PART IV.

MEDICAL MISCELLANY.

Reports, Transaotions, and Scientific Intelligenoe.

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 I ' I IYS[CIANS.

SESSION 1881-82.

GEORGF. JOHNSTON, M.D., President.

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

Wednesday, April 5, 188~.

J. W. MOORE, M.D., Vice-rres ident , in the Chair.

The late Sir E. .B. Sinclair.

DR. FITZeATRICK said he rose for the purpose of moving a resolution which he was sure would be unanimously a~'eed to by the Society. I t related to the death of Sir Edward Burrowes Sinclair, who had been for many years identitied with the Medical Society, and who was for- merly its Honorary Secretary. l i e (Dr. Fi tzpatr ick) had been acquainted with Sir Edward Sinclair for many years, and knew him to be a man of sterling character, honesty of principle, and straightforward in his views. I f he was sometimes impulsive he was always t rue; and whenever he found he had made a mistake no man was more ready than he to make the amende. His reputation as a practit ioner was well known in the city of Dublin, and there wa~ no need to dilate upon it. A part icular feature of his labours was his teaching of midwives for the army. l i e would move the following resolution : - -

"RESOLVED.--That at this the first meeting of the Medical Society held since the lamented death of Sir Edward B. Sinclair, M.D., who filled the position of Honorary Secretary for two sessions, when this Society was known as the Association of Fellows and Licentiates of the College of Physicians, and who was afterwards appointed a Member of Council, all the time taking an active p a r t in furthering its best interests~ the Society desires to place on record the great loss which the medical pro,

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fession in this city has sustained by his demise, and the members wish to convey to Lady Sinclair their heartfelt sympathy with her and the other members of his family in this their sad hour of trial."

DR. }I~RY K~:~NEDY seconded the vesolutlon. He was a member of the Society at the time when the late Sir Edward Sinclair was its Honorary Secretary, a~d he performed the duties of the office exceedingly well.

The resolution was then passed in solemn silence.

Peculiar Form of Sensory Paralysis. DR. WALTER S.~[~Tr[ exhibited a patient who was suffering from a

peculiar form of sensory paralysis. He came to the Dispensary of Sir Patrick Dan's Hospital complaining of numbness in his left side, and on examining him he (Dr. Smith) discovered some curious phenomena. The numbness or deadness of the left side, he said, came on without any cause about six months ago. He was employed in the Ringsend Bottle Works . There was no motor derangement whatever, but the sensory defect extended over a very large area of the left side. I t was slightly marked in the face, and well marked from the ear to the neck, and over the whole of the left thorax and back down to the hip, beyond which it did not extend, sensation being normal in the thigh and leg. Localisa- tion was good all over the area, the patient being able to localise any impression, l i e could also distinguish between a rough or blunt and a sharp point, but there was a remarkable insensibility to painful impres- sions. A handful of the small hairs of his neck could be plucked out without making him wince, and the skin of the affected area could be twisted until blood was nearly drawn without his feeling it. t ie was also unable to distinguish between cold and boilil~g water. The appli- cation of electricity produced contractions of the pectoral muscle, but even the Faradic wire-brush produced no sensation of pain. The moment, however, the middle line of the breastbone was passed sensa- tions of pain were perceived. • nice question arose under these circum- stances as to the nature of the mode of transmission of the sensations. The stimuli produced a greater reactionary flush on the affected side than on the other side. Reflex movements were unaffected, neither was there any impairment of sensation in the tongue. No observations had been made as to, the com.parat~ve temperatures of the affected and unaffected sides. I t was difficult to refer the affection to any central lesion on account of the area of the disturbance and the absence of all signs of derangement of the nervous system except those described. He (Dr. Smith) had seen cases of limited anaesthesia for which it was difficult to account, but he did not remember to have seen such extensive an~estl~sia before.

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DR. ~'ixo~r said the case was of interest as affording evidence that there must be a special nerve tract for the transmission of painful impressions as distinct from ordinary tactile impressions.

.Peritonitis caused by Caseous Mesenteric Glands.

DR. Nt:~oN.--This case is more interesting on account of the symp- toms of the disease and the course it ran than in respect of its morbid anatomy, which is of a somewhat ordinary kind. A girl, aged thirteen, was admitted into one of the surgical wards of the Mater Misericordi~e Hospital, on the 12th of March, suffering from what was apparently a strumous ulcer, about tile size of a crown piece, in the centre of the sternum. Some years previously she had a scrofulous enlargement of the glands of the neck, which suppurated and discharged for a con- siderable t ime; and then the ulcer formed in the sternum, for the treatment of which she presented herself. Mr. Hayes, the surgeon under whose care she was admitted, told me that shc had no symptom of pulmonary or abdominal disease. Af te r having been sixteen days in the surgical ward she complained, on Monday, the 27th ultimo, of headache. She also had vomiting o f a severe character, and diar- rhoea, and went to bed. On the following (Tuesday) morning her temperature was 104"4 ~ , and her pulse was exceedingly rapid; o n the evening of that day she was transferred to the fever ward. On Thursday morning I saw her, and her condition was then as fol- lows : - -She lay in bed on her side with her legs drawn up; she was stupid and drowsy, and apparently in a condition of collapse. She had a small thready pulse of 114 in the minute; her abdomen was tumid, and everywhere exceedingly tender4 and she had a dry coated tongue, t i e r temperature was 101 ~ On examining the chest I found a distinct basic impulse over the pulmonary artery, which was so remark- able as to attract notice when the chest was exposed. I heard distinct crepitation uudcr the left clavicle. She had vomiting of a very urgent character, the vomited matter being of a grass green colour; and she also had dlarrhcea, the motions being sometimes passed involuntarily. I t seemed to me that the at tack was one of peritonitis, from the sudden way in which it arose; and I was inclined to think that there had been perforation of the intestine. As there were also physical signs of disea.~e in the apex of the left hmg, it seemed natural to conclude that some strumoas or caseous ulceration in the glands of the intestines was going on, and that one of those ulcerations had reached the surface of the peritoneum and set up peritonitis. I treated the case as one of peri- tonitis, and gave her pret ty large doses of opium and creasote to arrest the vomiting, and iced soda-water and brandy to meet her condition of collapse On t h e following F r iday her condition was unaltered as regards temperature and collapse; but the diarrhoea and vomiting had

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ceased, and she had no pain. That night at eleven o'clock I found her moaning, but unconscious, and on the foUowing morning she died. A po,~t mortem showed that there was general peritonitis. The intestines were all matted together ; and there was a considerable quantity of thick purulent matter in the peritoneum which bathed the intestines. The liver still shows evidence of recent peritonitis. I carefully examined the intestines, but beyond what is a very usual condition--namely, localised patches of hypermmia-- I did not find any alteration. The patches of Peyer were unusually well marked, and towards the ileoc~ccal valve some of them presented the appearance known as tile " shaven beard," but I found no ulceration in the intestines. The mesentery is enormously thickened ; and ill tile thickened portion of the peritoneum there are grcatly enlarged mesenteric glands, some of which have under- gone caseation, and some even calcitication. One of these glands had at one point apparently ulcerated through the peritoneum. I think the en- hrgement of the glands of the mesentery and their subsequent caseation resulted in the extension of inflammation to the peritoneum~ where it set up the general peritonitis of which the patient died. On examining tile thoracic organs the left lung was found to present a very good example of fibroid phthisis or cirrhosis of the lung. The lung is con- sidcrably reduced in size ; and a through section of it disc, loses an enor- mous development of tibroid tissue with very well marked bronchiectasis. With regard to the right side of tile heart the ventricle is not dilated, nor are its walls hypertrophied. I should have mentioned that there was a considerable amount of hypermmia of tile interior of tile right lung. The points of interest in the case are the latency of the lung disease and of the abdominal disease having regard to the conditions met with after death. There was a striking analogy between this case and one I saw some months ago in tile hospital~ of a man who was admittcd for a cough, and had no very severe symptoms during a portion of the time that he was in the hospital. Suddenly he complained of extreme dyspncca, and on examining him evidences were found of very extensive tmeumothorax. This condition was so extreme that [ thought it advisable to let out the air in order to relieve hilu. IIowevci% he died ; and on a post mortemwe found a very small caseous nodule-- in fact, it was a case of lobular pneumonia, limited to an area not larger than a small marble. This lay underneath the pleura, which softened and gave way ; and a communication was thus established between the cavity of the pleura and the external air. I think it was exactly in that way that the peritonitis was brought about in the present case. We had the caseous mesenteric gland approaching the surface, probably rupturing the peri- toneuln, and then setting up a fatal peritonitis. On the day before the patient complained of shivering, headache~ vomiting, and diarrhoea ; she had been out in the garden playing about, and had taken her meals as

2 F

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usual. Wi th the exception of the ulcer, which was in the front of her sternum, she was apparently in perfect health.

DIl. W-4LTER SMiTII said that Dr. Nixon's theory of the peritonitis having been caused by perforation produced by an eroding caseous mesent~rlc gland found an analogy in what somethnes~ although rarely, took place in the chest when there was an erosion of the bronchus by a caseous tracheal gland. He had seen a ease of gangrene of the lung caused by the sucking in of a portion of the rotten gland through an ulcerated bronchus. Dr. Gee some years ago recorded a series of such cases in the " St. Bartholomew's Hospital Reports."

D~. lX'ixo~ said the girl got ill on a Monday and was dead on the following Saturday. I l e considered that the occurrence of pus as the result of peritonitis was generally the result of the extrusion of foreign matter into the peritoneum. I f in a case of typhoid fever with peritonitis i t was found after death that there was simply a lymphy exudation into the peritoneum the inference would be that the peritonitis had arisen from an extension of intiammation from contiguity without perforation. But if a quantity of purulent matter was found in tho peritoneum perforation had occurred, and the matter found in the peritoneum was foreign, having passed into the cavity from the intestinal tub% so causing peritonitis.

Acute Diplitheritic .Endocarditis in C]~ronic Valvular Disease.

Dn. NlXO~ said : The specimen which I now exhibit was taken from a patient who had very well marked aortic patency with mitral regurgita- tion. The points of interest in the case are three. First~ the extreme amount of disease involving the segments of the aortic valves. This was probably a case in which acute diphtherit ic endocarditis supervened on a chronic valvular lesion. I t is by no means uncommon in chronic valvular disease of the heart to find the sudden accession of severe symptoms~ including great dyspnoca~ dropsy, and pain, and then for the patient to die in a few days after the distressing symptoms had manifested themselves. The explanation of many of such cases is that acute diphtheritic endocarditis supervened on chronic valvular disease. Another point of interest is that the mode of extension of valvulitls from the posterior segment of the aortic valve to the anterior flap of the mitral valve by contiguity is well shown, Again, the spccimcn presents a good example of acute aneurism of the mitral valve. A n aneurism of small size projects into the auricle. The kidneys present a good example of the amyloid form of Bright 's disease, and the spleen presents a condition with which ] am not familiar, but I think i t corresponds to what is known as the sago spleen~ which is a condition of amyloid disease in which the amyloid matter is deposited in lit t le round nodules, like mil iary tuberculosis of the spleen.

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A Skeleton Respirator for Antise2tlc Inhalation. DR. E. M. COSGRXVE said that this was a respirator to be used in the

inhaling of antiseptic solutions. I t had certain advantages over other respirators. That designed by Dr. Coghill required that tile patient should be taught to inspire through the mouth and expire through the nose, which was often very difficult to do. Dr. Wil l iams' respirator, which covered both mouth and nose, presented some manifest disadvantages. The respirator which he (Dr. Cosgrave) now submitted simply consisted of a l ight cage, the four sides of which were completely open~ so that the air could pass through them. There was a grat ing in front for holding the piece of lint, which was to be saturated with the antiseptic solution. In the first place this respirator prevented the breathing again of foul air. The expired air was diffused from the vicinity of the mouth~ and fresh air was drawn in~ which was a great advantag~ in cases in which the lungs were much affected. Again~ it did not heat the air in the way in which Coghill's respirator did, nor did it cause any oppression of breathing. I t could be used in cases in which Coghill 's respirator could not, because the lat ter interferdd with the breathing~ especially in cases of young persons who had serious lung disease, and who had a nervous dread of anything interfering with their respiration. I t allowed the patient to speak without its being removed, i t was very light~ and the lint had not to be recharged nearly so often as with the other respira- rators. I t was being used at present by several physicians in England ; and he had notes of cases in which i t had been used with success~ especially by Dr. Mackey of Brighton.

The VICE-I~RESIDENT said he was not prepared to admit that the non- heating of the air by the respirator was an unqualified advantage. Another objection was, that in consequence of the sides being unpro- tected very little of the air which was impregnated with the antiseptic solution would enter the mouth.

DR. TWEEDY thought the respirator offered too large an evaporating surface to the antiseptic fluid. The air from the sides would prevent a great deal of the antiseptic vapour from getting into the lungs at all. In Steevens' Hospital the respirator used was Roberts's, which was enclosed at the sides.

DR. DUr-FEY said this apparatus was more an inhaler than a respira- tor, and~ as such~ some of Dr. Cosgrave's arguments in its favour were really objections to it. In antiseptic inhalation i t was an object to obtain inspiration through the mouth and expiration through the nose~ which was a thing that this inhaler did not accomplish. In all cases of consumption occurring in the hospital with which he (Dr. Duffey) was connected he used Roberts's inhaler, the gTeat advantage of which was that it covered the mouth. More recently he had used an inhaler

436 Transactions of the Medical ,Society.

by Dr. Saundby, one of the advantages claimed for which was that the patient could breathe through both mouth and nose, and at the same time expire without difficulty. He had never heard it complained of as heating the air or causing any oppression of breathing. I t also per- mitted the patient to speak. I t was very light, did not require to be often renewed, and was very cheap, costing about 4s. 6d. The substance he used for saturating with the antiseptic fluid was tow or flax, and he found about ten drops of oil of eucalyptus to be sufficient. The great disadvantage of Dr. Cosgrave's instrument was that the atmosphere was not rendered entirely antiseptic by it.

Die. WAI~TF~R S.~IITU said he had grave doubts about the advantage of any of those instruments. Some of them contravened the provision of nature that the nose should be the avenue of respiration; it was anatomically fitted to do two things which respiration did not do--namely, to warm the air and render it moist. IIe thought the principle of all these instruments was radically wrong, and that they should be discon- tinued. In a few cases they might be usefifl.

DR. I)O~'LE said he had used Roberts's respirator in cases which would not tolerate any other. He found it most usefid in the case of a gentle- man who was obliged to sit in a small office in which the air was bad in consequence of smoke.

The VICE-PUESIDENT said an interesting paper was read last year before the Society by the late Dr. Haydcn, in which he discountenanced the use of respirators altogether~ and proved conclusively that anatomy was altogether in favour of breathing through the nostrils. Infants always breathed in this-- the natural way.

DI~. COSORAVE~ in reply, said he should more properly have called the instrument which he had submitted an inhaler. ~No doubt it was some- times an advantage that a respirator should heat the inspired air, but there were other cases in which it was desirable to apply antiseptic vapour to the lungs without heating the air ; where it was desirable to heat the air he thought Coghill's respirator the best. He considered carbolic acid quite a sufficiently strong antiseptic. Lint dropped in a solution of the acid~ in ttle proportion of 1 to 30, was so strong that the patient sometimes found it impossible to continue breathing it. No doubt breathing through the nostrils was the normal process~ but people sometimes did not do it~ and when they were suffering from some affection of the chest ~t was no time to teach them to do so. They would then require some kind of antiseptic respirator in front of thc nose and mouth.

The Society then adjourned.