PART IV.

MEDICAL MISCELLANY.

Reports, Transactions, and Scientific Intelligence.

TRANSACTIONS OF THE MEDICAL SOCIETY OF THE

COLLEGE OF PHYSICIANS.

SESSION 1880-81.

GEORGE JOHNSTON~ M.D., President. ALEXANDER NIXON MONTGOMERY, ]K.K.Q.C.P., Honorary Secretary.

Wednesday, December 1, 1880.

DR. GEORG$ JOHNSTON, President, in the Chair.

The Late Dr. Alfred Hudson. DR. M'CLI~rOCK asked permission to move a resolution of a kind

which afforded him much pain and at the same time some gratification. He felt pain because the occasion of moving the resolution was the death of one with whom he had had an intimate acquaintance for over fifteen years, and to whose kindness and skill he was indebted, he might almost say, for the preservation of his own life on more than one occasion, and who had enjoyed the confidence not merely of his professional brethren, but of the public at large. Having regard to his eminence in his pro- fession, his straightforward, manly and gentlemanllke conduct and prin- ciples, and his liberal openhanded generosity on various occasions, it afforded him (Dr. M~Clintock) a degree of melancholy satisfaction in being permitted to pay a tribute to the memory of one so justly respected and esteemed as was Dr. Alfred Hudson. It would be perhaps out of place there were he to attempt to sketch even the merest outline of his character and abilities, and of the causes that led to his extraordinary success in his profession. He was sure that full justice would be done to his character and his life at no distant day by some one more com- petent than he was to tmdertake such a task. He would content himself by moving the following resointion : ~

"RESOLVED--That this Society desires to record with sincere regret the lamented death of Dr. Alfred Hudson, ex-President of the King and

60 True,suctions of the Medical ,Society

Queen's College of Physicians and of this Society, and Reglus Professor of Medicine in the University of Dublin. At the same time the members of the Society would give expression to their respect for the talents~ the honourable principles~ and the many excellent qualities of their departed confr~re~ who, as a physician, enjoyed the confidence alike of the pro- fession and the public~ and as a high-minded~ cultivated gentleman and generous benefactor, possessed the esteem of all who knew him. That copies of this resolution, together with the warm sympathy of the Society~ be conveyed through our Honorary Secretary to the widow and brother of the deceased gentleman."

DR. J. W. MOORE said he felt much gratification that the privilege had been accorded to him of seconding the resolution. He did so as an old pupil of Dr. Hudson, and as being now connected with the hospital where that distinguished physician had laboured for ten years of his valued life. He (Dr. Moore) never could forget his kindness to the members of the class of that institution, some of whom were at present in the room, and many of whom owed to him much of the success in llfe that they afterwards attained. Dr. Hudson's unvarying kindness was fresh in the memory of every member of the Society.

The PRESlUEI~T said that, in accordance with the usual practice on such occasions~ the resolution should be passed in silence.

Notes era case of Acute Eczema $n'esenting son~e Peculiarities. By J. M . ~ E FII~SY, M.D., Univ. Dubl. ; F.K.Q.C.P.I. i Physician and Dermato- logist to the City of Dublin Hospital.

E C z E ~ is such a very common disease of the skin, and with its protean forms every physician is necessarily so familiar, that to introduce such a theme to this Society as something novel or startling would be, on my part, an act alike of temerity and of inexcusable effrontery.

As~ however~ the following case of acute general eczema~ which shall illustrate any remarks I may make, exhibited some unusual features in the mode and distribution of the eruption~ and as I believe the more freely an interchange of thought and experience among the members of our Society on matters of common interest can be encouraged the more profitable and interesting will our meetings prove, I have deemed the subject not unworthy of short notice : -

Charles W , aged forty-four, married, in comfortable circumstances~ and living a regular life~ came under my care in July last suffering from an attack of eczema of about a month's duration.

The patient is a large, full man, weighing over 13 stone, with a ten- dency to corpulence, falr-halred~ and of a delicate white skin, covered with but little hair. He has always been healthy, and has never bad kidney troubles, gout, rheumatism~ or syphilis. His occupation~that of

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a secdsman~does not expose him to any of the usual causes, which, when acting as irritants on a delicate skin, may induce local eczema.

His own account of his present attack was as follows : - -Six weeks before he came under my care he had been suddenly attacked while iu his ordinary health with rigors. He became so ill as to necessitate his being confined to bed for a couple of days, and for four days he did not feel quite himself. The febrile attack was unaccompanied by vomiting, dorsal pain, sore throat, or any eruption, and it disappeared by profuse perspiration. A fortnight after this attack, which was presumably one of simple continued fever, the eczema made its appearance in his ears, face, and scalp. A friend of his, who had been a former patient of mine, and who had derived the greatest benefit from the use of phosphorus in chronic eczema of the hands, reeognising the diseas% recommended Charles W. to take a course of phosphorus, and suggested Kirby's pill No. IX.

As might be expected, after a treatment not suitable to every case of eczema, instead of improvement the opposite was the result, and, like all other folk who greedily avail themselves of remedies when suggested by a non-professional person, and who, when the expected benefit has not shown itself, invariably blame their advisers to the exclusion of their own credulity~ my patient remarked to me his belief that the phosphorus did him no good, but that it drove out the disease, and made the eruption more profuse and universal.

The following was his condition when first seen on the 10th July : - The whole hairy scalp was swollen and red, and thickly covered with minute small vesiculo-pustules, mostly discrete. There was an absence of exudation, and, consequently, of the matting of the hair, so usual in eczema attacking this part. On combing or scratching, a number of minute branny scales were shed. The ears were greatly involved, and stood out from the head, thick, rigid, and with the skin covering them so stretched by subjacent infiltration as to be immovable. They were covered, especially along the helix and over the lobule with immense numbers of minute vesicles, which exuded a very viscid, yellowish, gum- like fluid, in parts forming drops and in parts yellowish crusts, between which were several cracks or fissures. The skin of the backs of the ears and the adjoining portions of the neck were also red and oozing, while the rest of the neck was of a deep red colour, but unassociated with either exudation or squamation.

The face was, comparatively speaking, but slightly affected, and the eruption did not present the characters so commonly seen in eczema faciei of the impetiginous or pustular type. In place of the yellow or olive coloured honey-like masses (~' melitagra" and '~ crusta lactea" of authors), it was unaccompanied with any kind of exudation whatever, and in this respect contrasted strongly with the eruption of the ears.

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The lower half of the face entirely escaped, and of the upper half only the forehead and eyelids were engaged, although the whole face was puffed and fuller looking than natural. The eyelids were covered with very minute scales, and puffy~ though differing from ordinary mdema~ and presented none of the glazy, shining surface produced by extreme tension. The forehead close to the scalp was red and squamous, but elsewhere was mapped out with macul~e of a blulsh-red colour of the size of sixpence. These discoloured spots did not disappear on pre~sure~ nor were they raised or coloured with vesicles or scales.

On the trunk spots of a similar character~ but of a larger slze~ equal to that of half-a-crown~ were to be seen below the breasts and over the hypochondria~ preserving roughly the symmetry which obtains in eczema. .4. few similar spots, the size of a shilling, were also met with on the upper part of the thigh. These discolorations in some places were uniform~ and in others they were bluish-red at the outer edges, where insensibly the natural flesh tint was resmmed~ while their centre was more distinctly red, owing to a number of small reddish papules crowded together. Though I searched very carefully, both at the first visit and subseqently~ I never detected a vesicle nor the slightest exudation. When pinched up the skin was indurated~ and later on in the course of the disease it was covered in these spots with squam~e of a branny nature. The hands also were attacked, the eruption being confined to the backs of the wrists and fingers~ the palms being free. As is usual in eczema digitorum the vesicles were extremely minute~ and the affected parts unaltered in colour.

The patient made considerable complaint of the tingling and itching of the hands and scalp. His tongue was indented and covered with pro- minent red papilla~ at the tip. Though neither a drinker nor smoker there was follicular pharyngitis. The urine was scanty~ but free from albumen.

The progress of the case was shortly this :--Seen after a week's treat- ment there was little or no improvement to be noted except of the scalp and hands. On July 24th the face was reported improved~ the staining much less marked ; but on the trunk the spots have become much larger~ and where two adjoining patches united~ large areas of two square inches were seen; and several new discolorations have appeared over the thighs and legs ; no change~ except slight scaliness~ being noted on the older spots. Special interest lay in the hands and fingers. Here the eczema seemed completely cured, and now desquamation of a character, very unusual in eczema, was taking place. Along the ulnar edge of the palm the epidermic scales stood out semi-detached, while over the palmy fingers, dorsum, and wrists~ the cuticle was raised in little circular spots, whence it could be peeled off in fra~o~nents of quarter to half an inch in size, leaving under it healthy skin of a normal colour. These scales~ so

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far as could be judged without the microscope, were epidermic, and were not either crusts or scabs. I t should be remembered that the palms had not been attacked by eczema. The dcsquamation was completed in five or six days.

From this date improvement became still more marked and rapid, and on 14th August the only evidence of the disease was a slight thickness and roughness of the ears and the stains on the legs. The patient re- rosined under observation for another month without any relapse, and when seen on September 18th, nothing abnormal was to be discovered, except a deep bluish-red, painless, smooth stain about the internal mal- leolus of either foot.

The treatment consisted in regulating the diet so as to avoid all alcoholic and fermented drinks and the excess of animal food, and in calling the kidneys into action. The medicinal treatment was both local and constitutional. The latter included a combination of iodide of potassium in 3-5 grain doses, liquor arsenicalis 5 lrt, with alkalies and colchicum in infusion of juniper. This mixture was steadily persevered in for over a month, and then, with the exception of the iodide (which, owing to its producing a troublesome ache-form rash, was withdrawn) it was taken for another month. I t agreed well, improving the general tone and imparting vigour. The local treatment found to answer best for the scalp was a linctus of equal parts of olive oil, glycerine of borax, and glycerine of tannin. This was continued for some weeks, and then the last vestige of the disease was removed by the ung. hydrarg, ammoniat.

Oleate of zinc and vaseline, in the proportion of two parts to one, with a few minims of chloroform added, so long as itching was a pro- minent symptom~ following on an ointment of nitrat, bismuthi (5 j. ad.

j. vaselini), was the only application used for the ears, face, hands, &c., and to the oleate of zinc I attributed the best results. I t is a preparation which I have extensively used, and always with the happiest consequences.

Warm size-baths once or twice a week, in which the patient lay at full length for an hour at a time, gave great relief in allaying the terrible tingling and itching which attended the disease in its earlier stages.

Remarks.--The foregoing case presents, I consider, some features of interest, and suggests one or two questions not perhaps readily answer- able. Was the initial rigor, which preceded by a fortnight the appearance of the ert~ption, the beginning of the eczema (as the patient imagined), or did it stand in the position of an exciting cause, or was the febrienla but a coincidence ? From the analogy of eczema being so frequently developed (not produced) in scrofulous children by the slight febrile dis- turbance attendant on vaccination, I consider the attack of simple con- tinued fever acted in this case as a predisponent and exciting cause of the eczema by its general depressant effect, and by the determination to the skin which the diaphoresis induced.

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Again. what produced the desquamation of the hands which occurred six weeks after the first appearance of the eruption and a fortnight 's treatment ? Was it due entirely to the local eruption, to the initial fever of eight weeks ago, or to both causes ? Here I confess I can suggest no satisfactory solution, for it was unlike the scaliness which occurs in several varieties of eczema, and i t was not limited to the parts attacked. I t exactly resembled the desquamation following a mild case of scarlet fever. I t occurred to m% and it may perhaps occur to some, that it was a variety of pityriasis rubra (dermatitis exfoliativa), but i t had no features in common with that disease ; and as I had a case of that rare complaint under my care at that very time in hospital~ [ was the better enabled to note the points of difference.

Another peculiar feature of this case to which I would direct attention was the manner in which the eruption appeared on the trunk and lower extremities, and the unusual appearance and characters i t presented in these localities. I t is very nncommon~ at least I have found it so-- (1) to see eczema first attack these parts of the body in Patches of the size of half to two inches in diameter ; to notice (2) these patches to come out in regular order~ beginning above and extending down to the ankle ; and to note lastly, that the eruption~ so prominently vesicular in other places, should at no time ever reach the stage of vesiculation. They were, in truth, infiltrated inflammations of the skin followed by slight squamation, resembling in appearance, and yet differing in.character from~ erythema~ and exemplified the truth of the observation of Dr. Livelng, that in the diagnosis of eczema it is necessary to bear in mind not only the different forms assumed by the disease in its various stages of development, but also that i t may be arrested in its p ro~ess at any one of its stages without passing through all its usual phases, and that it may abort at a very early period.

As there can, in my opinion, be no reasonable doubt of the correctness of the diagnosis that the patient was suffering from but one disease, and that disease was eczema of an acute or subacute form, so must we fain view the unusual course and anomalous appearances it presented as but fresh evidences of the polymorphism assumed by this troublesome and common disease.

DR. WALTZR SMITH observed that tile diagnosis in the case was beyond question. The co-existence of the dry, scaly patches on the trunk with the vesicular form of eczema elsewhere on the body was far from rare, and was only to be expected from the natural history of the disease. I t was the exception in cases of eczema affecting the head~ neck, ears, and arms not to find some dry erythematous and psoriasis- looking patches on the body. Dr. F inny had adverted to the circum- stance of desquamation on the palms of the hands, although there were

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no inflammatory appearances. That was a very common condition when eczema attacked the backs of the hands ; it was quite common to find a scaly, brann~r desquamation on the front of the hands, but on looking carefully they would see a distinct pink redness underneath the surface. The explanation was that there was a thick skin on the hand, and when there was inflammation affecting i t only two effects were p r o d u c e d ~ namely, a slight redness which might escape notice, and such an altera- tion in the nutrition of the epidermis that i t would be thrown off in scales, but the disease was the same. I t was analogous to what occurred in smallpox, where the pustules and vesicles on the palms of the hands were in the early stage of the disease almost concealed from view by the thick epidermis, especially if the patient happened to have a horny hand. He would suggest to Dr. F inny to t ry the hydropathie treatment or " w e t pack" with the next case which presented itself. He (Dr. Smith) had found it very useful and effectual in dispersing the eruption.

DR. HE~R~" KENNEDY said there was a therapeutic point in the case which deserved more attention than it had received. Where arsenic or phosphorus was given for the disease it was by no means uncommon to find that the first result was to make the disease worse. That was an almost certain indication that the disease was under control. The treatment might afterwards be modified and the dose limited. Another point which had been alluded to was the desquamation on the hands where there was supposed to be no eczematous disease. He had seen epidemics of fever in which desqaamation occurred quite commonly, just as in scarlatina. In the present case he thought the fever which the patient had explained the desquamation on the hands. I f there had been any disease such as Dr. Smith supposed existing on the palms of the hands it would have been seen by the author of the paper, whereas he expressly stated that the skin seemed to be perfectly healthy.

DR. HARYE~" asked at what period the desquamation on the palms of the hands was noticed ?

Dm FiNNr, in reply, stated that the desquamation was not noticed until eight weeks after the initial rigor and five weeks from the begin- ning of the eczema. Dr. Kennedy had answered Dr. Smith by saying that there was no disease in the palms of the hands. He (Dr. Finny) was familiar with eczema on the backs of the wrist and of the fingers, where it was not always easily recognised, and entirely consisted of scaliness. There was no disease on this man's palms, or even on the tips of his fingers where eczema digitorum was often first seen. I t was not until the fourteenth day of treatment that the general desquamation of the backs of the fingers, wrists, and palms of the hands occurred, and in the latter place pieces of epidermis of all sizes came off. Dr. Kennedy's explanation of the case came nearest to his own. In cases where the hands were treated with long immersion in water, what

F

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occurred might be understood~ but nothing was applied to the palms of the hands which could have induced the appearances. The wet pack was not unfamiliar to him; he considered it to be a most valuable remedy in the dry form, which occurred chiefly on the wrists and hands~ but he did not think it would have suited this cas% where there was no infiltration or thickening~ and the disease responded well to the treat- ment given. Dr. Smith had not quite taken up what he had said as to the patches on the trunk and limbs. They were a t no time scaly or psoriasis-like~ and but very slightly branny, and aV the end they were perfectly smooth and shining. I t had struck him as unusual that when the rest of the body was. improving these should have come on and extended from above downwards. He considered that they were all parts of the eczema~ and he was of tile opinion expressed by Liveing that the disease in these situations was abortive.

Enteric Fever in South-eastern Africa. SURGEON-I~AJOR JACKSON read a paper on "Enter ic Fever and its

]~iodifications by Malaria in South Eastern Africa." l i t will be found at page 17.]

DR. HENRY K S ~ D Y observed that where a disease like typhoid could be modified in so marked a.manner by malarial poison, it showed what need they had for caution in dealing with such diseases. In diagnosing typhoid fever~ he would be sorry to be guided, altogether by thermometry. He would look mere to the general symptoms--the existenoe of spots~ the prevalence of diarrhoea~ and so on. I f the thermometer marked only 98"9 ~ he certainly would not, therefore~ conclude that the case was not typhoid. The bodily temperature~ as indicated by the thermometer~ was as liable to mislead as any other single symptom of the disease. Ar military medical gentleman~ Surgeon-Major Gordon, had lately published in the Medical Pre~s and Cirvular a series of most valuable cases showing the extraordinary phases through which typhoid fever passed in India. The fact mentioned by Surgeon-Major Jackson of tha spread of the disease to the lower animals was very interesting. He (Dr. Kennedy) recollected reading~ in reference to an outbreak of cholera in India, that every living animal seemed to be affected by it, various domestic animals being killed.

DR. FINN~" said that Surgeon-Major Jackson's remark as to the long persistence of the remittent taint in the system was particularly deserving of consideration. He believed in the identity of remittent and inter- mittent fever. The late Dr. Stokes laid it down that once a man got intermittent fever it followed him through the whole course of his life and modified any other illness that he got. Some months ago they had an old soldier in the City of Dublin Hospital for aneurism. Ten years previously he had got an attack of ague in India ; and after he had been

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two months in hospital the ague attacked him again, and ran his pulse up from 74 to 126, with imminent danger to the aneurismal sac. H e did not think the thermometer ought to be tabooed in enteric fever. He believed, on the contrary, that no indication of that disease was so valu- able as that afforded by the thermometer. The pulse in enteric fever was fallacious, and gave very little help, while the temperature gave very great help, but the reverse was the case in pneumonie fever. H e did not say that the temperature was the best guide in all cases of enteric fever, but in ordinary cases it was the best guide, and showed whether the patient was really recovering or a relapse was Coming on.

SURGeON-MAJOR JACKSON, in reply, said : Dr. F inny must allow him to differ with him on one" polntmnamely, as to intermittent fever and remittent fever being subdivisions of the same disease. He had seen a great deal of intermittent fever, and he had not seen a single case of remittent fever terminating in it. In remittent fever the liver and the pylorlc viscera were chiefly affected, whereas the spleen chiefly suffered in the intermittent type. Quinine was a specific for intermittent, but not at all for remittent fever.

JBrief Note on Typhuz Fever in Graves' Disease. By ARTHUR W'YNNE FOOT, M . D , Univ. Dubl. ; :Physician to the Meath Hospital.

GRAVES' disease has been not inaptly described as a pseudo-pyrexia, principally on account of the habitual rapidi ty of the pulse. This is owing to the fact that before the development of thermometrical mea- surements the rapidity of the pulse was especially relied on in the study of fever. Now, however, since increased temperature of the body is a necessary symptom of fever--s ince it is held that where i t is absent fever does not ex i s t - - the rapidity of the pulse has assumed a subordinate position in the estimate of fever.

The patient to whom this note refers had been nine weeks and four days in hospital for exophthalmic goitre, and had very much improved--- in fact, arrangements for her return home were being made- -when she contracted typhus.

On Fr iday, 15th of October, 1880, she had a headache and could not eat. In the afternoon of the same day she got a rigor, which continued through the night, and was attendeJ with ;t rise of temperature from 98 ~ to 104 ~ Fahr. , and an increase in the rate of her pulse. Her pulse had hitherto presented the increased rate noticed in Graves' disease. 101 observations had been made on i t before the invasion of the fever, and its mean average rate had been determined to be 129. On this evening (15th) it rose to 145. On the sixth day after the initial r igor a copious typhus rash made its appearance on the trunk~ with a morning temperature of 105 ~ Fahr .

On the evening and night of the ninth day she was delirious, and

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frequently got out of bed and sat over the fire, when she presented a strange and start l ing appearance, her incoherent ravings and delirious excitement heightening the effect produced by her large, rolling eyes and dishevelled hair. On the tenth day she suffered greatly from dysphag ia - - in fact, the nurse thought she would be choked. This seemed to arise more from acute congestion of the thyroid gland than from nervous dis- turbance of the muscles of deglutition. The pulse at this time ranged from 164 to 180. She was given draughts every two hours containing drachm doses of tincture of digitalis, after several of which the difficulty of swallowing was much diminished--according to the nurse's opinion " t h e draughts saved her l i fe" - -and she was able to get down a fair share of nour i shment - -v iz , four ounces of whisky and two eggs made with milk into ten ounces of egg-flip~ a pint of beef-tea, and three pints of milk. These full doses of digitalis, however, did not lessen the rapidi ty of the heart 's action or improve the character of the radial pulse, which was so flickering and uncertain that, on this account, and, owing to the subsultus tendinum, the rate of the circulation was habitually estimated at the heart with the stethoscope, instead of at the wrist. A t 11 p.m. on the eleventh day she had an at tack of convulsions for ten minutes, and similar attacks recurred every half hour till her death in the forenoon of the following day. Her death took place in the early part of the twelfth day.

The digitalis draughts had been discontinued twenty-four hours before the convulsions came on, and she was not taking them at the time.

Subjoined is a tabular statement of the temperature and pulse~ from which i t may be seen that the average morning temp. was 103-6 ~ F. ; the average evening temp., 104"3 ~ F . ; the mean average daily temp. (twenty-six observations) was 104 ~ F. The average rate of the pulse in the forenoon was 138; in the afternoon, 132; and the mean average daily rate (twenty-five observations) was 135 : - -

Day

1 2 3 4 5 6 7 8 9

10 11 12

Temperature

M. E.

O o

98 104 101"2 104 103 104 103 104"6 104"6 104"8 105 104"8 105"1 105 105 105"2 103"5 104"1 103'3 104 103"2 103"6

Pulse

M. E.

120 ]45 134 120 114 116 120 135 128 113 125 13~ 133 134 140 150 140 160 164 180 180 102