319ACADEMY OF MEDICINE IN IREI AND.

SOOREE CHARITABLE DISPENSARY.FRACTURE OF SKULL; EXTENSIVE EXTRAVASATION OF

BLOOD ON DURA MATER, PRODUCING COMPRESSIONOF BRAIN ; TREPHINING ; PARTIAL RELIEF OF

SYMPTOMS; DEATH.

(Under the care of Dr. G. C. ROY.)DURING a drunken affray in a liquor shop, the patient

was knocked down by a blow on the head from a heavy stick.He fell down insensible, but recovered consciousness aftera while and was able to speak, but soon relapsed into astate of insensibility, in which condition he was taken tothe dispensary next morning, and placed in bed.When seen, the man was unconscious and very restless,

tossing about in the bed, and he made no response to ques-tions put to him. His pupils were normal; the breathingwas at times natural, with a tendency to stridor. Pulse 72,small. There was no paralysis, but the limbs were ratherrigidly flexed. The scalp at the junction of the sagitto-coronal suture was contused and puffy, and a depression wasfelt in the skull just outside this line and to the left. Acrucial incision was made over the part, and the trephineapplied over the depressed segment. A linear line of frac-ture traversed this space, but the depression was limited tothe outer table, and was caused by the condensation of thebone from the force of the blow. A probe was gently passedbetween the bone and dura mater to scoop out any bloodthat might have been effused on its surface, but only a fewsmall pieces of clot could be thus removed. The wound wasdressed with cotton soaked in weak carbolic acid.Next day there was a return of consciousness. The patient

opened his eyes when spoken to loudly. He also put out histongue, and pointed to his head as the seat of pain. Hewas, however, very dull and stupid, and could not speak.The progress was impeded next day by an attack oferysipelas, which travelled from head to face and neck, andafter three days left him in a very exhausted condition.For the next three days the patient’s condition was hope-

ful. The wound was granulating. and he could answer

questions by signs, though still unable to speak. He tooka fair quantity of rice and milk. The rigidity of the limbsdisappeared, but the pulse went up to 116, and a tendencyto pneumonia of the left lung was manifested. On the ninthday after operation he was decidedly worse, the consolidationof the lung had progressed, and he died quietly at night.Necropsy.-The extensive fracture passed across the

squamous portion of the left temporal bone, and bifurcatedat the external angle of the orbit, enclosing a bit of loosespiculum. Another line of fracture radiated upwards fromthe centre of the first, and terminated at the seat ofoperation. A thick layer of coagulated blood rested on thedura mater just opposite the temple-dimension 5 x 3 x 1 inch.At the lower part it was an inch thick and adherent, butgradually thinned on the top. Another patch of coagulatedblood was found on the right side, opposite the parietaleminence. The dura mater and brain were healthy. Theleft lung was in the first stage of hepatisation. Other organswere healthy. The wound was healthy-looking.

Medical Societies.ACADEMY OF MEDICINE IN IRELAND.

AT a meeting of the Medical Section held on May 16th,Mr. JOHN B. STORY exhibited a patient suffering from

Atrophy of both Optic Nerves, and Paralysis of the Olfac-tory Nerves and of the Sensory Division of the Right FifthNerve. The patient was an unmarried woman, aged thirty-two, who had enjoyed good health till the winter of 1882-83,when she began to suffer from a violent pain in her head.The pain later on became so violent as to confine her to bed,where she remained for some months in the spring andsummer of last year. After a time she became com-

pletely unconscious, and when her consciousness returned(about July, 1883) she found her senses of sight and smelltotally lost, and sensation absent from the right side of herface and the little finger and ulnar side of the ring finger ofher right hand. She noticed at the same time a defect in thesense of taste in the anterior portion of the tongue atthe right side. The examination of the patient completely

established the truth of her statements, with the exceptionof the paralysis of the fingers, which did not then appearto exist. Corneal and conjunctival sensibility was completelyabsent, and the palpebral and lacrymal reflexes connectedwith it, while the cornea itself was perfectly healthy; andthe tension of the right globe rather above that of the othereye. He considered the case to be one of cerebral tumour,but could not assign any definite locality to the sup-posed new growth. The atrophy of the nerves was un-

doubtedly produced by optic neuritis. He commentedon the various theories explanatory of the connexion betweenpapillitis and brain disease, and upon the current views asto the production of neuro-paralytic keratitis. The secretionof saliva from the right parotid gland was, so far as carefultesting with vinegar could ascertain, completely abolished,that from the left gland being perfectly normal.-TheCHAIRMAN (Dr. H. Kennedy) would connect the symptomswith a tumour at the base of the brain, implicating particularnerves or parts. There seemed to be less vomiting thanusual in the case related. - Dr. C. J. NIXON consideredthat if Mr. Story was perfectly satisfied there was a lesionof both nerves of smell, and at the same time a lesionaffecting some of the fingers of the hand and the forearm,it would be perfectly possible to account for all the pheno-mena that existed on the idea of an isolated tumour. It wasremarkable to find that, with the implication of the sensorydivision of the fifth nerve, there was complete loss of thesense of taste on the corresponding anterior portion of thetongue. This was directly in opposition to a case recordedby Althaus, in which he excluded the fifth nerve as ad minis-tering to the sense of taste on the antero-lateral region ofthe tongue.-Mr. STORY, in reply, said he had tried iodideof potassium for some weeks without alteration in the sym-ptoms. In answer to Dr. Nixon, he pointed out that theywere all familiar with the fact that loss of sense of smell Ifollowed paralysis of the sensory portion of the fifth nerve.In this case a probe might be put up the right nostril with-out the slightest effect; but if the left were touched inthe same way, the patient shrank with pain. Assafcetida,valerian, oil of cloves, or ammonia, had no effect on the rightside, whereas on the left the sensation was produced con-sequent on inhaling strong smelling salts.

Dr. C. J. NIXON read a paper on Reflex Paralysis, inwhich he summarised the different views which had beenheld in favour of and against the theory of this form of para-lysis. He first examined the class of cases of paralysiswhich are usually cited as caused by reflex influence—viz ,amaurosis from affections of the fifth nerve, and paralysis ofthe orbital nerves from a like cause. Having shown thatthese cases may be explained without reflex mechanism, henext examined the evidence as to the existence or non-existence of reflex paraplegia. Examining the views of Brown-Séquard, Gull, Leyden, and others, and the experimentalobservations on the subject, he directed attention to theabsence of any true conception of the mode in which paralysisby reflex action is brought about, except we understand it-tobe produced by inhibitory influence ; so that reflex paralysis,if it have any meaning, must be inhibitory paralysis. Thisname had at least the advantage of suggesting the way inwhich the phenomena of disease are produced. Dr. Nixonthought, however, that there was no necessity to admit theexistence of an inhibitory paralysis, as, taking for instancethe cases recorded as reflex paraplegia, they could arise indifferent ways-as an ascending neuritis, which sets upmyelitis from extension of inflammation along the veinsto the spinal cord, or from a lumbar-sacral neuritis, whichdescends along the sciatic nerves.-Dr. McSwiNEY calledattention to the so-named reflex paralysis following wounds,of which Weir Mitchell had given many examples, includingparalysis affecting the upper extremities, right or left,where a wound had been received in the lower extremities,right or left.-Dr. BENNETT considered Dr. Nixon’s paperopen to the objection characterised by lawyers as "pleadingdouble." In his hospital experience Dr. Nixon had neverseen a case of reflex paralysis, while he quoted instances ofinhibitory nerve influence, which he held to be anothername for reflex paraplegia. It was difficult, therefore, tofollow his argument.-Dr. WALTER G. SMITH, looking atDr. Nixon’s conclusions as a whole, said his views must to agreat extent be felt to be in accord with those of modernteaching, supported by the pathology of nervous diseases ;so that very few, if any, physicians or surgeons wouldnow accept Brown.Sdquard’s teaching in his interestinglectures on Paralysis ot the Lower Extremities. Caution

320 CAMBRIDGE MEDICAL SOCIETY.

must be observed in dogmatising too strictly as to whatcould or could not happen in the domain of the nervoussystem. Dr. Nixon did not sufficiently allow for theextremely important effects of local sensory irritations, whichinclude both the skin and internal skin or mucous mem-brane-in other words, stimulation of a limited area

of the sensory nerves. The curious thing was that,no matter what part of the skin was stimulated, similareffects followed. It was known that death occurred duringthe early stage of inhalation ot anseathetics. Again, ticklethe inside of the thighs and in a bright light the pupilswould be seen to dilate. It was difficult to say whatchannel that influence travelled up, yet it was the influenceof reflex action. Indeed, it was well known that thevomiting centre could be approached by many channels.Modern teaching had undoubtedly narrowed the field ofreflex diseases, and while they should be thankful to thoseinquirers who had cleared away so much obscurity, it wastoo soon to urge anything positive as to the phenomenabeing a reflex arrest of function, without speculating thatthe mechanism by which it was produced might not arise inthe body.-The CHAIRMAN called Dr. Nixon’s attention to aclinical aspect of this question. He had himself put onrecord a host of cases of children, from five to seven monthsold, who had suddenly lost power of one arm, and in thesethe scarification of a gum or an active purge produced a cureat once. Thus the reflex paralysis was in these cases due toirritation of the mouth or the accumulations in the intes-tines.-Dr. NixoN replied that he had used the term " in-hibition first, as a step in getting rid of the theory ofBrown-Sequard that the paralysis was due to reflex spasmof the bloodvessels of the spinal cord; if not to that, it wasdue to something else, a number of things, and he took in-hibition as one to which it might be due ; and he had saidthere was no necessity for introducing this explanation ofthe theory of disease at all, inasmuch as it had been estab-lished that the paraplegia assumed to be reflex was due tocauses which had been ascertained, as an ascending neuritisor a descending neuritis, or a neuritis established by thetravelling up of inflammation along the veins. The receivedexplanation of the results of the operations he had citedwas that they were due to what was understood as thephenomenon of inhibition. If they were not satisfied thatthe cases of paraplegia recorded had most distinct and posi-tive pathological lesions to explain them, then the theory ofparalysis by inhibition was the one that would satisfy thescientific requirement best. But in the absence of neces-sity there was no use introducing a new term into medicalpathology. With regard to Dr. Walter Smith’s observationsas to the effect of stimulation, Brown-Squard had mentionedthat peripheral stimulus might act in three differentways-it might influence secretion, or the condition ofthe bloodvessels or of the muscles. In his paper beforethe section, he had confined his observations to thecondition of the muscles that might be said to be in-fluenced by peripheral irritation. He did not discussthe condition of the bloodvessels such as would be broughtabout from irritation of an extensive surface of the skinfollowing a blister, &c. Dr. Smith seemed to have dealtwith spasms as being connected with paralysis. There wasnot the slightest doubt that peripheral irritations of variouskinds-worms in the intestines and teething-produced con-vulsive phenomena ; but it was quite a different thing withirritation transmitted to the cord. Irritation was supposedto pass to the motor area, and yet the usual result was notattained. Although he had seen a great many cases ofparalysis, he had never seen one that he could connect withany of those cases of local irritation such as teething, or thatgot well on suddenly lancing the gum, and he did not seewhy paralysis should be cured by such a simple procedure.The object of his paper was to show that such a thing wasa physiological impossibility.On the motion of Dr. Grimshaw, the remaining papers on

the agenda were, for want of time to be read, referred tothe Publication Committee.

CAMBRIDGE MEDICAL SOCIETY.

AT the meeting on July 4th, Professor Humphry, M.D.,F. R. S., in the chair,Mr. BALDING (Royston) exhibited a specimen of Sareoma

of the Left Tonsil, taken from a female aged fifty-three,who first came under observation on Aug. 7th, 1883, in

consequence of sudden and profuse haemorrhage from themouth, which appeared to be arterial. At this time therewas sore-throat of a month’s duration, with some ill-definedindurated swelling in the left submaxillary region, greatfetor of breath, and complete fixity of the lower jaw, whichrendered any examination of the mouth or throat impossible.This alarming haemorrhage soon subsided, and only recurredonce, to a less amount, ten days later. On Nov. 8th theswelling in the neck had slowly increased, without havingbecome either very painful or tender, and some deep-seatedfluctuation now appeared to indicate the existence of pus.This was easily reached and evacuated, and it was estimatedthat an ounce was let out on the first day. This gave someslight relief, and at the end of a week the abscess hadcompletely healed. Ten days later a second abscess wasdetected and opened, and this healed rather quicker thanthe first. These abscesses were just on a level with theupper margin of the thyroid cartilage, the second posteriortothe first. There was no subsequent suppuration. Duringthe time of formation of these abscesses there was

considerable swelling of the tongue, especially in the lefthalf, so that for a few days it could be scarcely kept within themouth, but after the second abscess was opened the swellingsubsided, and was almost immediately followed by furtherswelling of the tongue, this time principally affecting theright side, so that it was protruded from the mouth andfirmly grasped by the teeth. The swelling subsequentlysubsided so as to allow the tongue to be returned within themouth. The patient died on Jan. 12th ; the swelling in theneck had for a fortnight previous to death encroached on thetrachea and caused some difficulty in breathing. Duringthe whole course of the case the patient was able to takefluid nutriment with but little difficulty. The necropsyshowed a firm growth involving the left tonsil; it extendedinto the submaxillary region, infiltrating the glands andsurrounding structures. The epiglottis was also partiallydestroyed. Microscopically, the growth proved to be around-celled sarcoma.Mr. MANBY (East Rudham) related a case of Morphia

Poisoning unsuccessfully treated by Hypodermic Injectionof Atropia. At 11.30 one evening he was hastily summonedto a lady who was known to be suffering from internalcancer, with considerable intra-peritoneal effusion &c. Hefound her lying on her back, with livid face, dropped lowerjaw, closed eyes, and apparently dead. Shortly after, respira-tion commenced, in Cheyne Stokes’ manner, with palatalstertor. The skin was moist; pulse 108, soft, and risingwith the breathing to 120 or more ; pupils contracted topins’ points, and insensible to light; conjunctivse insensateto the touch. The most violent irritants applied to thetrunk had no effect in exciting reflex action. On inquiry, hewas informed that the patient had that evening returnedfrom London. The previous evening she had an ineffectivehypodermic injection of morphia, in consequence of whichthe nurse, obeying instructions given her to increase thedose if necessary, without any clearly defined limit, hadabout 10 P.M. injected a larger quantity, correspondingto at least a grain and a half. It was clear also, fromthe account given, that the needle had not been inserted onthe previous occasion. The symptoms supervened very soonafter the injection. Mr. Manby made use of all the ordinarymeans to arouse her, but without success. He then, at11.45 P.M., injected beneath the skin of the arm five minimsof the liquor atropiae, without effect on the pupils or respira-tion. At 12 P.M. he injected another ten minims, whichhad a slight stimulating effect on the pulse, so at 12.15 headded ten minims more. Then, after using a powerfulmagneto-electric current to the prsecordium, another injectionof five minims was repeated. No improvement followed,and the patient died about 1.30 A.M., three and a half hoursafter the morphia injection. The amount of liquor atropiinjected was thirty minims, or a quarter of a grain ofatropine.

Dr. RANSOM related five cases of Croup. He said theterm " croup" was used to indicate a group of symptoms.All the cases were children under six years of age. Threedied and two recovered. The trachea was opened in one ofthe fatal cases. The symptoms in all the cases were verymuch alike. There was at first little or no constitutionaldisturbance, and in two cases at the beginning no rise oftemperature. The fever in no case exceeded 101° F. thetonsils were swollen, and there were patches of exudationon them and on the aorta, but very little appearance of in-flammation. All the fatal cases died from asphyxia; in one,