PART IV.

MEDICAL MISCELLANY.

Reports, Transactions, and Scientific Intelligence.

T R A N S A C T I O N S OF T H E M E D I C A L SOCIETY OF T H E

C O L L E G E OF P I I Y S I C I A N S .

SESSIO~ 1881-82.

GEOItGE JOHNSTON, M.D., President.

ALEXANDER I~I~XOI~ ~[ONTGOM:ERY, M.K.Q.C.IJ., Honorary Secretary.

Wednesday, March 1, 15'82.

T~IO)IAS FITZPATRrCK~ M.D, Vice-~President, in the Chair.

Asearis Lumbricoides.

DR. J. W. MOORE~ Vice-President of the College, exhibited a large specimen of the common round worm (azcaris lumbricoides) passed that morning by a girl aged sixteen years~ who had been admitted into Cork-street IIospital three or four weeks previously in measles. I t was a simple attack, and she regovered quickly, and was sent to a conva- lescent home, where unfortunately she caught cold~ and her illness passed into a severe at tack of catarrhal pneumonia. She was readmitted, seriously ill, and had to be treated with turpentine in rather large doses. Last night, in one of her fits of coughing, she coughed up the worm without the least trouble. I t was curious that the turpentine prescribed for the puhnonary affection should have acted as a verniieide.

Temperature Charts in Fever.

The VIeE-PRESn)ENT of the College submitted a series of charts illus- trat ive of clinical observations in continued fever.

CAsE I. Coincidence of Typhus and T~/phoid Fever.--In one of the closing days of last August a young man came from Wexford to Dubliu to visit the Horse Show. He had been subject to asthma~ and for this complaint he was admitted to the Meath Hospital a few days after his arrivM in Dublin. When he had been two or three days in hospital his

350 ~'ansactions of the Medical Society

temperature rose, and he seemed to be passing into an attack of con- tinued fever. He (Dr. Moore) came to the conclusion that the fever he was suffering from was typhus, for the disease was then prevalent in Dublin, and it could be well imagined that a fresh young countryman would fall an easy victim to it. The fever ran on, and his temperature rose on one occasion above 105 ~ . His skin became very dusky, but on no occasion did a true macular rash appear. On the seventh day of his illness there was an attempt at a crisis, his temperature falling between morning and evening more than 2 ~ , and from the same evening to the following morning another 2 ~ , but only to rise again. On the evening of the tenth day his highest temperature was 105"4% On the thirteenth day there was a second definite attempt at crisis, and on the morning of the fourteenth day his temperature fell to 100% On the eighteenth day he was almost apyrexial, his temperature being only 99% At this time there were troublesome chest symptoms, and he began to be feverish again. The fever rose, until on two occasions the thermometer registered 104~ the evenings of the twenty-fifth and twenty-seventh days of his illness. On the morning of the twenty-eighth day there was very considerable h~emorrhage from his bowels, and he passed several motions of a tarry consistency. This was followed by an attempt at defervescence. As this went on the typhoid character of the fever became more manifest, and a few rose spots appeared on his body. The fever contimted until the sixtieth day, terminating at last by lysis. The circumstances under which his two illnesses occurred were remark- able, and the whole history of the case was not made out until a considerable interval after he left the hospital. He went down to the county Wexford 'as soon as he was fit to be moved. After a few weeks he wrote to say that he was still rather weak, and that his mother was down in fever. When the h~emorrhage took place from his bowels suspicions of the correctness of the original diagnosis were aroused, and it was concluded that the fevcr was typhoid from the very outset, particularly as there had never been any true macular rash. However, there was no doubt that the fever of which the young man's mother was ill was spotted typhus. The truth at last leaked out-- that , before the young man came to town in August, his brother had been suffering from typhus. He, no doubt, came to Dublin in the incubation stage of the diseas% for the symptoms developed two or three days after his arrival in town; and it was clear that he passed through the typhus fever, and that he then got typhoid fever in Dublin. The history of the case was instructive~ as showing that the two continued fevers might coincide, or at all events follow one another very closely.

CAs~ IL Intestinal tfxmorrhage in Typhoid Fever.--The next chart was one of an ordinary typhoid fever, illustrating the important clinical

of the College of Physicians. 351

fact that hsemorrhage from the bowels at an early period of the illness was sometimes of advantage to the patient. The case was a typical one of typhoid; rose spots were present~ and there was a certain amount of diarrhoea. The patient was a young man of about twenty years of age. On the twelfth day he had considerable h~emorrhage from the bowels~ which lasted for twenty-four hours, t I a rd ly had it passed away when there was an immediate amelioration in his symptoms, t I is temperature rapidly dcOined~ so that he was completely apyrcxial on the eighteenth day. I t is well known that early hmmorrhage in typhoid might act remedially by causing depletion and relieving the hyper~emia of the intestinal mucous inembrane~ which so often precedes the development of typhoid ulceration of the ileum.

CAs~ I I I . Slow Pulse in Conval~vcence from Typhus.--The case repre- sented by a third chart was als% in many rest)ects ~ an ordinary one. I t was typhus maculatus, occurring in a young man twenty-three years of age. The fever ran a course of sixteen days. Tile record of the first few days showed that the pulse was weak and rapid. On the fourteenth day i t fell to 86. On the seventeenth day of his illness he was com- pletely apyrexial~ his pulse being only 40 in the minute ; and during four days afterwards i t never exceeded 46. Then it began to rise again~ reaching on the twenty-fourth day 72~ and on the twenty-fifth day 86 in the minute. That comparatively quick pulse coincided with a com- pletely apyrexial star% his temperature on the twenty-fourth and twenty- tifth days being only 98"4 ~ and 97"2 ~ respectively. As Stokes and Murchison had pointed out, there might be subnormal pulse during the pyrexial period of typhus, but it was more frequent in convalescence.

Dm ~NlXON said one point of interest in the first chart was the sudden reduction of temperature during the seventh or eighth day of the typhus. I Ie had had some experience of that phenomenon, and Liebermeistcr had called attention to the prognostic value of it. I f there was a marked reduction of temperature--sometimes to normal - -about the seventh or eighth day~ the case would probably run a favourable course. Some time ago he attended a colleague in typhus~ and the temperature on tile seventh day was dowh to normal. On the following evening it rose again~ and the fever went on to the thirteenth or fourteenth day~ but i t assumed a mild type.

])R. WALTER S]YIITH said that in Sir Pa t r ick Dun's Hospital this season that peculiari ty existed in every case of typhus~ and he pointed i t out to the class. In the great major i ty of instances i t occurred on either tile seventh or tile ninth day of the fever. In one severe case the temperature loop occurred on the eleventh day, which indicated that the fever would be a long one and of an unfavourable type. There were

352 Transactions of tl~e Medical Society

only two fevers in which this remarkable depression of temperature occurred namely, typhus and measles. In the latter, the temperature, after an initial rise, sank just before the eruption appeared--frequently dropplng to the normal--so that an inexperienced practitioner might think that the patient had merely a feverish cold. But when the erup= tion came out the temperature rose quickly again to a maximum, and then fell with the fading of the rash. In typhus a depression generally occurred on the seventh or ninth day. tn doubtful cases this fact was a matter of interest in regard to diagnosis.

DR. I-IENRY KE~'EDY said it had been observed that in continued fever the crisis commonly occurred on an odd day, such as the seventh or ninth, and very unusually on an even day. The depression of temperature in qucstion had also been more common in some years than in others. IIe had himself recorded a number of cases in which typhus and typhoid fevers were unfortunately mixed, and in these the typl~oid followed the typhus. There had been eases in which the maeulm and the rose spots appeared together, and others in which the maculw~ showed first and the rose, spots afterwards. I t was not uncommon for the tarry discharges to be set down as blood--in fact, it required a good deal of care to be sure that the discharge was bloody. Intestinal ha~morrhage was frequentl.y beneficial. A few years ago the late Dr. IIayden brought forward a number of typhoid cases of a different character, in which the h~emorrhage occurred at the end of t}m first week, and these were aU terrible cases, scarcely one of them having been saved. Dr. I I ayden showed three or four post mortem specimens from those cases at the Pathological Society, and there was no evidence to show that the ha~morrhage, came from any ulceration, but there was evidence of great general congestion. Still, as a general rule, the hsemorrhage was beneficial. Trousseau had drawn attention to the fact that for a long time htemurrhage was looked on as a grave occurrence, but that was questioned by the ]atc Dr. Gra~ces ; and he (Dr. Kennedy) thought he h'dd proved that h~morrhage, whether occurring in typhus or typhoid fever, was not by any means serious. On flxe other hand, he had examined cases in which there was not the slightest trace of ulcera- tion, and in which, nevertheless, the patients had died of hmmorrhage. In one of these cases he examined the body after death, and found a large quantity of blood effused in the i leum--such a quantity as was Snllicient to cause the girl's death, and yet there was no ulceration there. The last point was as to the slow pulse. That had repeatedly come under his notice. He had recorded cases in which the pulse fell to an extra- ordinarily tow degree during the fever. As a general rule it was not of moment, and as the patient got better the pulse rose.

DR. J. W. MOORE, in reply, said that the attempt at crisis at the end of the first week was a well-known phenomenon in typhus. I t might

of the College of Physicians. 353

be remembered that a few years ago he placed on record a series of cases of undoubted typhus, all of which terminated between the seventh and the tenth day. They were not cases of aborted typhus, but of typhus of short duration, in which the early defervescence was complete and final. As to the seven-day period, there was no doubt that in both typhus and typhoid the disease tended to terminate at the end of a week- -whether it was the first, second, third, or fourth week. Dr. Stokes long ago pointed out what he called the " l a w of periodicity," to which acute diseases were apparently subject. He agreed that in typhus there might be hmmorrhage from the bowels; but the cause of the h~cmorrhage in many cases was different from that in t ypho id - - namely, intense hypermmia of the mucous membrane relieving itself by hmmorrhage, which prevented subsequent mischief. The ha~morrhage of the bowels in typhus, and in the later stages of typhoid, was probably due to the dissolution of the blood ; and in typhoid there might also be hmmorrhage from ulceration and erosion of tile vessels. Murchison }lad given ])r. Kennedy credit for his observations as to slow pulse in the pyrexial stages of the fever.

Apparent Recovery fi'om Morbus Addisonii. DR. F1NN~ read a paper entitled, " A Case of Apparen t Recovery

from Morbus Addis6nii." [-It will be found at page 293.]

The patient who was the subject of the disease was introduced and examined by the members present.

DR. NlXO~ observed that there was nothing to make i t certain that the patient had suprarenal disease; nor was it certain that the group of symptoms associated by Addison with the disease named after him was at all associated with disease of the suprarenal capsules. One or two cases had come under his observation in the Mater Misericordi~e Hospital in which the symptoms laid down by Addison were present to a mm-ked degree, and yet afterwards there was a considerable abatement of them. In one remarkable instance, some weeks before admission, the patient vomited his meals two or three times during the day. He had squeezing pains in his abdomen, which shot up into his back ; and what specially brought him to hospital, along with the irr i tabil i ty of his stomach, was that he had noticed a discoloration in his skin seven or eight months before. I t began on the backs of his hands, and at first he tried to wash it off, but could not. When he presented himself at the hospital the discoloration was specially marked under the axill~e, and upon the hates, the prepuce, and the soles of the feet. The skin was dry and harsh, and the pulse 84, vory small, weak, and thready. The sounds of the heart were feeble, and could with difficulty be dis t in- guished. The discoloration of the skin remarkably contrasted with that

2 A

354 Transactions of the Medical Society

white pearly condition of the sclerotics which is so characteristic of Addison's disease. The temperature was subnormal~ being barely 98 ~ The case was looked on as a typical one of morbus Addisonii. The treatment was aimed at meeting the extreme irritability of stomach. After a little time the vomiting ceased. The man was in hospital for two months. The discoloration became less marked, and the man was ultimately able to take walks in the garden and was subsequently discharged, considerably improved. There was pigmentation at the time of his discharge. Three months afterwards he presented himself perfectly well, and there was no trace of pigmentation. When he saw the notice of Dr. Finny 's paper he thought it would be interesting to ascertain whether~ in the case of that patient~ the symptoms returned after the period of abatement. He accordingly wrote to Dr. ~icolls, of l~avan, who had sent the case to him, a~d received a letter from him stating that he saw the patient a week ago, and he was then perfectly well, and had no traces whatever of the symptoms of Addison's disease. If that man had died in hospital~ even without any examination of the suprarenal capsules, every member would have agreed with him in concluding that the case was one of Addison's disease; and he did not know that the circumstance of the patient getting better warranted them in disregarding tlie diagnosis as a mistaken one. Similarly, he did not think that because Dr. Finny 's ease was cured they were not to regard it as the special form of disease described by Addison.

Dl~. WOOD~OFF~, having been called on by Dr. Finny, said that on seeing the patient that evening he did not recognise her at all, so marked was the change for the better since he saw her first.

Dm It~NRY K ~ m D Y said it appeared to liim that they were at present only learning this disease. The number of cases that had occurred since the time of Addison was comparatively small. He con- curred with Dr. :Nixou that it did not follow that because a case recovered it was not Addison's disease. They knew that cases of cancer, phthisis, and fever varied~ particularly as regarded duration~ and he did not see why this should not be true as regarded Addison's disease. Dr. Finny 's case was a comparatively mild one, He did not learn h'om the patient that sh~ had had sickness of stomach at all. The sickness of stomach was an important feature in the great majority of those cases. He had long had the impression that this disease was in some way connected with the strumous diathesis--first, because it was found in the supra- renal bodles~ and~ secondly~ because the vast bulk of the cases that were examined after death showed symptoms of tubercular disease of the lungs.

Dm WALTrn SMITH said the diagnosis of Addison's disease after all amounted to a verbal quarrel. The most conspicuous symptom of the disease was the disturbance of the pigment formation of the skin, and

of the College of Pl~ysicians. 355

the most important symptom was the anemia, with its at tendant train of symptoms. They knew very litt le of the causes of the affection that was called idiopathic pernicious anaemia, and Addison's disease might be looked on as an analogous conditlon~ plus excessive pigmentation. They could not map out the boundaries between idiopathic pernicious anw, mia and ordinary anaemia. I f Addison's disease were the effect of anEcmia, plus pigmentation of the skin from unknown causes, i t would be con- ceded that it was idle to attempt to establish a positive diagnosis of it. I t was at present impossible to decide the question. As to the associa- tion of Addison's disease with struma, the same argument would prove diabetes to be strumous, for a large proportion of those who were afflicted with diabetes died of pulmonary phthisis. The rar i ty of leuco- derma had been spoken of; but i t should be remembered that diseases were often called rare only because well-marked examples of them were rare, the fact being that with symptoms in a minor degree they were common enough. A large share of the population had small n~evi over the body, but i t was rare to see them large enougl~ to at tract the atten- tion of the surgeon.

The C~AIR~A~" mc~tion~l the case of a boy who had discoloration of the skin and debility~ but who recovered under treatment. He was of a strumous habit.

DR. KNOTT said he had tried the experiment of ext i rpat ing the supra- renal capsules in cats, dogs, and rabbits, and very few recovered the operation. There was great pigmentat ioa of the rete mucosum in this c a s e .

D1~. FI~'Y~ in rep~y~ said the observations of most of the speakers confirmed his views, t i e did not, however, quite agree to what Dr. Smith had said about diagnosis. He (Dr. Finny) maintained that where the group of symptoms to which Addison had given a definite name, and which he recognised as a form of anmmia, presented themselves, they were justified in calling the symptoms by that name. In a great many cases of Addison's disease pigmentation of the skin was totally absent, and yet all the other pathological conditions of the disease were found in the patient during life. Agains t the absence of sickness of the stomach he put diarrhoea/which was a marked symptom in some cases of unmistakable Addison's disease~ and was present in his patient.

The Society then adjourned.