540 ROYAL MEDICAL AND CHIRURGICAL SOCIETY.vzv

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reintroducing the tube into the wound, which had partlyclosed ; the tube was reinserted. On the thirtieth day afterthe operation the tube was left out entirely, and on the thirty-fourth day the wound was closed and breathing through thenatural channel was completely re-established. Some slighthoarseness of the voice passed off in a few days.Rermarks.-Recovery in children under two years is rare.

The case illustrates the advantages of operation before thepatient has become moribund and of alcohol even for aninfant twelve months old.

Medical Societies.ROYAL MEDICAL AND CHIRURGICAL

SOCIETY.

Cases of Pleurisy caused by the Pneumococcus, and withConstitutional Symptoms resembling those of Pneumonia.-Relationship between Disorders of Digestion and Neur-asthenia.

AN ordinary meeting of this society was held on Feb. 27th,Dr. CHURCH, Vice-President, being in the chair.

Dr. WASHBOURN communicated a paper on cases of Pleurisycaused by the Pneumococcus, and with Constitutional Sym-ptoms resembling those of Pneumonia. He described threecases. In the first case the symptoms were those of

pneumonia, but the physical signs were not characteristicand the sputum was not rusty. The attack began suddenlywith a rigor, and on the tenth day the temperaturehad fallen and the constitutional symptoms had dis-

appeared. The patient was considered to be convalescent,but the physical signs did not clear, and the tempera-ture subsequently rose. An exploration of the chest re-vealed the presence of pus. A drainage-tube was insertedand the patient made a good recovery. The pus was foundto contain the pneumococcus by the usual bacteriologicalmethods. The case was at first considered to be one ofpneumonia followed by an empyema, but looked at it inthe light afforded by the other cases he believed that itwas one of primary empyema. In the second case the con-stitutional symptoms were those of pneumonia, and includedhigh temperature, cough, rapid breathing, delirium, and

herpes. The physical signs, though not typical, were notmore atypical than they often were in pneumonia. The

patient died after a few days’ illness. At the post-mortemexamination the lung was found to be healthy, but therewere fifty-four ounces of pus in the right chest. The puscontained the pneumococcus. In the third case, that of achild, there was double pleurisy with some effusion. Afew ounces of fluid were removed by aspiration, andwere found to contain the pneumococcus. The case

terminated fatally, and at the post-mortem examination bothpleuræ were found to be covered with thick tenaciousfibrin. It was well known that the pneumococcus was themost common cause of croupous pneumonia, and the sameorganism had been found in pleurisy and empyema. Suffi-cient stress had, however, not been laid upon the fact thatthe pneumococcus might produce the same constitutionalsymptoms when invading the pleura as it did when invadingthe lung. Dr. Washbourn believed that the second case showedthat this was true. The third case was of interest, inasmuchas the constitutional symptoms were similar to those of

pneumonia. The patient might have recovered, and the casewould probably have been considered to be one of pneumonia.He believed that many cases diagnosed as pneumonia,but with equivocal signs, were really cases of pleurisycaused by the pneumococcus. He would point out the

importance of exploring the chest in such cases, and wouldurge the necessity of the bacteriological examination of thepus of empyemata, as it was possible that, when due to thepneumococcus, a simple aspiration would be sufficient.-Dr. HALE WHITE said that, in addition to the two cases underhis observation which were recorded in the paper, he had seenfour other cases during the last few months. A man wasbrought to hospital with every sign of pneumonia, therehaving been a rigor, herpes, and rusty sputum, with rapidbreathing and high temperature. A loud rub on the right sideobscured the physical signs. The temperature gradually fellin eight days and he was only slightly better ; it then rose

again and the man died suddenly. At the post-mortem

examination a small empyema was found at the base of theright lung, and pus had soaked into the lung, which was.partly gangrenous. The patient also suffered from malig-nant endocarditis. A girl came into hospital with a fairlytypical history of pneumonia. At the left base there wasmuch dulness, but only a little bronchial breathing. Three-ounces of pus were obtained on aspiration. After elevendays the temperature gradually fell and she died suddenlyin the night. At the necropsy no signs of pneumoniawere found, but there was a thick layer of fibrinouslymph in the pleura, with some turbid fluid. A middle-aged’woman was admitted with marked signs of pneumonia at theleft base, but the area of dulness overshadowed the other-signs. The temperature gradually fell and then began slowly to.mount again. Repeated attempts to find pus resulted in theevacuation of four ounces ; after that she recovered. A boyaged six was admitted with a typical history of pneumonia.The temperature, after falling, began slowly to mount again.Half an ounce of pus was found by aspiration, and after thatthe patient did well. He related other cases to show the asso.ciation of the pneumococcus with empyema, meningitis, andendocarditis, and said that it perhaps explained the associationof jaundice with one case of pneumonia and of retraction ofthe head with another. In those cases of empyema due to,the pneumococcus the signs would not be typically those ofpneumonia, the local signs being especially aberrant : thetemperature usually fell slowly, the physical signs did notclear up readily, and the patient did not seem to be muchbetter after the fall of the temperature. With the furtherrise of the temperature diarrhcea often developed. Thedisease was general, and might affect not.only the pleura,but also the meninges &c. Pericarditis, when it occurred,was due to an infection of the pericardium by the diplo-coccus, and not to simple extension from the pleura, as hadbeen commonly taught. There need not always be pus presentto explain the physical signs, for in one case with the secondrise of temperature there occurred a rigor and a large fibrinousexudation without empyema.-Dr. SANSOM said that it didnot seem to him that influenza had been excluded from thesecases. The bacillus of influenza was very apt indeed to beassociated with other well-known bacilli. Thus, influenza}

pleuro-pneumonia was recognised, and influenza gave remark-able help to the development of tuberculosis. The casesrelated resembled the forms of pneumonia often met witbsince the influenzal epoch, the general symptoms being severe,while the local condition might be atypical. The influenzabacillus, having a tendency to attack nervous structures, dis-turbed the trophic condition of the lungs, and then the pneu-mococcus could develop more exuberantly.-Dr. KANTHACKsaid that it was generally admitted that the pneumococcus wasthe common cause of pneumonia. Since October he had ex-amined fifteen uncomplicated cases of pneumonia, and in allthe pneumococcus of Fraenkel was present; in thirteen it wasin pure culture, and in two others it was associated with thestaphylococcus pyogenes aureus and a streptococcus respec-tively. If the sputum of a patient before the pneumonic crisis.was injected into a rabbit or guinea-pig the animal died frompneumococcus septicæmia, but if sputum taken after the crisis.was injected the animal was rendered immune from pneumo.-coccus infection. He examined a case of purulent meningitisand found the lungs free, but the pus in the cerebral andspinal membranes contained pure cultures of pneumococcus.In a case of ulcerative endocarditis the pneumococcus was.found associated with the staphylococcus albus and aureus; qthe same three organisms were found in embolic abscesses inthe lungs. In a case of purulent peritonitis in a young girland in another of suppurative pericarditis and peritonitis withempyema, in two cases of otitis media, in one of empyemaof the frontal sinus and in one of pneumonia suddenly fatal!and associated with empyema pure cultures of the pneumo-coccus were found.-Dr. CHURCH asked whether any controlexperiments had been performed with the pus from ordinaryempyema to see whether the pneumococcus could be found inthem.-Dr. HALE WHITE, replying for Dr. Washbourne, saidthat pneumococci had been found in the pus of ordinaryempyemata. He said that it was remarkable that the pneumo-coccus often did not produce the toxic symptoms if it wasnot developing in the pleura or lung. People badly affectedwith the toxin of pneumonia were liable to die suddenly.A paper was then contributed by Dr. A. S. ECCLES on

the Relationship between Disorders of Digestion and Neur-asthenia. The definition of Beard that neurastheniais a chronic functional disease of the nervous system,the basis of which is impoverishment of nervous force,

541MEDICAL SOCIETY OF LONDON.

waste of nervous tissue in excess of repair," was adopted.References were made to Thomson and Kowalewsky in

support of the contention that neurasthenia arose fromdisordered digestion. Motor inefficiency of the gastro-intestinal tract appeared to be the commonest factor in theproduction of nerve malnutrition. Of 65 cases in whichneurasthenia and disorders of digestion coexisted 19 pre-sented signs of gastric ectasis and 17 were examples of intes-tinal muscular atony. Of the remaining 29 cases 13 sufferedfrom diarrhoea and 16 from disorders of digestion not asso-ciated with dilatation, constipation, or diarrhoea,. Dilatationof the stomach had been recorded by Dujardin-Beaumetz,Champagnac, Germain Sée, Albert Mathieu, and others as co-existent with neurasthenia. The cases quoted by Dr. Eccleshad been observed daily for periods varying from a fortnightto ten weeks, the dimensions of the stomach having beenascertained by physical and other tests. An appendix ofcases in a tabular form accompanied the paper, but certaincases were detailed in support of the view that local abdo-minal disorder preceded and caused neurasthenia in a largenumber of cases, and diagrams illustrating these were

appended. The present paper was devoted to the considera-tion of those cases in which either dilatation of the stomach orcoprostasis had induced malnutrition of the nervous system,the record of twenty-nine other cases of gastro-intestinal dis-ease resulting in neurasthenia being reserved for a future com-munication.-Dr ALTHAUS said that he objected to the term"neurasthenia " because it was not only indefinite but it hadunpleasant associations. The exclusive seat of these troubleswas in the brain, and he therefore proposed the term

I I encephalasthen,.a " The three principal areas affectedwere the intellectual sphere, the sensori-motor area, and themedulla. The gastric symptoms were due to disturbances ofthe gastric centre of the bulb. Two forms of dyspepsia wereusually present, one from undue excitability and the otherfrom loss of power in the medullary centre. The formerwas associated with irritable dyspepsia, with heart-burn,gastralgia, and vomiting, and was also associated with a red,furred tongue, while in the latter there was atonic dyspepsiawith retarded digestion. A neurotic inheritance was a con-stant predisposing cause.-Dr. HERSCHELL asked whether thehydrochloric acid in the gastric juice of these cases had beenestimated. —Dr. ECCLES, in reply, said that in his paper hehad used the terminology of Beard. His view was that thecerebral centres suffered from malnutrition induced by peri-pheral irritation. He had estimated the hydrochloric acidpresent by Gunsberg’s test.

MEDICAL SOCIETY OF LONDON.

Third Lettsomian Lecture on the Clinical Features and Treat-

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ment of Peritonitis. - -

AT an ordinary meeting of this society on Feb. 26thMr. TREVES delivered his third Lettsomian Lecture. Thefollowing is an abstract :-The general symptoms of peritonitis are so well known and

have been so precisely described that they call for no specialconsideration in the present lectures. It will be necessaryonly to deal with the characteristics of certain individualsymptoms and to define the clinical peculiarities of certainvarieties of peritoneal inflammation. The general arrange-ment of the nerve-supply of the parietes of the abdomenand of the abdominal viscera enables the most rapid possibleconduction of reflex impulses. Absolute rigidity of theabdomen, a limitation of the abdominal respiratory move-ments, and a tenderness of the surface are amongthe very earliest symptoms of acute trouble withinthe abdomen, the tenderness depending upon an actualhypersssthesia of the surface rather than on tendernesswithin. These signs are most marked in cases which aresudden and acute, and where the peritoneum at the time ofthe outbreak was perfectly normal. Great retraction of theabdomen has been for the most part noticed in connexionwith perforation of the stomach. As peritonitis advances,both the hyperæsthesia of the skin and the contraction of theabdominal wall usually disappear, and some cases run theirentire course with a flaccid abdominal wall and with scarcelyany tenderness. The pain, which the patient feels to beactually situated within the abdomen, has the pecu-liarity that it is not as a rule to be localised at first, but iscommonly referred to the great abdominal nerve centres ; butas the symptoms progress the localisation of the pain becomes

usually more and more precise, assuming that the troubleremains to a certain extent local. Into the great question ofthe physiology of peritoneal shock I have no intention ofentering. Certain symptoms which are collectively known asthe phenomena of shock mark almost without exception theclinical beginnings of those cases of peritonitis which areabrupt in their onset or acute or even subacute in their course.These symptoms are evidently entirely due to an impressionupon the nervous system and are independent of inflammation, on the one hand, or of septic intoxication, on theother. The signs of sudden and grave disturbance of theperitoneum are pain, profound exhaustion, a distressfulanxiety, pallor, a small, soft, quick pulse, cold extremities,shallow respiration, and vomiting; these symptoms are

common to all cases in which there has been a rude and

abrupt impression made upon the nerve centres within theabdomen. To these common phenomena of a crisis withinthe abdomen Giibler has applied the convenient term of"peritonism." That the nervous system plays a prominentpart in the symptoms of an advanced peritonitis is evidentfrom a study of intestinal neuroses : for colic, diarrhoea,meteorism, and feculent vomiting, and even some signs ofstrangulation may be present without intestinal lesion. It isusual in peritonitis for the mental faculties to remain clear upto the very verge of death. In the 100 hospital cases alreadyalluded to there were only 11 with intense headache ordelirium,all of which proved fatal. A rigor does not often mark thecommencement of peritonitis. There were 13 instances amongthe 100 cases, of which 10 died. The degree of meteorismmet with in peritonitis varies considerably and is influencedby conditions which are not yet fully understood. It is not

uncommonly absent in cases of septic intoxication attendedwith symptoms of a low type. It is most marked in peri-tonitis attended by actual intestinal obstruction, in examplesof perforation, in cases in which there is thrombosis of themesenteric vessels, and in instances in which opium hasbeen freely administered. It does not appear to varywith the amount or degree of the vomiting, nor doesit seem to depend upon obstruction in the lumen ofthe bowel or upon accumulation of gases in the intestineabove the lumen of the occluded point. Experimentsseem to show that meteorism, as met with in disease, dependsalmost entirely upon gross disturbances in the circulation ofthe blood through the affected portion of the intestines.Could one single symptom be selected as the one more-usually present in all cases of peritonitis, it would probably bevomiting, but this is most usually slight; it is more alarmingfrom its persistence and the evil prognosis it suggests. It is’very little in the more insidious septic cases, in the aged, and’in the subjects of advanced visceral disease, but it is usuallymarked and copious in the peritonitis following strangulatedhernia ; it is conspicuous in perforative peritonitis, but it isusually absent in cases of perforation of the stomach. Inthe peritonitis of typhoid fever the vomiting becomesmaiked if the action of the bowel ceases. Vomiting isnot pronounced in intestinal disease, including mischiefin the appendix; in the latter case it is less where thebowels act regularly. It is seldom very distressing in

pelvic peritonitis. It is rarely absent in those cases fol-lowing operation or accidental wounds. Constipation is aconspicuous feature in peritonitis. In the 100 cases fromthe London Hospital the bowels are classed as "loose"in 28. From a study of these cases it would appear that,other things being equal, a better prognosis attends the casesin which the bowels are acting, and that a specially evilprognosis must be associated with the cases marked byabsolute constipation. As to lung complications, among the100 cases there were no less than 17 in which pleurisy orpneumonia appeared after the peritonitis set in ; 7 of thesewere examples of peritonitis of intestinal origin, 5 of thembeing cases of hernia or of perforation, and 10 were cases ofperitonitis starting from the pelvic organs or from sourcesoutside the abdomen, 4 of the latter following a wound inthe abdominal wall. The nature of the peritoneal exudationappears to have little bearing upon the lung complica-tions. The temperature in peritonitis is liable to fluctua-tions so numerous and extreme that it is difficult, ifnot impossible, to deduce any type of temperature whichmay be considered to be characteristic of the disease.It is of little guide in estimating the gravity of thecase or in forming a dogmatic prognosis. Perforation leads atfirst to a sudden drop in temperature ; if the body heat beat the time high the onset of diarrhoea is associated with amore or less rapid diminution of fever. Of very’grave prognosis