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plaining of an unusual group of symptoms, which have been developing for the past six months. She complains of dizziness, accompanied with dull headache. There has been nausea, with a bad taste in the mouth, and sometimes vomiting. The appetite has been irregular, with gastric indigestion, flatulence, and acid eructations. There has been regular

main symptom. This is a form of muscular | a widow, with two children, comes to us comtremor associated with the weakness of the affected muscles, which, beginning in a single group, extends until it may involve the entire half of the body, or it may affect both arms and sometimes all four members. It is very apt to begin in the hand, but I have known it to begin in the feet. It usually comes on in persons advanced in life. Mental worry, long strain, care, and overwork favor its develop-action of the bowels. During the past six ment. Its lesions are somewhat obscure. The muscles may waste a little, or they may not diminish in bulk. The disease lasts many years; sometimes it is checked in its progress, but usually it goes on involving the muscles of the extremities, passing to the head, involving the lips, and finally affecting more vital muscles, and death results from gradual exhaustion. Paralysis agitans is a bad name, for the disease is not a true paralysis. It is a progressive muscular tremor, associated with some weakness and some wasting of the muscles.

What is the cause of the tremor in this case? Is it due to disease of the central nervous system? I feel doubtful about this. I consider that the local injury of the brachial plexus of the left side is of importance. I should not be willing to make an unfavorable prognosis until a prolonged course of manipulation and electricity has been tried. The partial anchylosis must be broken up by manipulation. There is also some stiffness of the right shoulder joint, which must be removed. The nutrition of the muscles has deteriorated. The tremor is most marked in those muscles supplied by the left brachial plexus. That may be due to neuritis or peri-neuritis of the nerve trunks. The condition of the right side is not sufficiently marked to make me express a positively unfavorable prognosis, yet the fibrillar quivering and slight wasting which has already taken place, and the growing weakness of the right arm, make me fear that the condition will eventually pass into one of progressive muscular atrophy.

The man shall be given a course of forcible manipulation to break up the adhesions. In ternally, I shall prescribe a tonic course of treatment, with the syrup of the iodide of iron in from ten to thirty drop doses, three times a day in water, after meals. We shall have the man again report in one month.

Localized Meningitis, or Intra-cranial Tumor. Our next patient, Mrs. C—, æt 50,

months the eyesight has also been failing.
When the dizziness comes on she staggers, but
has never fallen. There is no pain in any part
of the body, with the exception of the head,
but for some time there has been considerable
headache: The heart is normal. There is no
swelling of the face or of the ankles. She
rarely has to get up at night to urinate. There
has as yet not been an opportunity to examine
the urine. The ophthalmoscope shows double
optic neuritis.
We have, then, the following group
of symp-
toms: long-standing headache, worse during
the past six months; dizziness, almost constant,
and worse on making any sudden movement,
with a staggering gait, and occasionally with
the sense of surrounding objects moving; failure
of vision with double progressive optic neuritis;
more or less dyspepsia, and when the head first
began to trouble her, there was vomiting every
morning of one or two mouthfuls. She now
vomits not more than once a week. This was
probably the result of reflex irritation, cerebral
in its origin.

There are several features of marked interest in this case. The dizziness is an interesting symptom. This is often of a functional character, and connected with derangement of the digestion. In some cases, irritation of the stomach causes extreme giddiness. Then again. it is often connected with the imperfect elaboration and imperfect assimilation of food, and the passage into the system of matters crude and irritating, and these, acting upon the brain, will induce troublesome giddiness. Patients with so-called lithæmia, or internal gout, often manifest this symptom. Dizziness is often the result of feeble circulation. In cases of cerebral anæmia, where the circulation of the brain is interfered with, as by thickening of the arteries supplying the brain, dizziness is a prominent symptom. Dizziness may also be connected with general anæmia.

This symptom is sometimes connected with

organic disease.

In the way of treatment, I shall order a diet composed largely of skim-milk and of cereals. I shall apply counter-irritation around the base of the brain. For this I should prefer repeated light applications of the actual cautery. Internally I shall order iodide of potassium, to be continued for a long time, with this I shall employ mild mercurial courses, giving the remedy for a month, discontinuing it for a month, and then resuming. This treatment will be kept up for some time.

A few days ago, a physician | tribute the symptoms to meningitis. There have from the interior of the State called on me, been no convulsions. complaining of sudden spells of dizziness, coming on without warning. Objects around him suddenly rose into the air, and he would grasp out for something to steady himself, frequently falling to the ground. Three times within the past four months, he had suddenly fallen to the floor while shaving, fortunately without injuring himself. On no occasion had there been loss of consciousness. The giddiness passed over in a minute, and then he would get up. These attacks had come on a number of times during the past three years. In addition, there had been less violent attacks occurring more frequently. Examining him carefully, I found that this was connected with total deafness of the left ear and constant tinnitus, but with abso lutely no other evidence of derangement of the system. In this case we had an instance of aural vertigo, labyrinthian vertigo, or Meniere's disease, as it is commonly called. It is a rare affection, in which the irritation is sent to the surface of the brain from chronic affection of the filaments of the auditory nerve, and connected with serious disease of the middle and internal ear. In some cases these attacks assume almost the appearance of epileptic seizures.

Dizziness is frequently associated with brain tumor, where there is pressure on the surface of the brain due to the development of the growth. The other symptoms of cerebral tumor are pain, sometimes intense and local, sometimes more diffused; local palsy of some nerve trunk coming from the brain; optic neuritis, from extension of irritation along the sheath of the nerve, and, finally, strangulation of the nerve, causing its atrophy; of course with this there is impairment of vision, convulsions from irritation of the brain cortex, and these are often more marked on one side of the body than on the other, and sometimes there is loss of consciousness. Occasionally there is irritation of the pneumogastric nerve giving rise to hiccough and vomiting. It is unnecessary to say that a local meningitis with marked thickening of the membranes, whether syphilitic or simple, would give rise to much the same symptoms as a brain

tumor.

In the present case, the symptoms point to a circumscribed meningeal thickening or to a small intra-cranial growth. There is no apparent cause for this. The pain is scarcely as severe as in tumor, and I am inclined to at

HOPITAL FRANCAIS A LONDRES.
OBSCURE CASE OF CHRONIC RENAL DISEASE;

CASE OF PYÆMIA FOLLOWING REMOVAL OF
LIPOMA; CASE OF HÆMATURIA IN A MAN,
FOLLOWED BY SUPPURATION.

UNDER DR. VINTRAS. [Reported by ALFRED S. GUBB, L.R.C.P., M.R.C.S., Resident Medical Officer.]

ISA

SAAC C-, Russian, æt. 24. Cane worker. Has been sixteen months in England. Was quite well until six or seven months ago, since when he has gradually lost his appetite, and ultimately became unable to follow his employment. He has lost flesh a good deal, and suffers from indigestion, with nausea, and frequently vomiting after food. The vomiting, however, does not relieve the nausea. Patient is much emaciated and walks with difficulty, owing to a want of power in the legs. A fortnight ago he noticed for the first time pains in his hands and feet on attempting to work; these pains are absent except on attempting movement, and are not at any time really violent. There is no redness, swelling, or tenderness of the joints complained of, and there is no pains in the shoulders or hips. Patient complains a good deal of insomnia, but says he does not dream and does not suffer from headache.

He has never been ill until now, and never had syphilis. Has always been a sober man; smokes, but not in excess. His father died of heart disease, his mother is still alive; no consumption in family. His tongue is coated with a thin layer of white fur, and is tremulous, and his skin is dry and scaly. Says he had pains in his stomach some days ago, but has none now. Bowels regular. Pulse 80; regular. Heart and lungs normal.

No swell

ing of ankles nor around the eyes. Complexion the latter was contracted into a cyst, the only kidney substance remaining being a piece about the size of a hazel-nut at the lower end; the ureters were markedly dilated and hypertrophied. The walls of the bladder were also hypertrophied. No trace of urethral stricture could be discovered. There was no evidence of disease in the chest or abdomen.

pale and sallow. There is a peculiar tremor on extending the arm or leg, increased on voluntary movement; the tremor is coarse, and is not present when in repose. The patellar reflexes are exaggerated, and there is marked ankle clonus. Sensation appears normal. Patient says that he has no visual troubles. On oph thalmoscopic examination the fundus in both eyes is seen to be normal, but patient while being examined had an attack with some loss of consciousness and slight convulsive movements. He readily came round on being shaken and spoken to. The urine is normal in quantity and is pale in color-sp. g. 1015. Soon after admission he had suppression of urine for thirty hours, followed by an abundant emission of pale, limpid urine, in which a minute trace of albumen was present. None was found either before or after this occasion in other specimens of urine. His temperature was normal or slightly sub-normal. Patient gradually became thinner and weaker until he kept altogether in bed. He generally vomited his meals, no matter what was the nature of the food, and this occurred even when the patient was put exclusively on milk. Pre digestion of his food by means of Fairchild's pancreatic powders. seemed to relieve this symptom for a day or two, but it soon returned. The feeling of nausea was so great that the patient could with difficulty be induced to take adequate nourishment, which was now given cold and in small quantities, frequently repeated.

At the end of two months in the hospital, being dissatisfied with the progress of his case, he left, but was readmitted ten days later much the worse to all appearances, and was somewhat feverish, and after lingering on for another month, getting progressively more emaciated from inability to retain any food, but pre serving his intelligence unimpaired, he died from sheer exhaustion.

Autopsy. Rigor mortis well marked. Brain weighed forty-four ounces, and its substance was firm and normal to the naked eye examination. Cord removed; substance firm. Heart eight and one-quarter ounces, normal; valves healthy. Pancreas three and three-quarter ounces, normal. Liver forty-nine and onequarter ounces, normal appearance on section. Kidneys, right, three and one-quarter ounces, small, red, and granular, cortex in diminished capsule adherent; left, one and one-half ounce,

Case of Pyamia following Removal of Lipoma.—André S—, æt. 70, messenger, attended at the outpatient department of this hospital, with reference to a lump the size of a man's fist, situated on the outer aspect of the upper third of the left thigh, which lump, although not the seat of any pain or morbid feeling of any kind, inconvenienced him on account of the rubbing of the trousers thereon. The patient was apparently a hale and hearty old man, a Russian by birth, sparely built, but in good health. There was no history of any illness or indisposition for years past. The tumor was elastic, did not involve the skin, and was freely movable beneath it and on the subjacent structures. Patient was informed that the growth could be removed if he thought the inconvenience he experienced was such as to render its removal desirable.

Some days later he returned and requested that this should be done, and he was accordingly admitted to a surgical ward for that purpose.

The operation was commenced under antiseptic precautions (chloroform being given as an anæsthetic), and through an incision six inches long the tumor was exposed and carefully dissected away. During the proceedings a hitch occurred in the antiseptic arrangements, owing to a sudden stoppage in the spray apparatus, and some delay occurred before this was remedied. The wound was cleansed, and one or two ligatures having been applied to small vessels, the edges were brought together by means of seven sutures of carbolized catgut, and the usual antiseptic dressing applied. The tumor was an ordinary fatty growth, and was removed without difficulty. The patient was very unwell after the chloroform, and was thirsty and feverish. The next morning his temperature was over 102° Fahr., and his tongue was dry. There was a great tendency to somnolence, and when awake patient expressed great anxiety as to his condition. He was given sulphate of quinia every four hours, and was put on a nourishing, easily assimilable dietary. It became necessary to replace the

dressing on the second day after the operation, and this was carefully done under antiseptic precautions. The wound looked healthy, and seemed inclined to heal by first intention.

On the third day the patient's temperature was 103° Fahr., at 8 A.M., and his articulation was defective. The thirst and mental anxiety were both more marked, and the tongue was covered with brown fur and was tremulous; sordes on the mouth and lips. Pulse regular, full, and bounding-100. The dressing was removed, and the wound was found partly open, the ligatures having broken away towards the lower end of the wound. It was dry and the edges were everted. An angry red blush surrounded it, and this extended several inches inwards and upwards over the abdomen.

The antiseptic dressing was abandoned, and the wound was powdered freely with oxide of bismuth, and a simple compress and bandage applied. Nothing abnornal could be detected in the heart or lungs, and the patient complained of nothing more than a general feeling of malaise. The quinia was increased to five grains every four hours, and the patient was ordered half an ounce of brandy every two hours. A distinct trace of albumen was present in his urine, which was scanty and high-colored. There were profuse sweats at irregular intervals, with slight incoherence in speech, scarcely, however, amounting to delirium. A very nauseous odor emanated from the patient and polluted the ward, which was promptly cleared of all the other patients.

sweat.

On the fifth day the patient had a severe and prolonged rigor, and his temperature rose to 104° Fahr., and this was followed by a profuse The wound was now seen to be widely gaping, dry, and with a more marked eversion of the edges. The zone of redness had increased in extent, and patient complained of tenderness and pain over the left iliac fossa, where the skin was reddened and oedematous. The same dressing was applied; slight congestion at the bases of both lungs.

On the seventh day the same state of things existed, the patient's temperature oscillating between 100 and 103° Fahr. The skin over the left iliac fossa had sloughed and left a wound as large as the palm of the hand, scantily moistened by a small quantity of putrid odorous pus. Patient's condition is very low, and it is only with difficulty that he can be induced to reply to questions. He complained,

however, of the calf of the right leg, which was red and brawny.

Patient lingered on for three days, and then became quite comatose. He died on the tenth day after the operation.

At the autopsy the right calf and left thigh. were found infiltrated with pus on deep incision, as also in the right wrist. The lungs were heavy, and exuded a reddish fluid on being squeezed. The kidneys were found to be extensively degenerated and atrophied, scarcely any cortex remaining, while the capsule was strongly adherent. Numerous small cysts studded the organ.

Case of Hæmaturia in a Man, followed by Suppuration.-Alfred B, æt. 24, laborer, a thin, but hitherto healthy man, attended a neighboring fair on the 20th of September, and, contrary to his custom, indulged in several glasses of gin and water. He was subsequently carried home by his companions in a state of alcoholic insensibility and put to bed. Early next morning he awoke with an urgent desire to make water, which he found himself quite unable to do. His suffering, however, was such that he sent for me, and I immediately passed a gum elastic catheter, a No. 7, when about a pint of bright red liquid was evacuated. He was much relieved, but complained of a lancinating pain in the hypogastrium, which was tender on pressure. He had no pain in the back, but was feverish and thirsty. His abdominal muscles were contracted, and his tongue was furred and somewhat dry. I was urgently summoned a few hours later to relieve the same train of symptoms, and drew off about half a pint of the same red liquid. His temperature was now 103.5° Fahr., and his tongue was dry and covered with brown fur; sordes had formed, too, on his teeth. He was ordered turpentine stupes to hypogastrium, demulcent drinks, and a mixture of nitrate of potash and ergot. On drawing off the urine the next morning, the urine was of a natural color, but contained an appreciable quantity of albumen. Later in the day the red color had returned, and, examined microscopically, numerous blood-corpuscles were visible. Its smell was most offensive. His general condition was now very grave, the fever persisted, and he complained of great abdominal tenderness and thirst. Pulse rapid and wiry. Profuse sweating towards evening. No delirium. Pupils dilated and responded to . light as usual. This condition improved about

the fourth day; the fever dropped, and he was able to pass part of his urine unaided, but it was still very dark in color, and, when allowed to stand, formed an abundant red sediment and had an exceedingly offensive odor. The abdominal tenderness, too, diminished, and the appetite returned.

He stated that he had never suffered before from anything of a similar nature, and had always been healthy, but said his father had died a few months since from "inflammation of the kidneys" of short duration, and his brother also suffered in his water." No history of

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[Reported by W. W.]

ENTLEMEN: Our first patient this afternoon is thirty years old; married; has had one child, or rather a premature labor at about the seventh month; menstruated first at fourteen years, and was in fair health, except that the menstrual flow was scanty and irregular. After marriage the nervous symptoms grew more and more aggravated at each epoch until pregnancy, after which her health became better and remained so until the accident which resulted in the miscarriage. Succeeding her confinement she got up slowly, and seemingly felt quite well for a while, but at the return of menstruation the old symptoms recurred, and have been growing more and more aggravated ever since. As the time approaches for the menstrual flow she becomes irritable, dazed, and absent-minded, and at times consciousness is entirely lost, and she is unable to give any account of herself; the severity of the symptoms being inversely in proportion to the amount of the flow.

who was in the clinic last spring with a similar class of symptoms, save that she had never been pregnant. In that case the patient was picked up during one of her paroxysms and convicted of insanity, and actually placed in the asylum, where the nature of the case was recognized, and she was immediately released and sent here. I found a uterus undeveloped, almost infantile, stenosis of the internal os, and general congestion of the pelvic tissues. The cervix was dilated with a tupelo tent, and the insanity disappeared as if by magic. Now, that is just what we propose to do in this case. This patient, however, has been pregnant; still I find a severe stenosis, which, unquestionably, is cicatricial in its nature. In addition, I find an anteflexion due to incomplete involution after confinement. This partial subinvolution is due, in this case, to the injury to the cervix at the time of parturition, and the cicatricial stenosis is due to the same cause. This woman has been living in wedlock eight years since the confinement referred to, and has been barren. Now, if we can stimulate a healthy action in these pelvic organs, relieve the stenosis by proper dilatation, we may increase the menstrual discharge, relieve her sterility, and cure her insanity.

She came into the hospital this morning, and I introduced a tent, after making an incision, to partially enlarge the canal of the cervix, and now I will remove that tent before the class; the patient will be kept in bed a few days, and we will report the progress of the case to you at some clinic in the near future.

Laceration of the Cervix.-This patient is being etherized for the purpose of an operation. She is twenty-six years of age; married; has had three children; the second was a forceps delivery. After that confinement her recovery was very slow, and from that time she dates her ill health. Her appetite is poor, and her bowels constipated; she suffers from vertigo, palpitation of the heart, severe headaches, pain in the back, and extreme languor. Menstruation regular every four weeks, profuse in amount, lasting from seven to thirteen days, with an occasional inter-menstrual hemorrhage. The cervix is deeply lacerated, bilaterally; the surface excoriated, bleeding on touch, and covered with a thick, tenacious muco-purulent discharge. The uterus is large, heavy, and lies low in the pelvis, and a free hemorrhage follows the intro

Some of the class will remember a patient duction of the sound.

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