PART III.

MEDICAL MISCELLANY.

ReTorts, 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 COLLEGE OF P H Y S I C I A N S .

SESSION 1880-81.

GEORGE JOHNSTON~ M.D., President.

ALEXANDER NIXON MONTGOMERY~ M.K.Q.C.P., Honorary Secretary.

Wednesday, April 6, 1881.

The Vice-President, DR. WALTER G. SMITIt~ in the Chair.

DR. FITZPATRICK having taken the chair,

The VICE-PRESIDENT read a paper entitled "Notes on the Treatment of Diseases of the Skin.!' l i t will be found at p. 395.]

The CHAIRMAN (Dr. Fi tzpatr ick) said ache was a most difficult skin disease to deal with. He had come to the conclusion that it is a disease more or less of a constitutional nature, and that it is a semi-strumous affection. He had noticed that generally one parent (the mother) of the child was healthy and the father strumous. In the early stages, where the patients were about the age of puberty, and in which the disease often passes off without leaving any subsequent trace, local treatment alone would not be proper, part icularly local treatment of a repressive character. He was consulted by a very beautiful girl who had this disease, and he recommended her mother not to allow her to use local applications of an astringent character. The young lady was dissatisfied and went to some one else, and astringent applications were used. He was called in to see her some months afterwards, and found her labouring under phthisis~ of which she died. Therefore i t is only when Dr. Smith speaks of cases of fourteen years' duration that the treatment he recom- mends may be worthy of consideration.

DR. FINNY said his opinion went very much with that expressed by Dr . Smith. He hardly ever employed constitutional treatment. The only exceptions have been where intestinal disease or torpidity of the

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liver has been a concomitant--where the patient has had a coated tongue and constipation, and the functions of tile glands have been slowly per- formed. In those cases great henefit was derived from the use of common saline aperients~ such as Hunyadi J,~nos or Friedrichshall water. His treatment has been local applications of the acid nitrate of mercury carefully applied--a treatment which has answered so well that he never has h~d reason to make any change ; and also an ointment composed of iodide of sulphur (diluted according to the delicacy of the patient's skin), and as the case improves and induration disappears, dusting the face with precipitated sulphur. He had hoped that Dr. Smith would have referred to the troublesome acne rash which follows the administration of bromide of potassium, and would have mentioned the most appropriate treatment. In cases of acne due to this cause he had found the internal administration of arsenic and cod-liver oil useful, together with local applications of precipitated sulphur~ spirits of camphor, and rose-water, twice a day. There is a third form of the disease to which Dr. Smith did not make much referenc% and in .which there are great clusters of congested vessels springing from the larger tuberculated acne spots. In such cases he divided the most prominent veins, and allowed a little bleeding to go on to empty the vessels. As soon as the spot was thus treated a local stimulant application was sUfficient to complete the cure.

DR. HENRY KENNEDY said that in connexion with some of the cases which Dr. Smith had detailed~ he thought that some credit is due to the constitutional treatment that was adopted. Where iodide of potassium was employed with the fumigations it is clear that the two worked together; so that the cases must be interpreted as illustrating constitu- tional as well as local treatment.

DR. R. J. HARVEY remarked that the patient in one of Dr . Smith's acne cases was for a long time known to h im--no t professionally~ but socially. He knew that the lady had been for a long time under treat- ment by various physicians, without having derived any benefit from them ; he thought it only fair to bear his testimony to the eiiicacy of the treatment which Dr. Smith had adopted, l i e considered Mr. Francis Kane's fumigator an exceedingly valuable instrument. He did not think that either Dr. Smith or Mr. Kane meant to suggest that treat- ment by the employment of it was not likely to be very greatly assisted by the use of other remedies at the same time.

The VICE-PRESIDENT (in reply) said he was under the impression that he had conveyed that in common with every physician and surgeon he employed constitutional remedies, and relied mainly on them in his treatment of syphilitic sores. All that can be claimed for the fumi- gation method is that it is a valuable local adjunct to constitutional treatment~ and offers some advantages which are not gained by the ordinary methods in vogue. He might mention that another method

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which he had suggested to his colleagues was the application of calomel to the conjunctiva of the eye. The stream of air from the instrument is so gentle that the instrument might be used with the most sensitive conjunctiva. For some time past he had given up the use of sulphur. Too much care cannot be taken in using the ointment Dr. F inny has referred to, as it leaves marks on the face. I t should be a golden rule, in dealing with ladies, to use eolourless applications for tile face; and iodide of sulphur is far from that. He recognised the utility of what Dr. F inny had said as to the necessity of dividing the vessels. You cannot cause vessels of such size, when they occur, to shrink by internal means. The only method of dealing with them is to divide them with a fine knife. He thought bromic acne hardly came within the scope of his paper.

The ttONORARY SECRETARY read a paper, written by DR. BERNARD, entitled "Diphtheria in Londonderry." l'It wiU be found at p. 402.]

DR. ROBERT M~DONNELL said that he had had an opportunity of examining the lady mentioned in Dr. Bernard's paper yesterday, and he looked on her case as a very marked one of diphtheritic paralysis. The nasal intonation was extremely marked; her soft palate was hanging down, and her vision so much disturbed that she could not attempt to read even large type without the use of very powerful glasses. She requires a very powerful pair of convex spectacles. He also found that without having very marked palsy of the lower limbs her gait was very feeble, and in fact tottering. Even if there were no history of the case except her own account of her having had a sore throat, one could not fail to recognise the case as one of diphtheritic paralysis. He hoped she would recover, but it is too soon to draw a conclusion yet on the subject; her convalescence is only commencing. He had seen a good many cases of diphtheritic paralysis, but he never saw one in which that affection set in so early. I t occurred on the third or fourth day, which is a very unusual thing. In cases he met himself it was much later than that, and it was by no means confined to the ganglionic nerves ahout the face. Dr. Brodie will remember a case he saw some time ago in which a gentleman who had had diphtheria in his family, though not very badly attacked by it himself, got so feeble and suffere~ such ~ marked loss of power in his lower extremities that when he attempted to jump across a small stream he fell into it, and, being unable to get out, lay there until he was nearly perished with cold.

DR. BRODIE remarked that the gentleman got well in a few days under the use of iodide of potassium.

DR. FI~sY said it was a matter of physiological and practical interest to consider the relation between diphtheria and paralysis. Were they to be looked upon as cause and effect, or but exponents of the one

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poison ? Diphtheria is not necessarily followed by paralysis, and~ if it be, the paralysis is not limited to parts supplied by such nerves as pass through ganglia. Of late there have been very few cases of diphtheria in Dublin, so far as he could judge from hospital and private practice, but five or six years ago he saw some severe cases, which were not, however, followed by any paraplegia or other paralytic symptom, while other extremely mild cases of it were followed by those symptoms. From this, as well as from analogy, he was of opinion that the paralysis is not necessarily connected with the extent of the diphtheritic exudation, but is due to blood-poisoning, similarly as paraplegia is seen to follow long typhoid fevers, attacks of diarrh(ea, and other illnesses. The true cause of it probably lies in altered nerve function, due to some dis- turbance of the circulation in the spinal cord or other nerve-centres presiding over the part affected, so that they are in a state of an~emia-- a view which seems confirmed by the absence of all spasm or hyper- ~esthesia~ and by the benefit which follows the treatment by ergot, iron, and strychnia.

Da. DOYLE said a patient of his, a gentleman between sixty and seventy years of age, had been, for the last twenty years suffering more or less from an affection of his throat. His soft palate and the pillars of his fauces were completely covered with a whi te membrane, but not that thick white membrane which is seen in epidemic diphtheria. On removing a portion of the membrane he saw that the surface underneath it was quite raw ; he was also feverish. Under the use of lactic acid spray he has got on wonderfully well. Another gentleman about the same age who had resided next door to him~ died about five years ago of diphtheria. ~ i t h respect to the diagnosis of diphtheria, he had been called in to see cases i n which he found a false membrane partially over one of the tonsils and extending up the soft palate, and the patients did not complain much of sore throat, but only of febrile symptoms.

DR. HE~R:~ KENNEDY said diphtheria~ like other diseases, varies in intensity, and he had seen very different cases in the same families. One child had the white membrane over the throat~ and another had very little of it. l i e thought it a narrow way of looking at the subject to say that a case is not diphtheria because there is not as much white membrane over the throat as has been seen in other cases. The only difference is in the intensity of the disease. With regard to the paralysis, some time ago he saw a very remarkable case~ that of a boy seven years old~ who when asked to put out his tongue was unable to do it, although he knew perfectly ~ell what was said to him, and in the course of 24 hours he was unable to swallow, and in another 24 hours he was dead. He was at a loss a s to the diagnosis of the case, but four or five days afterwards another child who was in the same room with that boy was attacked with diphtheria in a form about which there could be no doubt~

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and then the case was cleared up. Some years ago when scarlatina was very formidable in the city, and it was the practice to blister the large tumours that formed, it was a common thing to see the blistered surface covered with the white membrane that characterlses diphtheria.

DR. FOOT said there is a great deal of confusion as to what real diphtheria is, and on that the difference of opinion depends as to whether it is a common or a rare disease. True diphtheria he believed to be as rare as true cholera and as destructive. Amongst the clinical features of the disease wer~ the tendency of the patient to sink from adynamia or asthenia, from early and unaccountable failure of the heart, an enlarge- ment of the peripheral lymphatic glands, intolerable f~etor of the breath, and the presence of albumen in the urine. The pathological features of true diphtheria are also distinctive. The diphtheritic membrane clips into the submucous tissue, and cannot be withdrawn or detached without causing loss of substance and bleeding, whereas non-diphtheritic exuda- tions are on the surface. I n the true diphtheritic membrane also the impregnation with bacteria is more marked than in the case of other sore throats. Many of the dangerous sloughs that cause fatal ha~morrhage in typhoid fever are diphtheritic sloughs of the mucous membrane of the intestines, and it is because they penetrate to the submucous tissue that they arc so certain to cause hmmorrhage in their detachment.

The following remarks have been since received from DR. BERNARD : - -

" I regret to say that the patient seen by Dr. M'Donnell~ and who was the subject of discussion, died on the 9th of April. Before she left Derry her gait was not feeble nor tottering. The paralytic affection must have increased rapidly during the few days before Dr. M'Donnell's examina- tion. This case proves that when there is any tendency in the paralysis to extend, a very guarded prognosis should be given. There are cases on record in which the paralytic affection set in before the disappearance of the membrane. In the first case the paralysis was entirely confined to the ganglionic branches of the third and facial. Dr. F inny 's ingenious hypothesis as to the cause of the paralysis fails to explain the fact observed by Dr. Jackson-- that the affection has a great preference for the ganglionic branches of the third and facial. I cannot agree with Dr. Foot when he says that true diphtheria is as rare as true cholera. I have never seen, since I left the Crimea, a case of true cholera~ and many cases of true diphtheria have come under my notice."

BLACK URINE IN ACUTE POISONING FROM CHLORATE OF POTASSIUM.

DR. JACOBI showed a sample of characteristically black urin% voided by a patient who had been poisoned by overdoses of chlorate of potassium, at a late meeting of a Medical Society at New York .~N. Y. Med. l~eco~l~ J a n , 1881.