549CLINICAL NOTES.-HOSPITAL MEDICINE AND SURGERY.

ircreased to 9 or 10 per minute. The rigidity, too, waspassing off, and freshly pounded carbonate of ammoniumapplied to the nostrils began to have some effect in rousingher. Just before midnight I visited the patient again andinjected 15 minims, which brought the total amount injectedto 115 minims, or about 1 grain of the sulphate. Next

morning I was not allowed to do more than feel the pulse,the hand being thrust through the bed-curtain as at thefirst visit. She was then quite conscious; the pulse was 128and she had some fever. As the bowels had not been movedand the bladder emptied since the day before taking theopium an aperient with some quinine was prescribed. Iheard no more of the case for a week or two, when I wastold that by the afternoon of the day of my last visit thepatient was perfectly well. The total amount of sulphateof atropine injected was about 1,3’ grain. The patient had atone time smoked opium, but according to the statement ofher friends had given up the habit about a year ago.Amoy, China.

NOTE ON THE PREVENTION OF LARGE MAMMARYABSCESSES BY EXPRESSION OF THE MILK.

BY WALTER G. SPENCER, F.R.C.S. ENG.,SURGEON TO THE OUT-PATIENTS AND TO THE THROAT DEPARTMENT,

WESTMINSTER HOSPITAL, ETC.

UNFORTUNATELY cases of large mammary abscesses areseen too often in the wards of a general hospital. A woman

has been exhausted by the previous pregnancy and lactationand is usually more or less worried about her family. Gene-

rally more than one incision has to be made, the sinuses arelong in healing, sometimes the removal of the whole breasthas been required, and even after healing the scars whichremain may become later the site of cancer. Doubtlesswith proper care the breast need never become so over-

distended, but when it is beyond the powers of suction toempty it the application of hot fomenta.tions, poultices, or

belladonna plaster is surely a mistake, for all the secondaryducts must quickly become converted into abscess cavitiesunless the milk be first removed. Professor Tarniersome years ago devoted a clinical lecture to the subject.

have had some half a dozen cases during the lasttwo years among the out-patients at the WestminsterHospital. In all instances the breasts were extremelydisteaded, lactation having been recently interrupted ; theskin over the breast was, however, still free from induration,so that the full ducts could all be felt. By the forcible expres-sion of half to a pint of milk suppuration was prevented. Intwo of the cases nitrous oxide gas was given ; the other

patients bore the pressure without an anavsthetic. Takingthe breast in the hollow of the hands and increasing thepressure very gradually and as uniformly as possible therefirst oozed from the nipple a few drops of whey, then a smallplug of curd, followed by a stream of milk. From each- duct a plug of curd had to be driven before milkcame. Finally, there issued streams of milk in many direc-tions as water from the rose of a gardener’s watering-pot.Directly milk flows tension is relieved and further pressuredoes not cause so much pain. The amount of pressure re-quired when the breast was so over-distended as in the casesailluded to indicated clearly that suction would have beenquite inadequate, whilst the fact that each duct was pluggedby curd showed why the milk was retained and how inevit-able must have been decomposition and suppuration. Inmy last case a small areolar abscess had already formedand blocked the nipple by its pressure. The abscess wasopened under nitrous oxide gas and nearly a pint of sweetmilk expressed. No further suppuration ensued. Afterwardsthe women have been ordered to foment and to squeeze thebreast frequently and to take iodide of potassium for a fewdays.

Brook-street, W.

RUPTURE OF THE TERMINAL EXPANSION OF THEEXTENSOR COMMUNIS DIGITORUM.

BY F. G. WALLACE, M.B., B.C. CANTAB., ETC.,LATE NON-RESIDENT HOUSE PHYSICIAN TO ST. THOMAS’S HOSPITAL, ETC.

ALTHOUGH perhaps coming under the head of " minor ail-’ments I think that the following case is interesting, partlyfrom its rarity and partly from its causation. I

A woman aged twenty-nine years came to me on ChristmasDay, 1895, complaining of inability to completely extendthe terminal phalanx of the middle finger of the left hand.She alleged that a few hours previously, while pulling up herstocking, in some way she caught the finger and heard asnap, although she felt no pain. On her attempting exten-sion the terminal phalanx formed an angle of 135° with therest of the finger. There were tenderness and swelling overthe back of the joint and some pain over the middle of thedorsum of the middle phalanx. It was put up in a splint,with the terminal phalanx as far as possible in a, state of

hyper-extension. Though the patient removed the splintseveral times, it was reapplied each time and kept on " forabout ten days, after which a splint with a spring whichpressed back the terminal phalanx was worn for a fortnight.Some improvement has resulted, attempted extension nowproducing an angle of 160°. Some tenderness over thedorsum of the middle phalanx still remains.

Earl’s-court-road, W.

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

UNIVERSITY COLLEGE HOSPITAL.EPILEPTIC HEMIPLEGIA ; VERY NUMEROUS FITS OF JACK-

SONIAN TYPE; RECOVERY.

Nulla autem est alia pro certo noscendi via, nisi qnamplurtmas et m or-borum et dissectionum historias, tum aliorum tum proprias collectashabere, et inter se oomparare.—MoBGAeNi De Sed. et Cau8. Jforb.,lib. iv. Prooemium. -

(Under the care of Dr. CHARLTON BASTIAN, F.R.S.)SOME of our readers may recollect a lecture by Dr. Bastian 1

which was published in THE LANCET on the subject of

Epileptic Hemiplegia. In that lecture he included twodistinct classes of cases under this head. There are. first,the cases referred to in a previous lecture, in which a verybrief and temporary hemiplegia is apt to follow certain severeattacks of unilateral convulsions, the hemiplegic conditionin these cases being presumably due merely to vascularspasms plus certain molecular changes in definite partsof the brain. Secondly, there is the much more for-midable group of cases in which we have to do with distinctand obvious organic lesions in the brain, giving rise both tothe epileptiform mode of onset and to the more persistenthemiplegic condition. Dr. Todd wrote on this subject. Ourreaders will also find interesting contributions by Dr. Hugh-lings Jackson,2 Sir J. Crichton Browne,3 and Dr. Kelley.4 Forthe notes of this case we are indebted to Dr. Harold C.Way, house physician.A married woman aged fifty-three years was admitted to

the hospital on Nov. 23rd, 1895, paralysed on the left side ofthe body. She had had influenza in the previous March,which was followed by constant headache and occasionalvomiting lasting for a period of five or six weeks. She thenwent away for three months and returned to her home in

August almost quite well. After this the pain over thewhole of the top of her head gradually became worse, butthere was no sickness. On Nov. 9th she complained oftingling and numbness in the left arm and on the left side ofthe face. On waking in the morning of the 10th shefound she was completely paralysed on the left side of thebody. On the llth she had a fit with twitching whichwas confined to the left side of the body. Similar fits weresaid to have recurred daily in batches until the date ofadmission. There was a history of insanity in the family,and four years ago her friends said she was completely " offher head " for some months which they had attributed tofamily troubles. Since then she had been mentally dull andchildish. There was no-history of syphilis, and previouslyher health had been good. On admission her condition wasas follows. She was constantly muttering and crying out withpain in her head ; the pain was not localised and there was no

1 THE LANCET, June 20th, 1874.2 Medical Times and Gazette, 1881, vol. i., p. 185.

3 THE LANCET, Aug. 15th, 1874.4 Medical Times and Gazette, 1878, vol. ii., p. 216.

550 ROYAL MEDICAL AND CHIRURGICAL SOCIETY.

tenderness. She was very emotional, crying when spoken to,and she could not give rational answers to questions put toher. She had also a number of delusions, still thinking shewas in her own home &c. The pupils were unequal, the leftbeing much larger than the right, but they reacted well tolight. The ocular movements were good in all directions.There was complete left hemiplegia, with some rigidityof the left arm and leg. The left naso-labial fold wasmore marked than the right, but the left angle of themouth was raised badly when the patient showed herteeth. The tongue protruded markedly to the left. Theplantar reflex was absent on the left side, but presenton the right. The knee-jerks were exaggerated on bothsides ; there was no ankle clonus. Sensibility could notbe satisfactorily tested owing to the patient’s dull mentalcondition, but sensation to pain was not lost. Muscularsense seemed, however, to be lost in the left limbs,as the patient continually cried out to have her armand leg "put down" while they were already straightdown in the bed. The heart and lungs were normal.There was nothing unnatural in the urine. The pulse was 86,regular and of low tension ; the temperature was not raised.There was no vomiting whilst she was in the hospital; andthere was no optic neuritis. During the first three daysafter admission the patient had from ten to fifteen fits daily,mostly occurring in batches during day and night. Forthe next three days the fits were less numerous and slighter,and none occurred after the 29th, on which day she hadthree slight attacks. All the attacks were similar incharacter. They commenced with twitching at the left

angle of the mouth, which slowly spread up the face, thenextended to the fingers, arm, and shoulder, and next to thetoes, leg, and hip of the left side. Occasionally in the moresevere fits the convulsion spread to the right side of the body.The whole body then became rigid, the legs and arms beingflexed; the rigidity was more marked on the left side.The head and eyes also were strongly turned to the left.Consciousness was not lost during the fits, the tonguewas not bitten, and there was no micturition. The lastfit occurred on Nov. 29th, and on the following day shewas able slightly to move her left leg. In the course ofthe next three days she rapidly regained power in the para-lysed limbs and face, whilst muscular sense was simul-taneously restored. On Dec. 16th the patient got up andwas able to stand and walk fairly well. There was no

dragging of the left leg and the left grip was fairly good.Her mental condition still remained weak, but there were nodelusions. When first admitted syphilis was suspected, andshe was put upon a mixture containing potassium iodide andliquor hydrargyri perchloridi. After a few days this wasomitted and she was given three times a day a draught con-taining ten grains of chloral and twenty grains of bromideof potassium. After Dec. 14th she took only a draught con-taining twenty grains of bromide of potassium every evening.Remarks by Dr. BASTIAN.-’When first admitted pachy-

meningitis or a growth in the right Rolandic area was sus-pected to be the cause of the patient’s symptoms. After afew days, however, the absence of optic neuritis, of vomit-ing, and of any localised pain or tenderness made thisnotion improbable, and it was supposed that the patientwas suffering from thrombosis of the first, second, andthird branches of the right cerebral Sylvian arterysupplying the Rolandic area. It was thought that thisoccurred in the night of Nov. 9th, as premonitory tinglingshad been felt during the day on the left side of the faceand in the left arm, whilst when the patient awoke the nextmorning she found herself paralysed on that side. On the

following day (Nov. llth) she had the first fit, and the fits

very frequently occurred daily till Nov. 29th. They weretypical attacks of "Jacksonian epilepsy," always beginningand spreading in the same way, and sometimes involving theopposite side of the body, though even then they were un-associated with loss of consciousness. One of the most interest-

ing features about this case was the very rapid way in whichthe paralysis (and with it the loss of muscular sense) clearedup after the cessation of the fits. This of itself showed thatthe hemiplegic condition could not have been produced by acortical haemorrhage, and led to the supposition that theamount of thrombosis in the branches of the right middlecerebral artery must have been small and perhaps asso-

ciated with a fit in the night of Nov. 9th (thus initiatingthe hemiplegia) ; or else, if larger at first, that it musthave become partially resolved and partially compensatedfor by the establishment of a free collateral circulation.

These cases, in which Jacksonian fits are occasioned

by vascular occlusions, are sometimes veryl’zdifficult to

diagnose from cases of new growth in or jus(beneath theRolandic area, an instance of which occurred in;my practiceat the National Hospital for the Paralysed and Epileptic,Queen-square, about two years since, in the case of a gillsuffering from double mitral disease.

Medical Societies.ROYAL MEDICAL AND CHIRURGICAL

SOCIETY.

Adjourned IJisc1lssion on the Parasite of .11Ialaria.. AN ordinary meeting of this society was held on Feb. 25th,Mr. HUTCHINSON, President, being in the chair.

’

The adjourned discussion on the Parasite of Malaria was-reopened by Dr. GEORGE THIN, who read a note on theAppearances found in the Tissues of a Fatal Case of PerniciousMalaria at Sierra Leone. The tissues examined were from apatient who died from pernicious malarial fever at Sierra Leoneafter being four days under observation. The temperaturewas 100&deg; F. when he was first seen ; during the night it roseto 1062&deg;. On the second day it was 984&deg;. On the third dayit rose to 106&deg; and was brought down by treatment to 102 4&deg;.He died on the morning of the fourth day. The cerebralfunctions were disturbed when he was first seen and he soonbecame comatose. Dr. Thin was indebted to Surgeon-Captain Duggan for sending him portions of the tissues.Brain: The vessels of the pia mater were congested, witbsome colloid-looking plugs penetrating the surface of the brainapparently in the tracks of the vessels. The substance ofthe brain itself seemed to be little changed, but the blood-vessels contained many parasites of malaria. The large vesselscontained very few and many none at all, but the smallvessels contained many parasites, and many capillaries werefilled with them. The parasites were in the red corpusclesand were found in all stages of development. The mostnumerous forms were those which were in a very early stage,appearing as little more than a stained point in the centre ofthe red corpuscles. Others were of an intermediate size,occupying an appreciable extent of the corpuscle. Others,much fewer in number, had a comparatively large mass ofcentral pigment and almost entirely filled the red corpuscles.The tissues not being in a perfect state of preservation thefiner structure of the spores of the mature parasite couldnot be observed. Spores in various stages, from the’smallest forms to those of central pigment, could some-times be found in the same vessel. Some of theendothelial cells of the vessels contained pigment.Spleen : All the sections examined contained manvwhite corpuscles laden with pigment. These pigment-bear-ing cells were most numerous in the spleen pulp. Many ofthe very large white corpuscles which contained considerable’blocks of pigment were evidently undergoing degeneration,their nuclei being scarcely susceptible of staining. A fev,of the white corpuscles contained, in addition to small pia-ment spheres, red blood-corpuscles with parasites in theninterior. The small lymphoid cells of the spleen did notcontain pigment, and very little of it was observed in theMalpighian corpuscles. The red blood-corpuscles in thespleen contained very few parasites. Several were observedafter along examination. They were in an early stage. Largewhite corpuscles containing pigment were observed in theveins. Bone rnarrom: : In a few sections of bone marrowexamined some white corpuscles containing pigment wereobserved, but they were few in number compared with thosein the spleen. No parasites were observed in the bonemarrow. The marrow was from a rib. -Liver: Parasiteswere not observed in the liver so far as the examination hadgone, but it presented much pigment. The pigment was con-tained in large white corpuscles in the interlobular network.In some parts the liver cells contained pigment. Apartfrom the deposit of pigment the liver seemed normal.- &’t<7K,ey.’ All the structures of the kidney in the partsexamined were normal except the convoluted tubes. Inthese tubes the epithelium was swollen and granular : soecells were broken down and in many of those which were

1 The report of the previous discussion was published inTHE LANCET of Feb. 16th, 1896.