P R O C E E D I N G S O F T H E P A T H O L O G I C A L SO CIE T Y O F

D U B L I N .

President---EDwARD HAMILTON, M.D.

Secre ta ry - -E . H. BENNET% M.D.

2Oopliteal Artery closed by Catgut Ligature.--DR. BENNETT said : This is a section made vertically through the popliteal ar tery and vein, fourteen days after their ligature with catgut, in amputation of the thigh. The case was one in which albuminuria had existed. On a former occasion (March 9th) I showed the limb which required amputation, having been in a most extreme state of ulceration. I t had been debated whether the operation was justifiable or not, considering the presence of albuminuria ; but after a consultation my colleagues and I unanimously agreed that the lesser of the two evils would be amputation, that a very speedy death was promised by the disease if left to go on uninterfered with, and that the amount of kidney disease was probably not so serious as to contra- indicate the operation. The amputation was accordingly done by the ordinary flap method~ close above the knee, with strict antiseptic pre- cautions, and was carried out successfully. The conduct of the case from the commencement to the end~ as far as the stump was concerned, was strictly antiseptic. We had absolutely no complication in the treatment except one, as far as the limb was concerned. The flap fell readily over the face of the part, and was retained in position by the ordinary catgut sutures. The limb of the patient was greatly deformed. I te had been in the habit of wearing it in an extreme state of flexion during his ordi- nary movements, and in such a way that we had some little difficulty in treating the stump, getting i t fixed and keeping i t quiet. _A. couple of days after the operation he became disturbed from some slight starting of the stump. This disturbed the flaps, and it was possible on the fourth day after the operation to see the site of the popliteal vessel in conse- quence of the tearing asunder of the recent union on one side of the flap. We weighted the limb with sandbags~ replaced the dressing, and restored the flaps, and everything went on without complication until towards the thirteenth day, when he began to show signs of very hard respiration. The stump at that time had not been dressed for three or four days. l i e died with symptoms of laryngeal distress, not such as suggested a resort to tracheotomy; but the idea suggested was that some acute form of ulceration of the larynx had been set going. The post mortem examina- tion proved that the obstruction was duo to (edema of the glottis. So far

Reports of tTte Dublin Pat]wlogical Societ~j. 341

as I could determine, I think the principal exciting cause of the laryngeal distress was the protracted effect of the ether inhalation on a system in such a condition of weakness as albuminuria induces. The great sense of dryness produced in the air passages and his own sensations--for days afterwards he did not lose the sensation of the e ther- -made me suspect that it had a large share in determining the oedema. These remarks, however, are foreign to the specimen itself. When the man died we opened the stump, tearing through the recent lymph that had closed it, and we saw no sign of any casting-off of any slough. There were two catgut ligatures used at the operation, one upon the femoral artery and the other upon the vein. Jus t as the stump was put up, a troublesome hzemorrhage occurred from the vein, and we applied a ligature to control it. The artery presents the normal features of a vessel closed by a ligature. We have a conical clot extending within i t for some distance. There is complete occlusion, and the walls of the artery are identified with the blunt end of the cone of the clot. A small amount of perfectly soft recent lymph filled the outer part of the walls, and the vessel was cut across by the ligature, which has completely disappeared. The closure, however, was complete and of the normal kind. Beyond the closure can be seen the remains of the part of the vessel outside the ligature which has not sloughed away. I direct attention to this, because some doubt is cast upon the behaviour of vessels under such circum- stances in a communication made to the Pathological Society of London by Mr. Callender. He says : - - " Having an opportunity for examining a superficial femoral ar tery which was removed from a thigh nineteen days after an amputation for ununited fracture of the left femur of a woman, fifty-one years of age, I found that the vessel was closed by an ordinary coagulum extendiag three-quarters of an inch from the cut extremity of the artery towards the heart. There was no trace of the carbolised catgut with which the vessel had been tied. There was no appearance of constriction at the free extremity of the artery, and there was no adhesion to its walls, save to some thickened tissue, which lay by their side." I bring this vessel under the notice of the Society because i t is clear that in this instance, at all events, the catgut disappeared, and that at the time of tim patient's death the vessel was closed not by coagulum only. Absolutely an opposite condition of affairs presents itself here~ so far as the closure of the vessel is concerned. The complete closure demonstrated by Jones has been effected, and we have no trace of the catgut ligature left. The same remark applies exactly to the vein. You can see that the closure of the vein has been effected, in identically the same way as that of the artery. The coats are compressed and brought to the form of a truncated cone below the clot, which is much softer than in the artery.--April 13, 1878.

342 Reports of the DuSlin Pathological Society.

Compound Comminuted Fracture of the Sphenoid.--Drt. E. W. COLLINS said : The fragments of dead bone which I exhibit are the larger sequestra removed recently from the great wing of the sphenoid~ under the follow- ing circumstances :--'In :November last, a fine healthy boy~ fourteen years old, was struck in the left temple by a moulding-cu~ter, propelled with considerable force-from some machinery eighCeen feet distant, which he was minding in a saw-mill. He was taken up senseless, and bleeding profusely from ~ke wound, so that he quickly lost a large quantity of blood. He was carried to Jervis-street Hospital in a condition of syn- cope, due to haeraorrhage and cerebral concussion. A large lacerated wound in the left ~emporal fossa commenced immediately above the zygoma and passed directly upwards for several inches. From a super- ficial examination it was evident that the depth was considerable. Owing to the collapse the htemorrhage had ceased. The wound, therefore, was interfered w, ith as little as possible, and any detailed examination re- garding its depth was avoided, in order not to disturb such natural hmmostatle processes as might already have taken place. Firm pressure was maintained over the wound by a large compress and knotted cape[line bandage. _A_t my visit on ,the following morning I learned that severe reactionary heemorrhage had taken place at 5 a.m, which the resident pupil had great difficulty in arresting by continued pressure over the wound. ~ therefore had the boy conveyed to the operation theatre, in order to thoroughly examine the wound and adopt such measures as might be necessary to prevent further recurrence of bleeding. That the bleed- ing was arterial, and from a ~essel of considerable size, I was convinced by the time ~)f its occurrence, its profuseness, and the difficulty experienced by the resident pupil in its temporary arrest. Ether having been ad- ministered and the compresses removed, masses of coagula were seen filling the wound, and profuse bleeding immediately took place. Having cleared away the coagula, my forefinger passed downwards and back- wards through the wound, between the zygoma and the sphenoid, into the zygomatlc fossa, where the internal maxillary artery lay. The zygoma was bared of periosteum to some extent, but unbroken. In the upper wall of the zygomatic fossa the top of the finger passed into a large fissure, where the base of the great wing of the sphenoid was so exten- sively fractured that the pulsations of the brain were perceptible. No loose pieces of bone were felt. Meanwhile ~rterial blood had rushed so profusely from the deepest part of the wound--either from the internal maxillary artery ~tself or from one of its largest branches (possibly the meningeal)~that the boy, weakened by the two previous h~emorrhages, became alarmingly collapsed. By the aid of ether, administered subcuta- neously, he rallied. Direct digital pressure within the wound somewhat controlled, but did not completely arrest, the flow of blood. The depth from the surface of the zygomatic fossa, in which the forefinger was

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buried ; the narrow, undilatable channel laading to it, between the zygoma and sphenoid, which admitted little more than the finger; and the con- stant welling up of the blood through the wound, rendered ir impossible to ascertain with exactness the source of the bleeding or t o adopt any other measure for its control than direct compression with'in the wound. Ligature of the carotid ar tery was reserved as a dernier ressort in the event of the failure of compression. The entire wound was therefore carefully plugged from the bottom with long strips of lint. This effectu- ally checked the htemorrhage. The gradual removal of the plugs was commenced on the fourth day, from which time they were thoroughly carbolised. On the ninth day the last plug was floated out without recurrence of bleeding. ~_~ each dressing, when the wound was filled with water, the fluid rose and fell in unison with the pulsation of the brain. ~ o untoward intra-cranial or other complications arose--owing, I believe, largely to the free bleeding. The wound rapidly healed by granulation to a certain point. The sinus, which continued to discharge in January, afforded evidence that necrosis of the fractured sphenoid bone had taken place. The boy was 'therefore sent home, to allow of the gradual and complete separation of the dead bone before its removal was attempted. On his return at the end of six weeks, the probe struck loosened dead bone. On the next morning, having opened up the wound in the temporal fossa, I removed many large, detached sequestra from the sphenoid. Smaller pieces of bone subsequently exfoliated, and were withdrawn from time to time, till the last piece was extracted about five months after the accident, and the wound then completely healed. The boy has since presented himself on several occasions, and is in the en- joyment of excellent health, both mental and bodily.--April 13, 1878.

Cerebro-Spinal Meningitis.--DR. HA~DEN said: I beg to submit a case which I think of some in teres t - -a t least prospectively. I t is an example of cerebro-spinal meningitis which proved fatal in the Mater Misericordi~e Hospital on the 1st of this month. I t is the third case of the k ind- -no t exactly similar in all its features, but in the main identical with the others--which I have witnessed within the last two months. I t may be well, perhaps, to impress facts of this kind upon the profes- sional mind, because it may be the first indication of an epidemic visitation of this formidable disease such as that which presented itself with such terrible features in Dublin some years ago. I have observed that within the last fortnight Dr. Maclagan, of Dundee, called attention to the great number of cases of this kind which had occurred in his practice ; but several features of the cases that he noted were not similar to those in the case to which I am about to direct attention. ~_ young man, aged twenty-four, a plasterer, of intemperate habits, having been out of employment for some time~ was admitted into the Mater

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)1isericordim Hospital on the 27th of last month. He was apparently in general good health, putt ing aside the disease which he was then suffer- ing from. He had, however, been subject, off and on, to attacks of pain in the head, as I learned from his friends. Ten years previously he had had an attack of this kind of a very aggravated character. He recovered and was able to pursue his trade. Three or four days before his admis- sion he was suddenly attacked with severe pain in the head, accompanied by vomiting. He had a rigor, and when I saw him on the 29th of February, his condition was as follows : - - H e was more or less incoherent, and was muttering and giving irrelevant answers. His temperature, I regret to say, was not registered, but as indicated by the touch it was rather high. The pulse, however, was rather slow. The conjunc- tivae were deeply injected, and the eye-balls were somewhat prominent. On his body--especial ly on the abdomen, the back, the posterior sur- faces of both arms and elbows--were large blotches of irregular outline, and of a light purple or dark-red tint, varying in size from that of a sixpenny piece to that of a half-crown. These spots became pale under pressure of the finger, but on the pressure being removed the colour returned. He complained of weakness on the right side, and I found that his r ight arm was manifestly weaker than his left, and that his r ight leg was similarly affected--articulation, however, was not affected. I at once declared the case to be one of cerebro-spinal meningitis, and had his head shaved and blistered. On the following day he had improved somewhat, was able to speak to me collectedly, and looked better, while the pulse was more steady, and he declared that the pain in his head was less urgent. Unfortunately, however, these improve- ments were of very short duratibn, for on the next day he was still worse than on the first day, and quite comatose; the eyes actually projecting from the orbits, the pupils dilated, and the conjunctivae deeply injected with purple blood. The r ight side, r ight arm and leg, were completely paralysed; the left side, however, was not affected. He could not swallow, and died in the course of that day. The patches, I should have observed, continued to the end. The brain and spinal cord are now before you, but have been changed in colour by the solution in which they were immersed. My resident pupil reports that he found in the cavity of the arachnoid five or six ounces of serum, and that the dura mater was firmly attached to the upper surface of the cerebrum in several places. The arachnoid at the base is opaque, but there is no lymph effused, nor is anything visible of the character of pus. General opacity and great vascularity are the features the brain presents. The choroid plexus is also vascular. The brain substance in one situation at the base is rather sof t - - the middle lobe, on the one side, being remark- ably soft, as well as the posterior boundary of the fissure of Sylvius. The cord presents features of great interest. You observe that about the

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middle of the dorsal region it has become perfectly diffiuent and of the consistence of thick pus. Immediately below this, and at about the level of the seventh dorsal vertebra, the substance of the cord seems to have entirely disappeared--no doubt, during the process of removal, leaving only the theca. I examined a portion of this soft creamy substance under the microscope, and as well as I could ascertain by a cursory examina- tion~ it seems to be simply the cord substance. There were large cells and fibres, and fragments of tlbres, but no pathological product whatever. The membranes of the cord were vascular before they became affected by the solution in which they were placed. I have no doubt the cord, already softened~ sustained injury during removal. I may mention that about a month ago I met another case in private practice somewhat similar to this, with prominence of the right eye-ball, injection of the conjunctiva, and dilatation of the pupil. The patient had several attacks of severe rigor like those of intermittent fever, followed by very high temperature~ but not by perspiration. In that case I could not make a post mortem examination. The third case to which I have alluded was that of a young man, aged twenty-one, who was admitted into the fever ward of the Mater Misericordim Hospi ta l He had severe pain in the head from the outset~ and other symptoms of cerebro-spinal meningi t i s - - such as partial incurvation of the spine, a feeling of soreness in the calves of the legs~ and constant moaning. He died, and I had no opportunity of examining the body. Dr. Maclagan reports that what was most noteworthy in the cases that he saw was their close resemblance to cases of typhus fever. The spots, however, were not of the same tint as those of typhus. They were rather larger~ and disappeared rapidly long before the subsidence of the fever. He makes no allusion to large blotches, nor to the proptosis which were the most remarkable features in two of the cases which I have referred to. One eye-ball only of the private case was prominent--whils t both eyes projected in the case from which the present specimen was taken. In addition to the dilatation of the pupils, there was a remarkable injection of the conjunctivm with dark purple blood.

AmpT, oric Resonance in .Pneumonia.--D~. N l x o ~ said : I t is unnecessary to be prolix as to the particulars of the case I am now about to exhibit, as it is in many respects an ordinary one. I t consists of the thoracic viscera of a man, aged fifty-six, who was admitted into hospital on the 26th of February. He gave us the history of a prolonged rigor which he had had some eight or nine days previously; and at the time I examined him I found that he had solidified right lung. t t i s pulse was very rapid, and his temperature ranged from 102 ~ to 104 ~ . His pulse was 120 and his respiration from 30 to 40. A peculiarity of the case from the start was the very remarkable condition of his tongue, which was extremely dry and brown~ like that which occurs in advanced

346 Reports of the Dubli,~ Pathological Society.

stages of dysenteric ulceration. In the course of the case an amphorie resonance became developed at the base of the right lung to an extremely marked degree. In fact it was better marked in this case than ever I found it before. The day befvre the man's death we found that he had distinct pericardial friction-sotmds. Fo r the first few days there was sputum of a rusty character, but no expectoration after that ; but as he had pericarditis I thought the case was one in which there had been pneumonia ending in the purulent infiltration stage. I make the remark because ir~ post martem examinations of cases of pneumonia which had ended in purulent infiltration, I' have always folmd more or less evidence of pericarditis ; sometimes it was only a small pasty exudation in the back of the auricle. In all those cases, to% there was a complication of pleurisy. I am not able to trace any connexion between the lesions of the lung and of the pleura, but merely say that in all the eases I found some evidence of pericarditis. The present case is agoed example of that marbled condition of the lung which accompanies purulent infiltration. With reference to the amphoric resonanc% I found quite sufficient evi- dence to account for it. Above~ the lung is~ as you can see~ apparently solid, and friable. As you go downy you find that the extent of the disease is much less marked. Towards the centre of the lower lobe of the same lung a portion of it crepitates, so that it evidently contains air. The explanation offered of this amphoric resonance is that i t is due to an extension of inflammation from the root of the lung upwards or downwards~ as the case may be~ which consolidates that part of the lung and presses the air into the uppermost or furthest part. Consequently you have the centre of the lung solidified and all round that centre portions of the organ permeable to a i r ; in other words~ the phenomenon is due to imprisoned air in the lung. :Dr. t tayden has shown that the old sup- position that it is due to air in the pleura is wrong. Last year I treated an old woman who suffered from this form of pneumonia, characterised by the lung being excessively large and almost solidified. In that case the amphorie resonances existed for three or four fingers' breadth below the clavicle ; and on the day of death i t reduced to only a finger's breadth below the clavicle. O n a post mortem examination I found the whole lung perfectly solid except a small portion at the top~ about the size of a marbl% which crepitated and evidently contained air. These cases show that the theory I have given is the correct one. The condition of the pericardium affords a ~ery good example of recent pericarditis. There was but a small quantity of fluid in the pericardium~ of a reddish- brown colour.

DR. H/~YDE'~'.--This form of pneumonia has received the designation of typhoid pneumonia. I t is most commonly met with in the apex of the lung. In that respect it differs from ordinary pneumonia~ and is also most ge~aerally met with in debilitated subjects who had been

ReTorts of tl~e Dublir~ Pathological Society. 347

addicted to intemperance. I have met several examples of this, and some years ago I grouped those which, up to that date, I had observed, and. published them in the Dublin Medical Journal. I then held, and still ho ld- -and I am glad to find that Dr. N.ixon's ease tends to confirm my v i e w q t h a t the phenomenon of what I called muffled tympany is due to the imprisonment of air in the pulmonary tissue. In fact, i t is the sound of static, or stagnant, air under percussion. The case is, moreover, of great interest in t h i s - - tha t the phenomenon occurred at the base of the lung. I have not personMly observed a case in which it was not strictly confined to the upper lobe of the lung, and I have regarded it as an indication of most decidedly stimulating t reatment-- large doses of quinine and whiskey.

TREATMENT OF TYPHOID FEVER.

DR. WILLIAM PEPPER in a clinical lecture remarks that in the second week of the disease, when the abdominal symptoms of pain and diarrhoea have fully set in, one-quarter of a grain of nitrate of silver with one- twelfth of a grain of belladonna, and from one-sixth to one-half of a grain of the watery extract of opium, should be given in pill form three times a day, after meals. Under this treatment diarrhoea and tenderness diminish, and patients make very rapid recoveries. In most cases very little stimulant is used. Milk and beef-tea are the only articles of food he allows. Quinia is given with other tonics. Fever is reduced by frequent spongings of the skin of the entire body. When the high fever resists sponging, cool baths are employed. Indiscriminate bathing in typhoid fever is often extremely injurious. The best time for the use of the cold bath is in the early stage, during the first week or ten days. In cases where the temperature rises above 103 ~ , and is not con- trolled by frequent spongi~gs, large doses of quinia (quinia acts most admirably, both in this and other disease s as an antiphtogistic) diapho- retics, &c. When the fever in the subsequent stages runs high, it is the nature of a sympathetic fever, largely dependent on the amount of intestinal lesion; hence cold baths are less valuable at that time and attended with more risk. l~itrate of silver is used both with the hope of limiting the amount of the specific follicular catarrh of the intestines, and with the intention of favoarably modifying the seeondary sympa- thetic symptoms. The very best results are also obtained by the con- tinued use of nitrate of silver in chronic infiamn~atio~ of the bowels, and in gastric ulcer. The nitrate is given in doses of a th i rd of a grain a couple of hours after meals. D r . Pepper has cured thirty-nine out of forty cases of typhoid fever in which it has, been employed by this nitrate of silver treatment. (The t~oston Medical and ~urgical Journal, October 257 1877.)--•ractitioner, Sep , 1878.