PART III.

MEDICAL MISCELLANY.

Reports, Transactions, and Scientific httelligence.

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

SAMUEL G.ORDON, M.D., President.

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

Wednesday, April 3rd, 1878.

DR. GORDON, President of the Society, in the Chair.

Exhibition of Cases. DR. HAYDEN exhibited to the Society a lad, nineteen years of age, the

subject of congenital atrophy, or arrest of development, of the r ight upper extremity. The contrast, in respect of length and volume between the two upper limbs, was very striking. There was also a very singular curvature of the cervical portion of the spinal column. There was a convex curve towards the right side, and a compensatory curve in the dorsal region on the left side. Dr. Hayden was rather inclined to think that the cervical curve was compensatory of the other. As far as the boy himself had been able to learn from his parents, he was strong, healthy, and well-developed at the time of his birth, and for some time afterwards. About a year after his birth he fell from a table, and his mother noticed that from that time he exhibited weakness of the r ight upper extremity, and was ill for five or six years, but it was not clear what the character of his illness was. His present measurements, made by Dr. Gunn, were as follows : - - I n height he was 5 feet 4~ incl~es. The scapula from the superior to its inferior angle measured on the l e f t - - which was the unaffected side--6~ inches, and on the right 4~; from the superior angle of the scapula to the acromion, 5 inches on the left, and 43 on the right ; from the inferior angle of the scapula to the acro- mion, 7~ inches on the left~ and 6~ on the r ight ; length of left clavicle 6�88 inches, and of right 5�88 from the tip of the acromion to the outer angle of the humerus, 12 inches on the left, and 8~ on the r ight ; from the head of the humerus to its outer angle, 8 inches on the r ight ; length

Transactions of the Medical Society. 423

of left radius 9 inches~ and of the right 9 ; left ulna 10~ inches, right 9~ ; left hand 7�88 inches, right 6~ ; circumference of the left arm, at the middle of the biceps, 7~ inches, and of the right~ at the same place, 55 ; circumference of the forearm, 5 inches below the elbow, 8�88 inches on the left~ and 6~ on the right ; circumference of left wrist, 6 inches, of right, 5~ ; length of left arm from the tip of the acromion to the tip of the middle finger 27~ inches~ of right, 23~. I t was apparent from these measurements that the difference in the length of the two limbs was mainly due to the difference in the length of the two humeri. Dr. Gunn had taken the trouble of comparing the lengths just given with the measure- ments contained in Dr. Humphrey's well-known work, and from the latter it appeared that in a person of 5 feet 6 inches in height~ the length of the humerus was 12"54 inches. In the case of the present young man the left humerus was 12 inches, and the right 8�89 According to the standard of Humphrey the radius should b'e 9"46 inches; its length in the present case was 9 inches. The length of the hand according to Humphrey's standard was 7"33 inches ; in this young man's case it was 6~. There was great atrophy of the muscles at the shoulder-joint, so much so that one's thumb could' be buried in the hollow. His right side was quite paralysed. He had no grasping power in the right hand~ but had fair grasping power in the left. A wasting process had gone on in the left upper arm, but not in the left forearm or hand. The right side of the trunk was less developed than the left ; and on careful observation it would be seen that the right face and the right side of the skull were also less developed than the left. The lad was fairly intellectual, and had gone through the greater part of the first book of Euclid~ and mastered it fairly well. He was sufficiently intelligent t5 write, but could not use his right hand for that purpose. He had been under magneto-electro treatment for some time. At first the muscles did not respond~ but afterwards they did~ and he felt that he was getting some little power in his right arm again.

Da. NIxos exhibited a boy~ aged eleven years~ labouring under cyanosis depending, he believed, on congenital lesion of the heart. The mother and two sisters of the boy had died of phthisis. About three years ago he complained of an attack of pain in the cardiac re ,on , dys- pncea on exertion, and neuralgic headache, and then the cyanotic condition developed itself. A short time afterwards he became subject to fainting fits~ and in order to obtain relief from these he presented himself at the hospital. Each of these fits lasted about five minutes. When he was examined on admission to the hospital, it was found that there was a considerable increase in the area of cardiac dulness upwards and to the left side. The sounds of the heart presented no abnormal phenomena; they were simply exceedingly distinct and accentuated. There was no murmur whatever. The temperature ranged from 95 ~ to 96~ ~ The

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marked cyanotic condition of the lips and tongue would be observed. Upon examination of the optic discs with the opthalmoscope the edges of the discs could hardly be distinguished from the retina. The veins were extremely engorged and tortuous, and were like a number of snakes crossing the retina. About three weeks ago a number of purpuric patches developed themselves on the extremities, but these had since disappeared. He had since been subject to attacks of epistaxis. He had, however, no cough, nor any sign of pulmonary lesion, his respiration being normal in both the front mad back of the chest. In association with the congenital lesion of the heart a very singular conformation of the left forearm existed, it being considerably shortened, and there being only one bone--namely, the ulna--which terminated in some of the bones of the wrist. He was first treated with peroxide of hydrogen, and afterwards with inhalations of oxygen.

DR. WILLIXMS (of Liverpool) read a paper entitled, ~ A few remarks ell the Treatment of Pleurisy and Empyema." [I t will be found at page 398.]

DR. HAYDE~r thanked Dr. Williams for reading his paper before the Society. He alluded to the difficulties connected with the treatment of effusion upon the chest, and observed that medical men had latterly taken heart, and had not hestitated to, act upon the dictates of common sense and remove by mechanical means the fluid which was interfering with the breathing of the patient. 2ks to the danger of admitting air into the serous cavity~ that bugbear had been likewise exorcised, and now they knew that, so far from aggravatfng the disease, the admission of air into that cavity really alleviated it, and perhaps started a process of cure. He had some difficulty with respect to the second of Dr. Williams's cases, in which a fistula was detected before the operation of tapping. They had not been informed as to the ultimate progress of the case, and as to whether the fistula continued, or whether the lung expanded. I f the fistula continued he could hardly suppose that the lung had expanded. He could not approve of the treatment of effusion by means of opium; he had never seen any benefit to result from it. He regarded opium as a mere palliative, and believed that so far from being an excitant, it was rather a depressant ; so that if the object was to excite the lungs in order to promote the discharge of the fluid, he could hardly suppose that, reasoning ~ priori, opium was a judicious plan of treatment. Having had some little experience of tapping the chest in cases of effusion, he believed that where it was serious, where it was the result of acute inflammation, and where life was threatened from the mechanical pres- sure of the fluid, after the ordinary means of quickening the action of the kidneys and bowels had been tried and had failed, no more time should be lost, but the operation of tapping should be at once performed.

of the College of Physicians. 425

Dr. HENRY KENNEDY alluded to the unpleasant effects that sometimes resulted from the injection of fluids into the pleural cavity, and asked had anything of that sort occurred in Dr. Williams's experience ? He had seen two cases in which the effect of the firs~ tapping was to withdraw fluid of the most fcetid description ; and thought that foetor of that sort was connected with the state of the patient's constitution.

Dr. FINNY observed that the treatment of pleurisy by strapping had been longer known in Dublin than Dr. Willianls gave them credit for. I t was done in the hospital he was connected with in nearly every acute case~ and the disease, he believed, was thus often checked. The question was one of obtaining physical rest ; and when this could not be procm'ed by strapping, it was necessary to have recourse to opium in order to arrest the circulation. In this way they strove to br ing about adhesion between the parts~ and thus prevent effusion. Dr. James Little, one of their Vice-Presidents~ had published cases of t reatment of the early stages of pleurisy by strapping. When the existence of pus was recog- nised, was it better to tap frequently with the aspirator in vacuo or give free vent to the pus at once by incision ? According to his own expe- rience he believed the latter course was the best. One reason for leaving the pleural cavity open was that sometimes large flakes of pus would not

pass through the aspirator. The PRESXDE~T said he had seen a great many cases of pleurisy with

effusion~ and had tapped over 25 cases~ and~ as a general rule~ with great success. He had tried strapping the chest in a great many cases ; and his experience was that i t afforded most relief in cases secondary to phthisis, particularly those in which there'happened to be pneumothorax. In those cases i t gave immense relief. On the contrary~ in cases of an acute type which ran into empyema~ it was not so applicable~ and~ if tried, gave great pain. Many such cases were accompanied with great external and internal inflammation ; and there was also external perios- titis which would not bear pressure. Cases of pleurisy supervening on phthisis derived sensible relief from treatment by opium. Another point of great interest was, that, as he had more than once seen~ when cases of well-marked empyema terminated in flstula~ the purulent matter expec- torated was the consequence of the fistula that had been formed. On the other hand~ where a fistula did not form~ the case became one of chronic empyema. That was the condition of affairs which led to such cases being mistaken for phthisis. The possibility of that occurring was originally alluded to by the late Dr. Green in a very able article in a comparatively early number of The Dublin Medical Journal. Another important point was as to whether the pleura should be completely emptied at once~ or the effusions withdrawn by portions at a time. This was a matter supposed to depend on the patient's health and strength. There was no question that formerly medical men were too much influenced

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426 Transactions of the Medical Society.

by the dread of allowing air to pass into the cavity of the pleura. The late Dr. Adams detailed a case in which there was a large empyema, and he completely evacuated the contents of the pleura, using all possible means to prevent the entrance of air. In a few hours the patient died. A t first it was thought that the intercostal artery had been w~)unded, and that the patient had died from hmmorrhage. A close examination showed that there was no wound of the intercostal artery~ but that a very large quantity of blood had been drawn into the cavity of the pleura.

Dr. WlLLIAMS~ in reply, thanked the Society for the attention with which they had listened to his paper and for the remarks that had been made concerning it. He had used strapping very largely and with much benefit in cases of phthisis, l i e was surprised r hear the remarks of Dr. F inny as to the frequent employment of strapping in I)ublin, and was glad to hear such testimony in favour of its utility. He had not seen the least harm result from the washing out of the pleural cavity. In the first of his cases he washed it out thirty-one days before he ventured to make the wound large; and he now believed that if he had made a large wound in the first instance the man would have got well in half the time. When the first opening was made, 108 ounces of most offensive pus were removed. He concurred with Dr. Kennedy that She smell of the pus depended on the constitutional state of the patient.

The Society then adjourned.

CHORF~ IN OLD AGE.

~F~. CHARCOT has at present~ at the Salp*tri~l,e, two cases of chorea in men over seventy years of age. One has had it ten years~ the other twelve. The affection is to be distinguished from the so-called chorea senili8 with which it has no af l lni ty-- i t is precisely the chorea which attacks children~ except that it resists all treatment and is incurable. The movements are a little slower~ and the variety of the grimaces rather less. There seems to be no relation between it and rheumatism, nor in the autopsies of several cases that came under his observation was there any lesion of the heart. I t begins generally suddenly after excitement or some other emotional cause ; and most cases are accompanied with impairment of the mental faculties. The malady as a rule does not tend to shorten life ; one old woman~ however~ who came under ]~I. Charcot's observation died with typhoid symptoms shortly after a violent attack of the affection~ and an old many the half of whose body only was affected, succumbed, a rapid rise in temperature preceding dea th . - -Le t)rogr~s Mddical.

S . W .