1124

diagnosis impossible. Dr. Alan Randle records a case inthe present issue ’of THE LANCET, p. 1111, which is a goodillustration of this difficulty. The patient, 43 years of age,a multipara six months pregnant, was thought to be suffer-ing from eclampsia, but at the post-mortem examination wasfound to have a large cerebral haemorrhage filling bothventricles and extending to the medulla, the patient dyingfrom respiratory failure. The urine contained a considerable

quantity of albumin, but there was no paralysis or true

ansesthesia. The kidneys were of the red granular type,the liver was congested, and the heart was hypertrophied.The patient had suffered from lassitude and headachefor ten days, but there was no history pointing to

any previous renal trouble and there was no oedema.

She was confined of a six months’ partly macerated

foetus, and as the condition improved after her deliverythe diagnosis of eclampsia was thought to be confirmed.It is very probable that not a few of the cases of so-calledeclampsia without fits may in reality be instances of cerebralhaemorrhage simulating eclampsia. Among the more strikingfeatures, as N. C. Carver and J. S. Fairburn have pointedout,l in cases where eclampsia is complicated by severe

cerebral hemorrhage, especially when it involves the pons,is the youth of the patients, the absence of any fit, or theoccurrence of only one or two followed by the onset of deepcoma with respiratory stertor and in many cases Cheyne-Stokes breathing. A correct diagnosis is of the utmost

importance if an accurate prognosis is to be made, but onlytoo often the cerebral hemorrhage is only discovered at a

post-mortem examination, and in. such cases the question asto whether the case is one of pure cerebral hemorrhage orcerebral haemorrhage complicating eclampsia will depend onthe discovery of the characteristic lesions of eclampsia in thekidneys and the liver. Luckily, cases of extensive cerebralhemorrhages, contrary to the general opinion, are in realityrare in eclampsia ; thus in 216 cases collected by variouswriters in only seven did there appear to have been any largecerebral haemorrhage. In an attempt to arrive at a correctdiagnosis of eclampsia in a comatose patient stress must belaid on the previous history, the age of the patient, usually ayouthful primipara, the discovery of a large quantity ofalbumin in the urine, the presence of cedema, the absence ofhemiplegia or rigidity in the limbs of one side, and theoccurrence of repeated convulsions. It is obvious that wherea large area of the brain substance is destroyed by thehemorrhage the diagnosis, as in Dr. Randle’s case, may

present almost insuperable difficulties, and it must be bornein mind that in some cases of hemorrhages into the ponsconvulsions are not uncommon.

OVERCROWDING ON THE DISTRICT RAILWAY.

IT is a commonly expressed opinion that what are calledfacilities for locomotion lessen overcrowding both in theconveyances themselves and in the streets. As a matter of

fact, the exact opposite seems to be the case as regardsLondon. The discomfort and in some cases the dangers ofovercrowding trains and the like have of recent yearsbecome notorious, and it cannot be wondered that numerousquestions are asked in Parliament on the matter. On

April 6th various members of the Labour Party attackedthe Metropolitan District Railway Company on account ofovercrowding. Mr. C. W. Bowerman pointed out that the

overcrowding took place at morning and night, which is anundoubted fact. Mr. W. Thorne, on the other hand, arguedthat a great deal of the overcrowding happened in the

middle of the day, because fewer carriages were run. Mr.

H. J. Tennant, on behalf of the Board of Trade, promised

1 Proceedings of the Royal Society of Medicine, vol. i., p. 90.

to make representations. That overcrowding does exist

is indubitable, but it is just as obvious and just as-

annoying upon the municipally owned tramcar as on

the capitalist railway carriage. As the " thousands of

working men and women," to whom Mr. W. Hudson,the Labour Member for Newcastle, referred upon the

same occasion, to say nothing of a few thousand

more persons to whom he would not grant the title

of working man, all have to get to their work between

the hours of 5 A.M. and 10 A.M., and all strive to.

get home between 5 P’.M. and 8 P.M’., we do not see

how overcrowding is to be averted. The modern bodypolitic is just as complicated as the natural body, and

all these difficulties are part and parcel of modern

industrialism. When the worker lived over his shop orthe rich tradesman had a few apprentices who livedin the house, while the journeyman lived only a few doors,away, the need for travel did not exist. But under modern

conditions no one in a great city lives near his or her work.Moreover, a great part of the overcrowding is due to

pleasure-seekers and the hordes of surburban dwellers whocome up for" sales " and theatres. It is evident from aremark of Mr. Thorne, " Are railways run for shareholdersonly," that the outcry against overcrowding on railways is.not solely due to anxiety in the interests of passengers,but is partly inspired by the wish for the nationalisation ofrailways. But the state in London of the municipallyowned tramcar forms a poor argument in this direction. At

present there would appear to be no remedy, although sucha state of matters is both dangerous to life and injurious- tohealth.

____

RUPTURE OF THE ŒSOPHAGUS.

WouDS and ruptures of the oesophagus are by no means.common. Phthisical patients occasionally rupture the

oesophagus and in inveterate alcoholics constant vomitingsometimes results in the walls giving way. Of course, also,injuries to the neck may, though they very rarely do, involvethe oesophagus. What is probably an unique case of

rupture by violent distension has recently occurred in

Sweden, which is reported by Dr. G. Petren, assistantin the clinic of Professor J. Borelius in the University ofLund. The patient was a vigorous, healthy man, 27 years ofage, who was employed as a cleaner and working by meansof compressed air conveyed through an indiarubber tube. Ashe wished to move he doubled up the tube with his hands andseized the end between his teeth. While doing so he slippedand lost his hold on the tube which delivered its contentaat a pressure of seven atmospheres directly into hismouth. He fell down complaining of a severe painin the chest and vomited a small quantity of mucus

tinged with blood. Three hours afterwards when ad-

mitted to hospital the neck, the integuments of the thorax,and the chin were emphysematous, the pulse was small,rapid, and irregular, respiration painful, and the generalaspect, very bad. The pain was referred to the epigastrium.The man could not stand or lie down but had to keep a sittingposture. A few hours later the emphysema had encroachedon the face, the eyelids, and the arms. The dyspnceabecame more and more pronounced and the heart’s actiongrew weaker and weaker, death occurring the next morning.At the necropsy a vertical clean rent in the oesophagus wasfound 6 centimetres in length, the upper extremity being1’ 5 centimetres from the bifurcation of the trachea; the

surrounding connective tissue was infiltrated with pus. Thusthe rupture in this very special case occupied the same posi-tion as ruptures due to vomiting generally do-that is, thelower end of the oesophagus, sometimes even involving thecardia. They are generally longitudinal and present clean

1125

edges as if cut with a knife, and they are generally situatedon the posterior or lateral aspect of the oesophagus. If a

diagnosis could be made sufficiently early it is quite con-ceivable that operative interference might prove successful.

PERIARTERITIS NODOSA.

THE obscure and rare condition known as periarteritisnodosa forms the subject of an interesting communication byDr. Warfield T. Longcope to the February number of theProceedings -a .f the Pathological Society of Philadelphia.The patient whose case was investigated by Dr. Longcopewas a coloured man, aged 35 years, admitted to thePennsylvania Hospital under the care of Dr. James Tysoncomplaining of praecordial pain, dyspnoea, and oedema of theabdomen and lower extremities. His illness commenced

about three weeks before admission with pains in the jointsand calves of the legs, slight malaise, and weakness. The

legs began to swell four days before admission and his

dyspncea increased. His temperature was 960 F., respirations28, and pulse 56, the radial pulse being of small volumeand tension, thready, and at times irregular. There wastenderness over the liver, which extended 3’ 5 centimetresbelow the costal margin. The leucocytes were found tonumber 13,200 per cubic millimetre. The urine contained atrace of albumin and numerous hyaline and finely and coarselygranular casts. About a fortnight later, after a temporaryimprovement, the urine suddenly became blood-stained andcontained many granular and hyaline casts. Later the leuco-

cyte count rose to 32,000, while the haemoglobin was foundto be 58 per cent. The patient became more dyspneeic anddied about a month after admission. At the necropsy theheart was found to be enlarged and there was a marked whitethickening over its vessels. Near the apex there were

greyish and yellowish streaks in the muscle. The liver was

enlarged and on section presented a curious coarse mottledappearance. Some of the small arteries were found to be

plugged with firm red thrombi. Both kidneys showed onsection a mottled appearance and it was often difficult to

distinguish medulla from cortex. There were numerous

small infarctions scattered through the cortex. On followingup the renal blood-vessels, thrombi, red or white in

character, were found in the arcuate arteries and ex-

tended as far as these could be followed. There was

extensive softening of the left occipital lobe of the

brain, and the left posterior cerebral artery was pluggedthroughout the greater part of its length by a firm red andgrey thrombus. On microscopical examination changestypical of periarteritis nodosa were found in the smaller

arteries of the heart, liver, kidneys, pancreas, testicles, brain,perineural connective tissues, and voluntary muscles. There

were ansemic infarctions of the kidneys, foci of necrosis inthe myocardium and liver, typical glomerular nephritis, anddegeneration of voluntary muscles. In the larger vessels

longitudinal section showed the presence of the nodules, andon approaching a nodule from a healthy portion of vessel,the first change noticed was in the adventitia where therewas infiltration with small round cells, a few polymorpho-nuclear leucocytes and eosinophiles. A short distance fromthis changes were found in the intima which presented slightfibrous thickening covered with cells of various types. Some-what nearer the nodule the media showed swelling of themuscle cells with loss of nuclei. Cross sections showedat the periphery of the nodule involvement first ofthe adventitia, then the intima, and, finally, more or

less complete but often irregular destruction of the in-ternal elastic layer and of the media. Some vessels showed

general irregular dilatation of the vessel, others showed

bulging on one side; occasionally the lumen was found tobe partially occluded by proliferation and infiltration of the

cells of the intima, but in other sections it was found to be

plugged by a thrombus consisting of red blood corpuscles,polymorphonuclear leucocytes, fibrin, and platelets. The

thrombi, like the changes in the walls of the vessels, werelocalised and were often confined to a very limited area. Inolder lesions the inflammatory changes were less prominentand the vessel wall was converted into a wide circular ringof cellular connective tissue, in the centre of which was anorganising thrombus. In some such nodules no trace was

to be found of the original smooth muscle of the media, orof the elastic tissue of the internal or external elasticlaminas. In the smaller vessels the lesions presentedcertain differences : they were usually clustered in definitelesions corresponding to the bifurcation of the arteries.

The perivascular lymphatics at a distance from the noduleswere distended with polymorphonuclear leucocytes and largephagocytes. The adventitia of the vessels as well as the

perivascular connective tissue showed oedema and infiltra-tion with various cells. This exudate was found to increaseand some infiltration with fibrin also appeared until it

formed a wide zone around the muscular ring of the media.The intima also showed infiltration with polymorphonuclearleucocytes, fibrin, and large pale cells. The fibrinous

exudate in the intima sometimes increased to form a

granular ring internal to the media which eventually becameinvolved in the inflammatory process, and in the central

part of all nodules it was entirely destroyed. Dr. Longcope,at the end of his valuable paper, discusses briefly thehistogenesis and etiology of the disease. He points outthat owing to its tendency to involve all the coats it isdifficult to be certain of the primary lesion. In his own

, case he was able to find two instances in which the

,

adventitia about minute arteries showed a localised infil-

, tration with small round cells without changes in the

,

media or the intima, and he is inclined to regard these as the beginnings of nodules. He concludes that in his

l

.

own case the adventitia was the primary seat of attack, but

L he is not prepared to suggest that this is the rule in all

. cases. In regard to the etiology, no evidence was forth-

: coming to connect it with syphilis and no spirochsetas were

l ,

demonstrated in sections prepared by the Levaditi method.By some mischance the cultures prepared from the liver andspleen were destroyed, so that no bacteriological studies couldbe carried out. Bombard in a recent case obtained staphylo-

l coccus albus in cultures from the liver and spleen, but with

I this exception the bacteriological investigation of these

; cases has given negative results. In spite of these failures,

r however, Dr. Longcope thinks that many of the features are

<

in favour of the view that the disease is due to an acute

, infection, notably the fever, the leucocytosis, and the typel J

of the inflammatory exudate. Moreover, the glomerularl nephritis present in the cases of Hart and Bombard, as well

s as in his own case, is consistent with this view of causation

l by some intoxication or unknown infective agent.

EPSOM COLLEGE AND A BEQUEST.

THE will of the late Surgeon-General Richard ChapmanLofthouse, A.M.S., which consisted of a formal will andfive documents explaining the testator’s wishes, was con-sidered in the High Court of Justice, Chancery Division,on March 17th and 18th. Although the testator declaredthat his trustees should, if possible, avoid taking any lawproceedings in regard to the construction of and the carry-ing out of the trusts of his will, and that they should beguided in the application of the residue as much by theterms in the will set forth as by written instructions which heintended to deposit therewith, it was found to be necessaryfor the court to decide various points, and to discriminatebetween conditions which were essential and those which