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Un dee symboles suivants apparaltra sur la darnlAre image de cheque microfiche, selon ie cas: la symbols — »> signifie "A SUIVRE", ie symbols V signifie "FIN". iVAaps, plates, charts, etc., mey be filmed at different reduction ratios. Those too large to be entirely Included in one exposure are filmed beginning in the upper left hand comer, left to right and top to bottom, aa many frames aa required. The following diagrams illustrate the method: Lea cartes, planches, tableaux, etc.. peuvent Atre fllmia A dea taux de reduction diff Arents. Lorsque ie document est trop grand pour §tre reproduit en un seul cllchA. ii est filmA A partir de Tangle supArieur gauche, de gauche k droite. et de haut en bas, en prenant ie nombre d'imagas nAcessaire. Las diagrammas suivants illustrant la mAthoda. I 't . ^ t 3 4 5 6 {Reprinted from tlic Montreal Mia>rcAL Journal, March, 1890.) MONTREAL GENERAL HOSPITAL. CONDBNSFD REPORTS OF CaSES IN Dr. MaoDoNNBLL's WaRDS. Exophthalmic Goitre. — Two cases have been before the class. A gii'i,. aged 21, for several years had woman, aged 35, in whom the exophthalmos was remarkable. The cause of the disease was probably fright. Ten months ago labor came on suddenly when she was quite alone in the house, and it was two or three hours after delivery before assistance arrived. Almost immediately afterwards the prominence of the eyeball was noticed and the sight became defective. She presented herself at the ophthalmic department, where the true nature of the disease was discovered. The pulse is not very rapid (100); the heart's action is not hurried. The thyroid is slightly enlarged, hut there is no thrill ; the exophthalmos is very prominent. When the pupil is directed towards the ground the upper lid remains perfectly fixed in its position, and it is in a constant state of retraction, so that the cornea is not covered. Lead Poisoning ; Chronic Interstitial Nephritis ; Hemiplegia : Death. — (JDec. 28f A.) — In the Hospital Report? of the October number of this Journal, page 291, the reader will find the history of W. S., aged 58, who, since IStS, has suffered from symptoms of lead poisoning. On the 11th May of the present year it was recognized thai he was the subject of chronic Bright's disease of the small kidney variety. He left the hospital on 31st August. On the 24th of December he was readmitted, this time profoundly unconscious. It appears that about a week before admission he had become suddenly un- conscious, and had remained so until admission. He died after being two days in hospital. His condition was as follows : There was speechlessness without, apparently, unconscious- ness, for although he gave no sign of comprehending the questions put to him, yet his eyes followed one about as if he partly understood his whereabouts. It would appear as if the whole body were powerless, but when the neck is irritated the right hand is raised, but the left arm is never moved. When the sole of the foot is pinched, the right leg is quickly drawn away, but this is not observed with the left leg. Knee reflex is absent in both legs. No evidence of paralysis of the facial nerve. Urine and fsBces pass invol arily. The former contains a very large proportion of albumen. The heart's action regular and the sounds nr.tural. The evidences of hemiplegia were slight, and as he had had transient hemiplegia of the other side on the 18th May last, it was thought that possibly the condition might depend uponureemia, though the extreme probability of hemorrhages ini^o the brain was fully taken into account. The case is one of exceeding interest, as showiug a succession of changes, all resulting the one from the other, — first the lead, then the granular kidneys, the arterial disease, the high tension pulse, and the final catastroplie — the rupture first into one corpus striatnm and ei^ht monthu later into the other. The post-mortem appear- ances explained all the symptoms which were present. Both might with advantage be represented in tabular form. Symptoiis. Left hemiplegia, with loss of consoious- nesi). On 18th May, 1889, transient right hemi- plegia. Q«neral mental enfeebloment. Urine pale amber, op. gr. 1017; small amount of albumen ; quantity usually not much above normal. Hyaline casts. Normal amount of urea. > Apex beat displaced downwards and out- wards. Increased area of cardiac dulness. High tension pulse. Ophthalmoscope shows albuminuric re- tinitis. Physical signs of lungs negative when formerly in hospital. Post-mortem ArpRAsiiiiORS. Recent hemorrhage into the right exter- nal capsule. Spot of softening in left internal capsule and corpus striatum. Minute recent hemorrhagic softening in the white substance or the left hemi- sphere. The smaller arteries of the brain under the microscope show ex- tensive fatty degeneration in the in- tima and media, with numerous aneu- r}'smal dilatations. Kidneys cirrhotic, greatly contracted; weight— leit, 80 grammes ; right, 70 grammes. Nornuil weight, 130 grammes. Hypertrophy and dilatation of the left ventricle. Retinitis on right side. Atrophic emphysema and healed tuber- cular nodule in left apex. Acute broncho-pneumonia (a late change). , Erythema Nodosum ; Phlebitis of the axillary and femoral veins, and subsequently of the external jugul?.r ; epigas- tric pain and ascites ; phlebitis in both legs ; evidences of consolidation at the base of right lung ; diarrhoea ; sub- cutaneous nodules ; asj (ration of 110 ounces of serum ; varicosity of the thoracic veins ; rapid dilatation of right heart; death; autopsy. - Annie D., aged 43, was admitted into the surgical wards early in September last with erythema nodoLum and stiffness of the muscles, especially of the neck. She was transferred to the medical wards almost immediately, and the following state on admission was noted. Slight swelling and tenderness of the left side of the neck and pain on movement. Physical signs of chest negative. Urine normal. No digestive disturbance. On the 4 fourth day after admission there was pain and swelling in left axilla, which was thought to be due to enlarged lymphatic glands. On the twelfth day there was severe epigastric pain, which was relieved by vomiting and passed gradually away. In the same evening there was pain and tenderness in left groin. Four days later there was evident phlebitis of the left internal jugular vein, which became distinctly cord-like and very tender. It was treated in the u&ual way, the pain and swelling gradually disap- peared, and the patient feeling stronger, left the hospital on the 19th October. On the 18th November she was readmitted, this time com- plaining of severe epigastric pain, abdominal distension, and a painful swelling of the left leg. After leaving hospital she had been very well for a fortnight, when »he began to menstruate and then to suffer from intense pain at the epigastrium. Tem- perature 100^? ; pulse 96. Nausea and vomiting after food. Evidence of fluid in the peritoneum. Dulness on percussion, bronchial breathing, and crepitant rdle at the right pulmonary base. Both legs are enlarged about the calves and very tender to the touch, especially the right. No affection of the joints. Sharp diarrhoeal attacks from time to time. The thoracic veins of the left side were noticed to be varicosed. The patches on the legs for which she originally^ entered hospital never entirely disappeared, but remained as reddish indurations, and now they are inflamed and angry-looking. They are situated about the calves of the legs. A week later similar physical signs, though not marked to the same extent, were found in the left base. Nov 21th, — One hundred and ten ounces of a clear fluid were removed to-day by the aspirator ; it contained no pus. The dis- comfort due to the abdominal distension was removed, but the symptoms were unchanged. The temperature is now generally about 100-101'* at night and 99° in the morning. Considerable epigastric pain. As a result of a vaginal examination by Dr. Gardner it was found that the womb was fixed in the pelvis, probably by old inflammatory adhesions. Dec. 10th. — The varicosity of the thoracic veins is becoming very marked. Dec. Wth. — Death occurred to-day, the following symptoms preceding the event. In the early morning she complained of very severe pain in the abdomen, and she became much more feeble. The pulse became rapid (144) and very weak. The thoracic veins became ns large as lead pencils, and the general surface of the upper part of the body on the left side was gene- rally cyanotic. The heart's action became visibly turbulent, the cardiac area of dulness became increased, and the sounds became confused, so it was impossible to distinguish one from another. At the autopsy thromboses were found in the right femoral and the popliteal, as well as in many of the smaller veins of the right leg. There was recent embolism of all the main branches of the right pulmonary artery. Old infarctions in both lungs, over one of which an adhesive pleurisy has occurred. The base of the right lung is collapsed. Pale, colorless clots dilate the right heart to an enormous size. There is chronic interstitial inflammation of tho pancreas, with the formation of some large cysts near the splenic end. Several small localized subcutaneous indurations containing pus are found in both legs and in je right arm. Fluid in abdomen and evidences of recent peritonitis. The diagnosis of this case was very obscure. That some one cause was producing the stagnation of blood in so many diflerent parts of the body was evident enough. There was no symptom present which could not be explained by the occurrence within the body of what we saw going on outside it. But to find a cause for this general tendency to thrombosis was a different matter. At one time it seemed as if the presence of tubercular peritonitis would account for the abdominal symptoms, but it would not explain the occurrences elsewhere. We must fall back on rheu- matism to account for the thrombosis as well as for the erythe- matous nodules and the peritonitis. . v^ .■-,,„. ^ Tubercular Meningitis in an Adult. J. W., aged 'Z2>, had been in hospital two years ago with a tumor of the testis, which, on removal, was found to be tuber- culous, and not very long after that he had an attack of pleurisy of the left side, from which he apparently recovered, but soon an abscess formed in the centre of the sternum, from which there came a discharge which continued up to the last. On admission (Jan. 27th, 1890) the chief symptoms were intense headache, which was constantly present, though it was said to be worse at night, and with this headache delirium and noisiness. There was a continued high temperature nnd a rapid pulse. The expression was remarkably dull and stupid, and the gait stagger- ing. He says that he has felt numbness in his right arm for the last two months. No history of tubercle in his family. The patellar reflex is lost in both legs. Cutaneous irritability is in- creased. Vision is very dim. Ophthalmoscopic examination reveals slight hyperaemia of the optic nerve and a tortuous con- dition of the retinal veins. The organs of hearing are unaffected. Physical signs of chest negative. The tongue is clean and flabby. He is not at present suflx^ring from vomiting, but it has been present before admission. Coma put an end to the headache and delirium on the eleventh day after his admission to hospital. At the autopsy gray granulations were found on the convexity, in the fissure of Sylvius, v/hile large patches of lymph were seen at the base. In the left cerebellar hemisphere a large tubercular tumor was found. A few tubercles were found in the apices of the lungs. Alleged " Fits" followed by profound Coma in a Young Girl after Mental Emotion; Death; General Thrombosis of the vessels of the Brain. Ou 3rd February a servant maid, aged 25, was admitted under the following circumstances. She was said to have been in good health until the present attack. Though she had always been nervous and excitable, yet she had never been known to have had fits of any kind or to be at all subject to hysterical attacks. No family history of nervous disease. Five days before admission she complained of dizziness and of dimness of vision, but she continued at her housework for two days, and on the 1st February was said to have fallen in a fit in her kitchen, but re- covered very soon, and was put to bed. On the following day she was said to have had fits every half hour. There was gasp- ing, sighing and rolling of the eyes, but no spasm of the arms or legs. These events were said to have followed some quarrel which she had with her mistress. On admission she was almost completely insensible ; eyes half closed ; mouth slightly open ; pupils react to light. Pulse lapid and feeble. Tongue heavily coated and abdomen scaphoid. In- continence of urine. Urine normal. The insensibility at the time of admission was not complete, for by an effort she could be roused to give her name and to say " yes" or " no," and she was able to take food offered to her, but immediate! v afterwards she lapsed into her previous state of insensibility. Reflexes nor- mal. Sensation lost. On the day after admission the coma deepened. Feb. 5th. — Breathing became rapid and swallowing was accom- plished with difficulty. Feb. 6th. — Condition much worse. Breathes more rapidly. Mouth continually open ; tongue dry ; mucous rattle in the trachea. Died on the following day. The diagnosis of this case was a matter of considerable doubt and uncertainty. At the outset there were many symptoms pointing to hysteria. A young, healthy girl, never previously ill, quarrels with her mistress, is put thereby into a state of great mental excitement, is said to suffer from a succession of mild *' fits," during which she does not bite her tongue or pass water involuntarily, and is finally brought to hospital in a semi-uncon- scious state. But subsequent observations soon disoelled that idea, for the patient presented no appearance of hysteria, but, on the contrary, there was profound stupor and no trace of clonic spasm. The incontinence of urine, which was present from first to last, added to the unlikelihood of hysteria. Though I could make no positive diagnosis, yet the possibility of the symptoms depending upon tubercular meningitis was before me, bearing in mind the case recorded by Gowers, where a young girl under circumstances somewhat similar developed symptoms which were at first regarded as hysterical, but which afterwards became ^^rious^ aud after being a few days semi-comatose and passing 8 water involuntarily, died on the eighth day after the onset. The post-mortem in this case revealed g?neral tuberculosis of the lungs, peritoneum and intestines, some small masses of yellow tubercle in the cerebral hemisphere, and meningitis of the base, the lymph being specially abundant about the pons and medulla, with opaque tubercular granulations.* Having just read this case, I thought it possible that a similar condition might be found to exist in my patient. Dr. Johnston kindly furnished me with the following abstract of the post- mortem report, wh'rh speaks for itself : " The vessels of the pia mater are very full, especially in the frontal region, where slight diffusion of blood has taken place into the tissues (post-mortem staining ?). Throughout the whole extent of the corpus callosum, fornix and internal capsule, the white substance is studded with innumerable punctiform capillary hemorrhages. A few similar hemorrhages are also found in the external and inferior part of both crura cerebri. The peripheral region of both optic thalami and the cortex at the spot of diffusion in the first frontal convolution are the only places where the condition extends to the gray matter. The hemorrhages through- out are perfectly symmetrically arranged. The only other lesion found was a moderate degree of bronchopneumonia, chiefly in the lower lobes. The lungs and all other organs free from hem- orrhages. Examination of the hemorrhagic spots showed them to be accompanied by, and probably caused by, thrombosis of the smaller vessels. The blood at these spots, as well as from other organs, was examined in the fresh condition and in stained preparations for bacteria with negative results." ' ,1 ' A Manual of Diseases of the Nerrous System. I^ondon, 19SS. Vol, I.; p. 323,