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"OBITER SCRIPT A" I.

)rasuiil notes from the Medical Clinic of tiie Royal Victoria Hospital.)

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<ims had been
merely headache and vomiting and the eye ground on examination
had shown marked papillitis. The similitude of symptoms in the
present case led at once to a retinal examination to complete tl'.e

classical trio of syrn|)

due U) intracranial p

niinuric retinitis. Tln' lu i

nephritis, being diniinisliod in i|ii

to the litre, 80 grains of urea in 21 i

gravity of 1012. There were nutnennis li\ n

thelial casts. The heart was slightly cnlargeil t<i tin <

apex there was a soft systolic murmur. The aortic sccon .

was accentuated ; the arteries showed no sclerosis. On the foiiuw

ing day he developed unilateral convulsions and coma, and during the

first 24 hours, only 1 1 ounces of urine wore passed.

Tredtment. — At the outset, .saline purgatives and hypodermic in-
jections of pilocarpine were freely administered, though with prac-
tically no effect, and on the next day he was given croton oil, which
was speedily followed by satisfactory purgation. His restless, con-
vulsed condition made it impossible to give vapour l)aths properly, so
that hot wet packs (for 20 minutes at a time, and at intervals of from
four to six hours) were employed, producing within 12 hours a re-
markable relief, the patient being quieter, partly conscious, and sliow-
ing distinct improvement in the pulse. During the first 24- hours, the
packs were given five times, and from that on with diminishing fre-
quency till after four days the patient was practically out of danger,
perfectly conscious, with no convulsions, or even restlessness. The
urine steadily increased in quantity, and three days later he passed a
normal amount. Nine days after admission, merely a trace of albumen
was left, the quantity being no longer estimable by Esbach's method.
Throughout the rest, of his stay in the hospital his condition pro-
gressively improved, and six weeks later he was discharged, the
pai'ents being given due precautions as to the treatment and diet, inas-
much as a trace of albumen or occasional casts were still present. It
was also noteworthy that during this time the urine was nr— h in-
creased " '' quantity, being frequently over 50 or 60 ounces pc uiem.

Remarks. — The case presents several features of no little interest.
While probably two-thirds or more of all cases of nephritis in child-
hood are associated with infectious diseases, and especially scarlatina,
yet, as in the present instance, a small proportion have a distinctly
obscure etiology. The question of diagnosis, so far as the general
disease is concerned, present? in reality very little difficulty, and the
similarity of symptoms to those in cerebral tumour is perhaps more
striking in the present instance from the coincidence above referred
to. Yet the complete absence of either oedema, dyspnoea or pallor,
as well as the lack of any specific antecedent cause might all very

ri'su

(lache &nd vomiting

nfc, the case well illus-

> 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 !•:■■ <u^ i' i

Tl.r 1

lerature was 1

'i K! ' .■ ;'.s

Tin- 1

t was not defii

t iv !, lit the n cond sound

.IS lii^'

itched and rin^

iir, ' ' (1 '■)■:,., wen' 11 'osed. The

IMC ll

ill the charactc

of :'■!' 1 u Ih'iiMrrhagii' 'itis.

1 !\H|i

ition of the abi

iicii ilii -ji tin tji-st t\' three days

IV lie

1 enlarged sple

to [.CI 11 1,1 tliMiiohi; 'an was not

pjl -ilil

ving to markeil

i^'i'lii \ . ' iiri III It coi ily be felt,

an<

led enlarged fo

•e\rr;il I'l , TI 1, (i'i , TB Ukcwise

assu

high remitteii

lApe, ai \ : u \ . 1 lood serum

was

made, giving oi

ill' six t 1 i! ■;> ! , a positive

react 1

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 <f 1
our cli ii(
of thi I
than )>
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.

'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.

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 <lirected on general principles, with-
out the application of local remedies of any kind whatsoever.

CASE III.

Hysteria' following operation for aypendicitis ; geometrical
(fflove and stocking) anaBSthesia.

Among the less common lorms of functional anoesthesia, though by
no means a rare variety, is that affecting one or two extremities
completely up to a certain well defined limit — such for example as
the areas included in the whole forearm to the elbow — or the lower
leg to above the knee — in other words, the condition described so
aptly by French writers as glove or gauntlet anaesthesia and stocking
aneesthesia.

A young girl who had successfully passed through an operation for
appendicitis, complained two and a half weeks later of soreness in the
right arm and leg, more particularly in the region of the elbow and
knee. With this, there was numbness and weakness of the affected
limbs. Examination revealed distinct paresis of both leg and arm,
though without evidence of atrophy, or joint disturbance. Sensatior,
however, was quite absent over the whole forarm to a zone imme-
diately above the elbow, while the same was found in the leg to just
above the knee joint. In each case the limiting line was astonishingly
well defined, and the anaesthesia of a general nature, i.e., touch,
pain and temperature. Furthermore, the skin was absolutely insen-
sible to the faradic brush (electro-anaesthesia) and pin pricks would
scarcely bleed at all, evidencing marked disturbance of the vasomotor
system as well.

Examination elsewhere revealed no other evidences of hysteria
except anaesthesia of the pharynx.

There was no history of lead intoxication.

The treatment now being adopted is directed to general improvement
of her moral, mental and physical condition, with local application of
the faradic wire brush.

CASE IV.

Hysterical tremor with marked aifeotion of special senses.

In this instance there was no etiological factor discernible, there
being no history of trauma or intoxications. The patient had suffered
from several hysterical convulsions since three or four months, and
later on developed a marked and coarse tremor, chiefly of the arms
and hands — less so of the lower extremities. Even while lying quietly
in her bed the arms and legs could be seen to tremble, often violently

tilt! oHcillntions ahviiys Ix'injf coarso atxl rapid. At times there wore
distinct contractures of the arms an<l legs with variable degrees ut'
paralysis.

The gait is unc(;rtain — at times markedly ataxic and at ot! ers
undia-taken with comparative ease.

With this are other stigmata, such as defective color vision, lost
taste and snuill and distinct alteration in hearing. The pharyngeal
reHex is absent. Sen.sation to pain is variable from time to time,
though the tactile and thermic sense seem pre.sent nornially.

" OBITER SCRIPTA " III.

Some Intekestino Cases AKFEcriNfj the Respiratory System.

CASE I.

Serous membrane tuberculosis, involving: pleura and periton-
eum, with ohronio non-tuberoulousmuoo-purulent bronchitis.
Terminal disseminated miliary tuberculosis.

Cases of this kind ai'e always of very great interest anu belong
really to the more uncommon manifestations of tuberculosis. The
victim of this disease was a young man, who, had according to his
accouut been in good health up to the onset of his present illness.

History. — He entered the hospital on the last day of Dece. .'r, 1897,
complaining of dyspnoea, cough, general malaise and an acute pain
in the left side which had come on suddenly two weeks previously.
All these symptoms had followed exposu'-e to cold and wet and in a
very short time copious expectoration and prostration supervened.
There was a family history of tuberculosis.

On admission, his temperature was lOOi", his pulse lOG, and the
respirations 28 per minute. He was markedly anaemic and the skin
was moist. Apart from some irregularity in the pulse, the circulatory
system showed no other evidence of disease.

His chest was of a tuberculous conformation being long with an acute
angle at the ensiform cartilage, widened intercostal spaces and gener-
ally flattened. Examination showed a left sided pleural effusion of
moderate degree, while on auscultation a few moist rales were heard
over the left apex ; the breathing on the right side was harsh. The
sputum was copious, muco-purulent i.: character, and repeated exam-
ination failed to give evidence of either tubercle bacilli o" elastic
tissue. The digestive system showed in the main, a full and tense
abdomen with no spontaneous pain, and palpation revealed neither
tenderness, tumour, nor evidences of fluid. The spleen and liver were
of normal size. The urine gave no evidence of disease.

Course. — Throughout the course of the malady the temper-
ature assumed the daily intermittent type ; there was copious sweat-
ing and rapid emaciation, while the cough and expectoration persisted.
Puncture of the pleural cavity revealed the presence of slight hsemor-
rhagic effusion, which on microscopical examination showed mainly a
few blood cells and very few leucocytes which had undergone marked
fatty degeneration Death followed in less than three months after
the onset of symptoms.

Autopsy. — The autopsy shewed bilateral hoi^norrhagic pleurisy,
more advanced on the left side ; tuberculosis of the peribronchial
glands ; a subacute more ur less dry chronic tuberculous peritonitis
which was obviously of longex standing than the pleural affection-
The mesenteric glands ■were, caseous and the ileum presented one
small shallow ulcer ovidently tuberculous in nature ; the pericardium
was free from disease. In the lungs there was a chronic simple muco-
purulent bronchitis, but no evidences of chronic tuberculosis. The
only other condition of interest at the autopsy was the generalised
miliary tuberculosis which evidently had induced the lethal termina-
tion.

Remarks. — The special features of interest in this case are as
follows : — A chronic peritonitis which had been completely masked
through the acute symptoms in the pleural cavity ; the course of the
malady throughout ; the presence of a simple muco' purulent expector-
ation with many rales in one lung, naturally arousing the suspicion
of chronic pulmonary tuberculosis, though oft repeated examination
for bacilli had been quite negative.

Infection had occurred here no doubt from the alimentary tract as
seen by the condition of the ileum and mesenteric glands, the periton-
eum being thereby secondarily involved. The pleura was infected
through the diaphragm as is usual in cases of this kind where the
peritoneum is the primary seat of disease. In many cases recorded
by Vierordt, the pleura was first involved and the peritoneum second-
arily, and not infrequently the pericardium was likewise secondarily
affected. That authority has never seen a primary pericardial tuber-
culosis under such conditions.

Clinically, cases of serous membrane tuberculosis vary considerably,
being often extremely insidious in the onset, at other times, as in our
present case, very acute. It is unusual to find other oi'gans of the
body affected. Frequently a pleurisy, evidently tuberculous in nature
becomes " healed " and then within some months after the pleural
symptoms have disappeared, the peritoneum shows evidence of acute
inffammation, and later on again the pleura becomes involved for the

second time. This feature in the course of the disease is often of aid
in the diagnosis. It would appear that, from various observations
made, fever is not a necessary nccotnpaniment of the disease, though
usually present. Dropsy is often a very marked symptom, and then
the differential diagnosis between cirrhosis of the liver and serous
membrane tuberculosis becomes extremely difficult, more especially
where fever is absent, The difficulties are all the moi'c striking when
the spleen is palpable, for in many ca.ses of this form of tuberculosis,
that organ is distinctly enlarged. Indeed, observations have shown
that not uncommonly cirrhosis of the liver occurs with serous mem-
brane tuberculosis, usually as a result of an old standing peritoneal
involvement and capsular ribrosis. When the double a.t'ection occurs
the actual condition must present great difficulties of diagnosis though
doubtless one of the two processes would readily be assumed. The
treatment is on the whole unsatisfactory, puncture of the pleural
cavity being recommended for effusions in that region, and laparotomy
for the peritoneal affection.

CASE II.

Latent pyo-pneumothorax. -SiRns of extreme pleural effusion ;
normal temperature, pulse and respirations.

(The notes of this case are in part abstracted from the careful
report of Dr. McCallum, one of the Resident Physicians).

A young woman who had cough, expectoration and dyspnoea, entered
the medical clinic last April under Dr. James .Stewart. She had
been ill for nearly a year from influenza, so she stated, upon which a
pneumonia had supervened. She was confined to her bed almost
constantly from July to October with cough and frothy expectoration
and slight intermittent attacks of dyspncoa. She never had had any
hsemopLysis, nor were there sweatings, chills nor other evidences of
pulmonary tuberculosis. The dyspnoea had at no time been very
marked till two weeks before admission, which in this connection is a
point of distinct interest, all the more so, inasmuch as she stated, that
in December, of the past year she noticed splashing sounds in the
chest on any rapid movement ; this only persisted for a few weeks,
and the onset had never been attended with any acute .symptoms or
pain. Ever since the splashing had Ijeen observed however, she had
also noticed palpitation of the heart on the right side of the chest.

Tiiere could be no doubt from the history givew that Mie patient
had been suffering from a pneumothorax contracted in the course of
a more or less chronic pulmonary disturlmnce. In the absence of
further history however, it was impossible to state more definitely
the actual course of the malady.

H'jf condition on admission was very briefly as follows : —

8ho was distinctly anoemic, preferred the left lateral decubitus,
other positions causing marked dyspnoea and distress. The tempera-
ture was 98°, the pulse 9(i and the respirations 20 per minute. Ex-
amination of the chest showed a condition typical of that induced by
extreme, left pleural effusion ; viz., fulness of the left side and obliter-
ation of the intercostal spaces ; diminished expansion ; absence of
vocal fremitus ; a flat note on percussion from the extreme apex to
the base ; absence of breath sounds and of vocal resonance on
auscultation. There was dulness too on the right side in front, close
to the sterr'im, up to the 2nd rib, and at the level of the 3rd rib this
duln(!ss extended outwards for three inches and was continuous below
with the hepatic dulness. In the 4th interspace three inches to the
right of the sternum, was seen the diffuse apex beat of the heart and
the dulness extended slightly beyond. Both basal .sounds were mark-
edly accentuated, but there were no murmurs. The spleen was dis-
tinctly palpal)le, being pushed down evidently by the superjacent
fluid. The urine was normal. The sputum contained no bacilli of
tuberculosis, and there were no signs at this time of pneumothorax.

On the day after admis.sion 30 oz. of creamy pus was removed,
though without altering to any marked degree the physical signs in
the chest. Cultures made of the fluid remained sterile. Three days
later she was again aspirated, and 15 ozs., removed. This time the
heart receded slightly towards the normal position ; there was a
tympanitic note over the upper third of the left lung, and the Hippo-
cratic sucussion was readily obtained, and quite audible to those
standing some distance from the bed. Beyond this feature, however,
there were no dcflnite evidences of pneumothorax, the coin sound and
metallic tinkling not being elicited. Operation was ui'ged but the
patient refused, and nine days later she was aspirated again, this time
40 ozs., of creamy pus and lymph being removed. Great relief fol-
lowed and the physical signs altered to a marked degree. There was
a tympanitic note on percussion as far as the 4th rib, and from there
down to the base the note was flat, the sucussion splash, coin sounds
and metallic tinkling being all readily obtained. Respirations were
performed with greater ease, and the patient felt in every way so
comfortable that she insisted on leaving the hospital the same day.

Throughout the course of her stay, with o.ie day's exception, her
temperature remained normal. The tuberculin test was not employed.

The case is of particular interest as illustrating how insidiously
pneumothorax may sometimes develop and quite in the absence of
the usual acute symptoms which call for urgent treatment.

Cases of tliis kind have been recorded by others, particularly by
S. West of London, who mentions instances where in the so called
apparently healthy, pneumothorax has been found from time to time,
and in many instances ar ociated with strain. Probably in 90 per
cent, of cases tuberculosis . . the main etiological factor thoucrh numer-
ous instances exist showing other causes to be at work, and in not a few
the antecedent condition has been, as in our own case, quite obscure'

OBITER SCRIPTA IV.

CaHiial notes from fclio Medical Clinic of the Royal Victoria Hospital.)

liY

C. F. Martin, B.A., M.D., Etc,

Lecturer In Medicine, McGill University ; As.sistant Physician to the Royal Victoria

Hospital.

AND

Hahvkv Smith, M.D.,
Resident Physician, Royal Victoria Hospital. ,

Some Atypical Forms of Pneumonia.

Year after year, diseases which are epidemic present variations not
only in the individual cases but likewise in the disease as a class, and
it is by no means easy to detect the reasons for these general
departures from the usual types Five or six years ago, for example,
it was a common experience to find in the epidemics of typhoid fever,
that diarrhuia was one of the most constant of the earlier symptoms,
while on the other hand, more recently constipation has been present
in probably 90 per cent, of the cases. In many of the epidemics too,
in present years, the vast majority of the cases have been of the
mildest type, while previously even with very much similar treatment,
the number of fatalities was certainly greater.

So far as the incidence of pneumonia is concerned, the epidemics of
influen/a have had an und(jubted influence on the statistics of the
disease, as has already been noted by several authors. Rankin of
Gltt.sgow. for example, described some three years ago a series of cases
following influenza where the t matures were distinctly unusual, there
being a very insidious onset without rigor, pain or cough, and where
nausea and gastro-intestinal symptoms were the prominent conditions.
In these cases too, the temperature was markedly irregular and the
pulse slow. Rendu, of Paris, and Gmeiner, have noted somewhat
similar facts though in less detail, referring more especially to' the
gradual onset, the irregular temperature, and the termination by lysis
rather than by crisis.

iff

During the pnst season, it lias been our experience at the Royal
Victoria Hospital in meeting with an unusual number of cases of
pneumonia, to find comparatively few typical so-called text-book
types. Only two or three at the most, out of fifteen or twenty cases,
have presented a frank pneumonia where the temperature has run
from five co ten days a liigh continued course followed by a crisis.
In many of the cases indeed, the onset has been most insidious, the
initial symptoms continuing over several days, and being those rather
of a mild form of influenza with slight malaise and perhaps chilliness,
headache and gastro-intestinal symptoms, all of which aro superseded
after some days by the initial pleural pains of pneumonia. In .several
of the cases too, the gasti'ic symptoms were so marked as to com-
pl:^tely mask in the earlier stages, the true nature of the disease.

One case is peculiarly interesting as showing precisely the reverse
of this mode of onset, the patient presenting the initial rigor within
12 hours of the time of exposure, his condition previously being that
of perfect health. True rigors at the onset of the disease have been
comparatively few, i. e., in less than one-third of all the cases. So
far as the children are concerned of which there have been 7 ill with
pneumonia, the onset was likewise gradual and was in no instance
demonstrated by convulsions which under ordinary conditions is
apparently fairly common.

So insidious has the onset been in certain cases th,a, it h<is only
been through the ordinary routine examination of the lungs that the
signs of consolidation were manifested, as in the case of one child who
entered the hospital because of some pain in the neck, while in
another instance, a child who was originally brought to the Outdoor
Department on account of general malaise, was found to have the
apex of one lung consolidated without there being any other subjective
or objective signs of the affection. This same child who had for some
five weeks a markedly high temperature accompanying the pneumonic
process, was never at any time in any obvious distress, and insisted
throughout the course of his malady on sitting up in bed.

Histories such as the following have been quite common in the
present epidemic. The patient entered tlie hospital complaining that
early in the malady for six days he had had coryza, neuralgic pains
in the legs and sore throat followed by nausea and occasional vomiting.
At no time did he have any chill. One week later, pain in the side
developed and the patient, though endeavouring to keep on with his
employment, was obliged to take to his bed, and a few days later
came to the hospital, one lung being found in a .state of partial con-
solidation. During the next week that he was under observation

there, his temperature assumed a distinct intermittent type as the
chart will show, (Chart Nu. I) and although a complicating pleurisy
with effusion was suspected on account of this irregularity in the
fever we were never at any time able to obtain proof of its presence .
This question of temperature has been throughout the series of
cases one of the most interesting features. In two patients where the
ordinary basal consolidation was present without complications, the
tempei'ature assumed a markedly intermittent type for at least one
week. Pseudo-crises have been the 'rule rather than the exception,
there being often several in the same patient. Remittent tempera-
tures and termination of the fever by lysis has likewise been among
the commoner manifestations as will be seen from the accompanying
chart No. II.

One of the patients in whom this was manifest was a young married
woman in whose family during the same week there had already been
two other cases of the same disease. Five days after the initial rigor,
she took the cars for some distance towards the hospital and then
walked a quarter of a mile in order to gain admission. She was
practically moribund on being placed in bed and the heart itself was
showing signs of failure, the second pulmonary sound being distinctly
weakened. However, the condition fortunately subsided, and though
no complications could be detected, the temperature ended in much
the same manner as do ordinary cases of enteric fever.

Among other interesting features which have been noticed in the
present epidemic has been the insidious manner in which pleui-isy
with effusion may complicate the disease, and in several cases where
the temperature was either on the descent, or had already attained
normal, fluid either serous or sero-purulent had collected without
manifesting any appreciable alterations in the temperature. In one
case indeed, the fluid collected within 24 hours, filling half the chest
without there being any evidence to indicate it on the chart. Aspir-
ation of this patient's pleural cavity, showed the presence of sero-pus
which disappeared without further operation.

That pus may be present in the pleural cavity without apprecial)lo
chart alterations is of course a well recognised fact, but to have it
completely fill the plcui-al cavity as in another instance, where the
pulse, temperature and re.spirations were normal, is certairdy among
the very atypical forms of disease. In yet another of our cases delir-
ium tremens was present and the pneumonia occupied but a very
secondary part of the .syirptomatology. It is perhaps less uncommon
to find in patients with delirium tremens a great elevation of temper-
ature, and the conditio ..ay go on insidiously though much of the
lung be involved.

Such was the condition in our case referred to where, thouf^h there
was but slipfht rise of teniporature, the rusty sputum and evidences of
consolidation in a portion of one lung, were quite sufficient to make
the diagnosis of pneumonia undoubted.

Examination of the blood showed that in most of the cases, leuco-
cytosis was present, and it has been our experience to find that in the
non-fatal cases, a good prognosis is certainly associated with its
presence. To this, however, wo have perhaps a slight exception, in a
young child whose condition was so .severe as to be considered practi-
cally beyond hope, and only 8000 leucocytes were present. The
disease became bilateral, the pulse reached 175 per minute, and the
respirations 72 ; for a time likewise there was Cheyne-Stokes respira-
tion. A few days ago, however, a cri.sis appeared and the patient is
now convalescing. It should be stated, however, that the day after
the crisis the leucocytes reached 16,000 to the cubic millimetre. The
most marked leucocytosis present in any case was 44,000 to the c.mm.

Delayed resolution had not been uncommon, the signs of con.solida-
tion persisting often for piany days after a crisis would have been
expected. In two instances occurring some months ago, delayed resol-
ution was of such a nature as to arouse the suspicion of a tuberculous
pneumonia although the temperature had attained the normal for
some days. Tuberculin was injected without a definite reaction, and
a correspondingly good prognosis was given to the friends, a proceed-
ing which was finally found to be quite justifiable, the patients both
ultimately making a good recovery.

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CHART I.

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CHART II.