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Un daa aymbolaa suivanta apparaftra sur !a darniira imaga da chaqua microficha, salon la caa: la symbola — *• signifia "A SUIVRE", la aymbola V signifia "FIN". l\Aapa, plataa. charta, ate, may ba filmad at diffarant raduction ratios. Thoaa too iarga to ba antiraly includad in ona axpoaura ara filmad baginning in tha ^ I Cb ' MEDICAL CASES, BY. GEOEGE R0S8, A.M., M.D., Professor of Clinical Medicine, MoGill University ; Physician to the Hospital. (From the Montreal General Hospital Reports, Vol. I., 1880.) M PRINTKD BY THK GAZETTE PRINTING COMPA.NT, MONTREAI-. •^^ ^,. ! •f I V CI MEDICAL CASES BY GEORGE ROSS, A.M., M.D., Professor of Clinical Medicine, McGill University; Phj'i-ician to the Hospital. I.- •Cme of Extreme Dilatation of the Stomachy caused by Pyloric Stenosis, resulting from the Contraction of an Old Ulcer. Mrs. D., aet. 37, a Swiss woman, was admitted into the Montreal General Hospital on the 10th December, 1878, complaining of uneasiness in the stomach, heartburn, and frequent vomiting'. Patient has always been strong and healthy until lately. The only illnesses she has ever had were ague 20 years ago, and small-pox about 15 years ago. Her youngest child was born 16 months ago. She says she was in her usual health at that time — a good appetite and no trouble in digesting her food : still she was obliged very soon to wean the infant because there was so little breast-milk. Since then she has menstruated quite regularly until three months ago. There is no reason to think that she is pregnant. About three months airo she began to suffer from dis- turbed digestion ; the symptoms which then showed themselves, and have since continued gradually increasing, were as follows : first a " squeezing sensation,'" as she de- sc ribes it, at the pit of the stomach. It would seem as if a sense of distension were meant to be also implied. Other uneasy feelings were also experienced, but at no time anything of the nature of actual pain. A severe and constant burning in the stomach and up the throat. Nausea was often felt, and she frequently induced vomiting pur- 2 DILATATION OF THE STOMACH. posely by irritating" the fauces with her finger. Vomiting- also spontaneously occurred at irregular intervals, but was uninfluenced by the taking of food. It would sometimes be absent for a period of 2, 3, or 4 days at a time, when she would bring up large quantities of sour-tasting fluids and food. Her appetite is good : she can eat meat or any other kind of food, and finds that she does not suff'er more from one kind of food than another. Bowels have been extremely constipated, and have sometimes failed to act even after doses of strong medicine. Has been steadily losing flesh and strength. Present Condilifn. — Much emaciated; skin harsh and dry. Tongue roated with a whitish fur, red at the tip. Pulse slow, soft, and compressible. On examining the abdomen, lineoe albicantes are well marked. Superficial veins considerably enlarged. The abdomen is distended, chiefly at its lower part. It is resonant, giving a decided amphoric note, except at the depending portion, which is dull. This dulness changes with the position of the patient. On palpation, it feels soft and elastic, like a half-filled bladder. There is no tenderness anywhere. When rapidly handled by both hands, a A'ery loud-resounding splashing of fluid is heard. On exposing the abdomen, and watching the surface for a few minutes, it is found that, at irregular intervals, certain very distinct and constantly-repeated moveiaents of a creeping or vermicular character are to be witnessed. A kind of Leaving of the left side is first to be observed, which, whilst becoming more pronounced and rendering the part unduly prominent, gradually extends downwards and round to the right side, where it is lost. Now the contraction is at its height, and the bagpipe-like outline of the stomach is clearly traceable through the abdominal parietes. If the hand is placed on this, it feels hard and firm, like a contracted uterus, but not so solid. The greater curvature seems to extend to the pubes — the lesser to enclose a small space, which is much depressed, BY GEORGE ROSH, M.D. 3 and lies just beneath the inner margin of the left hypo- chondrium. This state of contraction remains for a few moments and then again rehixes, leaving the parts as before described. In this state, if deep pressure be made to the right of, and below, the umbilicus, a small, rather firm, and somewhat irregular lump can b(; made out. This, which seems to ocoupy the seat of the pylorus, is not at all tender upon pressure. All the other organs were carefully examined, and no evidence of disease was anywhere discovered. The day after admission she vomited about 3 pints of what proved to be composed principally of fluids, with a small quantity of undigested food ; there was also in it a little stringy mucus. It was brownish in colour, very strongly acid, and covered with a thick layer of yeasty or frothy greyish scum. The odour also resembled that of yeast. Under the microscope it was seen to abound in sarcina3. She was fed by small quantities of milk and wine, fre- quently given, and small pieces of ice to allay the thirst, which was usually much complained of. In addition to this, enemata of beef-tea were administered every four hours. Sulphite of soda was also given to check the fer- mentative processes. Besides this, the stomach pump was regularly employed At the first evacuation, about a gallon of iluid, similar to that previously thrown up, was removed. The stomach collapsed into a very small space, and the tumour could be raised and thoroughly explored. It was found to be the size of a large hen's egg, very firm and slightly irregular on the surface. Under this manage- ment at first the patient's condition decidedly improved. Vomiting entirely ceased ; heart-burn disappeared. T"he bowels acted sufficiently of themselves ; but thirst and great weakness continued to be felt, and in spite of the temporary alleviation of the more distressing symptoms, it was soon evident that the nutrition of the body was 4 DILATATION OF THE STOMACH. daily losing j2:round, in spite of diligent attempts at pre- venting this by rectal alimentation. The patient gradually became thinner and thinner, with a drawn, pinched, and haggard face. The greatest possible muscular prostration and feebleness were witnessed ; the mind showed evidence of a starving brain by a mild delirium, and, finally, she died exhausted on the 2nd February, 1879. Autopsy — Body extremely emaciated. Belly slightly protuberant. Skin rough and harsh, and presents a few petechia?. On opening abdomen, an enormously dilated stomach is seen almost filling the entire cavity, occupying all the regions except the right hypochondriac and part of the umbilical. The organ is placed somewhat vertically, and passes down to within 4 centimetres of the pubes, where it turns into the right inguinal region, and termi- nates in the pylorus, about 5 centimetres to the right of the navel. The greater curvature is, of course, the most pro- minent — only a small part of the lesser curve is seen, the upper portion being covered by the left lobe of the liver. The only part of the intestines to be seen are the transverse colon, wedged between the stomach and the pubes, the caput ccBci, and the first portion of the duodenum. Stomach removed and laid on table measured 45 cm. in length, 19 cm. in breadth at the middle, and 21 cm. in breadth in the pyloric region. It contained 5 pints of a dark grumous fluid, in which were 35 large plum stones, numerous orange pips, two date stones, and a number of smaller seeds. Capacity of organ, measured with water, about 8 pints. (Esophagus dilated in lower two-thirds. When slit open, upper part natural-looking Ked muscle- fibres extend down from pharynx fully three inches from cricoid cartilage. The mucosa of lower half, particularly on posterior side of the tube, presents a number of irregu- lar losses of substance, the transverse muscle-fibres are exposed, and there is scarcely any normal mucous mem- brane, the strands between the ulcers being firm and cica- f!m MkiiAHiMilili BY GEOROE H(X' but a granular debris Remarks. — The diajjnosis oi this case, as far as regards the dilated stomach, was of course easy. At the time of admission, the deoree of distension was so great, and the peculiar alternating contractions of the organ so marked, that the stomach was plainly mapped out in a manner that made it impossible to mistake it for anything else. It was easy enough, also, to arrive at the conclusion that pyloric constriction was the proximate cause of the changes wit- nessed in the gastric walls. The fact that this is by far the most freqiuMit cause, and that we had an evident lump at or near the pylorus, both pointed clearly in this direction The only remaining c^uestion therefore was : the nature of the stenosis. I may say at once that after fairly examin- ing the case, the conclusion I arrived at was, that it was one of Fibroid thickening of- the Pylorus. The autopsy confirmed the fact that the pylorus was narrowed by the contraction of a new growth of fibrous tissue, but it showed us also, what we did not know, that the origin of the fibrous growth lay in the formation of such tissue for the cicatrisation of an old gastric ulcer of very considerable size. Now this patient was most carefully questioned with reference to her past history, wath especial reference to this A^ery point. She denied ever having sufiered from gastral- gia, or vomiting, or other dyspeptic symptoms in former years. This being the case, I excluded ulcer. It would, as I now see, have been wiser to admit the possibility of a long-previous ulcer, which had declared itself by no symptoms — another proof of the possible latency of this disease With reference to the treatment of these cases by the stomach-pump, or, perhaps, preferably, by the stomach- syphon, I should say that I am impressed with the correct- ness of the views expressed by Kussmaul and others on this subject. I am convinced that this woman was greatly re- *>5 BY GEORGE ROSS, M.D. 7 lievod olmimy distressinu; feelings by having her stomach freed from a great load of fermenting lluids, althouuh I chink i^ may fairly be doubted whether in^this ease life was actually prolonged. These eases of distended stomach are generally of a most hopeless nature, even apart fiom the too-often malignant nature of the obstructing cause. This being so, we should certainly be ready to employ all mea- sures calculated to ensure greater comi'ort to the patient, althouuh these do not enable us to modify the ultimate prognosis. IT. — Case of Cirrhutiia of the Liver ivith f^reat Enlnrg-emenf, characterised hy Jaundice, Fever and IIccmorrha!2:e.s. — Death . — AiUopay. Margaret Macaulay, a?t. 22. was admitted into the Mont ^nl General Hospital on the 21st October, 187H, with intense jaundice, and complaining oi vere abdominal pain and vomiting. Her family history is good. There are no indications of tubercle, cancer, or syphilis. Patient is a medium-sized, tolerably well-nourished Irishwoman. Has been married for 2^ years, but has had no children. Has always been regular up to 4 months ago, since which time she has " seen nothing" ; but does not think she is pregnant. With the exception of the usual diseases of childhood, has always enjoyed excellent health until the month of June last. She has, however, been addicted to considerable excess in the use of alcoholic liquors. About the time just mentioned, she was observed to be somewhat sallow, and especially was there yellow- ness in the ocular coujunctiva. Her urine also was dark in colour, and she vomited a little, more i articularly in the mornings. Several times the vomited matters contained blood, and once in July, according to the statement of her husband, as much as a large bowl-full of black clotted T 8 HYPERTROPHIC CIRRHOSIS. n! i ! blood at once. Thus she t-ontiiiued during the remainder of the summer — sallow, rather weak, without appetite, and with occasional vomitina' ; urine scanty, dark in colour, and frequentl}'^ voided. Did not lose Uesh to any material ex- tent. About the 1st October i'elt w^orse, and vomited pretty frequently, princix)ally iluid matters (she calls it w^ater- brash). On the 0th inst. she had several chills, and w^as very feverish in the intervals ; vomited bilious-looking fluids constantly. Jaundice soon became well marked all over the body. There was also very great pain, princi- pally across the upper zone of the abdomen (the situation of greatest intensity being in the epigastrium), but felt more or less over the whole abdomen, and sometimes also between the shoulders. The pain was constant, not par- oxysmal, and aggravated by movement. The symptoms as described — pain, thirst, vomiting, jaundice and fever — have persisted from their commencement until the time of her admission ; but there have been no more chills at any time. For a few" days previously, also, she has had a troublesome, dry, hacking cough. Patient feels dull, heavy, and w^eak, but has no headache. She has never been troubled with itchiness of the skin. Thinks she has grown slightly thinjier since this illness began. Upon examination the folio vvinu' notes were made : In- tense jatindice of deep, bright yellow colour. Abdomen full and rounded, markedly more so upon the right side. Some large distended blue veins tire seen ramifying over the right lower costal cartilages, and also on the sides of the abdomen. Linetc albicantes well marked. By palpa- tion and percassion it is Ibund that there is great enlarge- ment of the liver, its lower edge extending below the umbilicus, and down to the anterior iliac spine. The sur- face is smooth, and feels hard, but the lower margin seems slightly indented. It is everywhere tender upon pressure, but most so at the epigastrium and on the lower edge. There is also great teiulerness in the splenic region. The i ^: BY GEORGE ROSS, M.D. 9 dull area is very extensive, occupying- from the fifth rib to below the umbilicus, across the epigastrium, and through the lower costal cartilages on the left side, but not below them. The edge of the spleen cannot be felt. There is no sense of fluctuation in the abdomen, nor any dulness in dependent parts. The bowels are constipated, and she says the motions haA'C been black. The tongue is very slightly furred in the centre ; ver red at the tip and edges. The urine is scanty, high-coloured, and turbid, and de- posits, on standing, a copious sediment of a brownish-grey colour. Sp. gr., 1020 ; contains ^th by volume of albumen. On applying heat and nitric acid the urine becomes of a decided o/ive tint, and the albuminous deposit is deeply stained of a dirty green colour ; no sugar. Decided rea<'tion for bile-pigment. No reaction with Pettenkofler's test. Under the microscope, great numbers of scattered epithelial cells and broken-down debris, togeth^^r with numerous epithelial tube-casts. All these foreign matters are deeply stained of a bright yellow colour. Her pulse was 120 ; skin dry, and temperature 103" F. The chest was examined, but no abnormal physical signs observed. To avoid detailed report, the following extracts from the record may suffice : The fever continued for one week, the temperature ranging from ODo" F. to 102" F., after which it gradually ll'll, and became even slightly subnormal. The alvint^ evacuations weri^ regular, and always greyish or almost colorless. Very much abdominal pain con- stantly complained of, with persistent tenderness. The vomiting was soon checked by effervescing alkalines. Cough became very troublesome, and destroyed rest at night, but no physical signs ever appeared in the chest. On the 28th she became aphonic, with noisy laryngeal breathing, for which an inhalation was given. On Nov. 2nd urine was scanty (8 ozs.), though she was taking digi 10 HYPERTROPHIC CIRRHOSIS. I ■ talis, and was bloody, also containing a few clots. Sharp epistaxis occurred, necessitating plugging with tannin. In the evening, sudden suffocatiA'e symptoms showed them- selves. A laryngoscopic examination revealed the fact that a lirm, dark clot of blood was lilling the larynx. A sudden expulsive effort brought this away entire, with complete relief to the breathing. She had been, however, getting very prostrate ; epistaxis recurred ; there was some hnematuria, very little urine being passed ; a little blood passed by the bowels, and she gradually sank and died on the mornino- of November 8rd. Autopsy. — Liver much enlarged ; flattened from above downwards. Colour, pale yellow. Firm to the touch, and on the surface a number of radiating veins. Weight, 3080 grammes. On section, it cuts with remarkable firm- ness, considering its colour and manifest state of fatty de- generation. The surface of the section is of a light yellow- ish-brown colour. No trace of lobular blood-vessels, large or small. On examining with a low-power lens, each lobule is seen to be surrounded by a zone of light-greyish trans- lucent tissue about -.5 m. in thickness. The centre of each lobule is of a brown colour, from accumulated bile- pigment ; the periphery of an opaque dead white, from the present e of fat. Here and there an entire lobule is seen to be in this last condition. There is no puckering on the surface of the organ, nor are there any areas where the fibrous tissue is more abundant than usual. Biliary ducts free, and of natural appearance throughout. Gall-bladder contained small quantity of dark, viscid bile. ' Kidneys were large, soft, and mottled ; dark red in colour. Section u'reenish from bile-stainino-. Substance remark- 1 On mil TDScopic ixiuiiiiiiition L>r. Osl'- toiind a condition of advanced cinhosis ; tlic new growtii ln'inj;- > lii( tly aliniit individual lobulos — monolobu- lar — and in many instances extending; into tin; acini between tho cords of liver cells. There is no special divelopinent of bile canaliculi in the new tissue. Liver cells fatty. BY f^EORGE ROSS, M.D. 11 Sharp tannin, ed them- the fact ynx. A ire, with Lowever, 7-As some le blood died on n above e touch, Weig-ht, >le firm- ;'atty de- yellow- Is, larg-e h lobule h trans- ?ntre of ed bile- rom the 5 seen to ;' on the lero the •y ducts bladder colour. remark- advanced nonolobii- L' cords of the new ably swollen and llabby : outlines of the pyramids not distinct. General colour, reddish. "Whitish lines of fatty degeneration aiv seen along the tubules and extending- into the cortex, ilie pyramids are of deeper colour than the cortex, and in these also groups of tubules are filled with granular matter. The intestines contained dark tarry matter, like meco- nium The larynx contained a quantity of sticky blood-stained mucus, some of which can be washed nway by a stream of water. There was then left behind an extensive super- ficial clot extending- from above the false vocal cords to the bifurcation of the trachea. Nothing of importance was observed in any of the other organs. Remarks. — The pathology and clinical history of Cirrho- sis of the Liver with enlargement, as compared wath those of ordinary contracting cirrhosis, are not yet thoroughly established ; and this is my reason for contributing a case which must certainly be looked upon as affording a good illustration of many of the principal characteristic features which have been observed in connection with it. When first this patient came under obserA'ation, we had great difficulty in making a diagnosis, owing to the im- possibility of obtaining correct data from herself concern- ing her past history. She refused entirely to admit of drinking habits, and insist^'d that, having had a slight attack of jaundice, lasting three or four days, in the month of June, she had bi'cn perfectly well until the commence- ment of the last illness in October. It was only some days after that, having procured an interview with her husband, we were able to substantiate the facts as given above. ProA'iously to this, the opinion held was that it was pro- bably a i-ase of suppurative phlebitis of the liver, arising from some unknown cause. This idea w^as based upon the (then supposed) iicute nature of the attack, with chills 12 HYPERTROPHIC CIRRHOSIS. and lever ; the enlarged liver, with great pain and tender- ness ; and the jaundice, vv'ith absence of ascites. When, however, we learnt of previous hoematemesis, with an ingravescent jaundice of some mouths, cirrhotic enlarge- ment was confidently diagnosed. Murchison says that thest' casos frequently die with jaundice, htemorrhages, and symjHoms of blood-poisoning. This was exactly what was observed in this case. It is now generally admitted that this disease is essen- tially different from chronic atrophy or contracting cirrhosis. Certainly the course and character of the symptoms, as here exemplified, were entirely different from that seen in the common a. oholic disease. In the first place, its rapidity was much greater. In six months from the first indications of hepatic disorder, the patient died from its exhausting effects. In the other, usually many months or years elapse. Ascites is one of the prominent and almost constantly present -vmptoms of the small liver, whereas here it was entirely ; sent, although the changes in the liver existed to a marked degree. Of course this may have been exceptional here, as it may be equally in the disease with shrinking. I have recently been shown by Dr. Osier the liver of a woman in a most advanced condition of fibroid atrophy. She had died of pneumonia, and there had been no ascites or other symptoms referable to the liver. Marked jaundice would seem to be the rule in the one, whilst in the other it does not occur at all, except from casual pressure u])on the excreting ducts by contracting nodules. In consequcMice, also, of the blood-changes in- duced by the intense jaundice, tendency to h;emorrhage in distant parts (not mechanically produced, like ha?ma- temesis, &c.,) are more frequently met with than in the common disease. In this case, fever was a prominent feature at the outset. The reason for so much febrile dis- turbance I do not quite understand. Dr. Murchison speaks of symptoms of blood-poisoning, but I read this to mean BY GEORGE ROSS, M.D. 18 . tender- AVhen, with an enlarge- lys that rrhages, tly what s (\sseii- irrhosis. :oms, as lat seen )lace, its the first 3d from months I almost whereas ^ in the lay have ) disease by Dr. ondition nd there e to the le in the ept from tracting' iiii'cs in- orrhaijo ! hfcma- i in the eminent >rile dis- II speaks to mean such as we see in choh^mic states during Jaundice from various causes (which are essentially non-febrile), and not such as would occur from any septic derangement of the blood from the entrance of septic matters. I think, possibly, the renal disease, of which there was abundant evidence, was to some extent accountable III. — A Case of Athetosis, or Uni/ntera/, Slowly-moving, S/msm. Frederick T., let. 20, was admitted into the General Hospital on the 28th September, 1878. He was sent from a town in Ontario to be treated for some trouble remaining in his chest after an injury. It may be as well to mention the facts concerning this shortly now, as it is desired to draw attention specially to the nervous affection of which he was found to be the subject. About four weeks pre- viously he had, through the accidental explosion of a revolver, received a bullet wound in the sixth interspace of the left side, beyond the nipple. There was no wound of exit. He did not lose very much blood, but had suffered from a good deal of pain in that side. For some time before admission he had had occasional chills, followed by feverishness, and had occasionally sweated. His appetite was very poor, and he felt weak. Physical examination of the chest determined the presence of a considerable quantity of fluid. Its traumatic origin and the subsequent febrile symptoms indicated the probability of the occur- rence of suppuration. After waiting, therefore, a fev\^ days for the purpose of observing the patient, with the assist- ance of my colleague. Dr. Roddick, the left chest was opened by incision, and about 20 ozs. of very foetid, somewhat sanious pus removed. A drainage tube was passed, car- bolized and other disinfecting injections were regularly employed, and complete recovery followed, with, of course, some retraction of the side. He was (■'< ^rved to be the subject of an unusual spas- 2 14 CASE OF ATHET()SIS. modic condition of the right limbs. The following- history was therefore taken of the case : — His father is alive and W(dl but a drunkard. Mother died when he was an infant. Has only two sisters, both of whom are healthy. As far as can be ascertained, there is no account of neurotic disease in the family. As long as he can recollect he has been lame in his right leg and weak in the right arm ;, has no idea how or when this came on, but says he has always been so. Has, in consequence, never been able to do any heavy, manual labour, but was employed to do the light work about a house. Knew that his right leg w^as shorter than the left. The limbs of the right side, he states positively, were only loeak ; there never were any movements or twitchings in the muscles. Apart from this he has always been hearty and well. Has never had any illness except smallpox, two j'^ears ago. Four weeks ago he met with the accident above related. Ten or twelve days subsequently, and whilst he was suffering a good deal from the side, his right arm and leg were suddenly seized with active, continuous spas- modic movements. He says that the limbs jerked violently and continuously in this way for a length of time, so much so that his friends were alarmed, and endeavoured to re- strain the limbs by fastening them with bands to the sides of the bed. He never lost consciousness, and is not known to have had any kind of fit. This condition of clonic spasm gradually wore off, and then for the first time he began to notice that the peculiar motions of fingers and toes about to be described were more or less continually present. On examination, the following notes were made : Patient is a rather delicate-looking and pale lad, somewhat marked by smallpox. It is evident that the limbs of the right side are shorter and somewhat less developed than those of the left side. This fact is better shown by the following mea- surements : — BY GEORGE ROSH, M.D. 16 IIIOHT ARM. Hnnicnis 1 1;{ in. Ulna 8* '• Girth, Mid. Humerus 7.', " " Fort'iuni Hand— Longtli G\ " RKiHT LEG. Antr. Spine to licad of Fibula. \Gl in. " " " inner Maleolus 31^ " Girth, Mid. Thigh llf " " " Calf 9 " LEFT ARM. iJnmerus 12^ in. Ulna 9j surroundings as to set up first a condition of genuine clonic spasm, without epileptic loss of conscious- ness, and then left behind it " a state of i>er verted nutrition of certain nerve-cells," which caused this over-action which is productive of these determinate movements. IV. — A Case of Acute Spinal Paralysis in an Adult {Polio- myelitis anterior acuta). E. L., set. 20, machinist, was admitted into the Montreal General Hospital on October 15th, 1878, with paraplegia and emaciation. His family history is good. His father was killed in an accident. His mother and several brothers and sisters all enjoy good health. BY GEOR(JE ROSS, M.l). 19 Patient was always strong" and vig-oroiis as a boy. Has novor had syphilis. At ten years of ago had smallpox. With this t'xcc'plion had no illness whatever, but continu- ous good health until eleven weeks ago. At thi.s tiuK; ho felt, for about two days, that ho was not very well, but did not complain, and continued his work as usual. On the third day he was taken ill whilst at work, and was obliged to return home and Ho down. He suf- fered then from rather severe headache (principally frontal) with general pains, considerable fevt'rishness and complete loss of appetite. Alter two days he felt a numb- ness in the soles of his feet, which sensation kept increas- ing until it was present in a high degrcM'. After some days longer similar numbness was i'elt in the palms of the hands and inside of the fingers, and he thinks his len's were getting waniker, but he could move them about freely in the bed, and was able to stand and walk until about the twentieth day, when he had a fit of som(^ kind, fol- lowed at short intervals by several more, so that within about eighteen hours he had six fits. During the lit he is described as first stiffening up his limbs and then pre- sentino- much clonic convulsive movement. He was quite unconscious during the attacks, and is said to have breathed heavily for some time after, as though stertor had been present Thinks he first noticed after this that his legs were so feeble that he could not stand upright ; is sure that if then the attempt had been made he would have fallen to the ground. Noticed also that his arms and hands soon became markedly enfeebled, so much so that he could not grasp or hold even a very trifling object. At the same time, moreover, a marked change took place in the sensations experienced in his hands and feet. These parts, from having previously, as stated, been feeling numb, became now the seat of severe darting pains — these w^ere much worse in the feet than in the hands — sudden stabs of a most excruciating nature would dait TTTl 20 ACUTK Sl'INAI. I'A1!ALY.SIS. from th(! solos of his i'wt up the backs of his legs, and cause him lo scroum with pain; but the hands still felt somewhat numb. If auythiuy touched or struck aj^ainst the cuds or insidcs of the Hngers, ho would ex[)crieuco violent shoot iny- i)aius all tht! way up to the shoulder. But the pain rarely occurred spontaneously in the upper limbs. The soles and sides of the feet also evidently became excpiisitely hypm-jcsthetic, for he says he could not permit of eveu the liii'htest tou<'h upon these parts without a sense of •>reat sullerino-. During this time he had been riii)idly losinu; llesh. Has throughout had com- plett; control over both bladder and rectum. After lying in bed in this hi'lpless and painful condition for about two weeks longer (ic, about the tilth week of his illness), it was first observed that his knees were becoming some- what drawn up. He soon began to improve, and thinks he has much more ])ower in the limbs now than he had some weeks ago. The pains have gradually subsided, and are now nearly gone. On admission his condition is as follows : — He is very much emaciated, somewhat i)ale, and wears a look of pain upon his face. He lies upon his back, with both legs moderately Hexed at the knees. Any attempt to strain-hten them gives pain. He can, in bed, move the limbs in any given direction — the knees can be only partially extended owing to the contraction mentioned — but with this exception he can use all the muscles of the thigh and leg. The movements are very much weakened. The grasp with either hand is extremely feeble. Tactile sensibility is everywhere normal with the following exceptions: — the skin of the sides and soles ot both feet, and a considerable portion of the dorsums as well ; in fact, all but as mall area just in front of the ankle- joint, are markedly hy;; eruisthetic. The skin of the ends of the fingers feels somewhat numb, and it hurts a little still if they are struck. On scratching the soles of the feet, HY (lEOROE UOSH, M.l), 21 there are liv«^ly rcllcx m()v«'mt'nt.s; it is not easy to Judiye how much of this is voliiulary on account of th(^ sensibil- ity of the parts, but thc^ patient declares he does not draw them away because^ of ])ain. There is no increase in the tendon-rellex, either at the li<^amentum patellie or at the tendo Achillis. Chest origans sound. Heart only weak. The urine is pale, somewhat alkaline, deposits a ftood deal of white sediment ot ])h,jsphates. There is no fever. Pulse 90. Dr. Bullei kindly examined his eyes, and found no defi- nih' pathological ai)pearance, but noted a somewhat turbid stale of the margins of the optic disks, which he thinks might be the precursor of an optic neuritis. Since admission, I may state that up to the i)resent time (81. st October) this patient has improved very materially. This is most marked in the hands. Power of grasping has increased with great rapidity, being jilmost noticeable from one day to another. lie can move the le^i's with greater freedom, and can also extend them much more than before. The hyperiesthesia has l)ecome much lessened, and numbness has almost left the tips of the lingers. He has a good appetite, and sleeps fairly well. He has been taking — Potass, bromid, r,iv. ; Tr. ferri. mur., .",iii. ; Aqua? ad,, .ivi. ; .-,ss. ter. die., and has had lin. belladon. applied to the feet. The principal outlines of this case might, I think, be condensed in this way. A young and previously healthy man is all at once taken down with a feverish attack pre- senting no very special features — a feeling of sickiu?ss, headache, and pains in the back and limbs. Very soon there is added the first distinct indication of some disturb- ance in the nervous system in the form of paresthesia, numbness in the lower extremities. The fever continues, and the numbness invades the upper extremities. After twenty days occurs a series of iits of an indefinite char- acter, but apparently accompanied by loss of conscious- 22 ACUTE SPINAL PAHALYSIS. II ness. Immediately after {i.e., as soon as consciousness returns) he experiences pains in the previously numb parts (espeeially in the feet) ol' a very excruciating characti^-, and it is soon found that he is paraplegic. Great loss of power in the arms occurs soon after. lie gets rapidly thin. The soles and sides of the leet become excessivi^ly hyperiesthetic, and the lingers are affected in the same way to a less extent. He comes under observa- tion eleven weeks after the commencement of his illness. There is then great emaciation of all the extremities, and especially the legs. An incomplete paraplegia but no definite paralysis of any i)articular muscle or muscles, legs somewhat contracti'd at thi^ knees, great deficiency of power in the arms. Tactile sensibility normal every- where except on the soles and sides of the feet, which are markedly hypenesthetic, and some numbness in the fingers on being touched. The ordinary reflex movements increased. Tendon-reflex not present. Much improve- ment had taken place as to power over limbs ; and this improvement has continuiMl since admission. Intellect clear. No cerebral symptoms. No implication of bladder or rectum at any time. This series of symptoms is in itself sufficiently remark- able. I think there can be no doubt, from the })ara- plegic charai ter of the attack, from its involving finally all four L'xtreraities, and from the absence of all symp- toms of a cerel)ral nature, beyond the single attack of a spasmodic nature, that the lesion is situated in the spinal cord. Then whether, as I have been asked, the paralysis be consecutive upon ty])hoid fever or soijie other specific unrecognized febrile disease, I think the fact of the very early occurrence of the altered sensation in the limbs precludes entirely this idea. If this position, therefore, be correct, we have here had an acute spinal disorder, commencing with marked febrile symptoms, leading to a rapid and extensive paralysis of motion, HY GEORGE ROSS, M.D. 23 accompaniod by certain disturbances of sensation, but still leaving the general sensation in the aifected partfs intact. There is no allection, as far as I know, which presencs a similar symptom-picture except that disease which is the analogue of the one long known under the title of Infan- tile Spinal Paralysis. It is a recognised fact, in the present pathology of the spinal cord, that organic (-hanges of an exactly simi..4,r nature and locality to those found in infantile spinal paralysis may develop themselves in adults; and though quite common in the former, it is exceedingly rare in the latter. It is described under the name of A(;ute Spinal Paralysis of Adults, and by Erb (in Ziemssen, vol. xiii.,) it is designated, from an anatomical point of view, Poliomyelitis anterior acuta. With a view of substantiating the similarity of the case I have reported to those referred to this category, I may be permitted, as briefly as possible, to sketch from the descriptions of Erb, Hammond and others the main features of this allection of the anterior gray horns as seen in children and in the adult. Which done, I shall only add a few remarks upon som(! very striking symptoms observed in my patient which do not belong to the typical and uncomplicated disoraer. It is remarked that in adults, as compared with child- ren, the manifestations are esocntially the same, but merely modified by the fact that the brain of the adult offers somewhat more resistence to the initial disturbances, that the general organism is not so highly disposed to fever, and that the growth of the bones is alreai-'y completed, and the firmness of the joints is greater. It is said to begin wnth a general ill-feeling, with fever which is often introduced by smart pain in the back and limbs, and not rarely with pancsthesia (formication, a feeling of numbness, &;c). : cerebral symptoms are generally wanting. General convulsions have never yet been observed, but severe headache, dullness, somnolency 24 ACUTE SPINAIi PARALYSIS. and even slight delirium occur. Well-marked gastric symptoms have been frequently observed. In some cases the fever reaches great intensity. Then paralysis devel- ops rapidly— in one night i)erhaps, or in a very fev^ days. It is complete, widespread, and the muscles quite fla-:' ^'d. Iveilex action is lowered or exlinguhhed ; though, in some (>as('s (Erb), it may be retained, at least in those muscles which are not permanently or not completely paralysed. Then, as in children, follows rapid commence- ment of improvement in the paralysis, until linally it may entirely disappear, or at any rate some of the muscles quite recover, leaving only certain groups or higher muscles permanently affected. There is said to be no trace of dis- turbances of sensation. The patient is rarely sick enough to go to bed. The general nutrition soon gets quite good again. We are more familiar with the current of events in children. With them the first is often fever. Not seldom convulsions, and , sometimes other A'ery severe cerebral disturbances, such as deafness, coma and delirium. Then a pretty sudden paralysis of variable extent, with flaccid limbs and without disturbance of sensation, or implication of the sphincters, or bedsores. Then arrest of ^he paralysis and a gradual improvement, some special parts, however, remaining permanently pav'^lyzed. In these we have the reaction of degeneration. The development of the bones is retarded, contractions take place, and many varieties of deformities are thereby produced. It will, no doubt, be observed that the points in the case which do not agree with this description are the following : 1st. The tits. 2nd. The hypenesthesia. 3rd. The pains, and the increase in the reflex movements. 1st. With refertmce to the convulsive spasm, with unconsciousness, which is mentioned as having- occurred on the twentieth day of the illness, I may say that we iiad much diiliculty in getting any clear account of the BY GEORGE ROSS, M.D. 25 attack. His mothor has once described them as distinctly- epileptic ; on another occasion as entirely wanting the characters oi' epilepsy, but being- rather tetanic. On the whole, however, I think they must be looked upon as having been of an epileptiform nature, especially from the accompanying unconsciousness. As I have stated, Erb says that general convulsions ;,r. 3 never been observed in this disease, and they are not a. .ded to by any of the other authors I have consulted. Still, they do occur pretty fre- quently in children at the outset of the disease and before the occurrence of paralysis, which might be used as an argument (although admittedly a poor one) in favour of a possible similar occurrence in an adult. Besides, this case would appear to have been of an exceptionally severe nature. 2nd Tlie hi/perccsthesin. — In the typical disease, sensa- tion is unaltered. It must, therefore, stand as proof that other parts of the cord are all'ected than those implicated in ordinary acute paralysis. It would, perhaps, bo very difficult to hazard an opinion as to what part this is, as the manner in which hyperesthesia may be produced is certainly not well understood. 3rd. — The occurrence of severe excruciating pains after the onset of the paralysis and the increase of reflex movements may^ be taken, along with the exalted sensi- bility, to prove that some factor is present beyond the lesions ascribed to anterior grey myelitis, because it is painless, or nearly so, and the reflex acts are nearly al- ways unalfected. The question that has arisen in my mind is, Would extension of an acute tissue-change, going on in the ante- rior horns to the posterior horns, account for these extra- neous manifestations? If so, then we might be justified in looking upon this case as one of acute myelitis of the anterior horns of gray matter, plus some subsequent disturbances in the gray matter of the posterior horns. 3