PART III.

MEDICAL MISCELLANY.

REports, Transaetlons, and Scientific l'ntellige~lce.

R O Y A l , A C A D E M Y O F M E D I C I N E IN I R E L A N D .

President--SIR CHARLES BALL, M.D., F.R.C.S.I. Ge,era l Sec re t a ry - - J . A. SCOTT, M.D.. F.R.C.S.I .

SECTION OF MEDICINE.

President---Sin JOHN MOORE, M.D., D.Sc., F .R.C.P. I . Sectional Secretary--F. C. PURSER, M.D., F .R.C.P. I .

Friday, February 10, 1911.

THE PRESIDENT in the Chair.

(a) Athetosis. (b) Occupation Neurosis. DR. O'CARROLL showed two cases illustrating these con- ditions.

(a) The first case was that of a schoolgirl, aged nine. The patient 's right hand had been for four or five years un- manageable for action. The thumb was fixed in a position of adduction, but otherwise there was no noticeable differ- ence between the hands when at rest. Once movements were at tempted slow, spastic movements were noted in the right hand and fingers. The child had had severe whoop- ing-cough before the affection was noticed, and Dr. O'Carroll considered this had led to a cortical hmmorrhage into the right hand area, the athetosis resulting therefrom. When left to herself the child, who had learned to write with her left hand, exhibited perfect " mirror writing." The con- dition was improving.

(b) The second case was that of a barber. This patient

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exhibited weakness and choreiform movements in his right hand. His trouble had begun some ten months previously. At first there were malaise and difficulty in hair-cutting and shaving. These actions gradually became impossible. The patient was of a neurotic temperament. His work had kept him busy from early morning till late at night for many years. Dr. O'Carrotl considered the movements in the patient 's hand were fatigue phenomena, due to excessive use.

Dm CROFTON discussed the share of toxins in producing the neuro-muscular condition in the second case, noting tha*o the patient suffered from pyorrhcea alveolaris.

The Differences in the Mani]estations of Rheumatism in Childhood and in Ad'Mt Li]e.

DR. BOYD BARRETT read a paper on this topic. He referred to the occurrence in children of rheumatic tonsillitis, chorea, " growing-pains," rheumatic nodules, " stiff neck," and hip- joint affections of rheumatic origin, and cardiac trouble. Emphasis was laid on the absence of hyper-pyrexia and the rare occurrence in children of early years of acute poly- arthritis. He stated, in conclusion, that rheumatism in children was eharacterised by (1) the variety of its manifesta- tions, (2) its insidious onset, (3) the mildness of the arthritic symptoms and the corresponding severity of the cardiac trouble.

This paper gave rise to a lively discussion, in which the CHAIRMAN, and DRS. O'CARROLL, ]~RURY and :DAY, and Sm W. J. THOMPSON took part.

Myasthcnia Gravis. DR. T. GILLMAN MOORHEAD read a paper on " Myasthenia

Gravis." l i t was pubished in the number of this Journal for March, 1911, page 161.]

DR. CROFWON said he was much interested in Dr. Moor- head's paper, especially as regards the question of ~etiology raised by the condition of the thymus gland and the infiltra- tion of the muscles with small round cells. He referred to a report which had been made of two cases of thymie asthma, in which there had been extremely flabby muscles and general muscular exhaustion. The interest attached to these cases was the way in which they had been trea~ed. Their blood condition was different to that which Dr. Moorhead

Section o] Medicine. 463

described. There were less than 5 per cent. of mono- nuclear cells. These two patients were t reated by X-rays, and they got perfectly well; they lost their thymic as thma and their blood condition was restored to normal. Animals which had been injected with extract of thymus, causing toxic symptoms, died in the condition of asphyxia. He also re- ferred to the effect of giving extracts of the sexual glands. The two lines of t rea tment might throw light on the con- dition of myasthenia gravis. First of all, X-ray t rea tment of the thymus might be tried, then extracts of the testis might be given. In many cases of neurasthenia testicular extract had produced marked improvement . Pat ients who com- plained greatly of tiredness improved in a remarkable way.

DR. ~IOORHEAD said that in his case of myasthenia gravis he had hopes of being able to find an enlarged thymus, but there was no enlargement of the area of dulness on percus- sion, so he did not think X-rays would be of use in that par- ticular case. As to the thymus extracts producing toxic symptoms, he believed this was incorrect. He had re- peatedly injected thymus extracts into animals, and never found any toxic symptoms whatever. The toxic symptoms in Dr. Crofton's case were probably due to sepsis. Dr. Henderson ' s researches had impressed him with the idea of working out the inter-relations between organs as regards the effect of certain obscure metabolic products. I t might throw light on this case, in which he had found, so far, no single extract to be efficacious.

A Case o] Cerebral Tumour. DRs. PARSONS, BENSON, and WIaHAM and MR. JOHNSTON

brought forward a case of intra-cranial tumour which was successfully localised and removed. The patient, aged thirty-six years, was admit ted to the :Royal City of Dublin Hospital suffering from severe and continuous headache of about five months ' duration. On examination he was found to have double optic neuritis, more marked in the right eye than in the left, slight paresis of lower half of face on the left side, and slight deflection of the tongue, when protruded to the left. He positively denied any history of syphilis. He was given iodide of potassium, fifteen grains daily, for the following month, but the progress of his disease was definitely down- ward. He became odd in his manner , stupid, passed under

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him, and developed marked ataxy of the lower extremities. A diagnosis of a tumour in the right frontal lobe in the neigh- bourhood of the face and tongue centres was made. Mr. Johns ton trephined over this region, and removed a hardened mass in three portions, which was handed to Dr. Wigham, who reported that the mass was syphilitic. The operation was followed by complete loss of power in left arm and leg. The latter soon recovered, and later on he gained free power in both arm and leg. The optic neuritis rapidly subsided, and vision was almost normal when he was discharged. There was a marked improvement in his menta l condition, and all ataxy had disappeared. His blood, tested by Wasse rmann ' s reaction, gave a positive result. He was dis- charged from hospital a little over two months after the operation, in full possession of his menta l and physical faculties, except slight traces of optic neuritis, which was, however, in process of subsidence.

Mm A. H. BENSON said the case was the only one in which he had observed absolutely unequivocal signs of improve- ment in the optic neuritis after a decompression operation.

MR. G. JAMESON JOHNSTON described the technique of the operation.

Dm WIGr~A~ stated he had diagnostieated the specimen he had received as syphilitic. H e had tried the Wassermann reaction on the same pat ient without knowing it was the same patient, and had found it positive.

DR. DON•ELLY described two cases of a similar nature to that described by Dr. Parsons. In both cure seemed to follow the liberal administrat ion of iodide of potassium.

DR. I~fELDON believed tha t potassium iodide acted only in those cases which had been well treated with mercury. H~ said also that he bad administered the anaesthetic in this case, giving ether and oxygen, and that it was extremely satisfactory, there being no vomiting.

DR. PARSONS, in his reply, said the pat ient had been given over 400 grains of iodide of potassium, hut that , despite this, his condition had got steadily worse.

Section of Medicine. 465

Friday, March 10, 1911.

ThE PRESIDENT in the Chair.

Notes on Three Cases o] Paratyphoid Fever. DR. GEORGE PEACOCKE described three cases of this affection which had occurred among the nursing staff of an hospital in the month of November, 1910. The symptoms were similar in all cases, and closely resembled those of enteric fever. The onset was sudden, with fever, general malaise, head- ache and pain in the neck and constipation. Rose-eoloured spots were present on the abdomen in two eases, but in none was the spleen palpable. The duration of pyrexia varied from two weeks to four weeks. Phlebitis complicated one case and gall-stones another. Convalescence was in all eases prolonged. The agglutination test with Eberth 's bacillus was negative in all the eases, but clumping occurred with a bacillus isolated from the urine of one ease. This bacillus was subsequently proved to be Paratyphoid A.

DR. SCOTT said his attention was drawn to the fact that he failed to get the Widal reaction. He had an opportunity of examining a similar ease in which he failed to get a reaction with typhoid bacilli. There is a peculiar con- dition in which the clumps consist only of two or three bacilli, and in which he always felt in doubt as to whether he should call the reaction positive or negative. When such clumping with typhoid bacilli occurred further investigation often ~roved the case to be one of paratyphoid fever.

DR. DAY said on making an examination of the blood in the mild cases which first seemed to be typhoid one often eventually found them to be paratyphoid. He did not think that paratyphoid was necessarily a mild disease, and men- tioned the case of a man who went from bad to worse, and finally died from this disease.

DR. O'KELLY said he had a case of paratyphoid in which Peyer 's patches were inflamed but not ulcerated; but on the ileo-c~ecal valve there were very deep ulcers.

DR. BEWLEY mentioned three eases in young men who were brought into hospital. In one of these there was pro- fuse h~emorrhage. He said that paratyphoid was much commoner than it was thought to be.

DR. O'FARRELL and the PRESIDENT also spoke. DR. PEAeOCKE replied.

2G

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Htiology and Treatment o/ Diabetes MeIlitus. :DR. W~I. MERVYN CROFTON read a paper on the above. [ I t

will be found at page 420.] DR. MOORHEAD said the treatment of diabetes mentioned by

Dr. Crofton was built up by hypothesis based upon hypothesis. He asked what proof existed that Dr. Crofton's extract contained a co-ferment in this fluid. The only proof that he could find that this fluid contained any active principle was the statement published in a paper by Dr. Crofton last year, that this fluid enables the body to burn up its carbohydrates better, but that was an obvious petitio principii which no scientific man can accept. As regards secretin, he men- tioned Dr. Starling's statement that this substance cannot be absorbed from the intestine, and he (the speaker) said that his experience was that this drug was valueless in pan- creatic diabetes. Dr. Crofton had stated that he had seen cases of improvement follow which could not be attributed to anything else, but you will find variations in the amount of sugar and the absence of diacetic acid in diabetics without any treatment at all. He had given the drug a fair trial, and did not believe it to be of any use. As regards the com- bined action of pancreatic extract and muscle on carbo- hydrates, Cohnheim's experiments were still the subject of controversy. If they were not confirmed a great deal of Dr. Crofton's paper falls to the ground. Cohnheim's theory is first assumed to be true, and secondly it is assumed that quite likely the pancreas produces an immune body which takes part in metabolism. Another assumption is that there is a liability to bacterial infection--a liability which he quite admits - -but when he comes to the explanation that it is due to the absence of an immune body he finds merely unproved assumption based upon unproved assumption. As regards lesions in the pancreas it depended on whether one was look- ing for them or not. One person says that the islands of Langerhans are positively destroyed, while another says that the islands have nothing to do with diabetes. Dr. Crofton laid special stress on the fact that his patients improved on the extracts, and that with giving a full diet. He (the speaker) could not see where was the improvement con- sidering the so-called improved patients passed more water with a greater percentage of sugar. A mere statement by

Section of Medicine. 467

a patient that he felt bet ter was worthless, and until Dr. Crofton could adduce definite proof of improvemcnt in his cases he (the speaker) thought that the less said about his method of t rea tment the better.

~PROFESSOR COLLINGWOOD said as regards Cohnheim's ex- periments it is possible that they were due to bacterial in- vasion. There is a further action of secretin which has been neglected. I f pancreatic ferments are mixed with secretin these ferments are activated by the fact that secretin has come in contact with them.

Da. KmK~ATRmK said he had tried secretin in several cases, and he could not say there was any satisfactory result. He mentioned the case of one patient who con- tinued to lose weight under secretin, but increased in weight by 5 lbs. with Dr. Crofton's extract, and no longer com- plained of thirst or hunger. His experience of the drug in other cases justified his continuing its use.

I )m \u agreed in this view. DRS. :PARSONS, NESBITT, EUSTACE, and STEVENS also

spoke. THE PRESIDENT referred to the use of codein and liquid

extract of cascara sagrada. The former he regarded as more useful than any ferment in the t r ea tment of diabetes melli tus.

DR. CaOFTON said his extract differed in no way from Cohnheim's. He made his extract from pure pancreas. H e did not see how this could affect the co-ferment. He referred to the improvement which his patients have had when taking this extract, and he laid emphasis on the fact tha t he did not pretend to cure, but to render his pat ients ' lives more comfortable. As regards Cohnheim's theory that the malady was due to micro-organisms, this could be put out of court at once, for it was proved that microbic action was entirely absent. As to the metabolism of fat, it is no hypothesis, but an established fact. I t is certain that if you inject into the body foreign protein you will get these co-ferments. There was no great anatomical change in the pancreas. I n some there was an interlobular fibrosis, atrophy of its secret- ing epithelium, and the cell islands seemed to be diminished. I t looks like a pancreas which was undergoing atrophy. As regards mental influences he did not think the improvemenr could be put down to that, as the patients were very sceptical about the drugs they were getting. As regards the treat-

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ment by codein, he ~hought i~ very useful. I~ may act by blocking the messages sent to the brain asking for more sugar, or, by combining with dextrose, it in some way renders it easier for oxidation than it was before.

RESECTION OF POSTERIOR ROOTS OF SPINAL NERVES.

ABBE has an article on resection of the posterior roots of the spinal nerves for the relief of pain, pain reflex, athetosis and spastic paralysis. He describes how the operation was first suggested by Dr. Dana in 1888. He gives a brief report of the five cases on which he has operated; three of these have been fully reported before, the other two are new. He has somewhat modified the 3riginal operation, now removing only the laminae of the vertebrae on one side and dividing, not the whole of each of the dorsal roots, but only a half, or three out of the five strands composing each root. The first two cases were done for very severe spas- modic pain of the arm; in both cases the pain was intense, an~I various operative measures had been already tried, even to amputation. Both cases were greatly improved by the operation, but in neither case was the cure complete. The third case suffered from athetoid paralysis of the arm followed by severe and increas- ing neuralgia; here again various operations had been already done, ending in amputation at the shoulder, without relief. In this case also, although the operation of section of the roots caused considerable improvement, it did not bring_about a complete cure. The fourth case was operated on for unbearable pain, the result of inoperable sarcoma of the axilla ; the patient lived in comparative comfort for three months after the operation. The last case suffered from spastic hemiplegia of the arm accompanied by constant pain. The pain was completely relieved as was also the spasm. As might have been expected there was no change in the paralysis, t ie concludes as follows : - - " The further extension of the operation to attempted relief in cases of violent crises of pain and locomotor ataxia, and even in wryneck spasms, suggests a widening field not yet sufficiently tested for report. The principle of cutting the links in the sensory reflex chain is anatomi- cally and physiologically correct. Although in paralytics the motor nerve tru~fl~s may not be able to restore function in all cases, the return pain-stimulus which excites the spastic distor- tions are relieved."--Medical Record, March 4, 1911.