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

DUBLIN.

President---EDwARD HAMILTON, M.D.

Secre ta ry- -E . H. BENNETT, M.D.

Mechanical Hypercemia of Organs.--DR. J . W. MOORE said : About the 12th of January, a man, aged seventy-three or seventy-four years, was admitted, under Dr. Ormsby's care, into one of the surgical wards of the Meath Hospital. He had been suffering for a considerable time from obstinate eczema of both legs. After he had been in.the hospital for a day or tw% he was attacked with sudden palpitation of the heart. His heart was acting feebly, beating from 140 to 160 per minute. The pulse was extremely weak and fluttering. No cardiac murmur was audible. Bronchial r~les were heard all over the chest. There was very considerable and universal anasarca. The diagnosis we ventured to make at the time was that he was either the subject of fatty degeneration of the heart, in an advanced stage, or that he had mitral regurgitation. The evidence of mechanical hypermmia of the organs, in the absence of murmur, especially led to this diagnosis. The man died rapidly. The aorta presented a remarkable example of advanced atheromatous degene- ration. This was specially noticeable at the commencement of the descending portion of the thoracic aorta. The innominate, left subcla- vian, and left carotid arteries were also diseased, but the ascending portion of the aorta was tolerably free from atheromatous change. I t is dilated to a greater or lesser extent throughout its whole course. Along the base of the aortic valves, and also above their detached margins, atheromatous deposits are seen. At the right semilunar valve a dilata- tion is found, almost amounting to an aneurism ; it occurs at the springing of one of the coronary arteries. The left ventricle of the heart is found to be considerably hypertrophied and dilated. There is very great dilatation of the mitral orific% which freely admits the tips of four or five fingers. Similarly, we find the left auricle dilated; and the lungs, throughout almost their whole extent~ are passively congested. Turning to the right side of the heart, we find the pulmonary artery very consi- derably dilated, and the chambers are also dilated. These effects of mechanical hyper~emia were not limited to the thoracic organs. The liver is rather enlarged, and~ on section~ presents a very good example of the nutmeg liver. The centres of the acini are exceedingly dark and congested, but their periphery is pale. On a recent section of the kidney, the capsules were found to be exceedingly adherent~ and the

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cortical substance pale in colour, contrasting remarkably with the deeply injected medullary portion. The kidneys, like the liver, had evidently for a long time been the seat of mechanical hypera~mia. The starting point of the hypera~mia appeared to be the extensive atheromatous changes leading to the dilatation of the ascending portion of the aorta. F i r s t there must have been hypertrophy of the left ventricle, and when that was no longer capable of overcoming the great strain, there was dilatation of that chamber and of the other chambers of the heart. The start ing point of the atheroma might be found in the fact that the man was the subject of old standing gout. There is no doubt that the eczema of the lower limbs was gouty. He had been a butler in an old country family, and had, probably, become the subject of gout.

Commenting on the foregoing case, Da. HAYDEN observed that when- ever consecutive dilatation occurs leading to valvular incompetency, the tissue of the heart will be found to have previously undergone either granular or fatty degeneration. He agreed with Dr. Moore as to the sequence of pathological events in the present case.--January 26, 1878.

Aneurism of the Innominate Artery cured by the Method of Tufnell.--DR. HEAD said : Tile ease which I wish to present to the Society is one of an aneurismal sac that had undergone cure by the process upon which so much stress has been laid by Mr. Tufnel l--viz . , consolidation, by successive deposits of fibrin. The previous history of the case is short. In July last, the gentleman, who was leaving Ireland, came to thank me for my long attendance upon him, two years before, for a stomach affection. I had not seen him for these two years, and he told me that, during that time, he had suffered from intense neuralgia in the back and shoulder, along the back of the neck, and in the back of the head. Fo r this he had been treated in various ways, and he had used large hypodermic injections of morphia, which gave him a good deal of relief ; but, after some time, he was obliged to give them up, from the intense itchiness of skin which they caused. He then appeared to be well, and had not suffered much from neuralgia for some time. He was a Presbyterian chaplain in the army, and was going over to take charge of troops at Shorncliffe, in England. He mentioned to me that he had a little mark on his ches b beneath the right collar bone- -a dusky spot, about the size of a five-shilling piece, as if he had got a bruise, and asked me to look at it. Upon examining it, i detected a dis- tinct pulsation underneath, and came to the conclusion that he had a thoracic aneurism. But for the pu]sation~ however, it would have been impossible to detect an aneurism. There was no sign of pressure--no murmur, no difficulty of deglutition, no dilatation or irregularity of any vessel. There was no sign of interference with either recurrent nerve, and his voice was natural. The impulse of the aneurSsm was, if anything, slightly in advance of the heart's impulse, as if the commencement of the contrac-

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tion of the heart acted upon the aneurism before the apex of the heart struck the walls. This I have observed in two instances of aneurism of the aorta. There was no double impulse, and nomurmur or bruit. He complained of little or no pain, except a burning sensation. I told him that I thought be was not fit for duty, and explained to him, to a certain extent, the nature of his illness--that an effort should be made to cure him ; and I suggested a consultation with Mr. Tufnell, who concurred in my diagnosis that it was an aneurism, and most probably of the arteria innominata. As I considered that this gentleman was likely to be benefited by the treatment which Mr. Tufnell has so ably advocated, we explained to him the nature of the treatment. He said that he would be glad to adopt it. He assumed the recumbent position the last week in July, and continued it until the middle of October. I had to leave town myself at the beginning of August, and Mr. Tufnell was then kind enough to take charge of the ease. The patient took little or no medicine, and we did not give him any iodide of potassium ; but, when he was under my sole care, and, occasionally, when his heart beat a little fast, he got small doses of aconite, which reduced the frequency of the pulse a good deal. The principal treatment consisted simply of the horizontal posture, absolute rest, and a minimum of liquids, his food consisting as much as possible of solids, so as to diminish the quantity of blood, and at the same time keep up.its healthy condition, t ie bore his confinement very well ; but, in the beginning of October, lie began to show signs of great restless- hess, and I thought it better not to confine him anylonger. He began to get up, and gradually to go out; but became sleepless, and got into a state of great mental depression, fearing that he would be put on half- pay, and that he would be arrested for debts which really he did not owe. Mr. Tufnell and I now advised him to apply for additional leave of absence, thinking that, the aneurism being .now very much consoli- dated, a little more rest might enable him to go back to his duty. l i e applied for additional leave, and on the very day before the occurrence of the unfortunate act which terminated his life, went before a Medical Board; the leave of absence recommended was granted, but of this he could not be made aware, as the proceedings are private. He was now advised to go to tShe country for change of scene, and his friends were taking him there, when~ at the Railway Station at Kingsbridge, .he became suddenly excited, ran away from them, and threw himself over the wall, which is twenty-four feet in depth, into the Liffey. He was not killed by the fall, but the water in the river was shallow at the time, and he was immersed in the mud. From this he was extricated as speedily as possible, and taken to I)r. Steevens' Hospital, and after lying there for about two hours, lie died. I did not see him myself, but was informed that no impulse could be detected over the aorta, but he got a violent cough, which was characteristic of pressure. The Coroner directed a

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limited post mortem examination to be made, which gave the opportunity of ascertaining exactly the site of the aneurism and the result. While undergoing treatment Mr. Tufnell and I came to the conclusion that the aneurism had undergone a great deal of consolidation, although to what extent exactly we could not tell, because there was still a strong impulse. It, however, gave the impression of a solid tumour striking against the sternum, aud we could not feel any signs of lateral dilatation whatever. The centre of the impulse was about the edge of the sternum, between the cartilages of the first and second ribs, extending about an inch and a half in each direction ; and there mas also marked dulness on percussion. The heart was slightly displaced and pushed downwards, the apex beating between the sixth and seventh ribs, a good deal to the left of the nipple and over a considerable surface, and there was also some amount of dulness on percussion over the region of the heart. We came to the conclusion that the heart was slightly enlarged. Upon inspection by sectio cadaveris, a solid tumour was found, occupying the entire mediastinum, and firmly attached to the under-gurface of the sternum and the cartilages of the first and second ribs. A portion of the sac of the aueurism being adherent to the under-surface of the bones, it was supposed at first that the shock of falling twenty-four feet had burst the sac of the aneurism, but it was found that there had been no rupture whatever, nor were there any signs of extravasation of blood. The heart itself was covered with fat, and to some degree enlarged, flat, and .flabby. On opening the left side of tile heart, the wall was found to be very thin and the cavity a good deal dilated; but the valves were perfeet. When we opened the aorta, we found it very much dilated and altered by atheroma in a marked degree, with dilatation almost amounting to true aneurism. Upon slitting up the aorta, we found that the original aneurism occupied almost the entire of the arteria innominata. At the back of it the vessels were quite pervious--namely, the subclavian and the carotid on the right. Those on the left were also perfect; but the descending aorta was very athero- matous ; and, at a distance of between three and four inches, there was another small aneurism, the size of a walnut. This we could not diagnose during life ; but it, too, was all but filled up with fibrin. The principal interest in the case lies in the manner in which the aneurism was cured. The layers of fibrin are very firm and closely laminated, the layers of it being almost as thin as sheets of paper spread one over the other. I t is a most interesting example of what may be done by the absolute rest and other items of treatment advocated by Mr. Tufne l l - - in fact, this aneurism was cured. This case ought almost to have been Mr. Tufnell's, for he had more to say to the treatment ; but, as the patient was mine at the first and the last, I have laid the case before the Society. The age of the patient was fifty-six.

DR. BOOKEY said that the lungs were congested, and had a good deal

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of frothy fluid in them, such as is met with in the lungs of a person who has been drowned. The patient, who was a heavy man, sixteen stone weight, had fallen twenty-four feet, and was found lying on his face. He died within two hours after he was received into the hospital, and breathed, it was stated, all the time he was there.--January 26, 1878.

Knee-joint Disease, with Disease of the Tibia.--DR. T. E. LITTLE exhi- bited for Dr. Thompson, Surgeon, County Tyrone Infirmary, a specimen of the above disease. Dr. Thompson's report of the clinical history and progress of the case is this : - - " Anne L., aged three years, an appa- rently healthy child, was admitted into the Tyrone Infirmary, suffering from disease of the right knee-joint, tlistory.--The patient had been well and strong until about thirteen months ago. She then got some strain of the knee, which rapidly swelled, and became very painful. The child grew very thin, got little or no rest, and had little or no appetite. A medical man was sent for, who opened an abscess below the tuberosity of the tibia, giving exit to a large quantity of pus, and affording much relief to the severe pain. The joint afterwards commenced to contract~ the pain returned, and the patient rapidly lost flesh. S!/mptoms on admis- sion to the Infirmar~j.mThe face and body generally appeared fairly well nourished ; the right knee was bent at an acute angle to the thigh ; the joint was much swelled and extremely painful; fluctuation distinctly marked ; there were a number of enlarged superficial veins over the joint. A sinus immediately below the tuberosity of the tibia communicated with diseased bone. The probe passed in so far that there could be little doubt it entered the knee-joint. The glands in the groin were slightly enlarged. The limb started at night, causing much pain. Latterly, according to the mother's statement, the child has been rapidly losing tiesh. Progress of Case.--The limb was placed upon a splint, and efforts were made to extend it gradually. An abscess formed, pointed, and was opened about an inch to the inside of the first sinus, and exit given to a large quantity of thick, purulent matter, and relief was experienced for a time. Another large abscess, however, formed along the inside of the joint, but, apparently, external to it. The child getting rapidly weaker, I proposed amputation, to which proceeding the mother readily consented. The leg was, therefore, amputated at the thigh, by the double flap method, with circular incision through t he muscles, at about its lower third. Ether was the anmsthetic employed, and it answered admirably. For reasons which are self-evident, excision was considered inadmissible." In presenting and commenting upon the specimen of the amputated limb, Dr. Little made the following remarks : ~ O n examination of the removed limb, I find the disease chiefly and primarily limited to the tibial aspect of the joint and upper extremity of the tibia. Reviewing the pathological anatomy of the limb, as to the conditions of (a) the soft parts, (b) of the

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joint, (c) of the bones, we discover the following state of things : --(a) Soft Parts.--Two extensive sinuses exist over the region of the inside of the joint and upper part of the tibia. One of these presents a superficial fistulous opening below the internal tuberosity of the tibia, through which diseased bone could be reached with tile probe during life, and which communicated with the joint, in the manner described further on. This sinus extended in the subcutaneous fascia upwards as high as the internal femoral condyl% communicating, in its course, with an opening on the anterior surface of the tibia. The other sinus, less extensive, had been opened below the head of the tibia, and extended also upwards towards-- but not directly communicating with--the joint. (b) The joint was bathed in pus ; the exterior ligaments and capsular structures are rather thickened ; the cartilage is~ in places, ulcerated and absorbed to a consi- derable extent--this condition, however, only slightly applying to the femoral or patellar parts of the joint; the cartilage has almost entirely disappeared from the facets on the upper surface of the head of the tibia ; and the semilunar cartilages are almost completely removed--.the floor of both articular facets being perforated~ and communicating freely with the disease in the head of the bone; the synovial membrane, where remaining~ is~ in many places~ thickened and pulpy, with numerous vas- cular fringes in its various interstices hanging into the joint. (c) Bones.--The condyloid region of the femur and the patella appear to be healthy~ but there exists extensive disease of the cancellous tissue of the upper extremity of the tibia; here a considerable cavity is found~ with several small pieces of necrotic bone lying loosely therein. This diseased cavity had opened both externally, through the surface of the bone, by means of a round, smooth, and, evidently, old-standing opening~ with thickened osseous edges~ of about the size of a pea, and which communi- cated with the subcutaneous sinus already referred to ; and, internally~ into the joint by a couple of free and irregular perforations of the articular facets on the upper surface of the tibia, which form the floor of the joint. Remarks.--The most important and interesting pathological question which, I think, this specimen suggests to our consideration is that of the primary starting point of the disease. The evidences are, in my opinion, in favour of believing this to have been in the cancellous tissue of the upper extremity of the tibia, and rather point to the articular disease as secondary to this. Amongst sor~e of the reasons for this presumption [ would mention the situation of the original abscess, and of the apparent primary focus of the disease (as described in the clinical history), the early occurrence of abscess, presenting externally, would be at least unusual at such an early stage of joint disease, the comparatively late period at which contraction of the limb supervened. These, with the anatomical characters of the parts--viz., the small amount of disease of the cartilages of the femur and patell% and the presence of extensive

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excavation of, and necrosis of the head of the tibia itself, all appear to me to fa~vouv the view I have mentioned. [-Since making the above report~ i have heard that the case made an uninterruptedly good reco- very.--T. E. L.J:--February 16, 1878.

A scites induced by Tuberc~dar Dgvease of the Liver.--DIr BANK8 said : Oil the 4th of July last, a little boy, aged ten years, was admitted into the Whitworth IIospital. We could not get an accurate history of the child, but we learned he had been ailing for a considerable time ; and, on exami- nation, we found that his abdomen was enormously distended, and the umbilicus was the size of a large walnut. IIe was labouring under ascites, and so urgent werehis symptoms that, on the very day of his admission. it was found necessary to resort to the operation of tapping. He was a miserable, half-starved looking little fellow. The abdomen presented a remarkable appearance, being covered with a net-work of large vehas, which communicated with those of the thorax. Itis skin was of a dusky, dirty-yellow colour, with a faint icteroid tinge, and the conjunetivm were slightly yellow. He had had vomiting before he came in~ and was weak arid low. Five pints of straw-coloured serum were drawn off by the tapping, which was performed by an extremely small trochar. IIe ex- perienced great relief from the operation, and his general condition was, to some extent~ improved; but the fluid rapidly accumulated again--so much so, that in fifteen d'tys i~ was found necessary to repeat the opera- tion. On that occasion not so much fluid was drawn off. From that llme until his death, which occurred on the 19th of November, there was never any considerable amount of effusion. After the second tapping, localised peritonitis set in, attended with very acute pain, which was greatly aggrawtted on pressure, which, however, yielded to tl~atment by opium. There was a good deal of distension, but it was chiefly due to flatulence, there being evidently very little fluid. His state fluctuated from that period. Sometimes he improved; but diarrhoea occurred at intervals, and his stoumch frequently rejected food. He lingered on until the 19th of this month, when he died in a state of extreme maras- mus. On examining the liver, to which attention was naturally directed, it was found to be studded with globular masses of a white colour, which are not now nearly so large as they were in the recent state. Masses of a similar character were found in the peritoneum. Enlarged glands were found pressing on the vessels of the liver. Dr. Harvey was good enough to examine the liver. Time did not permit him to make an exhaustive examination, but he will do so at his leisure and make a report to the Society. Dr. Banks said that, having found cirrhosis in some cases at as early an age, he expected to find cirrhosis of the liver, notwithstanding the early age of the patient, all the symptoms indi- cating the existence of the disease. I t should be observed that there was

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no disease of the lungs. Dr. Harvey made the following report : - - " T h e liver was referred to me with a view of determining the nature of the peculiar elevated whitish masses, which occurred, for the most part, on the surface of the organ, but which, as I afterwards found, existed also, in considerable numbers, throughout its substance. On making sections, comprising one of the white masses, and the neighbouring liver tissue, I found the former were simply caseous masses, which presented no definite structure. These ~ regard as degenerated tubercles; for miliary tubercles, in considerable numbers, and in all stages of develop- ment, were found studding the healthy-looking portions of the liver. In one of the preparations, which I now submit to the Society, we have a very beautiful specimen of well-formed miliary tubercle close to an imperfectly-formed caseous mass ; while some of the other specimens show masses of small, round (lymphoid) cells, which, no doubt, are commencing tubercles. Accordingly, I have no hesitation in reporting the case to be one of caseous tubercle. Tile liver shows some increase of connective tissue, but there is nothing that could be called cirrhosis. Masses of indurated lymphatic ghmds existed in the porta, and pressed upon the vein." Hebruary 16, 1878.

Melanotic Carcinoma.~Dm BEt~NET~r said : The specimens I have here were taken from the body of a boy of about eleven years of age, whose case, although in many respects an ordinary case of malignant disease, still, I think, presents features sufficiently exceptional to deserve its being placed before the Society. On the 15th of last June the boy was admitted to Sir P. Dun's Hospital. He was, to all appearance, perfectly healthy, and was ruddy, fat, and of full size for his age. At that time he was able to walk without lameness; but what he complained of was a lump in the popliteal space. On examination we found the whole natural cavity of the popliteal space entirely obliterated by a some- what conical projection in the centre, enough to make us certain tha~ we were dealing with some outgrowth which was not a swelling from any accidental cause. There was no pain in the tumour. The boy walked with a slight embarrassment of the motion of the tendons, and from the fact that he could not straighten out the limb completely, but there was no lameness from any kind of pain. His own account of the matter was that about three weeks before that date he had been struck by a hand-ball in a playground, the blow taking effect in the popliteal space. On further examination of him, I found in the groin a large globular tumour about the size of a racket-ball. Evidently the lym- phatic glands of the groin were distended far above anything that we see in an inflammatory swelling. The enlarged glands were perfectly painless and adherent, ancl the contour of the glands could be made out

as clearly as possible. Evidently the enlargement was not inflammatory,

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but was from some new growth of the glands. His mother positively assured me that less than a week before his admission there was nothing whatever the matter with him, and that he had no swelling or tumour of any kind; and he himself said that up to a fortnight at least before that he knew nothing whatever of having any aihnent. The whole limb was slightly swollen. So far it was hard to read the case. Not satisfied with the examination of the poplitea] space and the groin, I made a further careful examination, and found that though the sole of the foot was at this time concave s still there was a tendency in it to become flattened down from the usual arched form, and that the structure of the sole of the foot was intensely hard. The fasci~ in tile middle of the foot were as tight as possible. In spite of the history the boy gave, that the blow in the popliteal space was tile origin of tile affection, I was forced to diagnose a malignant tumour in the sole of the foot, developed immediately under the plantar fascim. There existed a glandular enlargement of the popliteal space, and a second glandular enlargement of the groin ; and so clear were the indications, that it was impossible to avoid the conclusion that the evolution of the three tumours was almost synchronous. Cer- tainly the tumours in the groin and popliteal space seemed to have developed almost immediately ; but the growth in the sole of the foot was not noticed until I drew the boy's attention to it. There existed, there- fore~ a growth of malignaat character in the sole of the foot, and almost simultaneously with it the glandular growths in the popliteal space and groin ; the latter increasing at a pace we rarely see in malignant disease-- in fact, beating the original disease in the rapidity of their growth. The limb assumed the appearance of pMegmasia dolens without being painful. I t was greatly distended with a form of (edema which did not pit, which was evidently produced by venous obstruction. The surface of it showed small varices in the minute vessels of the skin. So the case went on till October of last year. For a long time the boy's health did not suffer apparently in the least. At last, about the end of September, in conse- quence of the size and weight of the limb, he had to be in bed, and after a time rapidly broke down. From the time when he took to his bed, in consequence of inability to carry the mass about with him, until he died, which was less than a month, hectic and diarrhoea supervened. There were no other features in the case. 5[o thoracic or hepatic disease could be detected; and, with the exception of his emaciation and the continuous enlargement of the limb and tumours, there was very little to notice. The tumour in the sole of the foot, however, which I regarded as the original turnout, in the end beat the two glandular tumours in its growth. The contour of the sole of the foot became extremely convex, and at last the fascim gave way, and a mass protruded through the under-surface of the sole. We have a measure of the depth of the sole from this vertical section. What you now see has been shrunk in spirit, but it shows about three

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inches depth of sole at what ought to be the hollow of the foot. The tumour was fungated, and there was a great flow of saneous serum from it, as is-usually the case in malignant disease. I t was the only one that ulcerated. On the post mortem examination some points of interest pre- sented themselves with respect to the distribution of the disease. I have here a piece of the sole of the foot. I t is greatly altered, but one of tile most remarkable features about it is that the mass is all through studded or infiltrated with cysts, from the size of a grain of shot to that of a small pea. In many parts there are bands of dark black matter, the colouring of which was better seen before immersion in spiri t than it is now. Each of the growths, in the popliteal space has the same infiltration of minute cysts, and also the bands of black discoloration. Tracing the deposit up, we found the infiltration in the glandular regions of the groin up to Poupart 's ligament, and there was an infiltration of black matter also in the abdomen, along the spine, through the mediastinuro, and up to the cavity of the thorax. The only glandular body in the thorax that showed this degeneration was the thymus gland. We examined the lungs, liver, and other solid organs, but found no trace of secondary deposit in them, although there were a few spots of black pigment in the thymus, In the glands around the kidney you observe the colour better than in any other part. The glands all along the spine have shrunk to a minute size, and there are little specks of black tissue through them~ instead of their being enlarged ; so that when they became subject to the melanotic deposit from the original tumour the majority of them underwent a cystic degeneration and shrank. A thin section from the sole of the foot~ viewed under the microscope, shows these melanotic cel ls ' ranged according to the pattern of a true carc inoma-- that is, it was originally a true carcinomatous tumour coupled with melanotic deposit here and there without rule or order. A singular feature in the case is the limitation of the path of this matter up to the thorax without any deposit occurring in the lungs or liver, and only a grain or two of melanosis in the thor'tx. The glands of the mesentery and those in the passage of the opposite iliac vessels are perfectly healthy.--January 19, 1878.