CLINICAL SOCIETY OF LONDON.

1386

logical

one.

the three

He himself

always

took his

pulse readings in

positions.

Dr. ’l’noROWGOOD observed that in the pregnant woman there was no difference in the pulse, whether they were standing or lying. The test of elevating the arms in cases of weak heart should be applied with care and caution ; he had seen a patient who tried it fall down in a faint and later the same man died suddenly of cardiac disease. Dr. STEPHEN MACKENZIE referred to the irregular heart which occurred in anmmia, in which there was often a peculiar rhythm, as pointed out by Dr. Wilks. In diphtheria there was a great alteration in frequency of action, together with marked irregularity. He agreed that the prognosis was graver when the patient was cognisant of the malady. He knew of a medical man who had had an irregular heart for twenty years and seemed none the worse for it. He had seen instances where an irregular or intermittent heart had become regular during the course of an acute disease. He quoted a case to show how suddenly rapidity of cardiac action niight come on and pass off. In cases of irregularity the trouble often passed off, but in cases of intermittency the

condition was generally permanent. Dr. SOLOMON SMITH doubted if there was a valid reason for drawing a line of distinction between cases of irregularity

of hearts which were diseased and those which were not. The symptoms and the causation of the irregularity in the two were precisely the same. Treatment in both, which was directed to external causes of irritation, was more likely to be efficacious than measures aimed at the heart itself. In all cases of irregularity there was a dislocation of stimuli, which made the heart contract arhythmically ; even where the cause was intrinsic it might not be always due to overloading of the heart and need not mean weakening of the heart muscle, This view of the even in cases of organic valve disease. origin of the irregularity would bring the two classes of cases more in line. Dr. ALLCHIN referred to the cases associated with mental trouble, and asked Dr. Sansom whether in such instances he had found the irregularity associated with a high tension pulse which remained permanently, but was unaccompanied by albuminuria, the heart itself appearing normal ; he had seen several such cases. The severity of the symptoms was generally in direct proportion to the acquaintance of the patient with his condition. Dr. SANSOM, in reply, said that one of the objects of his paper was to insist that cardiac irregularity might be perfectly devoid of really dangerous significance. He thought that nasal and aural troubles were the commonest reflexes which started the cardiac derangement. In the diphtheritic cases it was difficult to eliminate the myocarditis which might be present. Though irregularity often ceased with the onset of acute disease it usually returned after the latter passed away. Intermission was generally persistent and was serious only to a minority. He had related elsewhere many cases of irregularity coexistent with high tension. He concurred entirely in the view that the irregularities in cases of cardiac disease were ingrafts of a neurotic character on the cardiac lesion and were not part of the disease itself. Many cases of mitral stenosis were accompanied by irregularity, due to an interference with the transmission of nerve impulses between the auricle and the ventricle. The irregularity in typhoid fever was probably due to myocarditis. Fatty degeneration of the heart was not usually accompanied by irregularity, contrary to what was once the accepted teaching. The objects of his paper were to show that cardiac irregularity might co-exist with a sound and good organ, and that irregularity was one of the not infrequent associations of Graves’ disease.

CLINICAL SOCIETY OF LONDON. Subacute

Pulmonary oedema occurring above a diminishing Pleural Eff1lsion.-Excision of a Wandering Spleen for Axial Rotation.-Ilemiple,qia in Typhoid Ir’ever.-Ir’ract1lre of ZOK’0* Ja1v with Traumatic Aneurysm. AN ordinary meeting of this Society was held on Dec. 9th, Sir Dyce Duckworth, President, in the chair. Dr. JAMES CALVERT read a communication on a case of Subacute (Edema of Lung occurring above a diminishing pleural effusion. A man aged forty-five was admitted into the Royal Free Hospital on Sept. 22nd, 1891, with pleural effusion. On Sept. 23rd the whole of the left side was dull with fluid ; it was aspirated and forty-five ounces of clear yellow serous fluid drawn off, followed by partial expansion

The position of the heart of lung above the fourth rib. beneath the sternum was not altered by the aspiration; it was evidently held by adhesions. Two weeks after the operation the lung above the fourth rib became oedematous, with abundant subcrepitant rales, and profuse expectoration of grey frothy, watery fluid. During these two weeks the effusion had diminished, which was evidenced by the sinking in of the intercostal spaces, by the resonance of the sound side extending to the left of the sternum and by the breath sounds becoming audible at the base behind; theupper limit of fluid could not be percussed out with accuracy because of pleural thickening and adhesions. The osdema persisted for three weeks and then began to decline gradually, so that when the patient left the hospital in January only an occasional crepitation could be heard. He attended as an out-patient for six months and during this time he had no. cough, no expectoration, no crepitations, and he gained weight and strength. The temperature after the aspiration was normal throughout. This subacute oedema, evidently different to the acute oedema occurring immediately after aspiration, was not due to an increasing effusion compressing the lung, or to a rupture of the effusion into the lung, or to new growth obstructing the venous return, but was probably due to obstructed venous return in a lung held by adhesions and endeavouring irregularly to expand in presence of a diminishing effusion. Practical point :-These crepitations, limited to one apex and persisting for weeks, were not due to phthisis.Dr. SAMUEL WEST thought that the case stood almost by itself ; he had never seen anything of the kind. What, he asked, was the comparative frequency of acute oedema of the lung7 It occurred in only a small percentage of cases of pleurisy. He referred to an instance which was not long ago in St. Bartholomew’s Hospital, under Sir Dyce Duckworth. Paracentesis was performed and about two hours afterwards. the patient expectorated two pints of fluid. It gave rise to no symptoms because only one lung was involved, and in a short. time the expectoration subsided and the patient did well.The PRESIDENT could not believe that these cases were at all allied to acute cedema, which itself was exceedingly uncommon.-Dr. CALVERT, in reply, said that the colour of the. effusion which was drawn off was yellow, whereas the expectoration was grey, like soapy water. Therefore he did not think it could have come into the lung through a crack in thepleura, as some had suggested. Mr. BLAND SUTTON communicated the details of a case in, which he had performed Splenectomy for a Wandering Spleen. The patient, a married woman aged twenty-two, mother of one child, became aware of the existence of a swelling in the left half of the abdomen. In March she was seized with acute pain in the tumour, accompanied by vomiting and diarrhoea. On her admission to the Middlesex Hospital the tumour, which was very mobile, resembled!) hydronephrosis of a movable kidney, but the diagnosis was. eventually reduced to a hydatid cyst of the omentum or a wandering spleen. On March 21st an exploratory operation was undertaken and the swelling proved to be a greatly enlarged spleen, with a twisted pedicle. The pedicle was untwisted and the spleen returned to the left hypochonThe patient lost her pain, rapidly convalesced drium. and left the hospital wearing a carefully adjusted belt. Six weeks afterwards the spleen was in its normal posiOn July 7th the tion and apparently of proper size. patient came again to the hospital with a return of her trouble ; the "lump " had appeared again and she was suddenly seized with acute abdominal pain, vomiting, diarrhoea and haemorrhage from the vagina. After consulting with his senior colleagues Mr. Sutton advised the patient to submit to removal of the spleen. In order to give some idea of the wandering capabilities of the spleen it might be mentioned that on July 9th it was in the right iliac fossa in front of the caecum. On July 10th it was in the left iliac fossa, resting 011 Poupart’s ligament. On July 12th it was in the pelvis, its lower end resting on and doubling up the uterus. Splenectomy was performed on July 12th, the abdomen being opened through the scar of the first operation ; the incision extended from the umbilicus to the symphysis pubis. The pedicle was. twisted through three complete turns and with its distended veins looked like a huge umbilical cord. Thepedicle was transfixed and tied in two halves with thin but strong plaited silk and then encircled with a separate ligature for safety. The wound was closed in the usual manner. The patient was treated as after an ovariotomy and recovered without the least drawback. The spleen weighed sixteen ounces, and though of an unusual Aape

1387 was

in texture

quite natural.

Observations

on

the numerical

Mr. WAINEWRIGHT read the notes of

a case

of Fracture of

1 Lower Jaw associated with Traumatic Aneurysm. The strength and proportions of the blood-corpuscles were madethe before and subsequently to the operation, and it had been patient, J aged twenty-three, was admitted on July 24th, arranged to continue them for some months to come.—The ;1889, into Charing-cross Hospital, having been jammed PRESIDENT, while congratulating Mr. Sutton on his excellent 1by a descending lift, and sustained a fracture of the l result, hoped that the sequel of the case would be reported lower jaw on the left side together with concussion of the

1 Some days later an abscess formed on the right side Society. He remarked on the apparent thickness of brain. the splenic capsnle, as seen in the specimen ; but this wasand was opened. He left the hospital on Aug. 18th, but I on the 29th with fresh abscesses formed over the due to its shrinking and preservation in spirit.-Dr. GLOVERreturned asked if anything in the previous history explained the con-right side of the jaw, which were likewise evacuated. On i 31st he was seized with a sharp pain on the right side of dition found. Was it not possible to have fastened thethe i face and on examination a pulsating swelling was diswandering organ to the parietes ?-Mr. SUTTON, in reply, the said that Dr. Andrews in the St. Bartholomew’s Hospitalcovered in the parotid region. The house surgeon was sumReports had collected the histories of a number of cases ofmoned and, considering the pulsation to be merely transaxial rotation of abdominal organs. Such cases first camemitted from the carotid artery, cut into the swelling, giving into prominence when a discriminating diagnosis of ovarianexit to a small quantity of pus, which, however, was immetumours began to be made. The spleen was so greatly dis-diately followed by a smart gush of blood, when it was distended that he feared even to handle it, much more to put acovered that a traumatic aneurysm had been laid open. Mr. stitch in it. Records showed that it was very difficult to un- Wainewright was called and he found a second and hitherto twist the pedicle, and they demonstrated that the far safer unsuspected fracture of the jaw just below the right condyle. practice was to remove the spleen rather than allow it toThe right common carotid artery was ligatured and the remain or endeavour to replace it by external manipulation. wound healed readily, but a fortnight later hemiplegia slowly ( Dr. FRANcis HAWKINS read notes of a case in which developed associated with mental weakness culminating in Hemiplegia with Aphasia occurred during the course of Idementia. The mental symptoms subsequently improved to typhoid fever, and at the necropsy a thrombus was found ina limited extent. the left auricle and a clot in the left middle cerebral artery; the case was also complicated by purpura and haemorrhage OPHTHALMOLOGICAL SOCIETY. from the bowels. In an analysis of seventeen cases which had been collected from various sources, hemiplegia was found to have been associated with typhoid fever three times Kerato-malacia in Young Lhildren. - Panop hthalmitis following in children, the youngest being between two and three years ; Rupture of the Optic Nerve. the remaining cases occurred in adults, most cases at ages AN ordinary meeting of this Society was held on Dec. 8th, between twenty and twenty-five ; the oldest patient was the President, Mr. Henry Power, F. R. C. S., in the chair. Mr. HoLMES SPICER read a paper on Kerato-malacia in thirty. As regarded sex it was much more frequent in males than in females and the period of occurrence was between Young Children. These subjects were more liable to ganthe third and fourth weeks and during convalescence. In one grene of the cornea than adults when their vitality was instance hemiplegia was noticed as early as the ninth day. The reduced below a certain level. The gangrene might either right side was paralysed in twelve cases and the left in four. be spontaneous or the result of comparatively mild attacks of Facial paralysis was also present in some instances. Aphasia conjunctivitis. In the late stages of tuberculous meningitis was present in twelve instances, being associated in ten cases and in infantile diarrhoea the cornea underwent destruction, with right hemiplegia and in two with left. Haemorrhage this being due partly to exposure and partly to insensibility. from the bowels, syphilis and pneumonia complicated some After measles or whooping-cough, with bronchitis and cases. The duration of the hemiplegia was in most instances malignant varicella, where there had been much exhaustion, from ten days to several weeks, but in one case it lasted only the cornea was not infrequently seriously damaged by large three days. Recovery took place in the majority of cases, perforating ulcers. After serious malnutrition the cornea but the hemiplegia remained persistent in some cases and might slough spontaneously, as was not uncommonly seen death occurred in two instances. The cause of the hemi- among nurslings in countries where the mothers practised long plegia when it occurred late in the disease was thought to be religious fasts. In this country it was rare except among the due, as shown in the case recorded, to the formation of a hand-reared who had had insufficient nitrogenous diet. The thrombus in the left ventricle giving rise to an embolus, affection generally attacked both eyes of children from four to and so hemiplegia in these cases was regarded as a conse- nine months old ; it began with dryness of the conjunctiva, quence of a cardiac complication. Instances of such a con- with patches of froth on its surface and with night blindness ; dition in diphtheria and noma vulvse were quoted. When soon the whole cornea became opaque and perforated, the the hemiplegia occurred early in the disease it was suggested termination being very often fatal. In treatment a principal that another cause must be sought, and instances were feature should be the increase of the nitrogenous constituents quoted of hemiplegia being present in cases of pneumonia of food, some meat juice or raw meat finely powdered, in addiand phthisis in which no coarse lesion could be found.- tion to milk for young babies, and cod-liver oil. Locally Dr. HALE WHITE said that the cause of the hemiplegia was un- eserine in the form of ointment should be applied to the eye, doubtedly ante-mortem clotting in the left auricle or ventricle, with warm applications to the lids. Some of the cases under this treatment made a good recovery ; in one case the cornea an embolus being then carried to the cerebral vessels. The cases quoted demonstrated the late period at which the blood tended recovered, although the child eventually succumbed.-The to clot, and showed that a typhoid fever patient was not " out PRESIDENT alluded to the disease as met with in adults, and of the wood " when the temperature fell in the third week. mentioned a case he had recently seen in a woman completely The blood was likely to clot in cases in which severe hoemor- crippled by arthritis deformans.—Mr. DBAKE-BnocKMANN rhage had occurred, these being analogous to the thrombosis said he had met with many cases of kerato-malacia in anasmia and also in low-class, badly fed patients. He re- in India in times of famine, during epidemics of cholera garded the hemiplegia as a complication rather than as a and not infrequently in association with chronic dysensymptom, the blood clotting in the left side of the heart tery. He thought the condition in children was often instead of in the more common site-the left saphena vein.- associated with congenital syphilis. In many cases destrucDr. DIVER asked what line of treatment was pursued as soon tion of the cornea occurred with extraordinary rapidity.as the purpura showed itself.—Dr. VoBLCKER asked if there Mr. DoYNE mentioned the case of a child of six weeks in whom, was any evidence of softening as the result of the embolus. after this condition, -the cornea cleared almost completely.He referred to a case of septic endocarditis associated with Mr. PRIESTLEY SMITH (Birmingham) dwelt upon the neceshemiplegia in which on the cortex of the brain were found sity of keeping a careful watch upon the cornea in children distinct purpuric spots.-Dr. LONGHURST inquired if any and others prostrated by serious illness. The cornea was statistics were extant as to clotting fifty years ago, and he often exposed during sleep and prone to severe ulceration. asked if ammonia or other diffusable stimulant might not be Protection of the cornea by a bandage, or adhesive plaster on the means of preventing thrombosis.—The PRESIDENT said the eyelids, would often prevent this dangerous complication. that nowadays the attention of the practitioner was directed Sometimes even union of the margins of the lids was necestoo little to the patient and too much to the disease, and in sary, as in blepharoplasty. He split each lid at its margin, in these cases the peculiar needs of the individual should always its long axis (as in Arlt’s operation for trichiasis), and brought be thought of.—Dr. HAWKINS, in reply, said that he regarded together the raw surfaces of the upper and lower lids with the hemiplegia neither as a symptom nor as a complication, stitches, without loss of tissue, the results being satisfactory. but as the consequence of a cardiac lesion. No purpuric spots Dr. RoCKLlFFE (Hull) read the notes of a case of were observed on the brain, but there was some softening. Panophthalmitis following Lacrymal Abscess. The patient, to the

LacrynaalAbseess.-1’robable