^^.^^ IMAGE EVALUATION TEST TARGET (MT-3) % /. Y ^ 1.0 I.I 11.25 ■- lilM ■ 50 ""'= IIM 1.8 i.4 ill 1.6 V] (meaning "CON- TINUED"), or the symbol y (meaning "END"), whichever applies. IVIaps plates, charts, etc., may be filmed at different reduction ratios. Those too large to be entirely incli^ded in one exposure are filmed beginning in the upper left hand corner, left to right and top to bottom, as many frames as required. The following diagrams Illustrate the method: Les exemplaires originaux dont la couverture en papier est imprlmte sont fllmte en commenpant par Ie premier plat et en terminant soit par la dernlAre page qui comporte une empreinte d'impression ou d'illustratlon. soit par ie second plat, salon Ie cas. Tous les autres exemplaires originaux sont filmte en commenpant par la premiere page qui comporte une empreinte d'impression ou d'illustration et en terminant par la derniire page qui comporte une telle empreinte. Un dee symboles suivants apparaitra sur la derniAre image de cheque microfiche, selon Ir cas: Ie symbols — »> signifie "A SUIVRE". ie symbols y signifie "FIN". Les cartes, planches, tableaux, etc.. peuvent dtre fllmte A des taux de rMuction diffirents. Lorsque Ie document est trop grand pour dtre reproduit en un seul cliche, 11 est filmi d partir de I'angia sup6rieur gauche, de gauche A droite, et de haut en bas, en prenant ie nombre d'images nicessaire. Les diagrammes suivants iliustrent la mithode. 1 2 3 1 2 3 4 5 6 MONTREAL GENERAL HOSPITAL. Condensed Reports op Cases in Dr. MacDonnell's Wards.* October Ath. — The seBsion has opened with an unusual num- ber of instructive cases in the clinical ivards. During the fortnight previous to the opening of the session, five of the beds wei'a occupied by cases of pleurisy with effusion. In four, early aspiration was resorted to and with satisfactory results. One of the cases, tliat of a man of 30, was interesting from the fact of the fluid having escaped notice for a long time, and from the lengtli of time the patient went about with one side of his chest completely lull of fluid and his heart apex dis- placed to the right of the sternum. Another patient in a similar condition walked to the hospital from the end of St.- Antoine street. In one case the Huid partially disappeared spontaneously. On the 30th September a very interesting case of pleurisy was brought in. Here the cause was traumatic, the patient having had a lai-ge stone fall upon his chest some six weeks ago. The distension of the right pleural cavity was extreme. The heart beat two inches beyond the nipple line, and the liver could bo felt two inches beyond the costal border. Dyspnoea was very urgent. The temperatuie was slightly raised. Aspi- ration showed the presence of pus, and, accordingly, resection of a rib was performed by Dr. James Bell. The internal treatment of these cases of pleurisy with effusion has consisted of the administration of iodide of potash three times a day, and of concentrated doses of sulphate of magnesia in the morning. Typhoid Fever. The cases this year have been of much greater severity than those we have been accustomed to meet, and the mortality has been high. The following notes may prove interesting: — High Temperature. — A very severe case, occurring in a strong, healthy servant maid, showed a tendency to hyper- pyrexia. The thermometer registered 104^° to 105^° for the * I am indebted for the reports from which the following are condensed to Drs. England and Campbell, house-physicians, and to my clinical clerks Messrs. Adama, Hamilton, Bowes, Murray, MoKechuie and Inksetter. ^0 '^b '^0 '7c -^i;'. (H''\ ru^ 2 tirst four days, and iicilhcr aiitipyriri nor antil'ebrin had any oft'ect whatever. Alter the Hrwt wook in hospital the fovor abated. There wore three distinct rigors on the twentieth day, for which no cause could be found. The patient eventually recovered. Meteorism, — In the case of a strong man of thirty, who was brought to the hospital in about the middle of the fever, delirium having been very severe before admission, meteorism developed to an extraordinary degree. The abdomen became greatly distended, and brought such pressure upon the chest as to increase the respirations to 5G and to displace the heart and liver. The passage of a long rubber tube brought away a quantity of gas and gave temporaiy relief. We found it a good plan to leave the long tube in the bowel. However, we failed to avert the fatal result. The autopsy showed that death was the result of tyi)hoid fever witiiout any perforation or peritonitis. Delirium Ferox- A Hungarian, aged 35, was brought to hos- pital in a state of wild delirium, and became so unmanageable that it was necessary to lodge him in the padded room. The diagnosis was very dfjubtful, but after a few days the high temperature and the character of the evacuations enabled us to decide upon the nature of the case. Murchison mentions just such another case. He was called in to see a Goi-man gentle- man, who was supposed to be mad. After four days of slight malaise, which had attracted little notice, he passe;! suddenly into a state of acute maniacal delirium, requiring two men to hold him down in bed. He was thought to be sutt'eriug from an attack of insanity, but with these symptoms there was pyrexia, quick pulse, temp. 102°, dry tongue, diarrhoea, but no spots. Profuse Bash. — The case of a workman from Lachine is notable from the profuseness of the rash. Upon the chest anil abdomen the general appearance reminds one of measles. The symptoms were very severe, the system beiu;^ apparently overwhelmed by the intensity of the poison. There was deep stupor and incontinence of urine and fieces. At the time of death the rash was distributed over all the body. Syncopal Attacks. — A female patient, one of those from Point St. Charles, suft'ea-ed in the beginning of the fever from several 3 attackw of fjiiuting, Stimuljiiits vvoro frooly UHod and rocovory from the (bvor took placo, tlioii^li very Hlovvly. I IohI a palioiit Homo yoara ago from sudden and unexpected synt'ope in tlio cour.se of t3'i)li()id (ever. This mode of death haH been reported as occurring in acute pneumonia, and in diphtheria it is a common occurrence. Anterior Poliomyelitis Acuta. An intorenting case of this diseaHO was that of Maggie L., aged 11, who was admitted on tl>e 14th July with sudden loss of power in the left leg. The family history was somewliat neurotic, a sister having sutl'erod greatly from chorea. Six days befoi-e admission she was obliged to give up work, owing to a great sense of fatigue. Twenty-four hours afterwards, after walking a short distance, her left leg became quite powerless. She had to be carried home, and has been unable to walk since. There was no loss of consciousness and no pain. Slate on Admission. — Marked ■".r.t'cmia; slight pyrexia, the evening temperature running not higher than 100° for the tii-st few nights; slight headache and loss of appetite. There was double vision on the day before the first attack. Pain was never present. All four limbs were enfeebled, as well as the muscles of the back, but in a different degree. The left leg was completely paralysed and its knee reflex abolished, but sensation was unimpaired. The right leg could be feebly moved, and its knee reflex was not quite absent. Superticial reflexes are absent in both lower extremities; no ankle clonus. At the time of admission the hospital batteries were undergo- ing re|)aii', so that ele-jtrical tests could not be applied. How- ever, shortly afterwards it was fouiul that there was no response to the faradic current and a feeble one to the con- stant in all but the left leg. The weakness extended from the left leg to the right leg, to the left arm and hand, then to the right arm and hand. Lastly, the neck and back muscles be- came affected. The sphincters and muscles supplied by cranial nerves wei-e never affected. October 1th. — The patient has now been in hospital over two months, and there is considerable improvement. Theanremia has diminished, general nutrition is improved, and the para- lynis hsw disappoiuod, the change for the bettor being most noticeable in the inuHcles of the back, which seem to have been the first (o recover, but in the left log there is no change. There is at present no muscular atrophy, but probably this may be deceptive, owing to the fatness of the patient. XJRiBMIA. October ^th. — There are three cases of ura'mia in ward 11, each showing prominently a special feature of that condition. On the evening of the 7th of October a man, aged apparently about 50, was brought to the hospital by the police in a state of profound ccma. The breath was not alcoholic. The small quantity of urine which was withdrawn by the catheter was heavily loaded with albumen, llo was well purged with croton oil, and put into a hot aiv bath. Subsequently, pilocar- pin was given by hypodermic injection (gv. 1-fi) with a very good result. Convulsions had occuri-ed also. In twenty-four hours the comu had disappeared, but he was still in a very stupid condition, unable to speak and breathing noisily, owing to the flapping of his lips. To-day, i.e., 48 hours after admis- sion, there is still great mental confusion, though he is able to say his name. At the clinic it was noticed that the respira- tion, which had previously been noted as slow, had now a rhthymic character, and was inclined to be of the Cheyne- Stokes variety. October 10th. — The improvement was but transient, the con- vulsions recurred with increased violence and death ensued. It was confidently expected that m-"ked renal changes would be founil at the autopsy, but such was not the case. No cause of death was found, unless the kidneys were diseased to an extent merely recognizable with the microscope. The symptoms pi>esent, the convulsions, the coma, the scanty urine leaded with albumen, rendered any other diagnosis than that of urffimia highly improbable. The body being unclaimed, it was injected with preservative fluid before the kidneys were removed, and consequently their finer structure could not be examined, but they were of normal size and appearance. What was the cause of tha convulsions and the coma? 1. There is a slight chance of its being due to early renal changes. 2. A poison, e. g., alcohol or opium,— against this interpretation is the fact of IiIh complete recovery from the original coma and the recurrence of the convulsions. The second case showed eviddnces of urremia in a milder degree. The patient had had evidences of chronic Bright's disease for some years, dating from an acute nephritis nine years ago, which directly followed an attack of erysipelas. At present there are albuminuria, hyaline casts, and general dropsy, but the most important symptoms are the persistent frontal headache and the attacks of vomiting to which he is subject. The third case, thot of a baker, aged 34, was also one of chronic uncmia, and its principal manifest:! tion was extreme dyspnoea. At first there was orthopncea, but after a few days treatment this subsided. There was no dropsy. The patient for a long period had regarded himself as an asthmatic. It was difflcuH to determine whether these attacks were due to true asthma or were merely evidences of ui-romia. Progressive Muscular Atrophy. Two cases have been in hospital lately. The first case, that of a woman long past middle life, illustrates two points in con- nection with the etiology of the disease, its origin in f 'ight, and its occurrence in members of the same family. The vast- ing began two years ago, immediately after she had experi- enced a shipwreck on the Atlantic. Eight years ago she had been under my treatment at the Montreal Dispensary for ulceration about the knee, which was thought to be syphilitic. The family history is interesting. The father died from the effects of an accident ; the mother, an uncle and an aunt all died of " paralytic strokes." Two sisters of the patient died at the ages of 47 and 50, having suffered from a disease said to be exactly similai' to that of the patient. The occurrence of progressive muscular atrophy in families has been i-eported. Eecently, the following notices of this point have fallen under my observation. In the last number of the Bevue des Sciences Medicales, Lichtheim reports the history of a family of four brothers, three of whom suffered from progressive muscular atrophy ; and in the same journal there are two other histories of families — in one two sisters de/eloped the disease .shortly after puberty. In a histo.-y 6 reportod by Horringhani in Urain, the family troo, repiOHonling five gononitionH, hIiows that If) male members wore atrophic; the remainder, to the number of forty -six, including all the women of the family, entirely escaped. An interesting family tree will bo found in a paper by Di-. Osier in Seguin's Archives foi- 1881. The second case did not show such marked symptoms. The wasting and the loss oi powei" began after an illness, which was characterized by pain in tho stomach and vomiting. The wasting was very rapid. Tho patient was u street car driver, and suffered much hardship in the spring from the exposure to cold and wot incidental to his calling. He had been three months ill previously to admission. Tho right arm and shoulder first l)ecame weak, and there woi'o such sensations as pricking, tingling and foi-mication, and the symptoms e.x- tended to tho forearm and hand. Within two days tho left arm and hand became similarly affected. In two weeka the legs became affected, but to a much less degree. There was con- siderable pain and tenderness on pressure in the calves of the legs and the inner side of the thighs. The upper extremities are much wasted, the lower less so. There is dull pain in the arm and shoulder on both sides and exaggerated tenderness of the muscles of tlie arm and forearm. The extensors of the fingers and thumb ai-o wasted, but there is no wrist droj). Patellar i-eflexes are normal. P^ibrillar tremors are eli(!ited by percussion over the shoulder muscles. After a month's residence in hospital (here was marked improvement. Nov. 5th. — The progress of this case is such that a diagnosis of progressive muscular atrophy cannot be enlortained. Im- provement is distinct. Most probabl}'^ it ie a sub-acute polio- myelitis, and tho sharpness of the attack at tho outset rather favours that view. Aortic Aneurism. — In tho case of a man aged 50, a lumber- man, there are well-marked evidences of the presence of an aneurysm of tho ascending and transverse arch. The patient applied first to Dr. Major, the laryngologist, for tho relief of liis hoarseness, and was by hini referred to me. The loft vocal cord was paralysed. An interesting point in the case is the presence, in a vozy marked degree, of the sign on palpation of tracheal tu^gin^, an evidence that the tumour is in contact with the trachea or one of the large l)ront'hi, and also that conHolidation of the contents of the sac has not far advanced. The clanging; cough and the dyspnoea have boon much rclievedsince he began the iodidoof potassium treatment. Aeute Spinal Meningitis. — Bridget M., aged 10, caught a severe cold on the 11th of August, 1889. Hitherto she had been in very good health. The father is a drunkard, but there is no history of nervous disease in the family. Four days after- wards she had refused to eat her meals, had a severe attack of vomiting, which was followed by constipation and severe head- ache. For the next three or four days she was very feverish and was said to be delirious. She then seemed to improve slightly, but the gait was staggering and the articulation became thick and indistinct. The mother states that on one occasion she observed that the child was squinting. The patient was ad- mitted to hospital on the 21st August, when she appeared to be in very great suffering. The body was held continually in one position on the side, with the back stiff and the head well retrac- ted. The abdomen was hard and scaphoid. Meningeal streaks were readily obtained. Pressure on the legs caused great pain. Reflex action generally increased ; bowels very constipated, but there is no disturbance in the function of urination ; pulse, 120-140. Respiration (20-24) is somewhat irregular at times, but is not of the Cheyne-Stokes character ; no dyspnoea. Dur- ing the 85 days of illness the symptoms varied slightly. Ema- ciation and debility increased. Pupils varied in size at different periods. The fundus, which at first was quite normal, showed optic neuritis a few weeks before death. There were no signs of paralysis. Death occurred before the irritative stage was passed. Patellar reflex disappeared as the disease advanced. There was no continuous vomiting, general headache or paralysis of cranial nerves, hence it was thought that the disease was seated in the spinal and not in the cerebral meninges. Of the clinical features of the case, the most remarkable is the range of temperature, which appears in rhythmic waves. The first fifty-six days in hospital might, by the chart, bo divided into sections of four days each, and on the evening of the first 8 (lay of each section the temperature ran to 101® or 102*^ ; then on the throe remaining days it went down to a lower degree, until on the fourth night it was normal ; then a rise to 102" and a gradual fall in the next three days. The pulse was frequent (120) during the period of elevated temperature, but fell to 90 and 100 when the temperature fell to normal. The following abstract of the post-mortem changes is furnished by Dr. Wyatt Johnston, pathologist of the hospital : " Emacia- tion extreme. Cerebral ventricles are distended and contain seven ounces of fluid. Slight turbidity and oedema of pia at base of brain, not extending along the sylvian fissure. No lymph- No tubercles found in microscopic examination of the vessels of the perforated spaces, arteria profunda cerebr, sylvian arteries, or choroid plexus. No cerebral pachymeningitis, or disease of the bones of the skull. Slight optic neuritis. A severe and extensive pa'^hymeningitis throughout entire spinal canal, involv. ing sheaths of spinal nerve roots. Abundant fibrinous exudation between dura and bones, which has partly organized. Spinal pia oedematous. Spinal cord normal, except for slight grey de- generation in postero-internal tracts. Peripheral nerves (sciatic, ant crural and brachial plexus) in both sides normal. No dis- ease of bones ot vertebral column. Localized emphysema of left lung, with recent pneumothorax. No tubercle anywhere. Cause of pachymeningitis not detected." The pleumothorax, I take it, must have immediately brought about the end, because it is unreasonable to suppose that in the state oi" extreme debility in which she passed the last three weeks of her life, she could have stood the shock of the sudden entry of air into the pleura. Diseases of the Stomach. Q-astric Ulcer (Oct. 31st). — A well defined case of gastric ulcer, and two of cancer of the stomach, have lately been in the wards. The case of er occurred in a young married woman, aged 23, who entered on the 28th August, with epigastric pain, aggravated to an intense degree by food, and relieved by free voinitiri}^. The ejected matter consists of partly digest- ed food und a (juantity of slimy mucus, with hero and there Btroaks oi blood. These symptoms have been present for the last seven months, and are thought to result from the debility which followed a difficult labour a year ago. There had been one sharp attack of hosmatemesis. In the middle of the epigas- trium there is a spot of exciuisite tenderness. She left the hospital almost free from any gastric symptoms on the 8rd October. The treatment consisted of physical and physiological rest, a diet of milk with soda water exclusively, and at first a mixture of carbonate of bismuth, carbonate of soda and tincture of belladonna. When improvement had well set in, Fowler's solution in five minim doses was administered. Cancer of the Liver (probably) Secondary to Cancer of the Stomach. — F. 0., carpenter, aged 55, admitted August 29th, 1889 ; no distitict family history of cancer. For some years had been liable to slight attacks of dyspepsia, but with this exce[)tion had enjoyed good health until four months before admission, when he began to suffer from pain at the epi^'',8trium and upper part of the abdomen, flatulent distension after food, and vomit- ing, the latter presenting the following characters ; it was not present every day ; there were intervals of several days when he was entirely free from it ; the vomiting followed at a consider- able interval after the taking of food, and the quantity ejected at a time was stated to be as much as several pints ; the vomited matter consisted of a sour smelling, sometimes watery, sometimes slimy fluid. On several occasions before admission it was noticed to be of a dark brown color with a sediment (" coffee ground"). The pain was never in any way affected by the vomiting. The bowels have been obstinately constipated. These symptoms increased rapidly in severity, and soon the patient lost appetite for food and became rapidly emaciated. In June last he first noticed that the upper part of the abdomen was promin- ent and hard. There has never been any jaundice nor have the legs been at any time swollen. On admission patient was very thin ; weighed 129 lbs (former weight 167 lbs). The skin is somewhat lemon-coloured, but; B 10 there is no jaundice. The liver ia enlarged in the right mam- mary line, measuring eight inches, and extending (juite four inches beyond the margin of the ribs. In the middle line the edge of the liver reaches to within two inches of the umbilicus. There is marked tenderness on pressure over the liver, the sur- face of which is smooth, but just in the upper line a small nodule can be felt. Percussion over the left hypochondrium gives an unduly tympanitic note. The abdominal veins are not dilated. There is no ascites whatever. Splenic dulness is not increased. Tongue large, flabby and coated. Suffers continuously from pain, mainly in left hypogastrium, which is increased by food and not relieved by vomiting. The attacks of vomiting occur at intervals of two or three days, and are of the characters above mentioned. Since his admission there has not been any "coffee- ground" appearance of the vomited matters. October 31«<. — Since admsssion there has been very severe pain in the npper part of the abdomen and recurrent attacks of vomiting. There has not been any loss of weight. The ejected matter does not contain hydrochloric acid. Salol Test. — Dr. England reports that he found the salicylic re-action in the urine two hours and a half after he had admin- istered twenty grains of salol by the mouth. Cancer of the Pylorus ; Very Rapid Progress ; Death ; Autopsy. — Alexander E., a sailor, aged 57 ; admitted October 15th, complaining of severe abdominal pain, frequent vomiting and obstinate constipation. He states that he was in good health until about three weeks before admission, when the bowels beca.ae very constipated, and at that time he noticed that there was a painful lump in the epigastrium. A dose of castor oil freely moved the bowels, and after that the lump is said to have disappeared, but quickly to have returned. It was only fifteen days ago that he began to vomit, and he noticed that as soon as the vomiting set in the pain became very much worse. The bowels moved freely for about five days after the vomiting oc- curred, and then remained closed for the last ten days, Voa^it- jng occurs usually about four hours after food. The ejected matter is liquid and the quantity got rid of is very great. He 11 states that his usual weight is 160 lbs. Ilis present weight is ll2^ lbs. No family history of cancer. Emaciation is extreme ; no jaundice, but complexion is very sallow ; suffers extremely from pain in the epigastrium, which is markedly prominent and very tender on pressure, especially at a point about two inches from the umbilicus and one and a half inches from the middle line, where a hard nodule can be felt. The liver is of normal dimensions in the right lobe, but the left extends to within two inches of the umbilicus. The liver surface is smooth and its edge sharply defined. October 30