NZMJ February 1923

This Society has just completed its second year of work, and can record a most satisfactory session. The membership increased to eighty, and there was an average attendance of forty-eight for fifteen meetings. By the courtesy of the Hospital Board and Dr. Maguire, Medical Superintendent, the meetings were held in the schoolroom of the Children’s Hospital. The meetings lasted for an hour and a-half, during which time an average of eight subjects were dealt with, a special feature being made of the demonstration of patients, photographs and lantern slides, stress being laid on the needs for brevity and the desirability of emphasising deviations from the more generally recognised features of the disease. A few minutes of each evening were devoted to a pathological demonstration by Dr. Gilmour, and the evening terminated with the serving of light refreshments.

It is generally felt that these meetings have not only had great value from an educative point of view, but have also done much to promote a spirit of fellowship among the members of the profession in Auckland.

Dr. Hardie Neil has again held the Presidency of the Society, to the satisfaction of all.

We submit brief notes of certain of the matter presented which appears of the sufficient interest to put on record.

The President demonstrated by the direct method, a case of paralysis of one side of the palate, pharynx and larynx, together with spinal accessory palsy. There was also some lingual paresis, the case thus conforming to the Hughling’s Jackson syndrome. He also showed fibroma, papilloma, and malignant cord cases.

Dr. Geo Fenwick showed a group of cases of irido-cyclitis of differing ætiology. He emphasised the value of treatment by isolation. Later, he exhibited a case of sympathetic irido-cyclitis that was, by this method, given useful vision and a quiet eye. This demonstration aroused universal interest. He also showed excellent result from West’s operation for Dacryocystitis.

Dr. Fairclough demonstrated three cases of Hemianopia from cerebral hæmorrhage, and showed patients with lipoma and dermoid of the conjunctiva and rodent ulcer of the lids, outlining the necessary plastic work for the latter. Dr. Goldstein showed a stationary traumatic cataract, its association with an old injury bringing it under the Worker’s Compensation Act.

RAT BITE FEVER.–Dr. Bull.

In this case a girl had been bitten by a wild kitten. There was no local reaction but five weeks later she developed fever with a high remittent temperature, much malaise, enlargement of lymphatic glands, diffuse erythematous rash and much œdema of the nasal mucous membrane with free nasal discharge. The illness was severe, but was controlled by intravenous injection of novarseno-billon. There have been several relapses since, the last occurring seven months after the infection. Wassermann reaction has been negative, and examination of the blood and of an excised gland failed to show the causal organism. In the discussion that followed, a number of cases were cited, showing that the condition is not rare in this district. A patient was also shown who had had a severe attack 3 years before, a ragged primary sore forming suddenly on a finger six weeks after a rat bite. He was treated with galyl and is now well.

ADDISON’S DISEASE.–Dr. Abbott.

A middle-aged man had been off work for three weeks prior to his admission to hospital. He had complained of symptoms which seemed to indicate cardiac weakness. No definite heart lesion could be found—the blood pressure was 130. With rest he improved, and was getting about again when he was seized with severe abdominal pain and vomiting. He was sent to hospital with a provisional diagnosis of an acute surgical lesion of the abdomen, and the vomiting was frequent and distressing, all nourishment taken being immediately returned, and a certain amount of bile and mucus addiction. X-ray examination was impossible owing to his inability to retain the barium meal. The bowels were not disturbed. Neurological examination and the Wasserman test were negative, there was no pigmentation of the skin. The man’s condition became steadily worse, and, after consultation, and exploratory operation was done, but no lesion discovered. Death occurred on the same day. Post mortem examination showed a complete replacement of the adrenal tissue by caseous tubercular material. There was present, also, healed tuberculosis of the lungs and dorsal spine.

The unusual features of the case were the short duration of symptoms, the intensity and duration of the pain, the absence of pigmentation, and the comparatively high blood pressure a few weeks before death. Unfortunately no later measurements were taken.

ENCEPHALITIS.–Dr. Tewsley.

Four cases of encephalitis lethargica were shown at varying stages of the disease. One was a case of several years’ standing, and showed permanent sequel of the disease, Parkinsonian mask, constant dribbling of saliva and interference with finer muscular co-ordination. A second case had been accompanied by severe epileptiform seizures at long intervals. Attention was directed to the fact that these cases are less infrequent than is generally supposed and that they are protean in their manifestations.

TORSION OF THE SPLEEN.–Dr. Holmden.

An elderly woman had been aware of a tumour in the lower abdomen for a number of years, but it had given rise to no symptoms. She was seized with sudden abdominal pain and symptoms suggestive of intestinal obstruction. A tumour of the contour of the spleen could be felt just at the brim of the pelvis. Operation showed several turns in the pedicle. Removal was easy.

CHYLOUS ASCITES.–Dr. Milsom.

A boy of 12, admitted to hospital with swelling of the left side of the scrotum and adjacent portion of the thigh. A laparotomy was done, and chylous fluid found in the abdominal cavity. Mesenteric glands were enlarged, but there was no other lesion. Following the operation the abdomen began to fill up with the fluid and has required frequently repeated tapping, while the œdema of lower limbs, scrotum and abdominal wall has become very great. Chylous fluid has also been aspirated from the left pleural cavity. The causative lesion is not definite but is thought to be tubercular glands of the mediastinum, causing pressure upon the thoracic duct.

ADEMONATOSIS OF THE COLON WITH CARCINOMA.–Dr. Kenneth Mackenzie.

A male, aged 22, complained of severe diarrhœa, much abdominal pain and loss of weight. A large carcinomatous mass was found in the rectum. An abdomino-pereneal excision was done. The excised segment showed, in addition to the carcinoma, numerous small tumours of the mucous membrane microscopically simple adenomata. Subsequent examination with the sigmoidoscope showed similar tumours extending as far as could be seen along the colon above the excision. It is presumed that cancer, uncommon in so young a subject, had has its origin in one of these adeomata.

RAYNAUD’S DISEASE.–Dr. Carrick Robertson.

A woman in whom gangrene of the finger tips of both hands had resulted from Raynaud’s disease. Peri-arterial sympathectomy was done in the upper arm on each side, with improvement in the condition. More striking results were mentioned as having been obtained by this method in similar cases.

SYPHILOMA OF BLADDER.–Dr. Frank Macky.

This was demonstrated with the cystoscope. History of gonorrhœal infection, with gleet since 1917. Urine turbid, gonococci in prostatic secretion. Cystoscope in May, 1920, showed a small inflamed patch to the left side of the bladder trigone. In spite of treatment direct to the bladder the lesion was found in November, 1920, to have increased, and in July, 1921, it had greatly increased so that the whole trigone was involved in a gross bullous œdema. There were present a gleet, a turbid urine, some frequency of micturition, and discomfort in the perineum. The Wasserman had all along been negative, but now an illustration in the Medical Annual suggested syphiloma and arsenical treatment was commenced, with striking result, the bullous condition subsiding and the urine clearing. Recent cystoscopic examination shows only slight scar traces at the site of the lesion.

SPRENGEL’S DEFORMITY OF THE SHOULDER.–Dr. Kenneth Mackenzie.

A boy of 14.—Deformity of the left shoulder since birth, becoming more marked with growth. The left scapula was fixed with its superior angle just below the occiput. The muscles on the side of the neck greatly shortened, and marked asymmetry of the face, with a slight torticollis. The dorsal spine showed a moderate scoliosis with the convexity of the left. There was no movement whatever of the scapula, abduction of the limb being limited to 90 deg.

X-ray showed the scapula smaller than normal, with elongation of its neck and much deepening of the ventral fossa by the forward bending of the superior border. No bony attachment of the spine could be demonstrated. The cervical vertebrae appeared to be reduced by fusion to three in number, and showed deficiency in their laminæ. There were also marked irregularities in the upper dorsal vertebræ. The ribs showed much abnormality. On the right side eleven were found, on the left side only eight, the first and second being undeveloped, and the third and fourth being represented by a single posterior piece, bifurcating anteriorly.

Operation showed a bony connection between the scapula and the traverse process of a cervical vertebra. The bone was removed. It was about two inches in length, with a triangular base articulating with the venter scapulæ opposite the base of the spine. It tapered as it passed forward and outward and had fibrous attachment to the vertebra. Its removal was followed by a few degrees increase in movement of the limb. It was thought inadvisable to attempt to lengthen the muscles of the neck at his age.

EXTROVERSION OF THE BLADDER AND TERATOMA OF THE PERINEUM.–Dr. Carrick Robertson.

A newborn infant with complete extraversion of the bladder and a pedunculated teratoma of the size of an orange attached to the perineum. The teratoma was removed. Later deficiency of the anal sphincter showed itself in persistent rectal prolapse. Slips of gluteus maximus muscle were used to replace the deficiency with good immediate results.

Amongst the pathological specimens shown by Dr. Gilmour were the following:—

COMBINATION OF CARCINOMA AND TUBERCULOSIS OF THE STOMACH.

At operation an irremovable tumour of the pylorus was found. An enlarged gland was removed from the greater curvature. This proved to be tuberculous in nature. Death occurred some weeks later, and at post mortem the pyloric tumour was found to be carcinomatous. The enlarged glands were confined to the gastric area. Some showed cancer only, others tuberculosis only, and others a mixture of the two. No other tuberculous lesion was found.

PAGENT’S DISEASE.

The skull and the tibia showed the typical changes of the disease, which had existed for a number of years. Death resulted from a very large and rapidly growing sarcoma of the left ilium.

TYPHOIDAL SALPINGO-OOPHORITIS.

Specimens form a patient dying in the fifth week of typhoid fever. Bilateral ovarian abscesses and pyosalpinx. Rupture on one side with peritonitis. From the abscesses a pure culture of B. typhosus was obtained.

HORSESHOE KIDNEY.

The pelvis of each kidney was filled with a large branching calculus—bilateral pyonephrosis and perinephric abscesses.

HYDATIDIFORM MOLE WITH DOUBLE OVARIAN CYSTS.

Removed from a single woman aged 18. History of three months amenorrhœa, then about six weeks persistent slight hæmorrhage. Bilateral and apparently rapidly growing ovarian cysts were found at operation. No trace of ovarian tissue could be found, and they were removed together with the pregnant uterus. The uterus was, on opening, found to contain a vesicular mole. The question as to whether the destruction of ovarian tissue had any relation to the placental degeneration was put forward.

SPASMOFIC STRICTURE OF THE UTERUS.

Dr. Tracey Inglis reported two cases of dystocia from this cause. The first patient was a two-para. Eighteen hours after the commencement of labour no progress was being made although the cervix was well dilated, and no pelvic obstruction existed. A hand was passed into the uterus and tight constriction of uterine wall was felt around the child’s neck. After fifteen minutes of full surgical anæsthesia, and some manipulation, the stricture relaxed and delivery was easily effected.

The second patient was a primipara. After 18 hours’ labour, progress had ceased with the head low in the pelvis. Intra-uterine examination showed a stricture round the shoulders of the child. It relaxed under deep anæsthesia and a forceps delivery became simple.

Dr. Inglis queried the result of the administration of pituitrin or the application of forceps without recognition of the condition. He emphasised the absolute difference between a muscular stricture such as this and the physiological retraction ring.

Therapeutic notes were presented by Dr. Carrick Robertson on the use of intravenous injections of eusol in the treatment of streptococcal septicæmia, by Dr. Kinder on the use of the silver-arsenic preparations in syphilis, and by Dr. Falconer Brown on the value of guaiacol-glucose solution as a vehicle for the intra-muscular injection of N.A.B.

Dr. McDougall exhibited an interesting series of radiographs showing the bronchial tree of the living subject injected with bismuth emulsion; and also a number of slides of colon radiographs demonstrating the normal and the abnormal.

Dr. Bruce Mackenzie gave a short demonstration of radiographs illustrating changes recognisable in different types and stages of pulmonary tuberculosis; also radiographs of Dr. Holmden’s case of transposition of thoracic and abdominal viscera, and of Dr. MacDiarmid’s case of disease of the right sacro-iliac joint, where the only symptom was an abscess pointing in the left inguinal region. He also demonstrated by radiographs the diminution in size of an intra-thoracic tumour in an old standing case of lyphademona under X-ray treatment. Dr. Bruce Mackenzie also showed a case of mycosis fungoides responding to X-ray treatment, and another case of obstinate syphiloma of the nose which rapidly disappeared under the same treatment.

The last meeting of the year was devoted to re-exhibition of or further reports upon cases dealt with in the session.

NZMJ February 1923

This Society has just completed its second year of work, and can record a most satisfactory session. The membership increased to eighty, and there was an average attendance of forty-eight for fifteen meetings. By the courtesy of the Hospital Board and Dr. Maguire, Medical Superintendent, the meetings were held in the schoolroom of the Children’s Hospital. The meetings lasted for an hour and a-half, during which time an average of eight subjects were dealt with, a special feature being made of the demonstration of patients, photographs and lantern slides, stress being laid on the needs for brevity and the desirability of emphasising deviations from the more generally recognised features of the disease. A few minutes of each evening were devoted to a pathological demonstration by Dr. Gilmour, and the evening terminated with the serving of light refreshments.

It is generally felt that these meetings have not only had great value from an educative point of view, but have also done much to promote a spirit of fellowship among the members of the profession in Auckland.

Dr. Hardie Neil has again held the Presidency of the Society, to the satisfaction of all.

We submit brief notes of certain of the matter presented which appears of the sufficient interest to put on record.

The President demonstrated by the direct method, a case of paralysis of one side of the palate, pharynx and larynx, together with spinal accessory palsy. There was also some lingual paresis, the case thus conforming to the Hughling’s Jackson syndrome. He also showed fibroma, papilloma, and malignant cord cases.

Dr. Geo Fenwick showed a group of cases of irido-cyclitis of differing ætiology. He emphasised the value of treatment by isolation. Later, he exhibited a case of sympathetic irido-cyclitis that was, by this method, given useful vision and a quiet eye. This demonstration aroused universal interest. He also showed excellent result from West’s operation for Dacryocystitis.

Dr. Fairclough demonstrated three cases of Hemianopia from cerebral hæmorrhage, and showed patients with lipoma and dermoid of the conjunctiva and rodent ulcer of the lids, outlining the necessary plastic work for the latter. Dr. Goldstein showed a stationary traumatic cataract, its association with an old injury bringing it under the Worker’s Compensation Act.

RAT BITE FEVER.–Dr. Bull.

In this case a girl had been bitten by a wild kitten. There was no local reaction but five weeks later she developed fever with a high remittent temperature, much malaise, enlargement of lymphatic glands, diffuse erythematous rash and much œdema of the nasal mucous membrane with free nasal discharge. The illness was severe, but was controlled by intravenous injection of novarseno-billon. There have been several relapses since, the last occurring seven months after the infection. Wassermann reaction has been negative, and examination of the blood and of an excised gland failed to show the causal organism. In the discussion that followed, a number of cases were cited, showing that the condition is not rare in this district. A patient was also shown who had had a severe attack 3 years before, a ragged primary sore forming suddenly on a finger six weeks after a rat bite. He was treated with galyl and is now well.

ADDISON’S DISEASE.–Dr. Abbott.

A middle-aged man had been off work for three weeks prior to his admission to hospital. He had complained of symptoms which seemed to indicate cardiac weakness. No definite heart lesion could be found—the blood pressure was 130. With rest he improved, and was getting about again when he was seized with severe abdominal pain and vomiting. He was sent to hospital with a provisional diagnosis of an acute surgical lesion of the abdomen, and the vomiting was frequent and distressing, all nourishment taken being immediately returned, and a certain amount of bile and mucus addiction. X-ray examination was impossible owing to his inability to retain the barium meal. The bowels were not disturbed. Neurological examination and the Wasserman test were negative, there was no pigmentation of the skin. The man’s condition became steadily worse, and, after consultation, and exploratory operation was done, but no lesion discovered. Death occurred on the same day. Post mortem examination showed a complete replacement of the adrenal tissue by caseous tubercular material. There was present, also, healed tuberculosis of the lungs and dorsal spine.

The unusual features of the case were the short duration of symptoms, the intensity and duration of the pain, the absence of pigmentation, and the comparatively high blood pressure a few weeks before death. Unfortunately no later measurements were taken.

ENCEPHALITIS.–Dr. Tewsley.

Four cases of encephalitis lethargica were shown at varying stages of the disease. One was a case of several years’ standing, and showed permanent sequel of the disease, Parkinsonian mask, constant dribbling of saliva and interference with finer muscular co-ordination. A second case had been accompanied by severe epileptiform seizures at long intervals. Attention was directed to the fact that these cases are less infrequent than is generally supposed and that they are protean in their manifestations.

TORSION OF THE SPLEEN.–Dr. Holmden.

An elderly woman had been aware of a tumour in the lower abdomen for a number of years, but it had given rise to no symptoms. She was seized with sudden abdominal pain and symptoms suggestive of intestinal obstruction. A tumour of the contour of the spleen could be felt just at the brim of the pelvis. Operation showed several turns in the pedicle. Removal was easy.

CHYLOUS ASCITES.–Dr. Milsom.

A boy of 12, admitted to hospital with swelling of the left side of the scrotum and adjacent portion of the thigh. A laparotomy was done, and chylous fluid found in the abdominal cavity. Mesenteric glands were enlarged, but there was no other lesion. Following the operation the abdomen began to fill up with the fluid and has required frequently repeated tapping, while the œdema of lower limbs, scrotum and abdominal wall has become very great. Chylous fluid has also been aspirated from the left pleural cavity. The causative lesion is not definite but is thought to be tubercular glands of the mediastinum, causing pressure upon the thoracic duct.

ADEMONATOSIS OF THE COLON WITH CARCINOMA.–Dr. Kenneth Mackenzie.

A male, aged 22, complained of severe diarrhœa, much abdominal pain and loss of weight. A large carcinomatous mass was found in the rectum. An abdomino-pereneal excision was done. The excised segment showed, in addition to the carcinoma, numerous small tumours of the mucous membrane microscopically simple adenomata. Subsequent examination with the sigmoidoscope showed similar tumours extending as far as could be seen along the colon above the excision. It is presumed that cancer, uncommon in so young a subject, had has its origin in one of these adeomata.

RAYNAUD’S DISEASE.–Dr. Carrick Robertson.

A woman in whom gangrene of the finger tips of both hands had resulted from Raynaud’s disease. Peri-arterial sympathectomy was done in the upper arm on each side, with improvement in the condition. More striking results were mentioned as having been obtained by this method in similar cases.

SYPHILOMA OF BLADDER.–Dr. Frank Macky.

This was demonstrated with the cystoscope. History of gonorrhœal infection, with gleet since 1917. Urine turbid, gonococci in prostatic secretion. Cystoscope in May, 1920, showed a small inflamed patch to the left side of the bladder trigone. In spite of treatment direct to the bladder the lesion was found in November, 1920, to have increased, and in July, 1921, it had greatly increased so that the whole trigone was involved in a gross bullous œdema. There were present a gleet, a turbid urine, some frequency of micturition, and discomfort in the perineum. The Wasserman had all along been negative, but now an illustration in the Medical Annual suggested syphiloma and arsenical treatment was commenced, with striking result, the bullous condition subsiding and the urine clearing. Recent cystoscopic examination shows only slight scar traces at the site of the lesion.

SPRENGEL’S DEFORMITY OF THE SHOULDER.–Dr. Kenneth Mackenzie.

A boy of 14.—Deformity of the left shoulder since birth, becoming more marked with growth. The left scapula was fixed with its superior angle just below the occiput. The muscles on the side of the neck greatly shortened, and marked asymmetry of the face, with a slight torticollis. The dorsal spine showed a moderate scoliosis with the convexity of the left. There was no movement whatever of the scapula, abduction of the limb being limited to 90 deg.

X-ray showed the scapula smaller than normal, with elongation of its neck and much deepening of the ventral fossa by the forward bending of the superior border. No bony attachment of the spine could be demonstrated. The cervical vertebrae appeared to be reduced by fusion to three in number, and showed deficiency in their laminæ. There were also marked irregularities in the upper dorsal vertebræ. The ribs showed much abnormality. On the right side eleven were found, on the left side only eight, the first and second being undeveloped, and the third and fourth being represented by a single posterior piece, bifurcating anteriorly.

Operation showed a bony connection between the scapula and the traverse process of a cervical vertebra. The bone was removed. It was about two inches in length, with a triangular base articulating with the venter scapulæ opposite the base of the spine. It tapered as it passed forward and outward and had fibrous attachment to the vertebra. Its removal was followed by a few degrees increase in movement of the limb. It was thought inadvisable to attempt to lengthen the muscles of the neck at his age.

EXTROVERSION OF THE BLADDER AND TERATOMA OF THE PERINEUM.–Dr. Carrick Robertson.

A newborn infant with complete extraversion of the bladder and a pedunculated teratoma of the size of an orange attached to the perineum. The teratoma was removed. Later deficiency of the anal sphincter showed itself in persistent rectal prolapse. Slips of gluteus maximus muscle were used to replace the deficiency with good immediate results.

Amongst the pathological specimens shown by Dr. Gilmour were the following:—

COMBINATION OF CARCINOMA AND TUBERCULOSIS OF THE STOMACH.

At operation an irremovable tumour of the pylorus was found. An enlarged gland was removed from the greater curvature. This proved to be tuberculous in nature. Death occurred some weeks later, and at post mortem the pyloric tumour was found to be carcinomatous. The enlarged glands were confined to the gastric area. Some showed cancer only, others tuberculosis only, and others a mixture of the two. No other tuberculous lesion was found.

PAGENT’S DISEASE.

The skull and the tibia showed the typical changes of the disease, which had existed for a number of years. Death resulted from a very large and rapidly growing sarcoma of the left ilium.

TYPHOIDAL SALPINGO-OOPHORITIS.

Specimens form a patient dying in the fifth week of typhoid fever. Bilateral ovarian abscesses and pyosalpinx. Rupture on one side with peritonitis. From the abscesses a pure culture of B. typhosus was obtained.

HORSESHOE KIDNEY.

The pelvis of each kidney was filled with a large branching calculus—bilateral pyonephrosis and perinephric abscesses.

HYDATIDIFORM MOLE WITH DOUBLE OVARIAN CYSTS.

Removed from a single woman aged 18. History of three months amenorrhœa, then about six weeks persistent slight hæmorrhage. Bilateral and apparently rapidly growing ovarian cysts were found at operation. No trace of ovarian tissue could be found, and they were removed together with the pregnant uterus. The uterus was, on opening, found to contain a vesicular mole. The question as to whether the destruction of ovarian tissue had any relation to the placental degeneration was put forward.

SPASMOFIC STRICTURE OF THE UTERUS.

Dr. Tracey Inglis reported two cases of dystocia from this cause. The first patient was a two-para. Eighteen hours after the commencement of labour no progress was being made although the cervix was well dilated, and no pelvic obstruction existed. A hand was passed into the uterus and tight constriction of uterine wall was felt around the child’s neck. After fifteen minutes of full surgical anæsthesia, and some manipulation, the stricture relaxed and delivery was easily effected.

The second patient was a primipara. After 18 hours’ labour, progress had ceased with the head low in the pelvis. Intra-uterine examination showed a stricture round the shoulders of the child. It relaxed under deep anæsthesia and a forceps delivery became simple.

Dr. Inglis queried the result of the administration of pituitrin or the application of forceps without recognition of the condition. He emphasised the absolute difference between a muscular stricture such as this and the physiological retraction ring.

Therapeutic notes were presented by Dr. Carrick Robertson on the use of intravenous injections of eusol in the treatment of streptococcal septicæmia, by Dr. Kinder on the use of the silver-arsenic preparations in syphilis, and by Dr. Falconer Brown on the value of guaiacol-glucose solution as a vehicle for the intra-muscular injection of N.A.B.

Dr. McDougall exhibited an interesting series of radiographs showing the bronchial tree of the living subject injected with bismuth emulsion; and also a number of slides of colon radiographs demonstrating the normal and the abnormal.

Dr. Bruce Mackenzie gave a short demonstration of radiographs illustrating changes recognisable in different types and stages of pulmonary tuberculosis; also radiographs of Dr. Holmden’s case of transposition of thoracic and abdominal viscera, and of Dr. MacDiarmid’s case of disease of the right sacro-iliac joint, where the only symptom was an abscess pointing in the left inguinal region. He also demonstrated by radiographs the diminution in size of an intra-thoracic tumour in an old standing case of lyphademona under X-ray treatment. Dr. Bruce Mackenzie also showed a case of mycosis fungoides responding to X-ray treatment, and another case of obstinate syphiloma of the nose which rapidly disappeared under the same treatment.

The last meeting of the year was devoted to re-exhibition of or further reports upon cases dealt with in the session.