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

SA~IUEL GORDON, M.D., President. GEORGE F. DLTFEY, M.D., Honorary Secretary.

Wednesday, 5th December, 1877.

DR. GORDON, President, in the Chair.

DR. SIGERSON read a paper " O n Alternate Paralyses." l i t will be found at p. 97.J

Dm MAcSwI~-nr said the paper belonged to a class of communications that it was very desirable to have more frequently submitted to the Society. The subject of electro-therapeutics was engaging great attention, and such a learned essay as they had just heard, dealing with obscure lesions of the nervous system, should be looked on with great interest. Physicians knew how frequently cerebral affections baffled the utmost skill of those who sought to determine their nature, and how often also _post mortem examinations failed to reveal the lesions that were expected during life. The investigations of Charcot and Vulpian, in France, and of Ferrier and Jackson, in England, pointed out the perfect state of chaos in which cerebral physiology and pathology were at present. Dr. Brown-Sdquard's memorable lectures, delivered a year since, were remarkable chiefly for the manner in which that able and learned physiologist employed himself in ruthlessly demolishing the entire struc- ture which had been erected by previous investigations with respect to cerebral and nervous physiology and pathology. That proceeding on his part gave abundant evidence for fearing that the basis on which previous classifications had been built was unstable, uncertain~ and unwarranted. However, he did not add to his destructive work any work of reconstruction, so that such of them as were in the habit of attaching importance to the investigations of that distinguished physio- logist would have to wait for the new views that it would be correct to

148 Transactions of rite Medical Society

take, in the place of those ancient views which he had so mercilessly destroyed. Coming to particulars, it was satisfactory to find that the author of the paper had pointed out means whereby, if they were closely to follow them, they might be enabled with more certainty to detect the nature of the particular lesion which was present in the various forms of alternate paralysis to which he had called attention. The elaborate com- munication of the learned essayist was one from which the members of the Society would derive much more advantage by reading it in print than by any attempt to criticise it in detail now.

DR. HENRY KENNEDY said he did not know that the theory with respect to lesions in or about the pons Varolii giving rise to differences of temperature on either one or both sides of the body was tenable. I n the present year he (Dr. Kennedy) had had a remarkable case- -and he had seen other cases previously-- in which the lesion was confined to the neighbourhood of the ventricle, and in which the temperature of the body on the weakened side was constantly below the healthy standard. The disease was entirely confined to the roof of one of the ventricles. In the early stages of the disease the facts with respect to temperature were very remarkable. On the permanently affected side the temperature was from a degree to a degree and a half lower than it was on the sound side. The other point to which he wished to refer was the cause of the disease. He had seen cases very like the one in question in which the disease was distinctly traceable to gout, for many of the paralytic symptoms in those cases entirely disappeared when gout made its appear- ance. Some years ago Dr. Lynch, of Loughrea, published a case pre- senting symptoms very analogous to those detailed in Dr. Sigerson's paper, and in which, on the occurrence of gout, the greater number of them disappeared., Therefore, they should be very slow in concluding that those symptoms were always due to disease of the brain. Most serious cerebral lesions might occur in connexion with gout, and never- theless there might be no reason for supposing that they were caused by any disease of the brain. What was the age of Dr. Sigerson's patient ?

DR. SIG~RSONmSixty-five.

DR. WALTER SMITH remarked that Dr. Sigerson had called attention to the valuable aid that Duchenne had shown could be derived from local faradisation as a method of diagnosis in facial paralysis. But in the present state of their knowledge the galvanic excitability of muscles also required to be examined. They knew that in true peripheral facial palsy, as well as in other cases of nerve injury, the total absence of faradic excitability coexisted not only with the preservation of, but with the actual exaltation of, galvanic excitability. I t was possible that a further

of tl~e College of Pl~jsicians. 149

refinement of diagnosis might be gained in some cases by bearing that fact in mind.

Dm NIXON referred to the case given by Dr. Sigerson, in which, with hemiplegia of the body, accompanied by facial paralysis on the same side, there was inability to close the eye. This fact was interesting, as he (Dr. ~ ixon) believed that in Dr. Hughlings Jackson's large experience he had not met with a similar case in which the orbicularis palt)ebrarura was paralysed. With respect to Dr. Duplay's cases, he understood Dr. Sigerson to state that there had been multiple lesion; and, if so, the paralysis of the muscle might be accounted for by pressure on the nerve.

DR. SIGERSON, in reply, said the subject of the correlation of lesions and temperature was one into which he had avoided entering. I t was opened up by the quotation he had given from Dr. Brown-Sdquard, but he (Dr. Sigerson) had not sufficient data to enable him to proceed further. Neither could he give any opinion as to the probability of gout being a predisposing cause of the affections in question. He had very carefully tabulated all the home and foreign cases which he had found recorded, and gout was not mentioned in any of them. He admitted that it was possible--according to Dr. Kennedy's exper ience-- that gout might be present ; but having taken all possible precautions in the case which he had submitted, he (Dr. Sigerson) was as certain as it was possible to be that the lesion was in the pens Varolii, and he was almost as certain that the cause was a blood clot. I t was possible that gout might have helped the formation of that lesion. He was aware of the fact stated by Dr. Smith of the different effects of faradism and galvanism on muscular irritability. Indeed, he believed that Dr. Duchenne had first called attention to the fact that, along with diminution or even annihilation of faradic excitability, there might exist exaltation of galvano-muscular excitability. Rosenthal had referred to the fact as of use in cases of diagnosis ; but though he was prepared to admit with Dr. Smith that this afforded some further means of diagnosis in certain cases of paralysis, he did not think that in the present case it was necessary. He trusted that Dr. Walter Smith would work out the idea he had referred to. There was great probability that some further step in their knowledge might be accomplished in this direction. As to the question of the paralysis of the orbicularis palpebrarum, alluded to by Dr. Nixon, it was perhaps due to the length of the paper read that Dr. Nixon omitted to observe that Dr. Duplay's cases were not cases in which multiple lesions were discovered. Dr. Duplay had carefully examined the matter, as far as he (Dr. Sigerson) could ascertain, and had found that in aged persons there was a lesion of the cerebrum which could be correlated with paral~'sis of the orbicularis palpebrarum. In that case, of course~ there

150 Transactions of the Medical Society

was no multiple lesion, or at least no lesion pressing on the facial nerve, which would have been mentioned if it had occurred. With regard to the case of the boy who had been under Dr. Sigerson's care, there was paralysis of the orbicularis, and at the same time conservation of mus- cular contractility, which pointed to a lesion above tire point of decussa- tion.

The Society then adjourned.

Wednesday, January 2, 1878.

DR. GORDON, President, in the Chair.

DR. WALTER S~ITH read a paper on " F a c i a l Paralysis, with Remarks on the Action of Induced Currents and Interrupted Voltaic Currents." l i t will be found at p..125.]

The PRESIDENT complimented Dr. Smith on his practical paper. He had known facial paralysis of a transient character arise from deficient circulation. Such cases did not last more than two or three days~ and were generally confined to the region supplied by the portio dura nerve.

DR. HENRY KENNEDY observed that in one case of facial paralysis which had occurred in his practice he had found the treatment by mer- cury pushed to salivation successful In that case electricity had been tried and had failed, but it was at a time when its application was not so well understood as now. He had seen several cases of transient paralysis~ such as the President had alluded to. They were accompanied with syncope, and did not last more than a few hours, and were probably connected more or less with deficient circulation.

DR. AQUILLA SMITH said he had treated half a dozen cases of paralysis with mercury, and the treatment failed in every one of them. They were all afterwards successfully treated by electricity.

MR. I-I. G. CROLY said the last of the cases mentioned by Dr. Wal ter Smith had been under his care. Very early in the case he felt a small gland in the region of the stylo-mastoid foramen. Whether it pressed on the nerve, or came on from the irritation of a blister which he had applied, was hard to say. The case was almost well now, the child being able to shut her eye, whistle, and wrinkle her brow ; but there was a slight appearance of paralysis remaining. He thought the delay between the early treatment of leeching, &c, and the proper application of electricity by Dr. W. Smith had been too long delayed in this case, and that a certain amount of muscular atrophy had been allowed to

of the College of Pl, y sieians. 151

come on. If Dr. Smith had enjoyed an opportunity of applying electricity from the first~ he was sure the child would have been well by that time. He alluded to some cases in which facial paralysis had been induced in his practice as the necessary result of surgical operations, and asked if Dr. Smith had any experience of injecting minute doses of strychnine in facial palsy of lzhe portio dura nerve.

Da. FI~NY asked what interval should elapse between onset of the palsy and the application of faradic or galvanic electricity ? Dr. Smith's cases left them in doubt as to whether, in spite of the existence of galvanic excitability~ the cases would recover rapidly or not.

DR. WALTER S~Ir~-, in reply, said he had tried strychnia in several cases of facial paralysis, and had convinced himself that in no case was any improvement due to its use. He believed that the sooner electrical treatment was begun and carefully carried out the better would it be for the patient. A prognosis could not be derived from a single examination, but must be the result of several examinations made within short intervals of each other..

A Case of Typhus with IIyperpyrexia. By JOHN WILLIAM MOORE, M.D., Univ. Dubl. ; Fellow K.Q.C.P. ; Physician to the Meath and Cork- street (Fever) Hospitals.

THE present "Clinical Record" is interesting chiefly on account of the exceptionally high temperature observed during the death-agony of th~ patient, who succumbed on the nineteenth day of a typhus fever of th nervous or ataxic variety.

The following is a brief history of the case : - Margaret T., aged thirty-eight years, married to a shoemaker s and resid-

ing in Cuffe-street, Dublin, was admitted to the l~feath Hospital on the afternoon of Wednesday, September 12th, 1877. I t is worth noting that a young man from the same house was under treatment for severe typhus in Cork-street (Fever) Hospital from July 18 to September 8. There was no special medical history previously to her present illness, which commenced on Tuesday~ September 4th, 1877, with a shivering fit, followed by chilliness so great as to oblige her to hang over the fire the greater part of the day. She also suffered from pains in the limbs. She fought against her illness until the following Friday (4th day)~ when she took to bed, as she was getting much worse. On Saturday, severe pain in the small of the back~ and, next day, vomiting of " watery stuff" werc superadded to obstinate constipation, which was an early symptom. From the outset also she was very sleepless. She did not come into hospital until the afternoon of the ninth day. in the evening her pulse

152 Transaaions of tl, e Medical Seeiety.

was 120, her respirations were 28 per minute, and the axillary tempera- ture was 1~4"9 ~

Next morning her face presented a dusky, congested appearance ; the eyes were heavy, and the conjunetivm deeply suffused ; her tongue was heavily furred, but moist ; both it and the lips were exceedingly tremulous. There was a marked "nervousness" of manner. A profuse mulberr)r eruption covered nearly all parts of the body-- the original maculm had become true peteehim, which were unusually distinct and dark in eotour.. Her pulse was 124, not strong; respirations, 24; temperature, 104"3 ~ (at 10 a.m.). The heart's action was rapid and weak, but both sounds were audible, and the impulse could be felt in the normal situation.

Trecament.--It was decided to free the bowels by a simple enema of olive oil and warm water, to support the strength by strong beef-tea and abundance of milk, four ounces of port wine, and moderate doses of quinine.

September 14th ( l l t h day).mThe enema acted twice, bringing away dark, solid fteces in considerable quantity, There was a slight remission of fever, the morning temperature being I03 ~ .

September 15th (12th day).--She spent a sleepless night, being very restless and moaning constantly. The heart was becoming rapidly weaker--the impulse was feeble, the first sound indistinct, the second relatively strong--being thrown into relief by the subsidence of the systolic sound. Strychnia and digitalis were added to the quinine mixture; and the port wine, which had been increased to 8 ounces the previous day, was again increased to 12 ounces, wlth 4 ounces of whiskey. The heart's action was impeded by tympanites, to combat which a turpentine enema was administered. I t acted once, with some relief to the patient. The persistent sleeplessness and increasing head symptoms led me to try, cautiously, tartar emetic and opium, as recom- mended by Dr. Graves. Only two doses, however, were taken--too small a quantity to induce sleep on the one hand, or to be accused of injuring the patient on the other. One sixth of a grain of tartarated antimony and 10 minims of tincture of opium alone were given.

,September 16th (13th day).--She passed another sleepless night, with much muttering delirium. The tongue was moist; but there was pro- gressive failure of the heart. Its action was very weakmquita foetal in character. Port wine, ~xii. ; whiskey~ ~vi. Towards evening the temperature began to fall with an attempt at crisis. .At 7.30 p.m. there were marked cerebral symptoms ; but in the night the bowels moved, and both diaphoresis and diuresis occurred~ so that an evident effort at crisis was made.

September 17th (14th day).--The morning temperature was m~ ~ 102~ but this one favourable symptom was accompanied by a rise in the rate of both pulse and respirations--a circumstance of evil omen. The

of the College of P]~ysicians. 153

rash was on this day evidently fazling from the anterior aspect of the body, although it remained very petechial even in this situation.

September 18th (1,Sth day). The temporary remission of pyrexia was now succeeded by an exacerbation in the symptoms--a morning tempera- ture of 103"7 ~ , constipation, commencing retention of urine, and per- sistence of the rash. The increased meteorism obliged us to order another turpentine enema, which operated once.

September 19th (16th day) . - -Another pseudo-crisis occurred on this day, with profuse diaphm.esis, and a fall of temperature to 101"7 ~ Again there was a complete want of accordance in the symptoms-- the respira- tions remained as fast as ever (48 per minute), the pulse fell only four beats per minute, there was complete retention of urine. The pulse could scarcely be counted, owing, firs b to its weakness; secondly, to the intensity of the subsultus which was present. The urine was now slightly albuminous, and the urea was partially decomposed--the fresh urine, drawn off by catheter, effervescing briskly on the addition of dilute nitric acid.

September 20th (17th d a y ) . - - I n no way better, in some respects worse ; temperature rising ; bowels costive, with tympanites.

September 21st (18th day) . - -Morning temperature, 104"8~ pulse, 12"2 to 126 ; bowels have not acted ; no return of power over the bladder ; the urine is drawn off by catheter every eight hours or oftener ; a turpen- tine enema ordered, and to omit the 3-minim doses of liquor strychnim which she has bcen taking. In the evening a third attempt at crisis reduced the temperature to 103"2 ~ , but the pulse remained unaffected.

September 22nd (19th day) . - -Much worse in every part icular; unconscious, with coma vigil ; pupils contracted and sluggish to stimulus of l ight ; considerable albuminuria; morning temperature, 106"4 ~ Ordered : one grain doses of camphor and musk every second hour. A t 6.45 p.m. I visited her again. She was bathed in a cold perspiration; the extremities were cold, her eyes fixed, with coma vigil; bronchial r~tles heard universally over the chest ; axillary temperature (taken twice with two reliable thermometers) was 108"6 ~ . She was manifestly dying. A t 7.30 p.m. the last observation on the temperatfire was made ; it was found to be 109"1 ~ Three hours later she was dead. Unfortunately no observation was nmde after death. This was trartly owing to the late hour at which she died.

Authenticated temperatures as high as those noted in this instance--- namely, 108"6 ~ and 109"1~ so rarely recorded that I was induced to bring forward the foregoing " Clinical Record." So far as I am aware, no such temperatures have been observed in the 5[eath Hospital since the modern introduction of 5iedical Thermometry. In a wduable appendix to Dr. Stokes' work on Fever, my colleague, Dr. Ar thur

154 Transactions o f tl~e Medical Society

Wynne Foot, gives a rdsumd of thermometrical observations in the medical wards of that hospital during the three years, 1871, 1872, and 1873. Among 9~248 observations, the highegt reading noted was 107"2 ~ He s a y s : - - " On 27 occasions temperatures of 105 ~ Fahr . or upwards were registered in typhoid fever in 15 patients, and of the 15 patients in whom the temperature on one or more occasions reached 105 ~ Fahr . or upwards, five died." The highest temperature recorded was in " a girl aged 16 ; temperature on 30th morning 107-2 ~ Fahr . ; died on the 31st evening. Her mean temperature (51 observations) during the twenty-six days she was in hospital was 103"1 ~ Fahr . The morning temperature, 107"2 ~ was coincident with severe rigors~ preceded by violent pain in the abdomen~ ushering in peritonitis~ not due to perforation, but to propa- gation outwards of the irritation arising from numerous and extensive ulcerations of the intestinal glands."

Dr. 3/Iuvchison~ ~ speaking of the temperatare in typhus~ observes that '~ a severe case is often characterised, not merely by a high temperature in the first week~ but by an anomalous or irregular range in the second ; for example, by an absence of the morning fall~ or by a sudden fal l with a rise of pulse, or with no improvement in the general symptoms. In fatal cases there is usually a rise o f two or more degrees just before death or in the death- agony."

I have itallcised the latter part of this passage, as it bears so directly on the present case~ and is so fully illustrated by it.

Wunderlich b remarks that " F a t a l Cases of exanthematic typhus gene- rally announce themselves even from the very beginning by the enormous height of tile temperature (41"2 ~ C.-~--106"1'6 ~ Fahr.~ and even more). The transient remission at the end of the first week is wanting in these cases. Death may occur in the second week with continual high temperatures. I f the case enters the third week~ some remission may show itself on the fourteenth day, but this must not be regarded as a favourable symptom, and is very soon compensated.

~ Yet even in fatal cases the temperatures in the ?bird week are not so high as at the earlier periods, at least till near the death-agony. The daily maxima do not exceed 40"8 ~ C. (105'44 ~ F.)~ but are, for the most part, moderate. The danger to life during this third week is indicated not by the height of the fever, but by its continuance.

'~ Just before death, and in ~he death-agony, the temperature constantly rises in exanthematic typhus. In all my cases in which i t was possible to make observations, there was a rise of temperature during the agony of at least 1"25 ~ C.-~2"2 ~ F., in one case of even 3"6 ~ (6.48~ and on an average about 1"8 ~ C. (3"24 ~ F.) . During the agony the temperature

The Continued Fevers of Great Britain. Second Edition. Page 137. b Medical Thermometry. Translated by W. Bathurst Woodman, I~I.D. The New

Sydcnham Society. 1871. Page 331.

of the College of P@sieians. 155

was seldom so low as 40 ~ (104 ~ F . ) ; more usually it was about 41~ ~ C. (105"8~ ~ F.), and once 43 ~ C. (109"4 ~ F.) ."

The curves of temperature in this last case are given in Table IV. at the end of ]Vunderlich's book, and are also to be found in Diagram V I I . in Murchison's worlq where the ease is described as one of " Typhus, fatal on 17 th clay, with very high temperature (109"4 ~ F.) before death." The char~ is strikingly like that which is the subject of this paper.

The dread significance of such temperatures is aptly expressed by Wunderlich in his definitioh of ~ Hyperpyret ie Temperatures" ~--those ~ which in every known disease, except relapsing fever, in all probability indicate a fatal termination--107"6 ~ F. (42 ~ 'C) or more."

To attempt an explanation of this hyperpyrexia in disease would be foreign to the scope of this communication, which is simply a clinical record, l~or do I iu any sense feel competent to undertake a task which, up to the present, has apparently foiled even the ablest thinkers in the domains of practical medicine, of morbid anatomy, and of phy- siology. As Wunderlich well observes--" In the foreground is the question: cOn what does the abnormal temperature depend?' But this is by no means identical with the question : ~ Wha t constitutes fever ?"

I t will serve my present purpose to direct attention to an admirable r&umg of modern "Theor ies of Fever" in Wunderlieh's work (pages 184, et seq.) ; to Dr. Burden Sanderson's Monograph on the Process of Fever, in The Practitio~r for April , May, and June, 1876; b and to an original communication in the Medical Times and Gazette for 1877 (Volume I.), by Dr. C. Handfield Jones, on ~ Two ,Cases of Fever with Hyperpyrexia ." The last-named author holds " t h a t there exists a nerve-centre, or set of nerve centres, situated in the upper part of the cervical cord, or in its vicinity, which in health controls the development of heat, probably by lessening the combustion of protoplasm ; but which, under the influence of certain poisons, or heat, or exhaustion, or direct or remote injury, loses this faculty, and that this loss is the essence of fever." In proving his case, Dr. Handfield Jones .~ notices the occurrence of hyperpyrexia in cases of rheumatic, typhus~ typhoid~ and scarlet fevers. ~ The symptom," he says, " is commonly associated with low delirium, stupor, or coma. These might be regarded as the results of the overheated blood acting injuriously on the cerebral tissue. But, as instances of relapsing fever and Mr. Teale's case show that very high temperature does not neces- sarily produce these symptoms~ it seems more reasonable to regard them as co-effects of the hyperpyrexia, all being of the nature of paralyses, and all being produced alike by the original cause of the fever. High

a Lee. cir. Page 7. b Reprinted, by permission, from the Appendix to the Report of the Medical Officer

of the Privy Couned on Scientific Investigations. New Series. No. VI. Loc. cit Page 569.

156 Transactians of the Medical Society.

temperature is, I believe, most prone to occur in cases of the greatest gravity. In some fatal cases of scarlet fever Dr. B. Woodman has noted a temperature of 115 ~ The nervous system is so constantly and in- juriously affected by the fever-poison in all severe instances of the above maladies that it is no more than might have been expected that the heat- regulating centre should occasionally be paralysed."

Such is the neuro-pathological view of fever. Shall we further believe, with Dr. Burdon Sanderson, that the mechanism, by which the influence of this "schz~tzendes JEtwas" (as he more indefinitely describes the Law of Temperature) is exercised in restraining temperature, is not the cir- culation ? '

C L I N I C A L C H A R T OF T E M P E R A T U R E , & e .

M . T . Age, 38 ; Disease, Typhus Fever; Result, Death on 19th day.

I Dateof SelPt" I J Ob . . . . . . tions 18~7 I3 I4 I5 t 1 6 17 18 19 }~o , I 22 - -

I IO'

to9 ~

los,

[07~

tO6 r m

I :o5 ~ r

�9 ~ io4 r

[O3C

Pulse { " - - ]124 E. IZO I~O

Motions I o [ z

�9 ~ ~176

'Jl

12o t26 I36 I3o I28 I24 ~34 12o t34 1367 I36 124

28 34 44 48 4 * 48 30 40 48 48 52 50

o I loJ,

118 122 120 - - 124 I24 1487

48 46 I 44 -- l

5z 48 I 48

~ I I ' -

The PRESIDENT said the case reported by Dr. Moore was remarkable on account of the three efforts at crisis which had occurred in the course of it.

The Society then adjourned.