Select clinical reports

SELECT CLINICAL REPORTS.

Bv ARTHUR WYNNE FOOT, M.D. UNIV. DUELS;Senior Physician to the Meath Hospital;

Professor of Medicine in the Royal College of Surgeons in Ireland, &c.

[Read in the Medical Section, December 17, 1886.]

THE following cases, picked out of my hospital note-books, show

that as strange a mixture of odd cases may be observed there as is

to be met with in general practice.

Among the cases of dilapidated stomachs, contracted livers,

decayed lungs, broken-down nervous systems, and worn-out hearts,

it is a variety to meet with something besides the results of povertyand overwork.

1. OBSTINATE VOMITING FROM " LAND-SICKNESS."

At 11 a.m. on 18th September, 1885, a man, aged twenty-seven, applied at the hospital for relief for continued vomiting,which was accompanied with cramps in the abdominal muscles.Though there was no report of any purging, he was admitted andattended to at once, more particularly as choleraic cases were notunexpected about this time of year. He was put at once to bed,warmth applied to his feet and stomach, a sinapism to the nape,he was given effervescing draughts and ice to swallow in smallpieces, yet the vomiting continued all day and through the follow-ing night.

Next morning, 19th, instead of finding him well, as I had ex-pected, he had by his bedside a large basin nearly full of greenishfluid, towards which he turned himself every two or three minutesto make further additions, which were contributed with loud-roaring retchings, exactly similar to what is heard on a steamerduring a rough passage. Between the acts of vomiting he writhedwith cramps in the abdominal muscles. The urine was scanty;he 11 had not power to make any." The muscles seemed weariedout from their almost continuous tension. His head was clear and

Select Clinical Report. 25

he spoke most intelligently, but conversation seemed to aggravatethe sickness, and most of the interesting points in the history ofthe case were elicited afterwards. He was apyrexial ; the cir-culation was not hurried ; the tongue was discoloured with bile,but not particularly furred ; though there had been no evacuationfrom the bowels for six days, there was no evidence of internalobstruction. A mixture of chloral hydrate (3 i + aq. laur. cer.3 i + aq. chlorof. 3 vi. ; dose, 3ss., tertiis horis) was given him,sinapisms were reapplied to nape and epigastrium, and morphiainjected hypodermically, without checking the vomiting, whichcontinued, with a respite of three hours during which he hadsome sleep, of which he was much in want—till next day, 20th.

As he then (20th) complained of feeling very weak, he wasordered a mixture of equal parts of brandy and water, to be takenas often as he wished. He was put into a hot bath this day, andfelt immediate relief the stomach became quiet, he got hungry atonce, slept well the following night, and next morning (21st) eatheartily of bread and milk, and was making water freely ; thecramps and pains had gone, with the exception of some muscularsoreness. After another hot bath (on the 21st) he was quite well,and left hospital the following day.

The cause of this attack of obstinate vomiting was sea-sickness,which persisted after his leaving the vessel, and it was not the firsttime it had happened to him.

He had come from Glasgow to Belfast in a screw steamer on14th September, as a deck passenger. A sailor, taking pity onhis sufferings, had let him have his bunk for a small consideration.The passage occupied seven and a half hours (not longer thanusual). The sea, according to nautical estimation, was not par-ticularly boisterous; the sailors said "there was a bit of a swellon after a breeze " (there had been an 11 American storm " on the12th and 13th). His sea-sickness continued for two days in Belfast(where he stopped, hoping it would cease before he came on toDublin), continued during the railway journey from Belfast toDublin, and he vomited several times while driving across Dublinon an outside car. In Dublin, on the 17th, he had medical advice,and an enema was prescribed for him, after which he had a shortrespite from the vomiting. As it soon returned he applied nextmorning (18th) at the Meath Hospital, as before mentioned.

Twice already this year he had suffered severely from sea-sickness, continuing after he had reached terra firma. In January

26 Select Clinical Reports0

he had come from Glasgow to Belfast, been sick the whole time,and for two days afterwards in Belfast; on his return to Glasgowhe chose the shortest sea route, via Larne and Stranraer—channeland loch passage about two and a half hours. He was sick in thetrain between Stranraer and Glasgow, and continued so for fivedays in Glasgow before he recovered. He would not have temptedNeptune on the present occasion but for a wish to see his mother,who lived in Dublin, during his holidays, and that he thought theweather at this time of year would have been more propitious thanin mid-winter. He was a traveller for a draper in Glasgow, andhis excursions were limited to the vicinity of that city. He couldnever bear the motion of a boat of any kind, and had been madesick by a swing; had a "bad head for heights," yet he was notliable to sick headaches, nor of a bilious temperament; was easilysickened by alcohol, but not by tobacco. He was the only memberof his family so very susceptible to sea-sickness. He had brownhair and a fair skin, but could not be said to have the 11 light com-plexion and light hair " of those who sicken first at sea.a

This patient was an example of that kind of constitution which

is morbidly prone to feel the effect of the motion of a vessel.

There are some, on the other hand, who are totally insusceptible to

the concussions which in the majority produce nausea marina. The

continuance of his vomiting for nearly nine days, even after his

arrival on shore, shows how possible it would be for such a person,

on a lengthened voyage, to die of sea-sickness.

II. CASE OF MISTAKEN IDENTITY ON THE PART OF FOUR

PERSONS.

The following incident of the memorable "whisky fire " whichoccurred in Dublin on the night of 18th June, 1875, produced astrong impression on me, and the following is an account of theincident from notes I made of it at the time :---Michael Healey,aged twenty-three, a corn porter, was one of several men whowere brought to the Meath Hospital early on the morning of Satur-day, 19th June, 1875, 11 dead drunk" from whisky taken at thegreat fire of the bonded stores in Chamber-street on the previousevening.

He and three others, equally comatose from alcohol, lay on

11 See Dubl. Med. Press. Vol. XXIV., p. 41.

By Du. A. W. FooT. 27

mattresses on the floor of the theatre in very good light. Relativescame during the day to look for missing friends who were scatteredabout among various hospitals.

At 3 p.m., on the 19th, a woman of the name of Kinshela, whoseson was missing, came to look for him in the Meath Hospital.She immediately recognised the man Healey as her son, asked tosee his trousers, and swore to the clothes on him as those of herson. She sat beside him, lamenting over his condition and theevils of drink till 8 p.m. Meanwhile her husband had arrived;he, too, recognised his son, and observed to me with much parentalfeeling, ti Wasn't it an unfortunate thing for a father to see hisson in this condition," and " if he had stayed at home thiswouldn't have happened." Healey was still comatose from alcohol,and could neither speak nor open his eyes, but was not blackened,burned, or disfigured in any way beyond a somewhat bloated,congested appearance about the face.

Two daughters of the Kinshelas also came, and they, too, had nohesitation in agreeing they had found their missing brother. Thesupposed father remained by Healey for two hours ; the two girlsstopped a little longer ; Mrs. Kinshela, as before mentioned, leftthe hospital at 8 p.m. to go home for the night. She found herown son at home, but did not notify this fact to any one in thehospital till the following (Sunday) morning, when she told thegate-porter she had got her son.

On Saturday night, at 9 p.m., an hour after Mrs. Kinshela hadleft, the real mother came, immediately recognised her son, andwhen told that he had been claimed by several other people, shesaid, "If he has not marks of burns upon his back and the side ofhis neck he is not my son." On stripping him the promised markswere found of burns which, when a boy, he had received in a matchmanufactory. The real mother seemed to recognise him moreimmediately than the false one, and the resident pupil, Mr. HillMalone, told me the man appeared in a dim way conscious of thevoice of his mother; while in reference to the other woman, hehad not observed the least effect on him from her voice. Healeywas a married man, but his wife did not come to look after him,as she was in the Union Hospital, and had either not heard ofthe occurrence, or was unable to come.

All along Mrs. Kinshela seemed to have some misgivings about

Healey being really her son. She went home in the afternoon to

28 Select Clinical Reports.

get her husband to come and give his opinion on the subject. She

went home at 8 p.m. and left the man, though he was not expected

to live through the night, and, in fact, did die on Sunday morning.

The real mother remained all night. The opinions of the two

Kinshela girls were probably much influenced by those of their

parents—i.e., when the father and mother thought the man was

their son, the daughters, if they had any doubts about the identity,

may not have felt bold enough to differ from such unquestionable

authorities. Mrs. Kinshela offered to swear to the man's clothes,

but the dress of working men is often very much alike. Had he

been able to open his eyes, or to speak, the difficulty of identifica-

tion would have been much lessened, as, independent of their

colour, their expression gives a difference to features otherwise

similar ; and everyone knows how specially characteristic the voice

is, and that it will recall to mind an individual whose features have

been totally forgotten.

The whisky, which ran along the side channels in the streets

during the fire, was of unusual strength and a good deal of it new.

About thirty persons were brought to the hospitals in a state of

coma; two deaths occurred among those carried to the Meath, one

in the Richmond, and one in the Mater Misericordiae Hospital.

It is seldom that the question of identity is difficult to decide in

reference to a living body, and, when so, it usually arises in case

of one returning home after a long absence, or where the plea of

mistaken identity is put forward by one charged with some offence

against the law. More usually does this question concern the

dead Of whom is this the body ? (as in the case of Dr. Livingstone),

where a body is brought from abroad, and doubt exists whether

the remains are those of the person they are stated to be. It is one

of the questions specially submitted at every inquest to the jury

for their consideration.

11.1. ACUTE ARTICULAR GOUT.

On 27th October, 1885, a man, aged sixty-four, of sanguinetemperament, corpulent, full-blooded, of plethoric habit of body,was admitted to the Meath Hospital with all the objective symptoms

By DR. A. W. FOOT. 29

of acute gout in the great toe of the right foot and in the leftwrist. He had, in addition, a gouty abscess on the dorsal surfaceof the last phalanx of the middle finger of the left hand, andseveral tophi (gout-stones) in the helix of the ear on either side.He was the ; 1 jolly landlord" of a well-known house of rest andentertainment on the Naas road, weighed nineteen stones, and saidthat for the last thirty or forty years he had been in the habit ofdrinking fifteen or sixteen pints of porter every day ! A weekbefore admission he had been struck with a sudden pain in theball of the right great toe, and soon afterwards a similar painseized him in the left wrist. He had never felt a twinge in theseparts before, but, nine years ago, he had had his first attack—inthe left great toe and the middle joints of the right hand. Forthe week before admission he had had no sleep at night on accountof the severity of the pain, and had spent the nights " twisting aboutlike a windmill," not being able to lie with comfort in any position.He was otherwise apparently in robust health, his 11 Bardolphian"countenance beamed with good nature in the daytime (the pain wasthen in abeyance), and he had a joke and a laugh for everyone, ora story of incidents which had occurred on the Naas road. Theskin about the root of the right great toe was deeply red, with atendency to lividity—tense, glazed, and shiny, hot to the touch;the adjacent parts were oedematous, and coursed over by severalturgid veins. The left wrist was less reddened, but more swollen,than the great toe ; the superficial veins were not so conspicuoushere as in the foot, the pain and tenderness seemed equally markedin both places. The urine was scanty, high-coloured, very acid,and deposited urates copiously; the urates were deeply tinted withthe fiery pigment of purpurine. The right foot and left wristwere at once wrapped in fine wadding, and covered hermeticallywith guttapercha paper. After his bowels had been freed by mist,sen. co., he was ordered a mixture--viz., Vin. colch, 3ij ; Sulph.magnes., j.; aq. cinnam., 3viij. ; dose, 3ss., t. d. Milk diet, anda glass and a half of whisky in the day. At the same time Iopened the " gouty abscess " which was at the proximal side ofthe matrix of the nail of middle finger of left hand, giving exitto a lot of milky paste, consisting of pus mixed with urates. Hesaid it gave him relief to have this done.

By the 3rd of November (a week after admission) the pain andswelling had abated both in hand and foot; but, at 2 a.m. of thisday, he was seized suddenly with a pain, referred to his heart, and


said to be precisely of the same kind as that which had ushered inthe attack in toe and wrist. A sinapism was applied to the chest,the colchicum mixture was stopped, and one of cardam. tinct. co.and spt. am. arom. substituted for it. There was nothing unusualto be observed about the sounds or rhythm of the heart, and it islikely that this sudden anginal paroxysm (which did not recur) wasconnected with chronic endo-arteritis of the coronary arteries.

6th November. He was put on potas. bicarb., 3iij., sod. iod.. 3j.,and inf. calumbe, 3 8; dose, 3ss., t. d. While taking this bothankles were attacked; and, as he said the potash medicine wastaking away his appetite, he was given 15 grains every third hourof salicylate of soda, which was soon reduced to half the quantity.The skin over the affected joints desquamated freely, being par-ticularly itchy during the process. He left hospital on the 28th ofNovember, 1885, just a month after admission, with some stiffnessin his foot and wrist, but in such a condition that he could readilyattend to his business.

In this case there was no history of hereditary gout; it seemed

to have been acquired by the combination of insufficient exercise

and over-use of malt liquor. The cases in which the disease is

developed during or after middle-life mainly originate de novo. It

generally appears earlier in those who have inherited it. When

the anginal attack occurred at the gouty hour (2 a.m.) he was much

alarmed, because he had heard of gout 11 flying " to the heart, &c.

The expression 11 flying gout," which is a most extraordinary one,

seems to have been first used by Mrs. Hunter (wife of John

Hunter), in a letter to Jenner about her husband,a in which she

says (Sept. 13, 1785) :---"= He has been tormented with a flying

gout since last March."

IV. SUBJECTIVE OSMIDROSIS.

The following very strange case first came under my notice atthe Meath Hospital on the 23rd of September, 1878. He was acompositor, aged twenty-four, unmarried, stout, florid in com-plexion, of active and excitable temperament. He showed themost acute anxiety to be admitted and carefully examined, assuringthe pupils in the admission room that he was a peculiar case.

a Palmer's Life of John Hunter, p. 96.

By DR. A. W. FooT. 31

When I saw him in bed the next morning, the following particularswere elicited from him :--He was desirous to be cured of 11 anoffensive heat or vapour arising from his body or breath, of whichpeople complain," saying that his vicinity makes them sneeze, yawn,or feel drowsy. He declares that this emanation makes them turnpale, that it makes his own conjunctiva smart, and that his pre-sence similarly affects others near him. I smelt his breath duringthe fullest , expiration and after coughing, and it was almostinodorous ; he had not foetid perspiration of the feet ; he thoughtthe exhalation came most from the axilloe, but I could not perceivethat they were more hircic than such regions usually are, certainlynot peculiarly so. His skin was soft and greasy, there was anotable accumulation of fat over the abdomen, he used to indulgehis appetite in eating very much, and also took 1 { a fair share " ofdrink. He had been salivated for syphilis fifteen years ago ; hehad never had any symptom of lead-poisoning. It is two yearssince he became convinced that he was the source of the emanationof a noxious effluvium. If anyone sneezes near him he at onceattributes their doing so to his presence. He is civil and intelligent,yet has been kept from employment, he asserts, owing to menobjecting to work in his vicinity, and has for this reason lost situa-tions both in Dublin and London. He had consulted a doctor inKing's College Hospital, who gave him pills of creasote and car-bolic acid, and desired him to wear chloralum pads in his axillaeand on the top of his head, without benefit. His bowels are alwaysconstipated ; he has a tendency to flexor cramp in his hands andto closure of the lower jaw. His mind is very much distressedfrom thinking on the annoyance to which he believes he is subject,and his sleep is disturbed from uneasiness of mind. Though Istood over him in bed for nearly an hour I could perceive no moreodour from him than would come from any other greasy-skinnedman of gross habit. As a proof that his presence was felt in theroom, he told me that a young lad in the ward had sneezed sixtimes the day before; and on the morning of the 25th, when oneof the class sneezed, he interrupted me while speaking to draw myattention to that evidence of his complaint. He connects everysneeze with himself. He says people have sneezed at the oppositeside of tue road when he was passing by; and when I asked himwhat proof he had that he was the cause of their doing so, he sayshe never observed such a thing to happen till he got this com-plaint. No suggestion that they might have been taking snuff or


catching cold will he entertain for a moment. Thinking he mightbe affected with a subjective sensation of smell arising fromfaecal retention or a disordered stomach, his bowels were wellcleared with castor-oil, and he was put on a course of dilute nitro-muriatic acid with infusion of gentian, and permanganate of potas

-sium pills, while he had sound sleep at night from chloral andbromide of potassium. Still he remained quite positive that somenoxious odour emanated from him which affected the Schneiderianmembrane of anyone who came near him.

As about this time a curious case had occurred in Dublin of theelimination of sulphuretted hydrogen in the urine, I had his urinecollected carefully, and Dr. Lapper was kind enough to make amore accurate analysis of it than I could undertake :-

Urine of ist and 2nd of October = (24 hours) :--Total quan-tity = 61 fl. oz. ; normal tint, usual amount of sediment of vesicalmucus and epithelium ; no peculiar smell from it, heated or inthe cold ; specific gravity, 1014; very acid ; no albumen, sugar,or bile ; urea = 0 . 8 per cent. ; phosph. acid (P2 O b ) = 0.135 percent. ; chlorine = 0.324 per cent. Dr. Lapper could detect nothingabnormal in the sample.

As I could make no impression on him, he was not long re-tained in hospital. I considered him a kind of hypochondriac.He was morbidly attentive to the character of his excretions,used to defecate upon a piece of paper, the more convenientlyto study the qualities of his motions, and examined his pulse andtongue daily.

I saw no more of him for five years. He turned up again inthe month of May, 1883, and came to know had I yet found outa cure for his disease. I admitted him at once, and commenceda fresh study of him.

The following notes of his own words, taken down by myselfat the time, might seem too ridiculous to print but that I have metwith an analogous case in a gentleman of position and education,which will be detailed in connection with this :-

His complaint is that 11 when in the workshop (he is a compositor)for a month his fellow-workmen feel ill, bad, affected with lassi-tude." When he has affected them thus, he leaves 11 throughscruples of conscience." Can give me no other proof of theseresults of his presence than his own conviction. He affects horses,makes them yawn and shake their harness. Fowls yawn bystretching out their wing and the hind leg of the same side 11 to


refresh themselves." He makes people yawn at the other side ofa sheet of glass, as when looking in at a shop window. Whatannoys him most is that he cannot follow " his profession ;" if hedoes not leave the job he is employed on, his fellow-workmen giveit up. The sensation his presence excites is that of an oppressiveheat ; the temperature of a room he is in changes. He believes hehas communicated this disease to others—to his wife among them;and that in one instance it was communicated even to a thirdperson. Animals are affected by his presence ; he has heard catssneeze at him. A dog, ten months old, 11 and which was no foolof a dog," ran away from him. A singing thrush 11 became dumb "when he came near it. Horses and men have been affected againstthe wind—i.e., when to windward of him.

As I was aware that the late Dr. Jonathan Osborne a had ahigh opinion of the internal use of chloroform in hypochondriacaffections, I put him on ass. doses of spt. chlor. in decoction ofIceland moss three times a day. After a week of this treatmenthe had become very weak and faint, and perspired profusely. Thechloroform was stopped, and he was put on mist. quininae, - andthe next day he had quite recovered from what looked like chloro-form syncope. There was no alteration of his dominant idea. Hetook delight in talking of his "disease," even though his serio-comic observations created roars of laughter in the class. Forthe sake of discipline I was unable to keep him in, as he becamequite a show, and many strangers came to see the " sneeze-coni-peller," and to draw him out about his strange influence upon menand animals.

In January, 1884, he presented himself for the third time atthe hospital, and, lest I should have forgotten his case, he handedme the following characteristic document, written in a neat hand,which I copy verbatim :-

" GENTLEMEN,—III order to save time and to be explicit, I have,in reference to my case, placed upon paper these few

Observations :-

"When I go to work—when I lay my attention to my businessas a compositor--the room where I am employed becomes un-pleasant-_that is, 4 stuffy,' warm, and oppressive. After three orfour days all who have associated with me for that time becomeaffected as follows—they sneeze, yawn, turn pale, complain of

Dubl. Quart. Jour. Med. Sei. VoL XVI., p. 463.

0


headache, and feel generally disinclined to continue work. This Ihave proved in fifty different places, and have left them all throughconscientious scruples, but never explained. I disturb everyoneby my presence (much to my annoyance), and always feel better whenI am alone ; disturb people who may be near me from fallingasleep, and •when they ultimately do fall asleep they awake in themorning complaining of being tired and unrefreshed. Inferioranimals (the horse and dog, for instance) become uneasy if I amnear them for any time. Persons going smartly about their busi-ness in the street (30 say out of every 100) yawn as I pass by;others sneeze when I am near them in the street. Women crossthemselves when I suddenly meet them turning a corner (withoutcolliding). Young children run away when they see me approach.Wherever I go I am I suspected' after a short time. If I go intoa tavern, for instance, all present turn round and look at me afterstanding by a few minutes, and severe remarks are sure to follow---such as, E I thought Marwood was dead.' ' So did I.' { So did Itoo.' I Maybe 'tis Binns I' . . . When in company with thesex, they become disgusted with my presence, no matter how graciousI try to be. ' What kind of man is this ?' is the current remarkwith the ladies. • Persons who know me can tell whether I am in thehouse or not, even if they do not see or hear me come in ! ! Cannot fixmy attention on anything for more than five minutes. Cannotstay in the one place. Must always be moving. Perpetual miser-able feeling of ennui. After a short time persons get nervous in anycompany. I myself have a good nerve—could stand and see a mancut up by a locomotive without being moved in the least. Nothinghas a charm for me—not even money. 11íy whole anxiety isowing to loss of independence, caused by not being able to followmy profession in consequence of this infernal infirmity. Havehad to live on my relatives for years. Indecision. Depression.Food seemingly does not nourish the body, although I live pretty well,and have a good appetite. Thin blood, cold surface. Decay ofmuscle. Consider that the economy of the nervous system—orindeed the economy of nature's realm—has been disturbed throughsome cause---indiscretion, concupiscence, venereal disease, or whatnot. Pain in back of head lately. Never sought advice in Dublinoutside of this hospital. Was ever mortal so afflicted? Fouryears is a long time to live on such terms as these and to be in one'sright mind. Dr. is the only physician who has given me afair and patient hearing, and I believe his wish is that he could


cure me. Dr. -- also put a name on my disease, which gives

me a hope that he can yet do something for me.

"Obediently,

`= HAKPUK."

A case, similar to the preceding, which, though not an hospitalcase I had many opportunities of studying, came under my noticeseveral years previously, and appears from its singularity worthyof being related in connection with the above. It was that of agentleman who laboured under the impression that he diffusedaround him an unpleasant effluvium, any indication of which Inever could perceive, nor did I ever find any positive evidencethat any one else had ever done so. He was aged thirty, verystout ; weight, 15 st. 10 lbs. ; fair-haired, fresh-looking ; said hefelt in perfect health, and indeed looked the picture of it. Hecame to me complaining " that he seemed to use up all the freshair " in a room, railway carriage, or any confined compartment;that there was an overpowering smell diffused from his personwhich made people faint, open the windows in a railway carriage,or avoid his company. He asked me could he " be getting a skinlike a black's," and also for 11 a large dose of castor-oil to sweepit all out of him." It did not proceed from decayed teeth, diseasednose or tonsils, nor was it from his feet. As he drank and smokeda good deal, eat his meals hastily and at irregular hours, and hadsome feeling of weight in his stomach after eating, I hazardedthe conjecture that it might come from his stomach, although Icould perceive no unusual odour from his skin or breath, whilecloseted with him in a small room for some time. I did notventure on a first acquaintance to question the many proofs heoffered in evidence of the reality of his complaint. He was orderedpills of creasote, a mouth-wash of glycerine of carbolic acid, amixture of hyposulphite of soda, sulphurous acid, and infusion ofquassia, and advised to keep in the open air as much as possibleHe had of late been much hurried and worried by business; anelection petition had been lodged and carried against his brother,to whom he was agent, and this had thrown much extra workand trouble on him.

I saw him first 6th March, 1872. On the 12th he said he wassatisfied the odour did not come from his stomach, and thereforehad not used all the medicines ordered. He explains that it is notso much a bad smell from him that he suffers from, but that he


seems to absorb all the fresh air in a room, making it close, heavy,and oppressive. He even dislikes going into the smoking-room ofhis club, because he feels he is disagreeable to others. He thinksi{ the smell from his skin is much worse after Turkish baths thanbefore them." I increased the dose of creasote in his pills, andordered sulpho-carbolate of sodium with cascarilla.

8th June. He does not find the medicines have had any effect,and asks for something else, reminding me that 11 while enjoyingperfect health in every other respect, his presence had the effectlately of making a room so close and disagreeable as to bring waterto the eyes of every person present." I then gave him chlorate ofpotassium, dilute muriatic acid, and infusion of quassia.

22nd.--" The last medicine had not the slightest effect." Hewas afraid it would require something which would make a con-stitutional change to effect a cure. He would prefer any remedy,no matter how tedious, disagreeable, or dangerous, rather thanremain as he was, as, i 1 while quite well in other respects, hispresence at once brings tears to the eyes of anyone near, andmakes a room as suffocating as if fifty persons had slept there."Was put on iodide of potassium, in 3-grain doses, ter die.

23rd July.—The last prescription 11 no use." Has given upsmoking and become most particular about eating and drinking,takes both horse and walking exercise every day, Turkish bathsfrequently, sponge bath daily. He does not find anything wrongwith his stomach, and thinks his complaint must arise from " goutytendencies," although they have never otherwise manifested them-selves. He suggests that 11 some very strong and powerful medicinefor purifying the blood and removing the humorous matters mightbe what is required." Was given 4 min. doses liq. arsenicalis,with 5 min, doses tinct. sem. colch. in liq. ext. sarsa, ter die, andtold to drink lithia water freely.

11th August.---Had not experienced the slightest relief fromthese remedies. He had " gone on Banting," and been alreadyreduced a stone in weight. Begged of me to mention his case tosome of the celebrated physicians, and ask them had they met acase like it, and what was the cure for it. "I know the treatmentmust be perplexing, as I have no apparent symptom of disease toshow what organ is affected, my health and sleep being otherwiseperfect, and I take scrupulous care as regards my eating anddrinking, and about taking exercise. I have given over smoking,and I would sooner suffer from the most dangerous disease than


my present complaint." I now ordered 20 min. doses acid. sulph.arom. in water, twice a day. He had more than once spoken ofthe eyes of those near him smarting and becoming watery fromhis presence, and it occurred to me that some ammoniacal com-pound might be given off from the skin. It is stated that all sweatof a putrid odour contains free ammonia. a He was directed tosponge the axilke after his baths with a lotion of chloride of zincand rose water, use carbolic soaps, and continue on the Bantingsystem, till he lost 2 st. more.

8th September. Last prescriptions have had no more effectthan the previous ones. His weight is now reduced from 15 st.10 lbs. to 14 st. 2 lbs., and still lessening rapidly. He would saythat 11 the most remarkable symptom is that any person in mypresence, even in the open air, gets at once red in the face as wellas having tears brought into his eyes." Of late he has taken nowine or alcohol in any form, and even larger doses of his medicinethan had been ordered. Desired to continue the Banting tillreduced to 13 st., and suggested to try a wineglassful of Murray'sFluid Magnesia three times a day.

10th.--In reply to my inquiry whether he could perceive anyodour himself, he said : " I perceive the exhalation most plainlyin a room in which I have been for some time on my returnto it. I think I gave all the medicines a fair trial, as I took twoor three times the doses ordered of each for about a fortnight.Banting and grouse shooting are reducing my superfluous fat. Ishall continue the Banting till I reduce myself to 12 stones." Hehad at this time tried creasote, charcoal, hyposulphites, sulphurousacid, sulphocarbolates, chlorate of potassium, tonics, iodide ofpotassium, Turkish and cold baths, arsenic, colchicum, lithia;given up smoking and alcohol; exercise, fluid magnesia, aromaticsulphuric acid, carbolic soap, lotion of chloride of zinc, Banting.

16th December. --In nowise improved. Now advised him togive up butter and fat-forming foods, and to take plenty of exercisein open air. The butter was to be abandoned because it promotesthe formation of volatile fatty acids, eliminated by the sebaceousglands, as demonstrated by Magendie's experiments of feeding dogson butter. b

I suppose he gave me up in despair, as I saw no more of him

& Dis. of Skin. Erasmus Wilson. P. 583. Fourth Edition.b See Russell Reynolds' Syst. Med. Vol. III., p. 362.


till 26th February, 1875, when he said he was quite rid of his

complaint. He was then just as fat and florid as usual.

I have met with a third instance of this affection or disease.It was in a man who was sent up to the Meath Hospital, six orseven years ago, from the County of Carlow. I have lost, orcannot find, the notes I took at the time, but have a perfectrecollection of the main features of his case. He was driver ofa posting-car connected with Ward's Hotel, Bagnalstown, andcomplained that the smell he gave off annoyed passengers, evenon the other side of the car, in the open air, and that to such adegree that he said unless he could be cured he should have to turnto some other occupation. He was of middle age, robust, in perfecthealth, not red-haired, neither more nor less odoriferous (as far asI or any of the students could perceive) than other hospital patients.He thought he was more disagreeable in summer than in winter,but accounted for this by his wearing a heavier overcoat in wintertime, which interfered with the dissipation of the vapour whichhe believed came from him.

I have called these cases by the name of osmidrosis (óo-,a j, odor;Lapcis, sudor), because the perspiration, even in persons of the

Caucasian race, has, on account of volatile organic acids, often a

peculiar odour. It is, moreover, in use in the text-books.a I haveused the word "subjective " because I am inclined to think that

each of the individuals was labouring under a hallucination. In

the case of the two hospital patients none of the class or of the

nurses could ever perceive any smell at all approaching in degree

what they said they were the originators of. In the case of the

gentleman, though he said he made small rooms unbearable, I

several times asked people with very sensitive noses was there any

peculiar smell in a moderate-sized room where he had been for

fifteen or twenty minutes, and they never could perceive any

immediately after he had left it, nor did I ever find it necessary

to open windows or use deodorants after a visit from him. Hallu.

cinations of smell occur more rarely than of sight or hearing; yet

hysterical patients, in particular, often smell objects which are not

" Ex. gr., E. Wilson, Diseases of Skin : Quain's Diet. of Med. (Art. Per-spiration) ; von Ziemssen, Handbook of Skin Disease.


present—such as sulphur, musk, violets, &c. Feuchterslebena was

acquainted with a lady who was often tormented by a charnel

smell that seemed to follow her everywhere, for which there was

no organic cause. Cases are common enough of bromidrosis pedum

(fetid perspiration of the feet), which arises from decomposition of

the products of the sebaceous glands, but there are very few detailed

cases of the functional disturbances of the sweat glands. Prof.

Geber b mentions his having had under treatment a patient who

otherwise did not show the least trace of bromidrosis, but when-

ever he began to perspire more freely, as after eating and drinking

heartily, or by active exercise, so offensive an exhalation spread

around him that he was forced to shun all social intercourse.

Baths, cold ablutions, and hydro-therapeutics, continued for weeks,

produced no improvement.

Anomalies of the special senses occasionally occur in a state of

apparent health. These conditions are, as Griesinger remarks, in

general far too little studied, being usually thrown into the compre-

hensive class of hypochondriasis. Sometimes organic change is

found in connection with these sensory disturbances. In a patient

who had strong hallucinations of smell a fungus of the dura mater,

as large as a hazel nut, was found in the cribriform process, and

surrounded by the olfactory nerves. 0 In another patient, who had

been constantly followed for more than six months by a smell of

dead bodies, there was found an abscess of the corpus callosum.d

Suicide even has been resorted to so as to escape from the per-

sistent annoyance of a smell. On 17th April, 1882, a man applied

at University College Hospital complaining that so terrible a

stench came from ulceration of the stump of his leg (the limb had

been amputated by Mr. Marshall five or six years earlier) that no

one could bear to come near him. On examination this was found

to be a manifest delusion. On the following day, however, he was

admitted, having made a most determined attempt to commit suicide

4 Medical Psychology. Syd. Soc. P. 233.b Handbook of Skin Disease. Von Ziemssen. P. 506.C Vienna Asylum Report, 1858. P. 266.d Griesinger on Mental Diseases. Syd. Soc. P. 101.


by throwing himself upon the point of a sword-cane, which trans-

fixed the stomach and left lung. He died in five days. ,,

The opinion may, I think, be fairly entertained that in these

cases, which I have called subjective osmidrosis, there was some

disorder of the elementary sensory apparatus appropriated to the

function of smell, causing the sensory cortical centre to enter into

spontaneous activity in the absence of any external impression,

producing thereby a hallucination—that is, a sensation in the

absence of any external cause, or of any irritation of the peripheral

end organs or of the sensory conducting paths.

a Brit. Med. Jour., 29th April, 1882. P. 629.

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