A CASE OF CHRONIC PULMONARY TUBERCULOSIS TERMINATING IN ACUTE SURGICAL EMPHYSEMA
152 events, there can be no doubt that the clinical features of erythema nodosum and of urticaria were combined in one and the same patient. But such cases are not so very rare. I have met with them several times. The deduction to be -drawn from these observations is clearly that the alliances of erythema nodosum are with urticaria and that the malady has nothing to do with rheumatism, acute or chronic. As regards the distribution of the lesions in erythema nodosum it is generally considered
... t the rash is more or less confined to the lower extremities, its seat of election being the front of the tibia, yet in my experience it is by no means unusual to meet with the characteristic appearances on the flexor and extensor surfaces of the arms and forearms as well as the legs and thighs. In a few instances I have found the lower extremities to be practically free from the rash which was almost entirely confined to the arms and forearms. It is scarcely necessary to say that the treatment of this malady by salicylates or by anti-rheumatic measures generally is a perfectly futile proceeding. The relations of the affection are certainly not with acute rheumatism ; hence it ( is not surprising that therapeutic measures adapted to the management of that malady are altogether fruitless in this disease. Most important of all details of treatment is rest in the recumbent position and the use of lead and opium lotion may be agreeable and soothing to the patient. But when severe pain is present warmth seems to be the most efficient method of relieving it. Internally quinine may be administered, but it is more than doubtful if any drugs control the course of the malady. In view of the close relationship existing between erythema nodosum and urticaria it is scarcely necessary to insist upon the importance of attention being devoted to the diet, the condition of the stomach, and the state of the bowels. IT is probably a rare occurrence for a case of chronic pulmonary tuberculosis to terminate in acute surgical emphysema. Such a state of things was found in the case of a patient in the Halifax Union Poor-law Hospital. The patient was a man, aged 41 years. He had been phthisical for 25 years and presented all the signs of chronic pulmonary tuberculosis. When I saw him on the day of his death he was suffering excruciating pain in the region of his left shoulder. A slight emphysematous puffiness on the left side of his neck was all that could be made out then. The emphysema was very acute, two and a half hours only elapsing between the appearance of the first symptom and death. The patient, naturally a very thin man, soon became enormously distended. The emphysema was general, the skin all over the body being very tightly stretched. *At the post-mortem examination on opening the thorax the right lung was found to be fixed to the chest wall in places by old adhesions. The lung itself showed evidence of old-standing phthisical lesions. The left pleural cavity was entirely obliterated, it being quite impossible to separate the' lung from the chest wall. On attempting to do this there was disclosed, situated at the posterior portion of the apex of the left lung, a cavity of the size of a pigeon's egg. Projecting into this cavity was a sharp spicule of bone. A portion of the thick cap of pleura covering the apex of the left lung was necrosed opposite to the third left rib. The inflammatory process had spread to the bone and so weakened it that it had snapped about two inches from its vertebral end. Very little force mu-t have sufficed for this, as the patient was kept in bed and had very little cough. I am indebted to Mr. J. F. Woodyatt, the principal medical officer, for permission to publish the case. ; Halifax. IT is no uncommon thing to meet with a mild attack of jaundice in the newly-born infant, but I believe that the same condition in the foetus is rare, and still more so when the resulting poisoning causes death, as described in the following cases, all children of the same mother. Four years ago a patient under my care, then aged 29 years, was delivered of a male child who was free from jaundice and who is now living. At the age of two years he had a very severe attack which at the time I attributed to obstructive catarrh of the bile-ducts. Three years ago the same woman had another boy born. The child was full-time but stillborn. He was intensely yellow, as were the liquor amnii, the membranes, and the placenta, all of them being deeply stained with bile. Death had presumably occurred one week before birth. Two years ago another boy was born and the same condition of the liquor amnii and membranes obtained. The child, who lived three days, was green at birth and became more so afterwards. Symptoms of bile-poisoning supervened, terminating in coma. One year ago a girl was born. Here again the same condition prevailed, only that the child lived five days. On June 26th, 1902, another boy was born. The liquor amnii was less dark and the child was less stained than on the previous occasions ; but here, again, life seemed to flicker a few hours after birth. The child would not take the breast, cried pitifully and moaned, gradually became comatose, and died on the third day. In none of these cases was there obstruction to the flow of bile into the intestines, for the first and subsequent motions were deeply bile-stained. The mother had one attack of jaundice some three and a half years ago whilst pregnant with the child that was stillborn. She is otherwise healthy though fragile-looking. The father is the picture of health and strength and the family history is good on both sides.