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Mapa, platea. charts, etc.. may be filmed at different reduction ratioa. Thoae too large to be entirely included in one expoaure are filmed beginning in the upper left hand corner, left to right and top to bottom, aa many frames aa required. The following diagrama iiluatrata the method: Lea cartea, planchea, tableaux, etc.. peuvent Atre filmte it dea taux de rMuction diff Grants. Loraqua le document eat trop grand pour dtra reproduit en un aaui clichA, 11 eat filmi A partir de I'angle supArieur gauche, de gauche A droite. et de haut an baa, an prenant le nombre d'imagea ndcassaira. Les diagrammas suivants illurtrent la mithoda. 1 2 3 1 2 3 4 5 6 "OBITER SCRIPT A" I. )rasuiil notes from the Medical Clinic of tiie Royal Victoria Hospital.) HY C. F. Martin, M.D. Lecturer in Medicine, McG'll University ; A.ssiNtant Physician to the Royal Victoria Hospital. (In tlie ensuing casual k, tes are embodied a few observations on cases which are of interest eitlier in reference to diaijnosis or treat- nient, or as presenting .some instructive variations from the commoner so-called text-book type.-.. It is hoped that whi'e they oFer no fea- tures of startling importance, there may at least be a few facts of interest to some readers of the Journal.) SOME FORMS OF NEPHRITIS. CASE I. Urssmia affectingia boy in previously good health— General and special diagnosis of the renal condition— Treatment. A boy, set. 12, had been con)plaining for several weeks of inter- mittent headaches, occasionally quite intense, sometimes persisting thi'oughout an entire day, at other times being ([uite absent for several days together. With this there was vomiting, usually at the time of the headache, and at all events quite independent of the ingestion of food. The vomitus had no special characters. Careful enquiry failed to elicit any other symptoms or complaints up to the day of his entering the hospital. There was no history of scarlatina or other infective ilisease since infancy, nor could exposure to cold or any other etiological factor be discerned to account for the condi- tion present. On admission lie was very restless, held his hands to his head with the inten.se pains, and vomited several times on the first day. The tempej'ature was normal, the pulse 104 and of very slightly increased tension, and the respirations wen; 24 jv r minute. There was a coated tongue, anorexia, marked thirst and constipation. CEdema and anaemia were conspicuous V)y their entire al>sence. By a curious coincidence there lay in the adjoining bed a l>oy with cerebral tumour, in whom likewi.se the main sympt nation and the necssaity iii; where headaches per- Uire of the renal lesion, for Uian in adults, one is never .s of a kidney unless the deci(i' tend to If: in children, tli'- p: •• More especially may i)o i persisting throughout the cou: quantity when once recovei'y wa^ uric retinitis, which even under <(\ as acute or chronic ? To ult task ; certainly one would atiular kidney is extremely rare 1 1 ted very much to that diagnosis. iho urine of low specific gravity t lie disease, the markedly increased established, the advanced albumin- iny condition is extremely rare in children, and lastly, the persistent thii'st. In the light of such a diagnosis the ultimate outlook would be proportionately serious, these cases reaching a lethal termination in a much shorter period. CASE II. Aoute nephritis ushered in with symptoms 8imal..ting appen* dicitis The victim of this affection was a young man aged 26 years, whose illness was preceded by distinct exposure to cold. Following upon this was general malaise and ». vague feeling of abdominal dis- comfort, nausea and vomiting. The bowels were constipated. On the next day the abdominal discomfort was more marked, and tenderness in the right iliac fossa pronounc^id. An enema was administered, and after three hours the paia on pressure immediately outside McBurney's point was even more dis- tinct. Palpation in this arcti, revealed a finger-like body which was painful to pressure, and, so far as could be estimated, was the swollen appendix. The temperature was 1005°. The pulse 96. On the next day, however, examination of the patient revealed but little ten- derness in the affected area, even on deep pressure, while on the other hand the lumbar region became markedly painful. The tempera- ture now reached 101 "5°, but the general symptoms were no longer those of appendicitis, whereas the urine on examination revealed all the characters of an acute hemorrhagic nephritis. Repeated tests of till- liliKi Tum for tit tiv<' 11 SI The patii CL-iiru ti) :ovbry. nsheringr in UllV n ("Nephro-t. •alB r Sllcll !S as this arc T SO very nncon own clii we have seen wi ])ast two years ilistilliri f the kind. In t\\ lie patients the initi. Were sti >ical of Jicute aepl litis as to entirely mask loi- l,\V() or e days the sig ns of enteric fever. The present iiialiH|\ n\\WU'<\ girl of 16 yea s who had already passed through a severe ,itta(;k 1 abacute nephri s two years previously, and had not been Iniiril 1 1 11 February of tS, when she riM|uested admission to the wiinis, I enting all the lis of acute ' ' disease, viz., dropsy of tllr ryi- and all extn ies, pain vomiting, blurred \ isioii, < .nished quantit ' urine ci ists, etc., all of wliii'h ^ ptonis supervei 'H !•:■■ ! , a positive react 1 No s developed at ly tiiiir mi n .1! he disease. The pi ■ss of the case far as 1 u . n< i 'erned was one of interrupted rec TV, \y][ {{■ 1 • ■ i'i> '1 Inm the renal conditioi lias assumed u '• tlu' ( hill- i: r ■:! 1 ell parenchy- matous n< phritis with sec lary sli ii:l<-' "01 EK S( 11 n '.'• II Some Oli.M.S > K 1 . TKIU The protean manifestat ^ of th s h :.ly li.i\e ill formed a very large element in the latistic-- ()■■ ■Jise 1 \ er i 'lato first taught that the globus 1 -tel-ieli \v' s uluerd liy U'e of the uterus against the diapl .^111, .-III 1 ' 1'^ ei niinj , believed the CO iditioii existii rec( ' ' hav \v i clue ( lan bi lave 1 ome, otice. coughi rpetuatt itractui'f 'I by mr ilUistratf (listurbanc present soiri he study of n .lotor than to tl distribution of in any way to most cases quii difficult to det( true nature of A ft!W not V( their rarity by variu 3 forms. I '111'' C ls,'-. ' \ li( nit HIS .lis u < >ry hi .t.T (II 1 nil '. scri. .Il\ I |i|S, (it ii' r " SI "M I ( I'Ct li I ' 1 I I 1 1 ( 1 1 1 1 1 1 ' iiy 11 c in-^ tho existence of some new form of life . Within a very short period recently in numerous examples of the various forms laps, rather unusual and worthy of more hese J)r. James Stewart has already made barking girl, whose intermittent uproars he hospital phonograph. So also of the arm and leg permanently, so far as we are pnotism. Others admitted quite recently ■ tlie characteristic varieties of motor and lich are always of interest and which at s in diagnosis to those not much engaged ses. This applies naturally rather to the mifestations, inasmuch as the irregular 3 localisation to areas not corresponding >f nerve supply makes tlie diagnosis in either case, moreover, it is as a rule not Data diaboli" which help to elucidate the examples are here noted, not because of it as illustrating in a group some of the erioal p \ m, 36 ye. M ss the ankl iiMuli nd had liooki 'per. Hi till- I al diseat iiK'c liere was I'lU'v I lencies t( ion I' lad fallen Alls -- ewhat da illl)rtl^ after this iorciirii ', a condit ' ' • a severe uciating ■( 1 ed for t! I surmised 1 and ther litions hi 1 ed to aid owed I ,■ 11(1 i'X< I i)iri)il;ii \()ulil 1 I. V,'l ..hci \\ as II 1 1 (' CASE I. 'esis I t' t lower extremities with foot drop- red the hospital complaining of weak- / in walking. He was a Canadian by employed as a machinist, baker and ways been moderate, and apart from I, he had had no maladies o!* import- ;pecific history nor evidence of heredi- iimily. Some three years before admis- !ad somewhat severely ; as a result he ot lose consciousness for a moment, of a " pins and needles" feeling in the isted for months, and was soon fol- 'k, which he described as intermittent Two months after the accident, he f the difficulty in walking, due, as iption, to marked " foot-drop." On le difficulty in walking, while under 'ily, and in order to lift his leg he itl s hands. Ever since that time, uow s ot 1 ^.■, find I Iti' ''(■n s I -i' Msl liiiliii s 1) el 'S of vlllM lisolu ( l\ I lis.>!i> • n 11 ■itriki i;:' 1' .■(I, 1.1 t (i ■K- I'OI 1 i|, II \vl i( i; 1. ■ nil Iiilc fir,, (iiii V;l Ulii lll>' ,.-,t(M iui.' I -. i\r I lit I i ,1 r. 6 moro than threu years ago, tlu; patient has luen more or less thus afflicted/ On entering the hospital he was seen to he ii every way well nour- ished and apparently healthy, apart from the conditions ot" which hi; conipiained. His gait was the most characteristic feature ; the feet, during walking, were lifted high in the air, the toes pointing to the ground. On returning them to the ground when raised, the toes Hrst came into contact with the lloor, the heels later, and with a sharp thud. There was a most ohvious effort in walking to lift the toes well above the ground, though at times the patient utterly failed, leaving them meanwhile to drag, with inversion of the feet. This condition was marked in both legs, though uuich more so in the left- A slight ataxia was likewise prominent. Examination of the nervous system I'evealed good voluntary power in the muscles of the upper extremities, as also in those of the right thigh ; the muscles of the left thigh, however, were distinctly weakened, as well as those of both lower legs. The condition was brii;fly as fol- lows : Right leg, complete inability to Hex the ankles, slight power to flex the toes ; extension fair but distinctly weakened. Left leg, abso- lute paralysis for extension and flexion. The rejiexcH were throughout normal, except for some slight ex- aggeration of the plantar and patellar reflexes on the right side, and marked diminution of the patellar reflex on the left. Electrical reactions were normal Romberg's symptom was slightly present. Go-ordination and muscular sense were otherwise normal ; there was no disturbance of sensation. The tdches cerebrales were well marked. After a short stay in the hospital of three weeks, the patient was discharged, being slightly improved. Six weeks later he returned practically in the same condition. An effort had been made by Dr. Stewart to hypnotise him but with only moderate success. Complete paralysis was now evident in the flexor muscles of the left foot. There was no evidence of atrophy nor of advance in the condition in any other way whatsoever. The treatment employed throughout was unsatisfactory, inasnmch as after his second sojourn he was again discharged unimproved. The question of diagnosis in such a case is not a difficult one, rest- ing as it does mainly between three condition.s, peripheral neuritis, anterior poliomyelitis, and functional or hysterical paraplegia. The condition having lasted for so great a length of time without atrophy and with but slightly altered reflexes and a total absence of progressive changes, as well as the healthy condition of the muscles in their reaction to electriciil tests, would be quite sufficient to exclude the anterior poliomyelitis, or iiny clmnges whatsover in the condition of the fjanglion cells in the anterior horns of the spinal cord. Multiple neuritis, too, is readily excluded from the absence of all sensory symptoms in the lower extremities, both subjective and objective ; well preserved muscles, no atrophy, normal electrical reaction, the absence of any known cause, etc. The course and symptoms of the malady, moi'eover, would also render a ti'ansverse myelitis (|uite im- probaljle. The mere fact tliat such a condition had gone on for three years or more without appreciable change in the nutrition of the parts, makes the diagnosis of hysteria absolute, and the prognosis could not be considered serious. CASE II. Hysterical paralysis of the lower extremities following each effort to walk a short distance. The victim of this malady was, as might be expected ! a girl of about 80 years of age, who wa.s admitted to Dr. Stewart's clinic because of inability to walk. The first manifestations appeared some 7 years ago with dragging of the left leg, from which, however, she partially recovered for two years or more. The x'ecurrence ensued, and in a graver form of the disease, the patient being quite unable to walk for one year. Partial recovery again took place, and the patient was in the habit of taking fairly long walks every week for several years. The condition persisted thus till the middle of 1895, when she again became worse and remained almost constantly in bed from July, 1895, to February, 189G. At this time marked weakness developed in the right leg, and the left became quite useless. Crutches were now em- ployed till November, 1896, and since that period she had been fairly well till last year. Her gait, as observed on admittance, was quite remarkable. Being held up by the nurse at first she would exhibit obvious efforts in be- ginning to walk, and progression was characterized by distinct shuffling and dragging of the dorsum of the toes over the ground with inversion of the feet : this was far more marked on the right side. Although the first few steps were taken fairly well, until obvious weakness developed, each step was then succeeded by a weaker, till the patient fell into the attendant's arms. After a prolonged sojourn in the hospital the condition became gradually improved till by February, 1898, the patient left the hospital with complete use of her limbs. The treatment was in the main