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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''\

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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

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

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

(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;

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

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<A (37th day of illness). — Vomiting has been con-
tinuously present and is very distressing. It occurs whenever
anything is taken into the stomach, and consists of a large quan-
tity of watery matter, which contains no hydrochloric acid.
When salol (20 grains) is given by the mouth there is no evi-
dence of the presence of salicylic acid in the urine for six hours,
corroborating the evid'mce already stated as to the motor insuf-
ficiency of the stem ich. The bowels are obstinately constipated,
but can with great difficulty be made to move by castor oil and
by eneraata ; tongue coated ; constant desire to take food.
Emaciation has been very rapid. In ten days he has lost four-
teen pounds. Within the last twenty-four hours he has been in
a moribund condition ; very delirious, evidently dying by star-
vation.

Autopsy. — " Great distension of stomach. A zone of ulcera-
tion extending around the entire circumference of the pylorus.
On section the gastric wall in its entire structure is infiltrated
with scirrhus, which has also extended into neighboring organs,
the right kidney and supra renal capsule, the glands about
the pylorus, the retro-peritoneal and retro-thoracic glands at the
level of the diaphragm. The oesophagus at the cardia and bile
ducts are slightly pressed upon by these enlarged glands. The
growth has directly extended to the capsule of the liver beneath
the left lobe, but no secondary nodules occur in the liver sub-
stance." (Dr. Johnston's report.)

Herpes Zoster in Connection with Disease of the Spine, — A

woman past middle life was admitted, complaining of pain in the
lower part of the lumbar region. No cause could be discovered
in the abdomen, but there was found a prominence of the spine
of the dorsal vertebrae, in the neighborhood of which there was
very marked tenderness upon percussion. After being two dajs
in hospital, there appeared an eruption of herpes zoster, which
began at the prominent spine and ran down the side of the chest
and abdomen in the direction of the umbilicus.

Recurring Tonsillitis as an .Evidence of the Rheumatic
Diathesis. — In the case of a young man who had his first attack
of rheumatism (with endocarditis) there was a history of five
distinct attacks of acute suppurative tonsillitis.

Pneumonia. — Nov. 9th, 1889. Three cases have been in
my wards during the last week. The first of left apex pneu-
monia resolving rapidly, the second a more serious case, one of
right apex and left base, which ran a more protracted course,*
and in the third, a fatal case, the disease involved the whole of
the left lung except the apex, and the middle lobe of the right
lung as well. The respirations were very rapid, 80 and 90 on
the day after admission. Death occurred the day after the
crisis from oedema of the lungs. Loud mucous rales pervaded
both sides of the chest. There was throughout no expectoration.
The most interesting point in the autopsy, the discovery
that a fibrinous exudation, distinctly croupous, occupied the
trachea, in fact, a membraneous tracheitis existed. There was
commencing acute tubular nephritis on one side. There had
been albumen in the urine.

Cirrhosis of the Liver. — A woman aged 63 died in 24 ward
of the effects of portal obstruction. She had entered the hospi-
tal on July 26th. A history of spirit drinking ; venous stigmata ;
a moderate amount of fluid in the peritonaeum ; extent of liver,
dulness in right mammary line, 2| inches ; the splenic dulness
had increased to four inches in the axillary line. Had suffered
from bronchitis and shortness of breath upon exertion for the
last seven years, as well as from pain in the left inguinal region.

• Dec. 5th, 1889. The consolidation never underwent any resolution. The
patient, aged 44, an alcoholic, died in the fourth week, from the results, apparently,
of the concomitant bronchitis.

After some weeks residence in hospitals he went home, but re-
turned in a fortnight much worse. It was now noticed that at
about two inches below the costal margin a firm body could dis-
tinctly be made out upon palpation, and this was thought to be
the edge of a large liver. Contact of the finger caused no pain.
Appetite bad ; much thirst, and latterly vomiting. Jaundice
appeared about three weeks before death, but was transient. A
week before death there was wandering, and at the end she was
comatose.

Autopsy. — Peritonaeum contained 330 ounces of fluid. The
liver was typically cirrhotic (wt. 1100 grammes*). It is prob-
able that a quantity of serum must have collected between
diaphragm and upper surface of the liver. f There is no other
explanation of the fact that the edge of the liver had been felt
not only by me, but by many of the members of the class, ex-
tending a good three inches below the ribs. The spleen was
enlarged (wt. 460 grammes*). Emphysema of the lungs and
small spots of pulmonary hnemorrhage. A pedunculated ovarian
cyst, as large as a foetal head, was found at the brim of the
pelvis. Kidneys large ; veins full.

Supposed Sypliilitio Gumma on the Cortex of the Brain.— k
man aged 25 was admitted with sore throat on 1st September,
1889, and it was found that he was just recovering from a
chancre of the glans, and that a few weeks previously he had
had a swelling in the groin. The primary sore made its first
appearance in July, 1889, and on the 7th October he was seized
with a " fit," which began with a twitching and up drawing of
the left angle of the mouth, and afterwards he lost consciousness
and was taken to the hospital in the ambulance, but soon dis-
charged. On the following day, while resuming his occupation
(an hotel servant) , a similar seizure took place. Recovery was
rapid, for I saw him a few minutes after the occurrence, and he
had recovered himself completely. The bystanders told me that
there was "working" of the face, that he had suddenly turned

• Normal weight of liver is 1400 to 1700 grammes, and that of the spleen is 140 to
2O0 grammes.

t Vide Murohison on Diseases of the Liver, third edition, i). 333.

round several times and had fallen to the ground. There did
not appear to be any loss of consciousness.

On admission, on the 16tli October, the tongue was found
recently bitten ; mental functions obtuse ; severe pain on right
side of head, from the centre of forehead to as far back as the
right ear, throbbing and hammerlike, and much worse at night ;
tenderness on pressure and great pain on percussion ; no optic
neuritis. Ordered inunctions of blue ointment. In three days
the pain in the head was nearly gone, and he was enabled to
sleep all night, but tenderness remained some days after the
pain had disappeared. He remained in hospital until the 9th
November, and during that period there were clonic spasms of
the right arm on several occasions, and it was once noticed that
these slight clonic spasms affected the leg. No twitching of
muscle was noticed after the 27th October.

A True Relapse in Typhoid Fever. — Genuine relapses are
not very commonly met with. Murchison puts their frequency
at 3 per cent., Maclagan at 13 per cent. The true figure lies
between these extremes. John A., one of the cases of typhoid
fever sent to us from Lachine, was admitted on the 4th October.
The original disease was very severe, very tedious in its course,
and it was not until he had been thirty-nine days in hospital that
a normal night temperature was registered. The fever was high,
the bowels had been somewhat loose, and the eruption was scanty.
Convalescence was fairly established when the temperature began
slowly and steadily to rise, until in four days it reached 104^,
where it remained for about nine days with very slight lowering
in the morning. At the outset of the relapse there was very
severe frontal headache and pain in the right iliac fossa. On
the sixth day of the relapse a rash appeared on the chest
and abdomen, and remained for about a week. This rash was
very profuse, better marked and of a darker color than the
common typhoid rash, and almost was dark enough to classify
among the " taches bleuatres." Convalescence was gradual,
but quite satisfactory.

Qheyne-Stokes Breathing with Hypertrophy and Dilatation
of the Heart. — In the Hospital Reports already published

(Montri:al Medical Journal, Vol. xviii., p. 296), mention is
made of the case of a French-Canadian farmer, 60 years of age,
who presented the physical signs of a large heart, and whose
breathing was of the Cheyne- Stokes character. There was a
history of rheumatism in recurring attacks, but no evidence
whatever of valvular disease. The apex beat was one inch
outside the nipple line, but there was no enlargemen to the
right of the middle line of the chest clearly made out during life.
The heart's .todon was weak, diffuse and laboured, and the
sounds distant. Pulsation was visible but not forcible in the
external jugulars. The exact duration of the whole cycle, 1
minute 40 seconds ; respirations, 44 ; period of dyspnoea, 40
seconds ; period of apnoea, 40 seconds. No sphygmographic
tracings could be obtained. At the end the symptoms seemed
to undergo some improvement under treatment (tincture of
digitalis, 20 minims, every four hours), but on the 19th day of
his stay in hospital he dropped dead in crossing the ward
(against orders). There were no evidences whatever of renal
disease.

The autopsy, which was made by Dr. Finlcy, showed that the
heart was greatly enlarged, with its left border lying an inch
and a half outside the mammary line, and it weighed three and
a half times the normal weight ; the walls of both ventricles
were somewhat thickened and firm, and the cavities were much
dilated, the right con t?ining loosely adherent ante-mortem clots ;
the tricuspid orifice was dilated to almost double its natural
size, whilst the mitral was normal ; the aortic valves, though
slightly atheromatous, were perfectly competent, and the coron-
ary arteries were healthy : the lungs were somewhat oedematous,
but there was no pleurisy ; the liver was of the nutmeg kind,
and the kidneys had undergone cyanotic induration ; there was
hypersemia of the stomach with eight or ten haemorrhagic
erosions, and oedema of the upper part of the small intestine.
Microscopic examination showed that the muscular fibres of the
heart were healt'uy, and that there was no material increase of
connective tissue.

The sequence of events appears to have been hypertrophy of

the heart, dilatation of cavities, OBpocially of the right side,
which permitted tricuspid regurgitation and subsequent changes
in the various organs. We have no cause to assign for the
Cheyne-Stokos breathing except that of disturbed circulation in
the respiratory centres.

Another interesting case in which Cheyne-Stokes breathing
is marked is at present (Dec. 7th) in Dr. Molson's wards. In
this case, as well as in both those which I have reported,
mental derangement is a marked feature of the case, and in all
three a similar unrestful state of mind is present. They could
not be kept quiet, they must be continually getting in and out of
bed, and although they did what they were told, yet they im-
mediately repeated the offence the moment the attendant's back
was turned.

Hcemoptysis from Mitral Stenosis. — On Nov. 18th one of our
old patients reported himself for examination. He was pale and
thin, and said he had suffered from slight cough and shortness
of breath on exertion for the last three years. He had twice
lately been in hospital with severe attacks of hoemoptysis, and
he had somewhat the appearance of a phthisical patient, but fur-
ther enquiry established the fact that the hoemoptysis depended
upon quite a different cause. He had had acute rheumatism on
several occasions, and again last winter in hospital, and, more-
over, there had existed a systolic thrill, and at the time of exami-
nation a pre-systolic murmur which many of the students had an
opportunity of hearing. The lungs were in a perfectly healthy
condition.

Thoracic Aneurism. — Nov. 22nd — At to-day's clinic, D. J.,
aged 64, came for examination. This was the man who spent
the winter of '85 '86 in the hospital with an aneurism of the
descending arch, which projected in the back. There was local-
ized sweating. (For full report see American Journal of the
Medical Sciences for March 1888.) The symptoms are by no
means as severe as they were four years ago. He has been
taking ten grains of iodide of potassium every day since. Im-
provement was noted in the degree of dyspnoea and pain ; the
tumor was apparently smaller. The pulse was noted formerly

as bein^ collapsing, but now it certainly has not that
character. Tho improvement after the administration of the
iodide showed itself at beat for two years ; during the last year
he has felt feeble, and has suffered from paroxysms of very
severe coughing.

Locomotor Ataxy : Symptoms suddenly developed after an
Injury. — A man, jet 44, three months ago fell into a hole about
six feet deep, coming down upon his feet. He did not feel at all
injured, but two days afterwards he felt a severe pain in the
back, which lasted two days, and was immediately followed by
severe vomiting at short intervals for six days ; then the gait
became unsteady, and numbness in his feet and fingers was
perceived ; no pnin nor interference with sphincters of rectum or
bladder , no history of syphilis. On admission, three months
after the accident, the patellar reflex was found to be absent,
and there was great wavering of the limbs on an attempt to stand
upright with the eyes shut ; gait is decidedly ataxic ; never had
any lightning pains. After a month's stay in hospital there was
considerable improvement showing itself by an almost loss of the
numbness and by a much improved gait, but after spending three
weeks at his home, the numb sensations returned and the un-
steadiness increased. On readmision, it was found that the gait
was steadier than when he left, but there was no change in the
knee reflex phenomenon. Neuro-retinitis present in both eyes.

Cancer of Stomach with secondary Cancer of the Liver and
secondary deposits in the Peritoneum. — The patient whose symp-
toms are reported on page 451 in the last issue of this Journal
died on the 3rd of December. As was expected, the symptoms
became more urgent, emaciation was rapid, and the pain very
severe. Death appeared to have been caused by exhaustion.
Three weeks before death ascites made its appearance, and this
was the result of a recent peritonitis of cancerous origin, for the
membrane was reddened and the inflammation appeared to origi-
nate in a mass of jelly-like foreign material in the pelvis between
the rectum and the bladder. The stomach was not dilated.
There was an ulcer at the pylorus and the tissues about were
thickened, but a little finger could be passed through the open-

ing. Tliia was in accord with the symptoms, for although there
had been a history of copious vomitings, wo had not observed
any while he was in hospital. The salol passed through the
stomach within the normal time limits (2 J houis). There was
no hydrochloric acid in the vomit. The nodule we had felt
through the abdominal parietes in the right mammary line was
present, and there were very many more, but being situated
flatly in the surface of the liver failed to make themselves per-
ceptible. The liver weighed very nearly twice its natural size ;
spleen small.

The Oo-existenoe of Cirrhosis of the Liver and Tubercular
Peritonitis.— In the Montreal Medical Journal of May,
1889, p. 317, there will be found some reference to the coinci-
dence of these two affections. On the 4th December, 1889, Dr.
Johnston made an autopsy on a case which Dr. Molson had had
in his ward, and which he had very kindly allowed my class to
examine. The liver was very small and hobnailed, and the peri-
toneum studded with tubercle. There was also a deposit of the
same material in both lungs.

The clinical history was briefly as follows : The patient, aged
49, was admitted on the 15th November with jaundice, ascites
and oedema of the legs. History of spirit drinking. Present
illness was said to have begun eight weeks ago with jaundice and
pain at the pit of the stomach, which was followed in a fortnight
by dropsy of the belly and afterwards swelling of the feet and
legs. A brother died of dropsy and jaundice after an illness
lasting five months. There were on admission, evidences of fluid
in the peritoneum, enlarged abdominal veins, deep jaundice, sub-
cutaneous ecchymoses, which were especially extensive over the
inner side of the right thigh.

REPRINTED FROM THE MONTREAL MEDICAL JOURNAL.