P R O C E E D I N G S OF T H E P A T H O L O G I C A L SOCIETY OF

DUBLIN.

President--EDwARD HAMILTON, M.D.

Secretary--E. H. BENNETT, M.D.

Ascltes with Hydronephrosis of the Kidney.--DR. LYoNs said: The specimens I exhibit belonged to a man of about fifty years of age, who was unfortunately addicted to drinking in great excess. He had the morbid thirst for drink to such a degree that it seemed to be entirely beyond his control. He was admitted into the Whitworth Hospital between two and three years ago, and was then extensively dropsical. Both his lower extremities were so to a large degree ; his face was puffed, and his abdomen distended, but not remarkably so. His urine was abundant; it was loaded with albumen, and its specific gravity, though varying from time to time, never went below 1015, and was occasionally higher. He was threatened with gangrenous destruction of the integu- ments of the lower extremities, from the enormous amount of distension. I punctured his legs, and thus gave exit to a very large quantity of fluid, which afforded, for the time, very considerable relief. The tendency to accumulation of fluid in the legs seemed to be replaced by a tendency to the accumulation of fluid in the abdomen ; and the distress he suffered from fluid in the abdomen and the distension of his colon was so extreme that, having witnessed the good effects of tapping in two other cases in the ward, he entreated to be tapped. I accordingly tapped him, and drew from his abdomen about nine quarts of fluid; but although this man's sufferings from the distension of his abdomen were as extreme as ever I have seen in any one, yet the quantity of fluid drawn off from him never at any time reached much beyond nine or ten quarts, which all familiar with the operation of tapping know is, on the whole, a moderate amount. The fluid withdrawn was so very peculiar that I requested Professor Tichborne to examine it. I t was of a milky-white colour, and, in a glass vessel at a distance on a table, any one would have supposed it was milk. Dr. Tichborne examined the fhlid, and was kind enough, on the 15th December, 1876, to send me the following report : - -

" Composition of ascitic fluid : Ash - 0"67 Organic matter - 1"3

Total solids - 1"97 per cent.

"Th is solid matter contained, as regards the mineral constituents,

456 Reports of the Dublin Patholoyleal Society.

ehlovldes and phosphates of sodium ; albumen, 1"01 per cent. ; and urea (or a similar body), 0"2 per cent. Specific gravity of f l u id :1011 . "

He puts an asterisk at the word "urea , " and says, in a note, " urea, or a similar body." The history of the ease from that time afterwards may be briefly summed up. The fluid continued to accumulate in the abdomen, so that, at the end of every three weeks, he prayed and besought to be tapped. He had the greatest possible faith in the operation of tapping, he got such immediate and direct relief fi'om it, and was very urgent about it when the fluid reached a certain quantity. About ten quarts of fu id seemed to give him great distress. Altogether he was tapped eleven times, ten by myself, and once, in my absence, by Dr. Harvey. The fluid at all times had precisely the same peculiar milky colour and character, and was I presume, of the same specific gravity and composi- tion as that analysed by Dr. Tichborne. A period now arrived in this re- markable case in which the dropsical effusion seemed to be at an end ; and, after eleven tappings, it was never necessary to tap him again, nor, strange to say, did he require the drawing off of any fluid from his lower extre- mities. He got, in fact, into such a tolerably good condition of health that, at his own request, he left the hospital, and resumed his work for a consi- derable time. But his unfortunate propensity again mastered him ; and, on more than two subsequent occasions he had again to seek admission into the hospital, not so much from any reaccumulation of dropsical fluid in the abdomen or lower extremities as from the state of exhaustion into which he had reduced himself by excessive drinking. He drank every- thing that he could lay his hands on--whiskey, ale, porter, brandy, and wine. And being one of those cheerful good fellows he seemed to have an unlimited command at all times of the good (or bad ?) things of life in the way of drink, and was supplied by his friends freely on all occasions. While away from hospital I saw him repeatedly in the streets going about. He had been on one occasion a pedlar, then he took to labouring work, and he was finally occupied in some &lties connected with the Midland Great Western Railway. He was admitted to hospital for the last time some three weeks since. He admitted that he had had a heavy bout of drink- ing, and it seemed to have finally floored him. On the previous occasions he had exhibited the greatest confidence in his prospects of recovery, but now he seemed to have lost all hope, for he said that he had only come in to die. A certain amount of dropsical effusion had taken place in the lower extremities, but it was not very remarkable considering what was pre~ent on former occasions. :But he now exhibited what had never appeared on previous occasions--namely~ a very great amount of urgent dyspncea; and, if I can attribute his death immediately to any one com- plication more than another, I think it was due to the thoracic complica- tion. He died the (lay before yesterday. The post mortem examination was very carefully made by Dr. Harvey. We found first that the liver

Reports of the Dublin Patl~ological Society. 457

was certainly not in a state of cirrhosis. I cannot agree with those who think that whiskey or even porter drinking is by any means a necessary antecedent in the history of cirrhosis of the liver. In some of the most remarkable cases that I have ever seen the individuals had been tem- perate all their lives, and one case was that of a lady who had never at any time of her life tasted any kind of ale or fermented liquor, and she suffered in a mos~ marked degree from cirrhosis of the liver, which was the cause of her death. My opinion is that the alcoholic liver is one of a widely different kind~ and I think that in the future transactions of the Society we may, perhaps, be able to clear up a good deal of error with regard to the connexion between cirrhosis of the liver and the use or abuse of alcohol. I do not think any one can say that in the present case the liver is in a condition at all approaching to or like that of cirrhosis. The capsule of the organ is no doubt thickened here and there, but I would myself be disposed to attribute this to a certain amount of subacute peritonitis~ which is pretty generally the result of the operation of tap- ping. The liver is of a good brown colour~ but is somewhat smaller than it should be. The spleen exhibits a good deal of inflammation of the capsule here and there, but still is small in size, and not at all the spleen that we are familiar with in connexion with cirrhosis of the liver. I should observe that we are very much indebted to Dr. Harvey for the examination which he made in this case, as well as for his able assistance on all occasions. On opening the abdomen the appearances were striking. The two kidneys were united by a band of tissue, constituting a more or less complete example of horse-shoe kidney. Whether the band of con- necting tissue contains any renal element or not we axe not in a position to say. However, Dr. Harvey will be able to report on a future day whether the band be renal or ligamentous. The right kidney presents a marked amount of fatty degeneration. The capsule is somewhat adherent, but tore pretty readily without taking away much of the renal tissue. You will observe even in the exterior of the organ a considerable ten- dency to lobulation, which is evidenced still further by the sulci being deeper than usual. The cortical portion of the kidney is in an advanced stage of fatty degeneration; we have not yet been able to make a full examination of it under the microscope. The pyramids also are in a state of fatty degeneration. The principal interest is in connexion with the left kidney, which shows an extreme amount of hydronephrosis-- the kidney being separated into two distinct portions, and the posterior and the superior being entirely apart. In this "kidney, also, the tendency to lobulation is pretty well marked; and it seemed as if a congenital condition of ]obulation had been present in both kidneys. There is a considerable amount of urinous fluid retained in the kidney; and, having regard to Dr. Tiehborne's analysis, so kindly made on a former oecasion~ and showing that the elements in the contents of the abdomen then

2 I

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submitted to him were either urea or a similar body~ it was now acutely suggested by Dr. Harvey that the escape of urea from the kidneys, by transudations into the ~bdomen would account for the presence of the urea there. I t is, therefore, extremely probable that the body found was urea, and that it escaped by exudation from the secretion of the kidneys into the abdomen. I do not think we could at all' say that the total amount of fluid in the cavity of the abdomen at any time was attributable to escape from the kidneys in this way. There must have been some other cause for the collection of fluid in the abdomen ; but what it was I do not at present see. We know that it is not a necessary result of renal disease that there should be air accumulation of fluid in the cavity of the abdomen, although it may be so with respect to other organs. The abdomen is certainly not the favourite seat for the escape of fluid in large quantities i,n the case of renal disease. Where other organs are surcharged with fluid~ we often find that effusion takes place at the later stages into the cavity of the abdomen; but here, for two years at least in the, history of the case s there had been effusion to a very large amount into the cavity of the abdomen. Following down the ureters, Dr. Harvey noticed that one of the renal veins lay over the ureter in such a position that when the ttreter was distended with fluid the vein was subjected to a very considerable amount of pressure from beneath s so that the circulation through the kidney was no doubt consider- ably impeded. The ureters are pervious throughout, and without any obstruction; and the catheter passed easily into the bladder in both instances--in that of the left kidney particularly. The passage is quite free to the right kidney also, but that there is some obstruction internally is evident from the fact that though the fluid in the bladder drained away this morning s there has been since a gradual escape of renul fluid from the enlarged calices and pelvis of the kidney. Whether during life the pressure of the vein on the ureter was sufficient~ during the advanced stages of the diseases to retain this mass of fluid, and perhaps even more in the enlarged sac then formed by the ealices and the pelvis, is a nice point to determine. What t he immediate origin of the hydronephrosis in the case may be I do not at this moment see. As I have already stated, I believe that death was the result mainly of the thoracic compli- cation. Dr. Harvey found the right lung in a condition of extreme engorgement~ with evidences of old pleurltic inflammation, and adhesions to the parietes. The upper half of the left lung is a good deal engorged also, and the lower portion of it affords a beautiful and perfect example of emphysema. There was emphysema in the greater portion of it, but the lower portion manifested true emphysema, as was evidenced by the blowing up and distension of the pleural tissue and the escape of air. When the left kidney shall have been opened, and Dr. Harvey enabled to make a full examination, we shall be better able to say on a future

Reports of the Dublin Pathological Soezety. 459

day whether there is anything to account for this peculiar hydronephrosis. Whether i t was partly of congenital origin or was due to mechanical obstruction is not very apparent at this moment. The heart was tolerably healthy ; it was a little enlarged, but there was no valvular lesion of any kind.--December 1, 1877.

Excision of the Hip.--Dr. BENNET~ said : These specimens exhibit the result of the operation of excision of the hip, practised as a treatment for morbus cox~e. Unfortunately the case is, in one sense, too complete, for we have both the portion of the femur removed by the operation, and also the innominato bone an4 remainder of the femur, removed from the dead body many months afterwards. I t was one of ordinary morbus cox~e in a child of. between nine and ten~ years old; in whom the disease had reached the stage of suppuration. He was admitted into the hospital on the 16th of October, 1876, with morbus cox~e of some standing, a lengthened leg~ and an everted foot. On the 13th of March following there appeared, without pain or any marhed symptom attend- ing it, a large abscess in the trochanterie region of tile joint (by this time the llmb had become inverted, and apparently shortened). This pointed just below the aCtachment of the tensor vaginge femoris. He suffered from well-marked hectic. The temperature chart which I produce covers the entire period of his illness. The hectic was established at a temperature of 101 ~ with an evening elevation of 101"5 ~ and a fall to nearly a normal temperature in the morning. This con- dition of affairs extended for a considerable time, and the boy suffered from sweating and diarrhoea. The abscess pointed, and we opened it with antiseptic precautions, and the result was a most pronounced fall of temperature for some days. Then. there suddenly came on a great rise, which was coincident with a development of the phenomenon of putres- cence in the dressing. Al l through the child suffered from a diarrhoea which we could with difficulty control; and there was consequently great difficulty in keeping the dressings clean. They became soiled, and the antiseptic treatment failed from accidental soiling by fmcal matters, under the care of a nurse imperfectly trained in the treatment. The high elevation of temperature continued. The case went on with extreme hectic until the 23rd of the following month of April, and the condition of affairs was such that death became imminent, as the boy was wasting rapidly. In fact, he was then so low, from the prolonged irritation, that some of my colleagues thought it would be rash to at tempt any operation. Just at this time Mr. Spence, of Edinburgh, saw the boy with me, and strongly urged excision, even in spite of the con- dition of affairs. I accordingly operated. There was nothing about the operation requiring to be noticed except t h i s ~ w e had a very free discharge of pus from an abscess which opened on the outside; and it

460 l~eport8 of the Dublin Patiwlogical Society.

was clear at the same time that a large collection of matter existed on the inner side of the thigh extending half way down the femur. I t was a nice point to determine whether au abscess passing down along the femur was to be taken as an indication of disease of the shaft of the femur; and to a considerable extent I made up my mind that there was no positive evidence of disease of the bone. iN'o enlargement of the bone could be felt. I inferred that the collection of matter was the result of a want of drainage from the external opening. When we made the necessary incisions for excision there was a great discharge of matter. I do not think there was any other feature in the operation. The section was made through the base of the neck of the bone, and through the great trochanter, and the detached trochanter with the muscular attach- ment were perfectly healthy. At only one point below this level in the femur did we strike on diseased boae, where there was a species of softening ; this was on the shaft at the upper end of the inner side of the shaft. On passing my finger into the aeetabulum I found that it was bare and rough, and that considerable roughness existed on the inner side, but there was no very great area of the bone exposed. So small was the area of disease outside the limits of the acetabulum that I considered i t unnecessary to attempt to remove the floor of the acetabulum. 2k marked fall of temperature followed the operation for a fortnight~ and the morning and evening changes of the hectic ceased. From that time out the case again went backwards, but so slowly that at some times we had hopes that the final issue would be successful. The cause of the hectic can be seen in the specimens. We have the parts almost absolutely as they were in the operation. The front of the capsule was open. I had avoided cutting against the bridge of the capsule in front in turning out the bone, so that I was able to save the ligamentous connexion in front. There was a tolerably free passage for purulent matter, but still the caries seems to have progressed. The disease of the ilium has been prolonged upwards and outwards. Turning inside we find that though the acetabulum was not open at the b o t t o m - - that is~ that there was no absolute opening that the finger could detectM still a cribriform series of holes had opened into the intrapelvic sub- periosteal space, from which a narrow cleft from the joint led upwards and outwards. We had an abscess developed in the iliac fossa~ and caries developed on the outside of the ala ilii. This was the cause of the continuous hectic. The upper end of the femur is absolutely smooth, and there is an investment of lymph over the section ; it is absolutely sound, except at a minute point where the apex of the bone struck against the diseased ala ilii. There is no disease except where it has been imparted to it by friction against the carious surface of the ilium. If the caries had confined itself to the limits of the acetabulum, and not extended upwards~ in all probability we would have succeeded in the

R~ports of the Dablla Pathological Soclety. 461

case. The specimen is of interest as showing how the operation most commonly fails in such cases, through the extension of the disease to the pelvic bones in spite of the removal of the head of the femur. The operation was performed in the month of April~ and the boy lived until October. His temperature after the operation never reached such a height as i t had attained before it.--December 8, 1877.

Pol?tpus of the Rectum.--DR. BEmCETT said: The specimen I now present to the Society was originally of such small dimensions that it was hardly worth bringing it forward. One half of it is undergoing prepara- tion for microscopic examination. I have brought sections made in a perfectly recent state from the second~ of which one is beneath the micro- scope. The case is one of a disease not very common in this or any country, although all the authors on the special organ describe it--namely~ polypus of the rectum. The circumstances under which the case occurred were the following : - - A boy, about ten years old, apparently in ruddy health, was brought to me about two weeks ago. His mother reminded me that I had seen him that time twelve months for an affection of the bowel, involving hsemorrhage. I kept no note of the case at the time, but I recollect the facts. He was brought into the out-room, and his mother stated that he had passed blood in some quantity during two or three days. I made an examination of his rec- tum, but could detect no disease whatever. Hsemorrhage from the rectum in a child of his age being so rare from any other cause except po]ypus~ I assumed at the time that polypus exlsted~ but could find no proof of it. I administered injections~ and made examinations both digital and specular~ but could obtain nothing except negative evidence. This year he was brought back to me in exactly the same condition, and his mother stated that on and off during the whole year hsemorrhage had occurred. One point worthy of notice was that although these hsemorrhages, according to his mother's account~ had been so constant and severe, the child was not in the least degree blanched. He was ruddy and healthy, and had good red l ips; and evidently the hsemorrhages, although tolerably fre- quent~ must have been very slight at any time. On examining him digitally, I could obtain no evidence whatever of the disease. I adminis- tered an enema, and immediately after the action of it a tumour pre- sented itself in the anus. The boy told me that always of late when his bowels acted with anything like a freedom approaching diarhoea, the tumour came down, and he had to press it back with his fingers. When examining the tumour we had to be pretty quick, for there was a ten- dency to the withdrawal of the tumour immediately on the child being put lying down. I t presented the usual appearance of a small pile, and might be readily taken for it. The surface was slightly velvety, and of a purplish colour; it was about the size of a hazel nut, and, when

462 Reports of tl, e Dublin Pathological Society.

touched on the surfac% had a slight tendency to bleed. A probe passed round it showed that it was not anywhere connected with the margin of the anus. Having satisfied myself of its existence, I returned it into the bowel, and waited another day to secure it. After returning it, I passed my finger into the rectum, but could not feel the r at all. Next day, by repeating the enema, I got it down again. Having got it down, I withdrew it in the grasp of an ordinary pile forceps, and then learned that it was attached by a pedicle certainly not thicker than an ordinary goose-quill, and almost perfectly transparent. Knowing the ~umour to be of rare form, I was anxious to obtain it as little damaged by removal as possible ; I therefore handledit with great lightness. I was anxious to put a double ligature round the .base, as in some recorded eases h~emor- rhage has occurred from the slipping of the ligature. I set to work with an ordinary needle armed ~ith a double ligature, and proceeded to transfix the pedicle. As I did so, accidentally the point of the needle touched the skin~ and, the child withdrawing, the polypus broke away. I t was lucky I had it transfixed, otherwise it would not have been easy to pre- vent the receding of the pedicle into the anus; I took it with an ordinary artery forceps, and tied it gently. I t was necessary to do so very gently and softly, because it was clear that if we used force the ligature would cut it. Ch~rling is the on'ly English writer who describes exactly the nature of the pedicle which .contains a number of blood vessels, so that you must ligature it with the greatest lightness in order to avoid cutting through them. The size of this one, and the character of the attachments~ &c., all agree with the description given by Curling, who took his description from the original description given by Lebert. There does not see~n to be anything constant about the position of the attachment; it is usually towards the posterior side of the rectum, but there is great variety in the height ~of the bowel to which the pedicle is attached. In this case. as soon as the tumour receded, the ligature and pedicle withdrew into the intestine, and a great length of string was withdrawn into the bowel. Taking hold of the string with the forceps~ I passed my finger into the bowel along it, but could, by gentle traction, barely reach the knot, as the attachment to the pedicle was much higher, and the ligature passed beyond the reach of my finger in the bowel. This explains why we were not able to touch it in its ordinary condition. Many points of interest demonstrating the rarity of the disease appear in the accounts given of the structure. Lebert describes very briefly the details of the tumour, giving characteristics exactly agreeing with what I have given~ excepting that the symptoms in the case I have detailed were milder than they generally are, there being no violent diarrhoea or h~emorrhage. In all essential respects, however, the phenomena agreed with those given in the recorded cases. Lebert states that a walnut is the maximum size, the usual size being that of a hazel nut. With reference

Reports of the Dublin Pathological Society. 463

to the structure of these tumours, he says that the essential element in these polypi is a considerable agglomeration of follicles, very prolonged, and presenting cylindrical epithelium very distinct along the entire wall. Allingham~ in the second edition of his work, says that the microscopic structure of these polypi varies. Generally they co,nsist of a mass of fibro- nucleated tissue, overlaid with blood vessels, and wholly covered, though scantily, with scaly epithelium. Lebert states that the epithelium is cylindrical. The surface of the tumour--which Lebert does not describe, though mentioning it in connexion with the waU of the rec tum-- is in this case covered with epithelium of a form which is a modification of the cylindrical. I do not know a more remarkable specimen of a glandular tumour than this is. The whole mass of the tumour seems made up of follicles. Between the tubes of the structure, and directly supporting the epithelia, there is fine, soft, connected tissue, exactly the same as the fine tissue occurring in polypus of the nose. The ducts run every w a y . - - December 22, 1877.

A NE~ r GLYCOSURIC AGENT.

EVERY one knows the uncertainty of Trommer's test and the bother of Fehling's solution. Dr. Piffard~ of New York, states (h r. Y. Med. Record, 23rd March) that the following will be found a convenient substitute : -

Take of Sulphate of copper (chem. pure) - 1 part. Crystallised tartrate of soda and potassa 5 parts. Sodic hydrate (chem. pure) 2 ,,

Mix thoroughly in a mortar ; the more labour spent on this, the better the product. The result will be a pasty mass, which can be transferred to a wide-mouthed bottle and kept till wanted. To use it, take of the mass a piece about the size of a pill, put it in a test-tube, and add about two fluid drachms of water ; boil till the mass is dissolved, and the solution has a uniform pale-and rather dirty blue colour ; then add two or three drops of the suspected urine, and boil again for a moment. I f sugar be present, the usual reaction will be manifest. The mass may conveniently be made into pills of proper size, one pill being sufficient for a test.