1805

ROYAL ACADEMY OF MEDICINE INIRELAND.

SECTION OF MEDICINE.

Cerebro-spinal Meningitis.A MEETING of this section was held on May 18th, Sir

J. W. MOORE, the President, being in the chair.Dr. H. C. DRURY read a paper on Cases of Epidemic

Cerebro-spinal Meningitis. After a brief reference to the

past history of the disease from its first recognition in

Geneva in 1805 he discussed its pathology and then theetiology, quoting various authorities on the questions of its

contagiousness and mode of dissemination. The symptomsmore or less important in, or peculiar to, this form ofmeningitis were then taken seriatim and fully discussed,and the means of certain diagnosis by the method of"lumbar puncture" and bacteriological examination weredescribed in detail. Dr. Drury then related eight cases whichhe had met with in Cork-street Fever Hospital. The first

patient, a man, aged 20 years, was admitted on Nov. 18th,1899, and after a prolonged illness he recovered. Of the otherseven patients four died. In only one case was there arash-a feature so typical of the great Dublin epidemicof 1866-67-and this rash was not petechial, but pustular,with haemorrhage into the pustules, and it came late in thedisease. In all the cases the disease commenced suddenlywith rigidity of the neck or actual retraction of the head,and in some cases opisthotonos ; all of the patients haddeafness in some degree, pain in the head and limbs, andKernig’s sign. One case was mentioned, though not includedin the above eight cases, which without bacteriological exami-nation could not have been diagnosed. It was the caseof a man, aged 50 years, who had had pneumonia and wasup about the ward convalescent for a week when he suddenlydeveloped most marked symptoms of acute meningitis anddied on the fourth day. Post-mortem examination revealedpus all over the meninges and a fungous growth on one ofthe aortic valves. This vegetation and the pus yielded purecultures of pneumococcus and not the diplococcus intracellu-laris, though the pathologist (Dr. O’Sullivan) was lookingfor the latter, being unaware of the previous history ofpneumonia.

Dr. A. R. PERSONS read a paper on Cerebro-spinal Menin-gitis, which was discussed with Dr. Drury’s paper.

Dr. N. M. FALKINER presented a table showing the Numberof Deaths in the Dublin Registration Area from all forms ofMeningitis in the years 1895-1900. Taking the years 1895to 1899 inclusive the average number of deaths from allforms of meningitis for the first 19 weeks of each year was102’6, but in 1900 the number of deaths in a correspondingperiod was 182’0 and the increase embraced ordinary menin-gitis, tuberculous meningitis, cerebro-spinal meningitis, bydro-cephalus, and secondary meningitis. All forms of menin-

gitis should be treated as zymotic diseases. Sir CharlesCameron had adopted the proper course in making meningitisa notifiable disease.The PRESIDENT remarked that that was the first occasion

on which meningitis had been made a notifiable disease. Atthe Meath Hospital they had had 11 cases with three deathsand eight cases were still under treatment. This showedthat the mortality was not at all so high as in the epidemicof 1867. The first case was that of a girl, aged three years,who was admitted on Feb. 24th and who recovered. As totreatment, in the present epidemic he had found that themost successful measures were leeching behind the ear andthe repeated application of small blisters behind the ear.The agonisino, n headache was relieved by a combination ofacetanilide, caffein, and sodium bicarbonate.

Dr. 0’SuI,LIVAN described the post-mortem appearances insome of the cases. The fluid obtained by lumbar puncturewas turbid but colourless. The pus in the spinal region layin one case altogether outside the spinal dura, the cord beingquite firm and apparently healthy. In the other cases it layin the meshes of or underneath the pia mater and the cordwas softened. In the brain the pus was in all cases in orunder the pia-arachnoid. The distribution of the pus on thesurface of the brain was very symmetrical. In all cases thecerebro-spinal fluid was greatly increased in quantity and wasturbid, but it was not bloody or (to the naked eye) purulent.The diplococcus intracellularis was found in the turbid fluidand in the pus, usually in pure culture. It grew best on

Löffier’s serum, but also on glycerine agar, and less activelyon ordinary agar. In the pus the organisms were seen in thepus cells, usually in small numbers, as diplococci with theiradjacent surfaces fla.ttened, varying a good deal in size anddepth of staining. They did not stain by Gram’s method.Inoculation experiments were unsuccessful.

Professor E. J. MCWEENEY said that the first case

which had come under his notice was that of a schoolgirlwho died in the Mater Misericcrdiæe Hospital early inFebruary. There was an accumulation of thick mucoidpus symmetrically placed in the posterior cornu of eachlateral ventricle. Microscopical examination of the materialat once revealed the intracellular diplococcus. In allthe cases which he had subsequently examined postmortem the same features recurred : occurrence of actualsuppuration, the pus being very tough and mucoid ;symmetrical disposition of the lesions on each side of thebrain ; distension of the lateral ventricles with turbidfluid ; implication of the sides and back of the cord ; andpaucity of the intracellular cocci in the fibrinous exudationon the membranes. In working with cultures of theorganism care should be exercised, for three Germanobservers had all contracted severe rhinitis and in the caseof one there was some stiffness of the neck as well. Thiswould seem to indicate a slight affection of the spinalmeninges and if the observation were accurate it would serveto show that the path by which the infective matter enters.the cranial cavity is through the nose-possibly then throughthe ciibriform plate. There was a disease of horses, known inGermany as Borna’s disease, in which the essential lesionwas a cerebro-spinal meningitis. Intracellular cocci hadbeen found in the pus and it seemed quite possible that thedisease might prove to be identical with human cerebro-

spinal meningitis. He had heard that numerous cases had

lately been observed in horses about Dublin and this was ofinterest in connexion with the present epidemic amongst.human beings.

Dr. TRAVERS SMITH, Professor E. H. BENNETT, Dr. J.KNOTT, and Dr. J. CRAIG also discussed the papers.

BRITISH ORTHOPÆDIC SOCIETY.-A meeting ofthis society was held at the Orthopaedic Hospital, Bristol, onMay 19th.-Mr. A. H. Tubby read a paper on the Treatmentof Spinal Abscess. He advocated the opening of the abscessas soon as it approached the surface by two incisions as farapart as possible ; its thorough evacuation, and scraping orrubbing oE the lining membrane ; irrigation with iodoformsolution, paroleine, or menthol ; and closure of the incisions.-Mr. Noble Smith advocated incision and drainage and frequentirrigation.-Mr. Jackson Clarke, Mr. W. H. Harsant, andMr. J. Ewens also spoke, and Mr. Tubby replied.-Mr.T. Carwardine opened a discussion on the Treatmentof Severe Congenital Equino Varus. He divided cases

into four groups : (1) severe at birth, (2) severe inchildhood, (3) in adolescents, and (4) in adults. Treat-ment should begin early. Constant personal attentionwas required and persistence in after-treatment. In rigidcases of the third and fourth degrees manipulation alonewas not enough. Tenotomy and the gradual method withapparatus needed patience and perseverance for six or twelvemonths. Wrenching was suitable in patients aged five yearsand upwards. but it was unsurgical and its results weretemporary. Free subcutaneous section was too severe for

young children. The skin was usually too tight to allow ofcorrection. Phelps’s operation was therefore better. Withrespect to tarsotomy and tarsectomy he said that Phelps’soriginal operation did not correct the deformity of thebones, and it made a large wound which took a longtime to heal with subsequent contraction. The resultof astragalectomy was immediate and little after-treatmentwas needed, but it had ended in suppuration and amputationin some cases. Cuneiform tarsectomv corrected the varusdefcrmity and saved time and trouble and expensive after-treatment, but it was a mutilating method and it preventedthe gradual method being employed afterwards. It shortenedthe foot and destroyed the arch. interfered with growth, andleft a stumpy inelastic foot. It treated the effect on theouter side rather than the cause on the inner side of thefoot. Phelps’s latest operation had the following advan-

tages. It saved time ; bony mutilation was slight, planti-grade progression was immediate; the foot was not

shortened, nor was its elasticity impaired ; the ankle andtarsal joints were not interfered with and their mobility was

1806

preserved; being a less severe form of tarsectomy it wasapplicable to younger patients; it could not appreciablyinterfere with growth ; and it treated the foot at the point ofanatomical deformity.-Mr. Ewens, Mr. Little, Mr. Thomas,Mr. Jackson Clarke, Mr. Tubby, Mr. Noble Smith, and Mr.Harsant took part in the discussion, and Mr. Carwardinereplied.-Cases were shown by Mr. Ewens and Mr. A. F.

Blagg. _____________

Reviews and Notices of Books.Ulcer of the Stomach and Duodenum. and its Consequences.

By SAMUEL FENWICK, M.D. St. And., F.R.C.P. Lond.,Consulting Physician to the London Hospital; and W.SOLTAU FENWICK, M.D., M.R.C.P. Lond., Senior Phy-sician to the London Temperance Hospital, Physicianto the Evelina Hospital for Sick Children. London :J. & A. Churchill. 1900. Pp. 392. Price 10s. 6d.

THE morbid condition known as ulcer of the stomach is so

frequently met with and its diagnosis and treatment presentso many points of doubt and difficulty that a monograph onthe subject from such a well-known authority on diseasesof the digestive tract as Dr. Fenwick will be sure of a

welcome from medical men. He has been assistedin the preparation of the book by his son, Dr. W. SoltauFenwick.The work is divided into four parts. The first part deals

with the Pathology and Etiology of Gastric and DuodenalUlcer. The chapter on Morbid Anatomy contains a veryfull account of the various changes found in the walls ofthe stomach when ulceration has occurred, and numerousreproductions of photographs of morbid specimens of ulcerof the stomach materially add to the value of the descrip-tive letter-press. The authors have taken considerable painsin the elaboration of their conclusions respecting the morbidanatomy; the material was derived from the post-mortemrecords of 1015 cases of ulcer of the stomach and of 130 casesof ulcer of the duodenum. In order to avoid the errors thatare apt to arise from the collection of isolated examples ofthe disease the authors wisely confined themselves to the records of hospital cases. One of the principal features ofthe analysis of the cases is the distinction which is madebetween the acute and chronic forms of the complaint asregards their origin, appearances, and modes of termination.Some of the points drawn attention to in this respect areinteresting. For instance, the relative frequency of acute.and chronic ulcers in different regions of the stomach. Outof 39 cases of acute ulcers 13 (33’3 per cent.) occurred inthe pyloric zone, whilst out of 70 cases of chronic ulcers noless than 53 (75’7 per cent.) were found in that region.The chapter on the Results of Ulceration contains a large

amount of useful information. Attention will naturallybe paid to the remarks on hemorrhage and perfora-tion. Considering the wide area of destruction wroughtby a chronic ulcer and the extreme vascularity ofthe stomach, it seems surprising at first sight that

only about 18 per cent. of the fatal cases die from

haemorrhage. The authors therefore remind the readerthat not only is liability to bleeding minimised to a greatextent by obliterative inflammation and thrombosis of thevessels in the immediate neighbourhood of the disease, butthat any rent in their walls is rapidly closed by the contrac-tion of the muscular coat and the coagulation of the bloodat the seat of puncture. It is probable, therefore, that inevery case of fatal hæmorrhage one or more of the followingconditions will be present: (1) non-obliteration of thevessel previously to its erosion ; (2) insufficient contractilityof its muscular coat; (3) deficient coagulation of the blood ;and (4) an abnormally high tension in the arterial or venoussystem of the organ.The effects of perforation of the stomach and duodenum

are treated in an able manner. The pathogenesis of

ulcer of the stomach has always been open to doubt.

Many theories have been from time to time advanced,but no single one has been universally accepted, and theremark of the late Dr. H. Gawen Satton in his lectures tothe students at the London Hospital will probably com.mend itself to the majority of practitioners : " When

asked, What is the cause of simple ulcer of the stomach ?’say, I I don’t know.’"

" The authors of the work under

consideration enter fully into the many views which havebeen expressed, for there are few subjects in pathologythat have given rise to more discussion than the modeof production of a gastric ulcer ; and finally they statethat although our knowledge concerning the causationof gastric ulcer is still very imperfect certain factswarrant us in coming to the following conclusions. Anacute ulcer of the stomach or duodenum may either appearas a primary affection or develop during the course of someorganic or constitutional affection. Acute primary ulcerationoften commences as a hæmorrhage into the inner coats of thestomach during the hyperasmia which takes place at eachmenstrual epoch and under other conditions. Chronic ulcerof the stomach or duodenum may follow the acute disease in

young women or commence by the superficial digestion of aportion of the mucous membrane, where vitality has beendiminished by certain conditions, such as obliteration of anutrient vessel by atheromatous, fatty, lardaceous, or

syphilitic disease, chronic inflammation of the mucous andsubmucous tissues, local ansemia of the gastric wall frompressure, or fibroid or fatty degeneration of the mucousmembrane such as occurs spontaneously after the age of 40years.The second part of the book contains a description of

the symptoms, varieties, and treatment of acute ulcera-tion of the stomach and duodenum. The separation ofgastric ulcer into two varieties-acute and chronic-is certainly to be commended, as without this classifica-tion confusion has arisen in differentiating many clinicalvarieties of the complaint according to the exceptionalprominence of some particular symptom. If this patho.logical basis be accepted the clinical sub-division is

unnecessary. The account of the symptomatology and ofthe treatment is clearly and concisely written, and the

style adopted is one calculated to attract the attention ofthe reader. The surgical treatment of perforation has beenfrequently carried out and the authors have collected thestatistics of a large number of cases so treated. The resultsshow that the operation depends for its success or failure uponthree factors : 1. The time which is permitted to elapsebetween the occurrence of the perforation and the perform-ance of laparotomy. The earlier the operation is performedthe greater will be the chance of its success. 2. The treat.ment of the hole in the stomach-it is absolutely necessarythat the perforation should be closed. 3. The care withwhich the peritoneum is cleansed. After a careful study ofthe reported cases the authors believe that in course of timethe early performance of laparotomy, combined with skilfnlclosure of the perforation and thorough cleansing of the

peritoneum, will render the surgical treatment of perforatedgastric ulcer one of the most successful operations of itskind.The third part of the book deals with the symptomatology

of the ordinary chronic ulcer. Five varieties are differen-tiated and the difficulties involved in their prcgnosis,diagnosis, and treatment are discussed. The classificationis based on clinical grounds, according to the special pre-dominance of some particular symptom such as pain,vomiting, dyspepsia, haemorrhage, and cachexia. The

chapter on Diagnosis is particularly well designed, and theintroduction of tables summing up the points to be reliedupon in differential diagnosis is to be commended.