PART IV.

MEDICAL MISCELLANY.

Reports, Transactions, and Scientific Intelligence.

T R A N S A C T I O N S O F T H E M E D I C A L S O C I E T Y OF T H E C O L L E G E O F P H Y S I C I A N S .

SAMUEL GORDON, M . B , President.

GEORGE F. DOFFEr, M.D., Honorary Secretary.

Wednesday, April 12, 1876.

DR. GORDO~ President, in the Chair.

The adjourned discussion on Dr. Hayden's paper on "B i l i a ry Colic" was resumed.

DR. HAYDEN said the points he was desirous of having discussed by the Society were the possibility of confounding some cases of biliary colic with ordinary colic, with gastralgia~ and even with abdominal aneurism~ and also the best mode of treatment. The best remedies for the pain he had found to be the warm bath and hypodermic injections of morphia. I t was very desirable to have free action of the bowels. Wi th respect to preventing the returns of the paroxysm of pain, diet and exereise~ he thought~ formed the best means of averting them. ~ o doubt~ as long as calculi remained they should come away.

DR. GRIMSHAW said that since he had heard Dr. Hayden's able paper he had had an opportunity of applying some of the information which he had derived from it in a case under his notice which had been diagnosed as one of gastralgia. Dr. Hayden's remarks threw a good deal of light on the case and assisted him much in arriving at a diagnosis of biliary colic~ although he did not get a calculus, more rapidly than he otherwise would have done.

DR. HENRY KENNEDY had observed that hydatid cysts of the liver exhibited similar symptoms to those produced by gall stones. He alluded to the case of a girl twenty-five years of age, apparently in

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robust health, who was attacked with violent pain in the right hypo- chondrium, accompanied with very severe fever and constant vomiting. After a few hours a tumour appeared. The symptoms were exceedingly severe, and did not yield to treatment. She died at the end of thir ty- six hours. On post mortem examination a very ragged b~]iary calculus was found impacted in the duct with surrounding localised peri- tonitis. The diagnosis of biliary calculi was not a simple matter. In a considerable number of cases most of the symptoms of biliary cal- culus presented themselves, but no calculi came away. He had re- peatedly examined the bodies of persons who during life had expe- rienced no pain or other symptoms of calculi, and had found the gall bladders quite full of calculi. I t was only when a calculus got into one of the ducts that suffering occurred.

The PRESIDenT said that bil iary colic might be mistaken for cholera. Some time ago he was called on to see a lady who, he was told, had been suffering from a sudden attack of cholera, but on examining her he had no doubt that it was biliary colic. She suffered from extreme and continuous vomiting, coldness of surface and collapse, which would have led some to suppose that she was suffering from cholera. The intermissions of pain and collapse were very marked, the recoveries from collapse being followed by attacks of intense pain, and these again being succeeded by collapse. Dar ing the attacks of pai~, which were very agonising, he administered chloroform pretty freely, and at length with perfect success. He concluded that while she was under the influence of chloro- form the spasms subsided, and at length the calculus passed through. He administered the chloroform four different times, as fast as she came out of the collapse, and it proved most successful. He did this in con- sequence of having been told by Sir D. Corrlgan that a few nights before he was called on suddenly to see a nobleman who was suffering from intense bi l iary colic, accompanied with agonising pain and vomiting~ but no collapse, and that the administration of chloroform completely relieved him.

Dl~. GRIMSHAW read a paper on ~' An Outbreak of Small-pox." l i t will be found at page 405~ in the number of this Journal for May.]

The CnAInMA~ (Dr. Hayden~ Vice-President) observed that those who had seen epidemics, both of cerebro-spinal meningitis and of small-pox, must have observed the resemblance between the form of small-pox in which there was discoloration of the skin without pustulation and cerebro-spinal meningitis.

DR. HaNR~" KENN~Dr observed that in cases of cerebro-spinal menin- gitis with purpuric spots, the suffering was far greater than ever he had

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seen in any case of small-pox. In the former disease the pain was generally referred to the nape of the neck, whereas in small-pox it was for the most part referred to the lumbar regions. There might be head- ache in cerebro spinal meningitis~ but it was not of a violent character. Many of the symptoms were certainly the same, but he was not aware that there was the suffering in the limbs in small-pox which frequently occurred in cerebro-spinal meningitis.

The CHAIRMAN said he quite agreed with Dr. Kennedy. He never saw a case of cerebro-spinal meningitis unattended by pains in the calves of the legs, and he should make a presumptive diagnosis from the presence of that symptom alone. Dr. Kennedy was also right in saying that there was greater suffering in cerebro-spinal meningitis than in small-pox. In the latter disease there was more or less apathy and prostration~ while in the former there was moaning~ and pain in various parts of the body.

DR. J . W. ~IOORE said that the paper read by Dr. Grimshaw afforded a striking example of how much might be done by an intelligent observer in investigating an outbreak of zymotic disease. I t was clear that if the isolated cases he had mentioned had occurred in some country district a serious epidemic of small-pox might have been the result. Fortunately, they had occurred in Dublin, and were closely and accurately observed. In Dr. Grimshaw's inquiry into the facts bearing on this localized out- break~ they had in Ireland for the first time an example of that pains- taking investigation of outbreaks of disease which had so signally crowned with success the labours of their brethren in England during many years. He could not but hope for great things from this. I f they had a few men like Dr. Grimshaw working in this country for the elucidation of such outbreaks of disease, there would be an opening in future for preventiv% as well as for clinical, medicine in Ireland.

Af ter some remarks from SURGEON-MAJOR GORE and Da. J. A. ]~YRNE~

DI~. GRI~SHAW~ in reply~ said the point of interest was the question of diagnosis between malignant purpuric small-pox and meningitis. He was unable to decide on the symptoms that distinguished these diseases. No doubt severe pains in the limbs were a usual characteristic of menin- gitis. On the other hand, he had met a considerable number of cases of meningitis in which those pains were not more significant than the ordinary pains of acute febrile disease, and those were the very cases in which black spots were present. Unfortunately, for some reason or other not known, but noticed by every writer on epidemics of cerebro-spinal meningitis, they had had a large number of cases of an extremely

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malignant character amongst the Constabulary at Phoenix Park. Between fifty and sixty cases of cerebro-splnM meningitis occurred amongst those men; some of them were affected with purpuric spots~ and in these cases the suffering was much less than where there were no spots at all. He accounted for this by the excessive depression which affected the patients at the onset of the disease. They were struck down and became insensible almost at once. Possibly the pains might have been present while the patients were too prostrated by the disease to express suffering~ but certainly the suffering was not so great~ according to his experience~ in the black cases of meningitis as in the cases where there were no black spots. The man who came from America complained of general pains, such as were met with in cases of acute febrile diseases. He had nothing marked, except intense pain in the back~ of which he complained very much. As to the spots them- selves, they were raised in both diseases. They had a peculiar shotty feel under the fingers, and the only difference between them in the two cases was as to the site they occupied on the body. In meningitSs the shotty spots--not the large black patches--appeared first, and were more common on the legs than anywhere else. In the case he had mentioned the spots were both on the legs and on other parts of the bady~ but were more thickly spread on the legs than anywhere else ; whereas in menin- gitis the shotty spots seldom appeared there unti~ late ~n the disease, although that part was occupied by large purpuric spots. For his part, he would not be satisfied to ~aake a diagnosis, either from the position of the spots or from the nature of the pains. The spots themselves~ he thought~ did not differ at all from each other in the two diseases~ as far as the naked eye or touch could discern. With resp6et to the observa- tions of Dr. Moore on the preventive question~ the care with which the case alluded to was foUowed up in Liverpool struck him as very remark- able. The records of every lodging-house were examined~ in order to find whether a small-pox case had appeared in any one of them~ and also the records of every ship that entered the port within the period of incubation. Such a thing~ he need not say, would be impossible in this city. I t turned out afterwards that the man, as Dr. Trench supposed, had not slept in :Liverpool, but had come to Dublin the evening of his arrival in :England. Another point on the preventive question was the relation between the means of modern transit and the spread of epidemic diseases. Here the man left America, and carried the disease right to Dublin, without contaminating any one on the way. He could not con- taminate any one on the way, for he did not develop the disease until he reached Dublin~ though, no doubt~ he contracted it either in New York or Brooklyn. Out of forty-nine cases of purpuric small-pox in the hospital~ seven recovered. I t was a rare thing for such cases to recover, but he had since read in The Medical Record notices of other cases of that

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description having recovered. Still their recovery was so rare that Dr. Collie, when speaking to him about them, said he had never had a case of that kind which recovered. He had heard, however, of other recoveries in the Mater Misericordim Hospital and in the Hardwicke Hospltal~ so that they had had a considerable number of recoveries in Dublin. But Dr. Collie told him that all the hospital cases of purpuric small-pox under his care died.

DR. CHURCHILL read a paper by Dr. King Kerr~ entitled "Notes on some Epidemics in the District of Coagh, in the Count~r of Tyrone." [-It appeared in the number of the Journal for May~ at page 442.]

DR. Gm~sr~xw moved that the thanks of the Society be given to Dr. Kerr for his paper. He trusted that other gentlemen who made com- munications to the Society would not consider themselves slighted by this vote, but it was very important that gentlemen practising in remote parts of the country should be encouraged to send papers to the Society. Reports of local outbreaks of disease were instructive in many ways. The type of scarlatina referred to by Dr. Kerr appeared to be one of extreme malignancy. The conditions under which the people lived was a matter of great importance, as was exemplified during the recent scarlatina epidemic in D'ablin. No doubt Dr. Kerr was right in attri- buting much of the fatality of the outbreak in his district to the bad sanitary condition of the village and the extensive use of whiskey among the patients and their friends. Pec~pl% no doubt, might live a long time under unhealthy conditions without an outbreak of typhoid fever, but it was not the less probable that an outbreak of that disease would, owing to those conditions, eventually take place. The poisoning of wells and the soakage of the earth by sewage matter, which was a principal source of typhoid affection, took a considerable time. Gravelly soils were very soon contaminated. In Coagh the surface of the ground was formed of boulder clay, which would protect the water for a considerable time. He hoped shortly to bring the subject of the difference of soil-surfaces in Dublin before the Society. A large portion of Dublin stood on boulder clay without gravel, and another portion of it on the same description of clay with gravel, and he believed this led to a considerable difference in the mortality in diarrhoea and cases of fever, cholera, and other epidemics in those respective portions of the city.

Dry. MAcSwlNEY seconded the motion, which was unanimously agreed to.

The Society then adjourned.

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Wednesday, May 10, 1876.

DR. GORDON~ President, in the Chair.

DR. GmMSHAW read a paper on a " Case of Malignant :Purpuric Fever." l i t will be found at p. 520.]

The CHAIRMAN remarked that the case was an extremely interesting one. In some of these cases the cerebro-spinal symptoms appeared first~ and then the purpuric eruption; while in others the purpuric eruption appeared first~ and the cerebro-spinal symptoms ensued, and showed the true nature of the case.

DR. HENRY KENNEDY said a curious point in the case just submitted to them was that the temperature should have remained for several days so low. That might have been partly due to general nervous depression. The form of the eruption, the pains, and the temperature kept hand-in- hand. In most of the cases that he had seen the temperature was above the healthy standard. Some years ago he felt inclined to tres this disease more actively than Dr. Grimshaw stated he had done, and he had had no reason to alter his opinion since. Dr. Grimshaw was, no doubt, well advised in administering the bromide and the iodide of potassium, but he was in favour of a more arttiph)ogistical treatment. He never hesitated to apply leeches to the spine, and to give calomel and opium. Whenever the disease came under the influence of calomel he generally thought the patient perfectly safe. I t would have been very interesting to know the state of the intestinal tract. He had seen some cases of epidemic fever.in which the pains were as bad as ever he had seen them in cerebro-spinal arachnitisr although those pains afterwards passed away.

DR. GRIMS~AW said he had used very active treatment in eases of cerebro-spinal meningitis, but where purpuric symptoms presented them- selves along with the other conditions he was not inclined to use mercury or leeches. He had seen a good deal of disease of the purpuric type in Steevens' Hospital, and he had found that stimulants and agents such as turpentine were the most beneficial. Iodide of potassium had also proved a useful remedy. He did not say that mercury might not be usefully employed in many cases where there were no purpuric symptoms, and the depression was not great, but he should not like to use it in such a case as he had described. He believed that if he could have examined the intestines in the case reported he would have found congestion. In other cases of the sort he had found congestion not only of the intestines, but of all the abdominal viscera. He had never met with such obstinate diarrhoea as presented itself in the present case. Lymph was effused on the cord, but not in such great manses as he had seen in other cases ; nor

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was there any very considerable diffusion of the fluid. There was very active congestion in the anterior portion of the cord, and the lymph that existed was all below the middle of it. The case was like one which he lately submitted to the Society, ~ in which one of the symptoms of cerebro- spinal meningitis was chiefly manifested in the upper part of the cord.

SURGEON-~IAJOR GORE read a paper on " A Case of Typhoid Fever." l i t will be found at p. 513.]

Dm FINNY observed that no proof had been given that the woman caught the enteric fever from the patient she attended. She had been living for four days with her, and might have got the disease from the same cause that gave it to her patient. Unless it were shown that Mrs. S. did not drink impure water, or that she was not exposed to effluvia or other emanations, such as were usually believed to produce enteric fever, the case of contagion would not be made out. As to the tubercular stage, he thought that what had been stated about that had not been made out either, as it did not appear whether she had suffered from tuberculosis or not. The woman was still alive, and, therefore, was presumably better. That she had had degeneration of the apices of the lungs was plain enough.

:DR. FOOT said the well reported and accurately observed case which they had heard~ bore out the views which had been expressed by Dr. I t . Kennedy as to the connexion between enteric fever and struma. By adopting the middle term ~ struma~" they steered clear of tuberculosis. The case had been described as one in which there were evidences of a strumous constitution, and the occurrence in the patient of enteric fever bore out the observations of Dr. Kennedy. From his observation of post mortem examinations~ he had found that in nearly all the acute cases of enteric fever terminating in perforation the patients were persons of eminently strumous constitutions. He was sure that Surgeon-Major Gore, although he spoke of tubercular phthisis, meant what was com- monly known as strumous phthisis. He (Dr. Foot) did not~ of course, say that enteric fever was confined to persons of strumous constitution. He agreed with Dr. F inny as to the difficulty in tracing the origin of enteric fever.

DR. HENRY KENNEDY said he was glad to find that Dr. Foot bore out the views he put forward in a paper read seven years ago before the Society, in which he pointed out the close connexion that existed between typhoid fever and tuberculosis. Since that time he had seen cases of tubercle in which that disease was lulled by treatment, and in a year or two afterwards the patients, who bore evidence of struma, such as

Dubl. Journ. of Med. Science. u LXI., p. 405.

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corneitis and sears left in the neck by strumous abscesses, got phthisieal symptoms. Nothing was more important to keep in mind in a case of typhoid fever than the probability of its running into phthisis, whether strumous phthisis or the more common form of tubercle. In Surgeon- Major Gore's case i t was more than probable that it was pneu- monia that attacked the apices of the lungs. Struma was capable of assuming the forms both of isolated tubercle and pneumonia. The frequency of h~emorrhages in cases of this sort was another proof of the strumous origin of the disease. He had seen a case in which a patient threatened with phthisis had h~emoptysis, and two years after- wards that patient died of well-marked and acute enteric fever, with h~emorrhage from the bowels.

D~. GRIMS~XW said the relation between typhoid fever and pneumo- nia and phthisis combined, raised a very wide question. That typhoid fever was frequently complicated with pneumonia was known to every one. He bad paid special attention to the subject, in conjunction with his friend, Dr. J. W. Moore, and they had ascertained that that complication was more common than was generally supposed2 The two diseases, enteric fever and pneumonia, went hand-in-hand. As to the relation between enteric fever and phthisis, enteric fever was frequently followed by phthisis, because the former was frequently accompanied by pneumo- nia, just as pneumonia in other cases was frequently accompanied by phthisis. He did not believe there was any direct connexion between enteric fever and phthisis. I t was the explanation of the pneumonia that they required, more than the explanation of the phthisis. They certainly met with enteric fever in strumous people, but it attacked numerous other people that were not strumous; and he believed the facts would show that people who were not strumous did not get phthisis after enteric fever. The enteric fever being frequently accompanied by pneumonia, if the pneumonia arose in a strumous individual, that person would probably be afterwards attacked by phthisis. I f the person was not strumous the pneumonia would pass away with the enteric fever and leave the person perfectly free. The frequency with which enteric fever patients attacked by pneumonia recovered was well known--plenty of such cases got perfectly well. He thought i t would be found that i t depended on the constitution of the patient whether the pneumonia passed off easily or degenerated and ultimately ended in phthisis. I Ie was not a t all prepared to believe that enteric fever was more common in strumous people than in others. I t was certainly more fatal in such patients, but so were other diseases. The disease might attack strumous people more than other people, simply because they were more delicate; but that there was any reason to believe that, other things being equal,

Dub. Jour./Vie& Sci. Vol. LIX., p. 399.

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persons of strumous constitution were more liable to enteric fever than to other forms of zymotic disease, he would be sorry to affirm~ and for his part he did not believe it. They found that enteric fever attacking strumous people was, in some cases, followed by marasmus, owing to the effect it had on the mesenteric glands, and to the destructive changes it produced in the intestines and the glands connected with the mesenteric glands. He had met with many cases in which marasmus followed enteric fever. He believed that this bore the same relation to enteric fever that phthisis did. The marasmus was not the direct result of the fever, but was owing to the effect that the disease had on the glandular structures which, when they degenerated, gave rise to the marasmus. In the same way he had met cases of enteric fever which were followed by tuberculosis. The long continuance of the fever produced disease of the mesenteric glands, which became caseous, and produced poisonous effects on the general system~ and that ended in attacks of acute tubercu- h)sis. He was, of com'se, assuming that certain views as to tuberculosis were true. Another point worth looking at was as to the relative health of localities. I t had been ascertained by Mr. Sir~mn that enteric fever, diarrhoea, and cholera, all diminished in localities where the general conditions of drainage and water supply had been materially improved ; and that along with that diminution the death-rate from phthisis diminished. From this it would, on the first glance, appear that enteric fever, cholera, and diarrhoea had a common cause; but the fact might be explained in another way. Where enteric fever prevailed it was some- times accompanied by a low form of pneumonia dependent upon mias- matic causes, and this of necessity produced a certain amount of phthisis. The same cause that produced the enteric fever produced the pneumonia, and the latter produced the phthisis. Of course phthisis was more liable to occur in strumous constitutions than in others ; but it was carrying the thing too far to say that strumous people, because they were strumous, were more liable to enteric fever than other people. The only liability was that their general delicacy made them more liable than others to anything that was going. As to the question of contagion, many people thought that enteric fever was not contagious at all. He did not concur in that opinion. He thought that Surgeon-Major Gore had, to a certain extent, established the efficacy of contagion as a cause of enteric fever by the method of excluding all other causes. He did not think there was any other way of getting it, and that therefore the patient must have got it at Beggarsbush Barracks. She must have got it there for either of two reasons. One was that she attended a patient who bad the fever; and the other was that the causes that produced enteric fever were supposed to be prevalent in that neighbourhood. But as there did not appear to be a considerable number of cases of enteric fever in the barrack at that time, he thought that where a person in

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close contact with a patient in enteric fever got the disease shortly afterwards, the case might be set down as one of contagion. He had met with two cases of enteric fever which, he believed, arose from contagion. One was that of a nurse in Cork-street Hospital who got the fever and died of it, and who, he believed~ could not have got it from any other source than the patients; and the other was that of a patient in Steevens' Hospital, a constable of the Royal Irish Constabu- lary, who, after recovery from measles~ and when about being discharged, kindly undertook to assist the nurses in looking after a comrade of his who had enteric fever in an adjoining ward. He contracted that disease and died of it. There was no reason for supposing that he could have got enteric fever from any other source.

SURGEON-MAJOR GORE, in reply, observed that Dr. Fox, in a recent paper in The ~British Medical Journal, gave three or four cases of enteric fever contracted by contagion. The woman whose case he (Surgeon- :Major Gore) had mentioned did not live in the house with the patient whom she attended ; she only went in the morning, and returned in the evening. The water supplied in the patient's house was the Vartry. With respect to his use of the term chronic tuberculosls~ he should probably have said destructive lung disease, embracing all the various forms of phthisis. He did not think there were any signs of pneumonia in the case he had submitted. In fact s all the symptoms pointed to the ordinary tubercular form of phthisis. There was hsemoptysis, and the whole appearance of the patient pointed to chronic tubercle. He had seen a great number of cases of pneumonia co-existent with typhoid fever, and if there was no struma in the constitution the rule was that the patient got well.

DR. NlXON detailed a case of "Paracentesis Pericardii." [-This paper will be found at page 525.J

DR. HUGHES could vouch for the candour and accuracy of Dr. :Nixou's description. He had seen the patient from time to time, and could bear testimony to the improvement which resulted from the operation.

DR. 1V[~VEAGtI said a case had come under his notice of large effusion into the pericardium, resulting from acute rheumatism long after the affection of the joints had ceased. He recommended the operation of paracentesis, but was overruled. The patient afterwards died suddenly.

DR. HAYDEN said that this case was the first that had been brought under the notice of any Irish medical society, and the first that had occurred in Irish medical practice. He had seen the case before the operation, and he believed that but for it the man could not have survived

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twelve hours. The advisability of the operation depended on two sets of circumstances--first~ the urgency of the case and the failure of other modes of treatment ; and~ secondly~ the confidence of the practitioner in the accuracy of his diagnosis. Before attempting so formidable an operation~ and one of which they had had so little experience~ and the general results of which had been so unfavourabte, every judicious prac- titioner would exhaust every other means. As to diagnosis~ he did not know of anything that could be more confidently determined than a case demanding an operation of this kind. He had thought a good deal over the matter~ and his disposition was not to find fault with Dr. Nixon's procedure~ but, as a general rule~ he would be inclined to modify it~ rather from the results of the operation in other cases than from the result in his. He would be strongly disposed to place the patient some- what diagonally towards the right side, in order that the weightier b o d y - - the hea r t - -migh t gravitate in that direction~ and that the fluid might accumulate between the two layers of the pericardium~ and that the puncture should be made a little towards the left sid% somewhat behind the fold of the axilla. He had been for many years waiting for an opportunity of performing this operation.

The CHAm~AN agreed with Dr. Hayden~ that pericardial effusion to a large amount was a disease capable of most certain diagnosis. He had long ago made up his mind that if a case of pericardial effusion to a large amount presented itself to him he would certainly tap the patient. In a case which he had met with some years ago he desired to perform the operation~ but the patient would not consent to it~ and died~ as they usually did in such cases~ within about forty-eight hours. He was so satisfied with the accuracy of his diagnosis that he performed the operation post mortem. I t was a case of pericarditis~ with effusion to a large amount of a bloody character.

DR. HENRY KESNEDY said he could not entirely concur in what had been said as to facility of diagnosis. I t frequently happened that the effusion was not limited to the perlcardium~ but also involved the pleura~ and it was not easy to distinguish the pleural from the pericardial effusion. He had been surprised to find large effusion into the peri- cardium and also into the pleura at the same tim% and he had been puzzled to decide~ ante mortem~ whether the effusion was into the peri- cardium or not. I f the pericardial effusion was exceedingly larg% it was because there was also effusion into the pleura. I f the effusion was confined to the pericardium the diagnosis was simple enough; but he believed that that was not generally the case.

The Society then adjourned to next session.