opinion. "I believe," he says, "the use of topical applications is advantageous in diphtheria, so

long as they are of such a character that they do not cause destruction or inflammation of tissue; that the best applications to use are either sulphurous acid of P. B. strength, or carbolic acid, one part of acid to sixty pirts of water; or permanganate of potass, one grain to an ounce of water; or peroxide of hydrogen (ten volumes strength); and that the best method of applying one or other of these solutions is in spray.'

Dr. ALDER SMITH (of Christ's Hospital) also writes thus: "I most certainly believe in the use of topical remedies in diphtheria. I consider carbolic acid to be the best application, and would advise its use in the form of a dilute steam-spray. If the patient were old enough, I would also use to the patches the following solution :-R. Glycer. acid. carbol., acidi sulphurosi, liq. ferri perchlor. fort., aa, partes æquales. But I think the repeated use of a dilute carbolic acid spray to be most important.

66 one

Dr. THOMAS BARLOW coincides very much with these opinions, and suggests a mode of dealing with the disease when it attacks the nasal passages-a complication usually regarded as very serious. "There is," he says, group of cases of pharyngeal diphtheria where a very simple topical remedy is, I am sure, advantageous; those, namely, where there is an acrid discharge from the nostrils, and a presumption that there are shreds of tenacious mucus and half-membranous stuff on the posterior nares and the back of the palate. In these cases, so simple a measure as twice a day flushing round the posterior nares with plain water through the nostrils-the mouth being kept open-gives sometimes great comfort in breathing and swallowing, and, as I believe, lessens the risks of septicemia. The quantity of membranous plugs which can be removed in this way, without any risk of leaving a bleeding surface, is sometimes considerable. In regard to applications to the tonsils and soft palate, glycerine of carbolic acid has seemed to me the best thing to use. It does not make a superficial white slough like hydrochloric acid and nitrate of silver; and it is not so painful, and it can be applied daily. Occasionally, it is true, membrane re-forms over the area where the carbolic has been applied; but I have seen the same thing occur with the caustics above

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