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 THE LIBRARIES 
 
 COLUMBIA UNIVERSITY 
 
 Medical Library 
 
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Royal Infirmary Cliniques. 
 
Royal Infirmary 
 
 Cliniques. 
 
 BY 
 
 ALEXANDER JAMES, M.D., F.R.C.P.E., 
 
 PHYSICIAN TO THE ROYAL INFIRMARY, EDINBURGH. 
 
 EDINBURGH : 
 OLIVER AND BOYD, TWEEDDALE COURT. 
 
 LONDON: SIMPKIN, MARSHALL, HAMILTON, KENT, AND CO., LIMITED, 
 
 1896. 
 

 PRINTED BY OLIVER AND BOYD, EDINBURGH. 
 
PREFATORY NOTE. 
 
 I HAVE long held the opinion that note-taking during 
 Clinical Lectures has certain disadvantages associated with 
 it, and it has been my custom, since I obtained Wards in 
 the Edinburgh Eoyal Infirmary, to publish the various 
 Clinical Lectures which it has been my duty to deliver. 
 I am thus aware that most of these Lectures are already 
 within the reach of those for whom they were intended, — 
 namely, the students of the Class of Clinical Medicine. 
 As, however, it is possible that some of them have been 
 published in journals to which the students have not been 
 able readily to gain access, I have thought it best to bring 
 them together in this form. 
 
 To the students of the Clinical Medicine Class I have 
 now much pleasure in dedicating this volume, in the hope 
 that they may find its perusal of some value, and as a 
 token of gratitude to them for their valuable assistance in 
 obtaining the material out of which the various lectures 
 were composed. 
 
 ALEX. JAMES, M.D. 
 
 10 Melville Crescent, 
 June 1896. 
 
Digitized by tine Internet Arciiive 
 
 in 2010 witii funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/royalinfirmaryclOOjame 
 
CONTENTS. 
 
 PAGE 
 
 1. Two Cases of Empyema, ..... 1 
 
 2. Pulsating Empyema, . . . . .10 
 
 3. Case of Fibroid Phthisis, with Great Displacement of 
 
 THE Heart, ...... 22 
 
 4. Case of Kenal and Cardiac Disease ; with special 
 
 reference to the diurnal and nocturnal 
 Excretion of Urine, . . . .32 
 
 5. Case of Primary Contracting Kidney, . . .43 
 
 6. Case of Hydronephrosis Treated by Aspiration, . 57 
 
 7. Diabetes Mellitus, ...... 63 
 
 8. Two Cases of Liver Cirrhosis in Children, . . 80 
 fd. JZJase of Dysentery Treated by Deemetinised Ipecacu- 
 anha, ....... 90 
 
 10. Aortic Aneurism ; with special reference to Sensitive 
 
 Areas on the Skin, . . . .95 
 
 11. Case of Epilepsy Presenting some Peculiar Features, 104 
 
 12. Case of Spinal Injury, . . . . .117 
 
 13. Case of Friedreich's Ataxy, . . . .128 
 
 14. Case of Combined Paralysis op the Nerves of the 
 
 Arm due to Injury, .... 138 
 
 15. Case of Pons Lesion, ..... 145 
 
 16. Case of Addison's Disease, .... 156 
 
TWO CASES OF EMPYEMA. 
 
 Gentlemen, — We have had in our Ward examples of 
 empyema arising in a variety of ways. We have had it 
 following a sero-fibrinous effusion ; we have had examples 
 of it in which from the first the effusion seems to have been 
 purulent; and we have had examples of it resulting from 
 suppurative processes beneath the diaphragm. But we have 
 had lately two examples of it occurring in a way in which 
 it very often seems to occur, viz., associated with pneumonia, 
 and to these I propose now to direct your attention. 
 
 The first is that of a man, Noah P., aged 56, a commercial 
 traveller of Portuguese nationality, who was admitted to 
 Ward .30, February 24, 1894, complaining of pain in the 
 right side of his chest, of shortness of breath and great 
 weakness, and stating that he had been ill six days. 
 
 Family History. — His mother died of consumption, and 
 his father is also dead ; but he has twelve brothers and sisters, 
 all living and in good health, as far as he knows. 
 
 Personal History. — States he has always enjoyed good 
 health. He travels about a good deal in his occupation, and 
 so is exposed to all kinds of weather, but has always had 
 good food and been well lodged. Up till a year ago he seems 
 to have been a little inclined to alcoholic excess, but for the 
 last year has been teetotal. He gives no history of any 
 specific disease, or indeed of any previous serious illness. 
 
 Present Illness. — He states that six days before his admis- 
 sion he was feeling quite well. He had been indoors two 
 
2 TWO CASES OF EMPYEMA. 
 
 days because of the bad weatber ; but in the evening he had 
 gone out for a walk, and on returning to his hotel he had 
 felt very ill and had a severe shivering. He had then and 
 for the following two or three days no great cough and no 
 spit, but he felt a sharp pain in the right side of his chest 
 when he drew a breath. On the fourth day of this illness 
 he felt a little better, so that he ventured out for an hour or 
 two, but on that same evening he felt distinctly worse, — the 
 pain in the right side of the chest was very severe and was 
 also felt in the abdomen. He had also a cough and was very 
 feverish, so that he went to bed. Feeling himself getting 
 worse and worse, he two days afterwards called in a doctor, 
 who sent him to tlie Infirmary as suffering from pneumonia. 
 
 State on Admission. — Patient is a tall man, rather slightly 
 built. Is evidently suffering from great pain in breathing. 
 He is sweating profusely, and his face is rather cyanosed. 
 His temperature is 100° F., his pulse is 104, respirations 32. 
 
 Respiratory System. — He complains of pain in the right 
 side of his chest, as of a pin sticking into him and stopping 
 his breathing, which is consequently shallow. 
 
 Physical examination of the lungs revealed over the right 
 upper lobe anteriorly a tympanitic percussion note with 
 harsh breathing and prolonged expiration. Over the right 
 lower lobe posteriorly there w^as marked dulness of the 
 percussion note, with somewhat faint bronchial breathing 
 and a few crepitations. The vocal fremitus was noted to be 
 very slightly marked, and the vocal resonance, though clear, 
 was not loud. The expectoration was scanty, viscid, and 
 rust coloured, and films of it stained showed the pneumo- 
 coccus. 
 
 Circulatory System. — The pulse is about 104 per minute, 
 and shows a tendency to irregularity as regards time and 
 force of beat. It is rather soft and compressible, but the 
 arterial walls are healthy considering the patient's age. The 
 heart is in its normal position. Its sounds are rather weak. 
 
TWO CASES OF EMPYEMA. 6 
 
 but there is slight accentuation of the pulmonary second 
 sound. 
 
 Digestive System. — The tongue is thickly furred. His 
 appetite is gone, and there is great thirst. With the excep- 
 tion of evidence of slight splenic enlargement the abdominal 
 viscera were found normal. 
 
 Urinary System. — The urine, about 40 ounces in the 
 twenty-four hours, was rather high-coloured and slightly 
 turbid. It contained a trace of albumen, but no blood and 
 no sugar. There was slight diminution in the chlorides. 
 
 As regards the Integumentary System, it was noted that he 
 sweated a great deal, especially on the head and chest ; and as 
 regards the Nervous System, it was noted that he was anxious 
 and restless, and slept very little. He was treated by rest 
 in bed, hot fomentations to the right side to relieve the pain, 
 milk and beef-tea at short intervals, and for the condition 
 of the heart, ammonia, strophanthus, and strychnine were 
 administered at intervals. 
 
 His condition remained the same during the day after his 
 admission, but on the second and third days, as a reference to 
 the Chart will show, indications of some improvement were 
 manifested. He stated that he felt better ; his temperature 
 and pulse-rate were lower, his cough was less painful, and 
 the sputum more abundant, frothy, and muco-purulent. Still, 
 his pulse was weak and tending to irregularity, and he looked 
 ill, and the physical signs presented by his chest remained 
 very much the same. In this state he remained until the 
 6th of March, when it was noticed that his temperature 
 began to show oscillations. These oscillations continued and 
 became more marked until the 9th of March, when the 
 following was the note of his condition : — " Very slight 
 improvement is manifested. The pain in the side is still 
 present, but less than formerly; the pulse is still weak and 
 tending to irregularity; the temperature rises at night, and 
 with tlie fall in the morning temperature tliere is great 
 
4 TWO CASES OF EMPYEMA. 
 
 sweating. On examination of the chest, there is lessened 
 vocal fremitus and faint tubular breathing over the right 
 lower lobe, with a percussion note so absolutely dull as to 
 suggest fluid, especially over an area slightly outside the 
 inferior angle of the right scapula. Into this area a hypo- 
 dermic needle was inserted, and some thin pus was found, 
 which on staining revealed numerous pneumococci." 
 
 Now, gentlemen, we have in this case, I believe, an 
 example of an empyema developing in a way in which it 
 very often develops, — that is to say, associated with a 
 pneumonia. In our patient we had, as you will have noted, 
 a distinct history of a pneumonia. He had the initial rigor 
 six days before his admission ; he had the fever, pain in the 
 side, cough, and later on the rusty, viscid spit containing the 
 pneumococcus, the dyspnoea, the sweats, the slight albu- 
 minuria, and the other characteristic symptoms of the 
 disease. Then he had a fairly marked crisis about the 
 eighth day, as shown by the temperature chart, and corre- 
 sponding with the fall in the temperature he described 
 himself as feeling somewhat better. 
 
 But the question will occur to you — Was this a pure 
 croupous pneumonia, and did the empyema develop upon it 
 after the crisis, or was it from the first a pleuro-pneumonia ? 
 
 ISTow here you will remember that every croupous 
 pneumonia in which the inflammation has extended to 
 'the surface of the lung has associated with it a certain 
 amount of pleurisy, but ordinarily such a pleurisy is accom- 
 panied by little or no fluid exudation. That this should be 
 so you can easily understand when you remember that when 
 a lower lobe is in a state of pneumonic consolidation there 
 cannot be much space for fluid in the pleural cavity. But 
 in our patient we believe that there has been a pleuro- 
 pneumonia — i.e., that there has been a croupous pneumonia of 
 a part of the lower lobe of the right lung, and that an 
 associated pleurisy had occurred and resulted in an effusion 
 
TEMPERATURE 
 CENTIGRADE SCALE 
 
TWO CASES OF EMPYEMA. O 
 
 which had caused collapse of the remainder. That the 
 pneumonia had been a pleuro-pneumonia was indicated, in 
 the first place, by the physical signs. You will remember 
 that over the dull lower lobe the vocal fremitus, though 
 present, was not increased, as is usual in pneumonia ; indeed, 
 it was rather less marked than might have been expected, 
 even with a healthy lung. Further, the tubular breathing 
 sounded somewhat faint and distant, and the vocal resonance, 
 though clear, was not intensified. 
 
 On the day on which the case was read (February 28) 
 those peculiarities in the physical signs were noted, and 
 whilst we contemplated the possibility of the presence of 
 fluid, we remembered that such a condition might be the 
 result of a blocking of some of the bronchial tubes with 
 secretion. But, in the second place, the symptoms indicated 
 a pleuro-pneumonia rather than a typical croupous pneumonia. 
 Although the disease had begun with a rigor, and it showed 
 a crisis on the eighth day, the crisis was not a complete 
 one. Although the temperature fell below 99° F., and 
 the pulse became slower, yet the patient was not well. He 
 had still chest pain, and his pulse was weak and intermittent, 
 so that strychnia, strophanthus, etc., had to be given. Now 
 all this indicated that there was something more than an 
 ordinary croupous pneumonia. And when about a week 
 after the crisis the temperature chart began to show oscilla- 
 tions, we suspected empyema, and this was verified, as stated, 
 on the 9th March by an exploratory puncture. 
 
 But now, granting that this had been a pleuro-pneumonia 
 terminating in an empyema, do we know if the pleuritic 
 fluid was purulent from the first ? Or if the pleuritic fluid 
 was not purulent from the first, can we say when it became 
 so ? These questions I cannot answer. I can say that in 
 similar cases I have explored the chest with a hypodermic 
 syringe, and obtained sero-fibrinous fluid, and a week or so 
 afterwards I have punctured again and found pus. I can 
 
6 TWO CASES OF EMPYEMA. 
 
 say also that the oscillations of the temperature chart and 
 the sweatings, so very characteristic of the presence of pus, 
 seem to indicate resorption from a purulent collection, not 
 a formation of pus. 
 
 The diagnosis having been made, the treatment was a 
 simple matter. On the 10th March, chloroform being 
 given and all antiseptic precautions observed, I made an 
 incision into the right side below, and slightly external to the 
 angle of the scapula, and let out 19 ounces of rather thin pus. 
 An ordinary drainage-tube was inserted and dressings applied. 
 After the operation there was very little sickness, and the 
 patient expressed himself as much easier. On the day after 
 the operation it was noted that the pulse was still weak and 
 that the patient sweated a good deal, but that the temperature 
 was down to normal. Kapid improvement set in from the 
 second day after the operation, the temperature remained 
 normal, the pulse improved in rate, strength, and regularity, 
 the cough disappeared, the appetite improved, and the patient 
 gained in strength. On the 22nd of March the drainage-tube 
 was taken out, the discharge having ceased, and on the 23rd 
 March (thirteen days after the operation) the patient got out 
 of bed. On the 9th April the patient was discharged, 
 recovered. The wound was healed, and there was only some 
 slight dulness at the base of the right lung to be detected. 
 All this will doubtless clear up in the course of a few weeks. 
 
 The next case to which I wish to direct your attention is 
 that of the boy J. C, aged 7 years, who was admitted to 
 Ward 30 on April 16, 1894 
 
 We were told that he had been ill some five weeks, his 
 illness having begun suddenly with fever and cough. Dr 
 Macnab, who had recommended his admission, in writing me 
 about him, stated — " I never at any period of his illness 
 detected with certainty an effusion ; all that I made out was 
 a very distinct patch of pneumonia immediately in front of 
 
TWO CASES OF EMPYEMA. 7 
 
 his left scapula, wliicli was a very considerable time in clearing 
 up ; perhaps it may not be entirely gone yet." (Six weeks 
 after) : " He had little cough during the day ; at no time 
 anything like distinct pneumonic spit." Dr Macnab farther 
 stated his suspicions of an empyema having occurred. 
 
 On admission we found the child pale and weakly-looking, 
 with a very frequent and irritating cough. There was 
 absolutely no expectoration, — but this, we had little difficulty 
 in recognising, was simply because what should have been 
 expectorated was swallowed. His pulse was rapid and 
 feeble, but his temperature, though it showed some oscilla- 
 tions, was mostly subnormal. On examination of the chest 
 we found at the left apex anteriorly a slight impairment 
 of the percussion note, with harsh breathing and a few 
 crepitations, and over the left lung posteriorly we found 
 percussion impairment in the supra-spinous and upper inter- 
 scapular regions, with prolonged expiration, harsh breathing, 
 and some crepitation. At the base of the left lung, however, 
 we found the percussion note more distinctly impaired, and 
 the breath-sounds and vocal fremitus somewhat faint. 
 
 This was practically all that we could make out of the 
 case, and the idea which first entered my mind to explain 
 the condition was that there had been tubercular mischief 
 at the left apex of some standing, and that some six weeks 
 before, a basal pneumonia and pleurisy had occurred. In 
 this connexion we had to regret that owing to the facts of 
 the patient being too young to give any account of himself, 
 and of his friends all residing in the country, we could not at 
 the time ascertain whether the patient had had any symptoms 
 of phthisis, cough, fever, night-sweats, etc., previously to his 
 recent acute illness. Further, we could not get a specimen 
 of spit to examine. The nurse exercised all her powers of 
 persuasion to get the little patient to spit into the spittoon, 
 but to no purpose. 
 
 I have now no doubt that had we succeeded in ffettinsj the 
 
8 TWO CASES OF EMPYEMA. 
 
 spit at that time, we should have made our diagnosis much 
 earlier than we did, — for instead of the muco-purulent 
 phthisical spit showing the tubercle bacilli, we should, 
 I believe, have obtained the diffluent purulent spit char- 
 acteristic of an empyema which is emptying itself, or 
 attempting to do so, through the bronchi. 
 
 Partly because we contemplated the possibility of the 
 lung mischief being tubercular, partly because the tempera- 
 ture continued a subnormal one, and partly because we 
 continued to hope that we might yet get a specimen of the 
 spit for examination, we, for nearly two weeks after his 
 admission, limited our efforts to the endeavour to improve 
 his general health. We gave him nourishing food at short 
 intervals, with a teaspoonful of the Vin Nourry twice a day. 
 During this time, however, absolutely no improvement showed 
 itself ; indeed, we did not fail to notice that his general con- 
 dition and cough were becoming distinctly worse. On April 
 29 (thirteen days after his admission) it was noted that his 
 temperature, hitherto subnormal, had begun to rise at night, 
 and that the percussion note at the base of the left lung 
 continued very dull. Further, that at a point near the angle 
 of the left scapula the percussion note was specially " dead," 
 and distinctly suggestive of the presence of fluid. I there- 
 fore made an exploratory puncture there, and finding pus, I 
 next day, with all antiseptic precautions, incised the chest, 
 evacuated 6 ozs. of pus, and inserted a drainage-tube. 
 
 The child's progress towards recovery was practically 
 uninterrupted. The temperature and pulse-rate returned 
 to normal, the irritating cough ceased, and the appetite, 
 digestion, and general condition improved. By the middle 
 of May the tube was removed and the patient was out of 
 bed, and on June 2 he was discharged, recovered. 
 
 These two cases seem to me good examples of empyema 
 associated with or following pneumonia. The first case was, 
 from the diagnostic point of view, perfectly simple, but the 
 
TWO CASES OF EMPYEMA. 9 
 
 second was rather confusing. In it the physical signs were 
 not at all distinctive, and the consideration of the temperature 
 chart rather misled than helped us for a time. I believe 
 that these anomalies, as regards physical signs and tempera- 
 ture, were mainly the result of the fact that the purulent 
 collection was to some extent finding its way out through 
 the bronchi. The quantity of pus in the chest was thus 
 comparatively small, and the lung was adherent round about, 
 so that vocal fremitus and breath-sounds were never absent. 
 Further, there was for a time no resorption fever, which 
 would have indicated on the temperature chart the presence 
 of pus. Had the condition been in an adult, so that we 
 might have been able to get the spit, we should probably 
 have recognised it earlier. As already mentioned, in such 
 cases the spit is purely purulent, and it runs together in the 
 spittoon, — that is to say, the individual spits cannot be seen. 
 
 An important point, however, which all this brings out 
 prominently, is that exploratory puncture is the only sure 
 way of recognising empyema. I have said exploratory punc- 
 ture — I should rather have said repeated exploratory punc- 
 tures — for in cases of small localized empyemas it often 
 happens that one does not strike the pus until after several 
 attempts. For such punctures I am in the habit of using a 
 rather large-sized needle, with at least one side opening, so 
 that if the point goes through into the lung, the pus will 
 still be drawn out by the side opening. You may ask, Does 
 exploratory puncture ever do harm ? To this I would answer, 
 that I have never seen any harm result from it, but that I 
 have often seen great harm result from its neglect. 
 
PULSATING EMPYEMA. 
 
 Gentlemen, — I propose to bring before you to-day a case 
 of pulsating empyema, and in connexion with it to discuss 
 with you in some detail the cause of the pulsation. 
 
 T. E., aged 26, a brewer's clerk, was admitted to Ward 
 30 on January 15, 1895, complaining of pain over the 
 heart, with swelling in the same region, and a cough. His 
 father died at the age of 32 of heart disease. He had 
 one brother who died at the age of 18 of heart disease, 
 and a sister who is delicate and suffers from a cough. 
 His mother, another brother, and two sisters are alive and 
 healthy. The patient had measles when a child. Eight 
 years ago he had to give up his occupation as pupil-teacher 
 owing to nervous strain. He has had no accidents nor other 
 ilhiesses until the present one. 
 
 His present illness seems to have commenced in July 
 1894. He then caught cold, and he noticed that on taking 
 a deep breath or sneezing he felt a pain over the region of 
 his heart. He still, however, continued at his work, and he 
 expressly states that he had no cough and no night-sweats. 
 About the 5th or 6th of January, however, he seems to have 
 again caught cold. A cough then commenced, which has 
 continued and which has been accompanied by a severe 
 pain over the heart. A few days after he caught this cold 
 he noticed a swelling over his heart. This and the cough 
 and weakness, with shortness of breath on exertion, led him 
 to consult a doctor, who recommended his coming to the 
 Infirmary. 
 
PULSATING EMPYEMA. 11 
 
 State 0)1 Admission. — Patient is about 5 feet 6 inches in 
 height, aad weighs 110|- pounds. He says he has been 
 losing flesh lately. His temperature varies between 97° 
 and 99°; his pulse is usually about 80 per minute. 
 
 Over the praecordia a pulsating expansile swelling is seen. 
 It is somewhat difl'use, and in extent is about 4 inches in 
 diameter, its centre being between the fourth and fifth ribs. 
 On palpation, its expansile character is better recognised. 
 It can be somewhat reduced by steady pressure, and when 
 the patient coughs it can be felt markedly to increase 
 in size. There is pain when its centre between tlie fourth 
 and fifth ribs is pressed upon. Over the swelling, and 
 over the lower half of the sternum, there is some slight 
 cedema. 
 
 Percussion gives complete dulness over the whole of this 
 swollen area, and over the entire upper lobe of the left 
 lung in front there is a markedly impaired note. Over the 
 lower and lateral portion of this lung the percussion note 
 is, however, resonant. Posteriorly there is impairment on 
 percussion, from the apex down to nearly the angle of the 
 left scapula. Over those parts of the lung which are dull 
 to percussion, auscultation reveals weak bronchial breathing. 
 At the apex of the left side, anteriorly and posteriorly, a few 
 crepitations can be heard. Over the lower part of the left 
 lung, and over the whole of the right lung, the breath-sounds 
 are vesicular in character; over the right lung they are, in 
 addition, exaggerated. Over the swelling in the preecordia, 
 and the neighbouring portions of the left upper lobe in 
 front, vocal fremitus is absent. Over the rest of the left 
 lung it can be detected. 
 
 The precise position of the heart cannot be made out 
 exactly by percussion, but it seems to be displaced to some 
 extent to the right. With the exception of a somewhat 
 reduplicated first sound, its sounds are normal. 
 
 The other systems and organs are healthy. 
 
12 PULSATING EMPYEMA. 
 
 In making a diagnosis in this case, several possibilities 
 entered our minds. There was, in the first place, the possi- 
 bility of aneurism, which, indeed, we were informed, had 
 been suspected piior to his admission. But we remembered 
 that our patient gave a history of lung trouble ; that the 
 pulsating tumour had shown itself suddenly, and had rapidly 
 reached its present stage. We noted, further, that the pul- 
 sating swelling was not in the position usual in cases of 
 aneurism ; that there was no evidence of cardiac or vas- 
 cular disease, and that there were no pressure symptoms of 
 aneurism. Finally, we had no hesitation in making an 
 exploratory puncture with a hypodermic syringe, and we 
 readily ascertained the presence of pus. Next we thought 
 of the possibility of suppuration from a diseased rib or from 
 mediastinal abscess. As regards the former supposition, we 
 remembered that in such cases the pus is more apt to come 
 outward than to extend into the pleural cavity ; whilst as 
 regards the latter supposition, — viz., mediastinal abscess, — 
 we remembered that such a condition would not likely cause 
 such an extensive area of dulness over the upper part of the 
 left lung as was present in this case. Then we naturally 
 thought of pulsating empyema, and we noted that in some 
 ways the symptoms and physical signs seemed to indicate, 
 and in other ways to contraindicate this. As regards 
 symptoms, there had been no marked cough, and there was 
 practically no fever, hectic, nor sweatings, such as one 
 expects to find in empyema. But, on the other hand, these 
 symptoms are often absent, and we remembered that in 
 pulsating empyemas the symptoms are apt to be latent in a 
 special degree. Then, as regards physical signs, we found 
 that the empyema, if it were such, was limited to the upper 
 part of the left lung, and this, of course, we recognised a-s 
 very unusual. But, taking into consideration the history of 
 lung-trouble of some months' duration, and the fact that 
 there was evidently apical disease, as betokened by the 
 
PULSATING EMPYEMA. 13 
 
 crepitation and other physical signs, we came to the con- 
 clusion — (1) that our patient had been suffering for at least 
 several months from tubercular disease of the left apex ; 
 (2) that this had resulted in pleuritic adhesions over various 
 parts of the left upper lobe ; (3) that over a portion of this 
 lobe anteriorly, where adhesions had not formed, a purulent 
 pleurisy had started ; (4) that the pus from this, prevented 
 from gravitating to the lower part of the pleural cavity by 
 adhesions, had collected in the upper part, and had found 
 its way outward between the fourth and fifth ribs, thus 
 forming the pulsating swelling over the prsecordia. This 
 being our diagnosis, the treatment required was obvious. 
 The patient having been chloroformed, an incision was made 
 over and into the pulsating swelling. This abscess cavity 
 having been opened, the finger introduced through the 
 incision found a large opening of communication between it 
 and the empyema cavity. This was found to be lar^e 
 enough to contain some fourteen ounces of pus, and, as had 
 been diagnosed, to be limited to the upper part of the side. 
 In order to facilitate drainage, an opening was made into 
 this cavity between the fifth and sixth ribs in the anterior 
 axillary line, a small portion of rib resected, and an ordinary 
 drainage-tube inserted. With the removal of the pus it was 
 specially noticed that the heart, slightly displaced to the 
 right, showed no tendency to resume its normal position. 
 All antiseptic precautions weie, of course, observed at the 
 operation, and have been at the subsequent dressings. 
 
 The progress of this case I shall refer to later on ; in the 
 meantime I propose to go over with you in some detail 
 the subject of pulsating empyema. Of this, two forms are 
 to be recognised, — (1) pulsating intrapleural empyema, and 
 (2) pulsating empyema of necessity. In the former, all the 
 fluid is in the pleural cavity ; in the latter, a certain amount 
 of the fluid has, as in our patient, found its way outside of 
 the pleural cavity, and forms under the skin a pulsating 
 
14 PULSATING EMPYEMA. 
 
 tumour. In both cases the left is the side almost invariably 
 affected, and the effusion is usually at the lower part of the 
 chest, — not, as in our patient, localized in the upper portion. 
 
 Pulsating Intrapleural Empyema. — Observe, in the first 
 place, that all the pulsating intrapleural effusions which 
 have been reported have not been purulent. Several in- 
 stances of pulsating sero-fibrinous pleuritic collections have 
 been met with, and interesting examples of such have been 
 given, among others, by Douglas Powell and Comby. But 
 the great majority of these cases have been purulent from 
 the first, or have become so in the course of the disease. 
 Hence we are justified in speaking of them as pulsating 
 empyemas. Some of the earliest recorded cases of this are 
 those of MacdonelP and Stokes.^ Stokes's case is especially 
 interesting. He describes how, in a huge empyema, which 
 had powerfully pushed the heart to the right, he bad ob- 
 served pulsation of the entire sac. " Thoracocentesis was 
 performed three times, and each time a large quantity of 
 more and more purulent fluid was removed. Before each 
 operation the beats of the heart produced a diastolic (?) 
 pulsation of a most strange character, which made itself felt 
 in the left lateral portion of the chest and through the entire 
 thorax. The bed was shaken by each contraction of the 
 heart, tlie force of which seemed to be increased, — the violence 
 and extent of the pulsations were such that the sleep of the 
 patient was interrupted. The fluid had never any tendency 
 to find its way outside, and it is very remarkable that the 
 heart never left its position to the right of the sternum after 
 any of the emptyings of the chest." Other more or less 
 similar cases have been reported, the most complete collec- 
 tion of which I believe to be that given in Comby 's recent 
 work, VEmpyeme Pulsatile, to which I would refer you. 
 
 Pulsating Emi^yema of Necessity. — In this form, as already 
 
 ^ Dublin Journal of Medical Science, March 1844. 
 '^ Diseases of the Heart and Aorta. Dublin, 1854. 
 
PULSATING EMPYEMA.. 15 
 
 stated, the fluid lias found its way through the chest parietes, 
 and forms a subcutaneous tumour, pulsating and expansile, 
 at some part outside of the thoracic cavity. Like the 
 former variety, it is almost invariably in the left side of the 
 chest, and the fluid is usually at its lower part. Unlike the 
 former variety, however, the fluid is always purulent. This 
 can easily be understood when we remember that only 
 a purulent fluid can penetrate the chest-wall. Further, 
 the pleuritic process which has given rise to this effusion is 
 usually a chronic one. This we can understand when we 
 remember that time is required for the accomplishment of 
 the process of perforation. As regards the position of the 
 pulsating tumours, this is most frequently found, as in our 
 patient, to be about the prsecordial region, — that is to say, 
 on the left side, somewhere between the mid-sternal and 
 nipple lines. But just as an empyema may perforate the 
 chest-wall and point elsewhere., so the pulsating tumour may 
 be found elsewhere, — e.g., in the posterior or lateral parts of 
 the chest, or even in the lumbar region. These tumours 
 vary in size, they are usually, as in our patient, somewhere 
 about 4 inches in diameter, and the expansile character 
 of the pulsation can usually easily be recognised. The 
 respiratory act readily affects such tumours. As can be 
 understood, whilst inspiration is apt to cause a slight 
 diminution, expiration may cause a corresponding increase 
 in their size. The acts of coughing and sneezing are 
 specially apt to increase their bulk, and a change may also 
 be produced by the patient's sitting up or lying down. The 
 tumour may to some extent be reducible, and cases have 
 been reported where partial reduction by pressure and 
 manipulation caused a marked increase in the dyspnoea. It 
 is evident that to permit of the occurrence of these variations 
 in the size of the tumour, the opening of communication 
 between it and the intrapleural collection must be free. lu 
 our patient this opening readily admitted the finger. 
 
]6 PULSATING EMPYEMA. 
 
 But now, how is the occurrence of pulsating empyema 
 either with or without an extrapleural tumour to be ex- 
 plained ? It is evident, in the first place, that the condition 
 or conditions which give rise to this must be rare. Cases of 
 large pleuritic effusion and cases of empyema necessitatis 
 are not uncommon, and yet the pulsating character is very 
 rarely met with. What, then, is it wliich causes the 
 pulsation ? 
 
 On this subject a great many theories have been brought 
 forward, to some of which we may refer. Let me first quote 
 the following from Gueneau de Mussy, " Quand avec 
 I'dpancheraent se trouve, dans la cavite thoracique, un gaz 
 eminemment compressible ou une portion considerable du 
 poumon encore permeable a I'air, on comprend que la systole 
 ventriculaire puisse refouler le liquide contigu au pericarde 
 et lui communiquer un ebranlement ondulatoire qu'elle ne 
 pent pas produire quand elle agit sur une masse absolument 
 incompressible." 
 
 Fereol seems to have practically adopted this, and bases 
 his explanation of the occurrence of pulsation upon tlie 
 existence of an associated pneumothorax. But cases have 
 frequently occurred where there was no pneumothorax : our 
 patient is an example of such. 
 
 Traube seems to have believed that the pulsation depended 
 in some way on pericarditis and pericardial effusion, but 
 cases have occurred without these. Walshe ^ says of the 
 pulsation that it " seems to be merely an excess of the slight 
 fluctuation movement in the fluid which is not very un- 
 common in ordinary cases." Powell^ concludes that 
 " probably nothing more is needed than an amount of fluid 
 which shall exercise a certain degree of pressure, neither 
 too much nor too little, upon the beating heart." Many 
 other explanations have been proposed, for details of which I 
 
 ^ Diseases of the Lungs. London, 1871. 
 
 2 Diseases of the Lupc/s and Pleurce. London, 1886. 
 
PULSATING EMPYEMA. 17 
 
 would refer you to the works of Bouveret ^ and Comby,^ but, 
 as it seems to me that none of them are quite satisfactory, 
 and that a study of the physical conditions existing in the 
 thorax may help us in this matter, I shall briefly proceed 
 to this. 
 
 Fig. 1. 
 
 Section of thorax at level of sixth dorsal vertebra in a case of left-sided 
 pleural effusion. 
 
 Let the Diagram (Fig. 1) represent a section through the 
 thorax at about the level of the sixth dorsal vertebra in a 
 patient with left pleuritic effusion : H is the heart, A the 
 collapsed left lung, B the healthy right lung, and c the 
 effusion. It is evident that as the effusion is, like all fluids, 
 practically incompressible, and as it is contained in a cavity 
 the walls of which are practically rigid and unyielding, the 
 systolic and diastolic movements of the heart will be com- 
 pletely resisted on this side. On the other hand, they will 
 readily be allowed to take place on the right side, the healthy 
 and elastic air-containing right lung readily yielding to any 
 enlargement of, or movement of, the heart to the right, and 
 as readily following any diminution of, or movement of, the 
 heart to the left. But now supposing that along the zigzag 
 line D (see Fig. 2) the heart be fixed, by pleuritic, pericardial, 
 
 1 L Envpyenie, Paris, 1888. 
 
 2 L'Empyeme Pulsatile, Paris, 1895. 
 
18 
 
 PULSATING EMPYE:\IA. 
 
 or mediastinal adhesions, and supposing that the fluid c in 
 
 the left pleural cavity be in free communication with a 
 
 subcutaneous abscess cavity F, it is evident that the 
 
 mechanical conditions will be quite reversed. Increase or 
 
 diminution in the size of the heart, or movement of any part 
 
 of it to right or left in systole or diastole, will readily affect 
 
 the fluid effusion. This can be because the fluid in the 
 
 pleural cavity will readily yield and recoil with the cardiac 
 
 movements, being now in free communication with the fluid 
 
 in the subcutaneous cavity, the walls of which are distensile 
 
 and elastic. 
 
 Fig, 2. 
 
 Section of thorax at same level. At d adhesions between the pericardium and pleura 
 have occurred, followed by bulging of the effusion through the chest-waU. 
 
 Hence, we should conclude that in pulsating empyema of 
 necessity the factors which bring about the pulsation are (1) 
 fixation of the heart, and (2) distensibility and elasticity of 
 the walls of the empyema sac. 
 
 But it will now be asked, How is the existence of pulsa- 
 tion in intrapleural empyemas or in other intrapleural fluid 
 collections to be explained ? To this I would answer that 
 the factors are practically the same. The heart must be 
 more or less fixed, as in the former case, whilst the yielding 
 and recoiling of the fluid to its movements may be due to 
 
PULSATING EMPYEMA. 19 
 
 such conditions as the presence of air in the pleural cavity, 
 to the existence of a portion of semi-inflated lung, to a 
 yielding and elastic diaphragm, to the yielding of the inter- 
 spaces through paralysis of the intercostal muscles, or even 
 to the comparatively yielding chest parietes of early life- 
 Perhaps the best illustration of how pulsation may be 
 brought about by yielding parietes is to be obtained from 
 a study of the cranial circulation. Thus if in the cranium 
 of a living animal a trephine opening be made, through this 
 opening the exposed brain can readily be seen to pulsate. 
 If now this opening be completely closed by a piece of 
 glass, it will at once be seen that the pulsations cease. 
 Hence, we may say that whatever permits of the yielding 
 of walls tends to bring about pulsation. 
 
 It is evident that the degree of fixation of the heart, and 
 the degree of yielding and recoil which the chest parietes 
 or contents permit to the fluid, must vary much in different 
 cases. Thus the strength and extent of the pulsations in 
 pulsating empyemas must vary correspondingly. In Stokes's 
 case, previously referred to, we are told that the strength of 
 the pulsations was so great as to shake the patient's bed. 
 This statement has been regarded, by some as incredible ; but 
 we have little hesitation in believing it, if we remember the 
 hydrostatic law, and tlie fact that the normal contractile 
 force of the heart is somewhere about 4 pounds per square 
 inch. We can understand again, in other cases, how the 
 pulsations may be so slight as to be hardly perceptible, and 
 we cannot doubt that, if carefully looked for, pulsation might 
 be found in many cases in which its existence has not been 
 suspected. 
 
 And now to refer again to our patient. Since the removal 
 of the pus he has felt considerable relief, the left lung is 
 expanding, and the heart is showing a tendency to return 
 to its normal position. But he is now evincing the symp- 
 toms of phthisis, he has a muco-purulent spit containing the 
 
20 PULSATING EMPYEMA. 
 
 tubercle bacillus, and his temperature chart and pulse-rate 
 betoken fever. Whilst we may anticipate for him some 
 immediate relief from our interference, our ultimate prognosis 
 is of course a very grave one. 
 
 [This prognosis was borne out by events. Up till the end 
 of February he remained fairly well, although indications of 
 slight sero-fibrinous effusions at the left base had shown 
 themselves. By the beginning of March, however, he was 
 evidently losing ground, as the following excerpts from the 
 case-book show : — 
 
 March 8. — Patient is being dressed every other day; the 
 discharge is but slight. Temperature has begun to show 
 oscillations, rising to 102° at night. Appetite and general 
 condition not so well maintained. 
 
 March 13. — Temperature as before ; general condition of 
 patient not so good, more easily wearied, and appetite failing. 
 
 March 20. — Complains of headache, and towards evening 
 became somewhat delirious, trying to get out of bed. Tuber- 
 cular meningitis suspected. 
 
 March 22. — Headache persistent, and does not recognise 
 his friends. Is refusing food. 
 
 March 23. — Condition worse; pupils react very sluggishly. 
 
 March 24. — Practically comatose. 
 
 March 25. — Died this evening. 
 
 Permission to examine the chest only was obtained, and 
 the following is Dr Muir's report : — 
 
 " Sectio, March 28, 1895. 
 
 "External Appearances. — Body was much emaciated, and 
 there was marked pallor of the surface. Kigidity slight, 
 lividity slight posteriorly. There was an opening in the left 
 side into the pleura in the fourth space close to tlie sternum ; 
 another further back where a portion of the fifth rib had 
 been resected. 
 
 " Thorax. — Slight adhesions on the inner aspect of the right 
 
PULSATING EMPYEMA. 21 
 
 lung. Pericardium normal. In the left pleura there was an 
 old empyema over the upper anterior part of the lung. The 
 cavity contained a small quantity of pus, and was limited 
 by dense fibrous adhesions. There was great fibrous 
 thickening along the left border of the sternum, fixing the 
 pericardial sac. Over the rest of the lung there were 
 scattered fibrous adhesions, and there was a small quantity 
 of serous effusion at the base posteriorly. 
 
 ''Left Lung. — Weight, 1 lb. 12 ozs. The pleura showed 
 great thickening in relation to the empyema cavity. There 
 were one or two old tubercular nodules scattered through the 
 upper lobe with fibrous thickening around, but there were 
 no cavities. Throughout the lung there was well-marked 
 tubercle, the nodules being fairly numerous, grey in colour, 
 and about the size of a pin's head. 
 
 ''Right Lung. — Weight, 1 lb. 11 ozs. It was congested 
 posteriorly, and showed acute tuberculosis, as in the other. 
 
 "Heart. — Weight, 10 ozs. All the valves were normal, 
 cavities of normal size, myocardium pale and soft, not fatty 
 but anaemic."] 
 
ON A 
 
 CASE OF FIBROID PHTHISIS, WITH GBEAT 
 DISPLACEMENT OF THE HEART. 
 
 Gentlemen, — J. S., aged 52, a pilot, was admitted to Ward 
 30, October 14, 1892, complaining of pain in the side and 
 cough. 
 
 History. — An uncle on his mother's side died of stone- 
 mason's phthisis, but with this exception his family history 
 is excellent. He is the father of eight children, of whom six 
 are well and strong ; the other two died in infancy. Habits 
 have always been temperate, and his surroundings at home 
 have always been favourable. At work he is somewhat 
 exposed, but as a pilot his work is not unhealthy. 
 
 Previous Illnesses and Accidents. — Twenty-two years ago, 
 when sitting on the top of a loaded omnibus with his back 
 to the horses, he was driven through an archway which seems 
 to have been too low for its requirements, for the back of his 
 head was knocked against it so violently that he was thrown 
 senseless to the ground. He soon recovered from this, but 
 he states that ever since then his sense of smell has been 
 completely lost. Ten years ago, when pulling in a boat race, 
 he became completely exhausted, and had to be lifted out of 
 the boat. He then threw up more than a large teacupful 
 of blood, and for about two months continued to throw up 
 blood in smaller quantities. Ever since then he states that 
 
CASE OF FIBEOID PHTHISIS, ETC. 23 
 
 he has had a cough, but up till two years ago it troubled him 
 so little that he paid no attention to it. Two years ago, after 
 exposure to bad weather, he complained of pain in his left 
 side, and for this he came to the Infirmary, and was treated 
 for a dry pleurisy. After six weeks' treatment he went out 
 much improved. At this time the condition of his right 
 lung and the position of his heart, to which we shall have to 
 refer later, were observed. 
 
 Present llhiess. — Six weeks before his admission he had a 
 severe bleeding — throwing up at least a breakfast-cupful of 
 pure blood. This bleeding, but in smaller quantity, continued 
 for nearly a fortnight, and he states that during this period 
 he also spat up material " as from a rotten gathering." Four 
 weeks ago a severe, cutting pain arose on his left side at the 
 same place as two years ago, and finding himself unable to 
 work, he came again to the Infirmary. Although his present 
 illness began six weeks ago, he seems to have been distinctly 
 weaker for over a year. His appetite has been failing : for 
 example, after a small breakfast he rarely had more than a 
 sandwich and a glass of whisky — and often not caring for 
 this — till night, when at supper a cup of tea and bread, with 
 perhaps a little fish, sufficed. 
 
 State on Admission. — Height, 5 ft. 4f in. ; weight, 7 st. 
 6f lbs. ; before this illness was 9 st. 6 lbs. His muscles have 
 the appearance of having been well developed, but are now 
 small and flabby. Temperature varies from 98° to 99° F. ; 
 pulse about 70 per niin. 
 
 Respiratory System. — Eespirations, 25 per min. Cough 
 slight, specially in the mornings. Spit scanty, viscid, muco- 
 purulent and opaque. Repeated examinations have been made 
 for bacilli, and we have concluded that, if these or lung tissue 
 are present at all, they must be in very minute quantity. 
 
 On inspection and palpation, marked flattening is recog- 
 nised over the upper part of the right chest, with deficient 
 respiratory movement and increased vocal fremitus. Over 
 
24 Case of fibroid phthisis, etc. 
 
 the second and third right interspaces anteriorly the palpat- 
 ing hand can feel crepitations. The entire left chest seems 
 enlarged. On measurement over the nipples the left side 
 is found to be 16| inches as against 16| on the right side. 
 It appears, therefore, to be larger than it really is, but 
 it is to be remembered that the right chest is normally the 
 larger. 
 
 On percussion, dulness is found over the upper part of the 
 right lung, extending downwards to the fourth rib anteriorly, 
 and to about 1 in. below the spine of the scapula posteriorly. 
 Over this dull area, but specially marked in the infra- 
 clavicular region, auscultation reveals prolongation of the 
 expiration — bronchial or cavernous breathing — coarse con- 
 sonating crepitation, and increased vocal resonance and 
 whispering pectoriloquy. Over the lower portions of this 
 lung the breathing is harsh and indeterminate, with a few 
 crepitations and rhonchi. Over the left lung the percussion 
 note is everywhere resonant, and the breathing is puerile, 
 with here and there a few rhonchi and crepitations, and in 
 the sixth and seventh interspaces in the axillary line well- 
 marked friction is heard. 
 
 By percussion and auscultation the boundaries of the lungs 
 are made out as follows (see Plate) : — 
 
 Left Lung. — Upper border can be traced from the left 
 sterno-clavicular articulation upwards and outwards to the 
 edge of the trapezius muscle, where it is 2\ in. above the 
 level of the clavicle, thence inwards and downwards to the 
 vertebra prominens. 
 
 Right Lung. — Upper border cannot well be demonstrated 
 at the right sterno-clavicular articulation, but at the anterior 
 edge of the trapezius muscle is 1^ in. above the level of the 
 clavicle. From this point it can be traced to the vertebra 
 prominens along a line which is nearly straight. 
 
 Left Lung. — Anterior border can be traced from the left 
 sterno-clavicular articulation to the right and downwards, so 
 
^ :S 
 
 ^ CD 
 
 ^ 
 
 
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 1 
 
 rm 
 
 <u 
 
 o 
 
 ,i3 
 
 g s 
 
 ;>5 
 
 ftH 
 
CASE OF FIBROID PHTHISIS, ETC. 25 
 
 that at the second right interspace it reaches a point one-half 
 inch to the right of the right border of the sternum. Thence 
 it passes downwards, slightly inclining to the left, till at the 
 level of the fifth costal cartilage it meets the liver dulness 
 about one-half inch to the left of the right border of the 
 sternum. 
 
 Eight Lung. — Anterior border cannot well be traced above, 
 owing to its being more or less consolidated, but, in the right 
 parasternal line, is found at the level of the second interspace 
 an impaired percussion note, and at the level of the third 
 interspace a dull note, due to the displaced heart. At the 
 level of the fourth rib the anterior border of the ri2;ht lim"- 
 is at the right nipple, being apparently retained at this point 
 by the apex of the displaced heart. From this point the 
 anterior border of the lung passes oblicjuely inwards and 
 slightly downwards till it merges into the liver dulness at the 
 level of the fifth rib, about 1\ in. to the right of the right 
 border of the sternum. 
 
 Left Lung. — Lower border in parasternal line corresponds 
 with the sixth costal cartilage, in the mammillary with the 
 seventh costal cartilage. In the axillary line it corresponds 
 with the ninth rib, and in the scapular with the lower border 
 of the twelfth rib. 
 
 Bight Lung. — Lower border corresponds in the mammillary 
 line with the fifth, in axillary with the seventh, and in the 
 scapular with the ninth rib. 
 
 These marked changes are all, as we shall see shortly, 
 connected with the cicatricial healing processes which are 
 going on in connexion with the disease in the right upper 
 lobe. Let us now pass on to the circulatory system. 
 
 Pulse, 72 per min., beat rather soft ; arterial walls normal. 
 
 Inspection shows visible pulsation in second, third, and 
 fourth right interspaces, and a very distinct impulse beat in 
 the fourth interspace about half an inch internal to right 
 nipple line. These signs are corroborated by palpation. 
 
26 CASE OF FIBROID PHTHISIS, ETC. 
 
 Percussion shows the dull area of the heart to be irregularly 
 quadrangular in shape, its extreme right limit being at the 
 right nipple, its extreme left about the middle of the sternum, 
 its upper border coursing obliquely across the second and 
 third interspaces, and its lower border merging into the liver. 
 
 Auscultation shows nothing more than that the heart sounds 
 are heard loudest to the right of the sternum, and a cardio- 
 graphic tracing taken from the impulse beat in the fourth 
 right interspace has all the characters of an ordinary apex 
 tracing (see Tracing). 
 
 Digestive System. — Though his appetite is not great, his 
 digestion seems to be fairly well performed. He is always 
 rather constipated. Inspection and palpation of the abdomen 
 reveal nothing abnormal. The liver is evidently drawn 
 upwards, its upper border corresponding in the nipple, 
 axillary, and scapular lines with the fifth, seventh, and ninth 
 ribs, its lower border being about 1 in. higher than the costal 
 margin in the nipple line. The spleen appears normal. 
 
 Urinary System. — Amount 40 ozs., acid ; sp. gr., 1020; no 
 albumen. 
 
 Integumentary System. — Normal; never perspires much. 
 
 Nervous System. — Normal, with the exception of his loss 
 of the sense of smell. 
 
 The diagnosis made was chronic pneumonic or fibroid 
 phthisis of the upper lobe of the right lung of some ten 
 years' duration. Though gradually progressive, it has been 
 associated with, and its progress restrained by, marked cica- 
 tricial fibrosis of the lung tissue, and this fibrosis had led to 
 the shrinking downwards of the lung apex, to the shrinking 
 
CASE OF FIBROID PHTHISIS, ETC. 2? 
 
 upwards of the lung base, to the marked displacement of the 
 heart to the right, and to the enlargement (hypertrophic 
 emphysema) and dragging over of the sound lung. 
 
 Now I wish to say something about this fibrosis and its 
 results in general, and in this case in particular. Observe, in 
 the first place, that in the main it is a salutary process. 
 Occurring around foci of softening or around cavities, it tends, 
 like cicatricial tissue elsewhere, to contract and encapsule or 
 obliterate them, and in many cases where the lung mischief 
 is limited it completely succeeds in its healing efforts. 
 Unfortunately in so many cases the foci of disease are 
 multiple, and so contraction around one focus or set of foci is 
 apt to drag on or tear the new-formed tissue round others, to 
 dilate other cavities or bronchi, and so to act injuriously. Like 
 everything else in nature, this fibrosis presents harmful as 
 well as beneficial aspects, but like everything else in nature 
 it tends also in the main towards the latter ; and where, as 
 in our patient, the yielding of the parts around — chest-wall, 
 liver, healthy portions of lung, heart, and opposite lung — can 
 all work together to help it, it is wonderful how the effects of 
 disease can by it be counteracted. 
 
 This patient illustrates the immense importance, from the 
 prognostic point of view, of the disease being unilateral. It 
 is evident that if the other apex, the left, were also affected, 
 not only would the fibrotic change in connexion with it be 
 rendered more difficult, but it could not yield the same 
 assistance to the disease at the right apex. The most rapid 
 cases of phthisis are those in which at an early stage both 
 apices are found affected, and in practice you will often find 
 that a patient in whom unilateral disease has gone on till the 
 lung is little more than a mass of fibrous tissue and cavities, 
 will come to see you year after year, looking little the worse ; 
 whilst another, in whom you have found only a little 
 impaired percussion note and crackling at both apices, has 
 lived only a few months. 
 
^S CASE OF FIBROID PHTHISIS, ETC. 
 
 The displacement of the heart to the right which this 
 patient presents is more than one usually sees, and merits a 
 few remarks. I have seen it occurring to a similar extent 
 in four cases — three males and one female. In two of the 
 males the disease of the lung which had brought it about 
 had been arrested years before I had seen them, and coming 
 before me for other ailments, the condition of the heart had 
 been recognised accidentally. The evidence of old lung 
 mischief was easily made out in the shape of impaired 
 percussion note and weak respiratory murmur at the right 
 apex, and indications of shrinking in this locality. In three 
 of the male cases (including the patient whose case we are 
 now considering) there was a distinct history of strain. 
 
 The mode of displacement of the heart in this and other 
 such cases I believe to be as follows : — With the base of the 
 heart as the fixed point and centre of a circle, the long axis 
 of the heart, like the radius, has described an arc to the 
 right, whilst at the same time the organ has rotated on its 
 long axis so as to bring the left ventricle more anterior. No 
 doubt the entire organ and the mediastinum are dragged 
 over to some extent en hloc, but I believe that this tilting of 
 the apex to the right and the rotation are the chief causes ; 
 and it is to be remembered, too, that the dragging up of the 
 liver may now be assisting in this displacement. With such 
 a displacement one might suppose that some twisting or 
 kinking of the large vessels would certainly occur and cause 
 bruits, but such bruits have not markedly been present in 
 the examples of this condition which I have seen. 
 
 A question which you may ask here is, How long has this 
 displacement existed ? We cannot say definitely. We know 
 that it has been so for the last two years at least ; we may 
 suppose that it has been so for a much longer time. In one 
 of the other cases, in which I found a very similar displace- 
 ment, the mischief in the right upper lobe had existed for 
 two years. 
 
CASE OF FIBROID PHTHISIS, ETC. 29 
 
 So much for the fibrosis and the results of it which this 
 patient presents ; let us now say a little as regards some 
 other features in his case. 
 
 It will be remembered that the disease seems to have 
 begun some ten years ago, when as the result of a severe 
 strain he felt faint and coughed up a large quantity of blood. 
 He tells us that since then he has noticed the cough, which 
 is still going on. Are we to suppose that this is a case of 
 pTitMsis ah hcemojjtoe, that we have here an example of a 
 haemorrhage setting up a chronic phthisical process ? Or are 
 we to suppose that, unknown to our patient, there had been 
 some tubercular deposit at his right apex in connexion with 
 and eroding the wall of an artery ; and that, as the result of 
 the increased blood-pressure which the straining entailed, 
 the wall had given way at that point and caused the 
 haemorrhage ? By the older WTiters the first view would 
 have been upheld, whilst the new school would most 
 strenuously uphold the latter. To say which has been the 
 cause is well-nigh impossible. Although his family history 
 is good, although his health prior to the accident had been 
 excellent, and although subsequent to his illness his constitu- 
 tional strength has been able so well to counteract the ravage 
 of the lung disease, we can never be sure that tubercular 
 deposit did not pre-exist. Further, we know that in the 
 great majority of cases of phthisis which are said to have 
 begun by a haemorrhage, closer inquiry will show that tuber- 
 cular deposit and erosion of a vessel has been the real factor. 
 On the other hand, we cannot deny tliat phthisis ah hcemoptoe 
 may have a real existence. Hemorrhage into the lung may 
 occur independently of tubercle, and haemorrhage means 
 injury and irritation of the lung tissue, and the induction in 
 it of a nutritive condition so weakened that the attacks of the 
 ubiquitous tubercle bacilli cannot be withstood. The precise 
 meaning of the first liaemorrhage in this case cannot well be 
 understood. Had it been caused by some external injury 
 
30 CASE OF FIBROID PHTHISIS, ETC. 
 
 instead of by a strain, the argument in favour of the phthisis 
 db hcemoptoe theory would, of course, have been stronger.^ 
 
 But next it is to be noted that subsequent bleedings have 
 occurred. These, as regards causation, are easily understood. 
 By the fibrotic contraction cavities and dilated bronchi have 
 their walls dragged upon here and there, and arteries in these 
 walls exposed. These, from want of support and other causes, 
 develop miliary aneurisms, which in their turn are very liable 
 to rupture. Indeed, it is in cases of this kind, with fibrosis, 
 cavities, and dilated bronchi, that severe and sometimes fatal 
 haemorrhages are most prone to occur. These are the cases 
 in which miliary aneurisms are most common, and the patient's 
 general condition being fairly good, the heart is strong and 
 the blood-pressure high. 
 
 Next, as regards prognosis in this case. There is no doubt 
 that in such patients the immediate prognosis is favourable 
 enough. In the absence of active lung mischief the cough 
 and expectoration cause little trouble, whilst fever, with its 
 associated anorexia, dyspeptic troubles, thirst, sweatings, etc., 
 is absent. 
 
 But the remote prognosis is most unfavourable ; the extent 
 of the disease has long since precluded the possibility of com- 
 plete arrest and healing. The cough and expectoration must 
 continue, and as time goes on we may expect that, with the 
 gradual lessening of the nutritive power, the disease will 
 spread more rapidly and the fibrotic contraction will be less 
 efticient to counteract it. A tubercular element may gain 
 prominence. The other lung may be involved, and this, as 
 we have described, M^ould tremendously accelerate the progress 
 of the disease, whilst attacks of hsemorrhage are, as we have 
 seen, likely to occur from time to time, and still more weaken 
 the patient. 
 
 With the lessening of the aerating surface in the lungs, 
 
 '' For instances of phthisis following injury to the lung, see Mendel- 
 sohn, Zeitschrift fiir Klin. Medicin, Bd. 10. 
 
CASE OF FIBKOID PHTHISIS, ETC. 31 
 
 congestion of these organs will be apt to occur, and this will 
 entail increased liability to attacks of bronchitis, or pleurisy, 
 or pneumonia. Further, the backward pressure of the blood 
 is apt to extend to the right heart and cavse, and with ensuing 
 congestion of the liver and portal system, of the kidney and 
 of the lower limbs, digestive troubles, nephritic troubles, and 
 dropsy may at any time show themselves. In such cases 
 clubbed fingers are distinctly frequent. 
 
 The treatment in instances of this kind is mainly attend- 
 ance to the general health and the careful avoidance of cold. 
 Cough mixtures are quite unnecessary, — a warm drink — tea 
 or milk — in the morning being all that is required for the 
 cough and expectoration. The diet should be as nourishing 
 and in as small bulk as possible, and should therefore consist 
 to a large extent of animal food ; alcohol in one or other of 
 its forms has been recommended on the theory that it pro- 
 motes the formation of fibrous tissue. Cod-liver oil and 
 syrup of iodide of iron seem often to suit such patients, 
 whilst any work or exercise which necessitates strain should 
 for obvious reasons be avoided. Sunlight and the open air 
 are always to be desired, and were our patient's circumstances 
 such as to permit of his spending the winter and spring 
 months under good climatic conditions, he might without 
 doubt even yet add years to his life. 
 
 The only other point in this case to which I wish to refer 
 is the loss of the sense of smell. This I believe to have been 
 due to the blow on the back of his head (see page 22) having 
 caused rupture and consequent degeneration of the fibres of 
 the olfactory nerve at their points of passage through the 
 cribriform plate of the ethmoid bone. 
 
ON A 
 
 CASE OF RENAL AND CARDIAC DISEASE, 
 
 WITH SPECIAL REEEEENCE TO THE DIUENAL 
 AND NOCTUENAL EXCEETION OF UEINE. 
 
 Gentlemen, — J. W., set. 39, a blacksmith, residing in 
 Edinburgh, was admitted to Ward 30 on October 13, 1892, 
 and examined October 14. His complaints were swelling in 
 the legs, scrotum, abdomen, and face, and also shortness of 
 breath, and he stated that his illness liad commenced three 
 months ago. 
 
 Histonj : — Hereditary Tendencies. — His mother had died of 
 some disease in which there was swelling of the legs. Habits 
 as to Food and Drink — Has always had plenty of good food, 
 and is not a heavy drinker. Surroundings. — In consequence 
 of bis employment, is liable to physical strains, and when 
 overheated is often exposed to draughts. Previous Illnesses. — 
 Had measles and small-pox as a child ; occasional slight 
 rheumatic pains later. 
 
 Origin and Course of Present Illness. — About three months 
 ago patient got a severe wetting one morning, but after drying 
 himself at the furnace in his shop, continued to work all day. 
 On retiring to rest that night he felt chilly, and felt also 
 pains in his knees and ankles. Although he did not stop 
 work, he says he has never felt well since then, and about 
 
CASE OF EENAL AND CARDIAC DISEASE. 33 
 
 four weeks after he noticed his ankles swollen at night. A 
 week ago the swelling of the ankles became suddenly much 
 worse, and he noticed also the swelling affecting the scrotum, 
 abdomen, and face. The quantity of urine has markedly 
 lessened during the last week, and he has begun to suffer 
 from shortness of breath. 
 
 State on Admission. — General nutrition and muscular 
 development good. The only morbid appearance is the 
 marked general dropsy. 
 
 Uri7iary System. — Micturition three or four times day 
 and night ; no pain. Urine — quantity (on day after ad- 
 mission), 23 ozs. ; sp. gr., 1022 ; acid, no blood, albumen 
 in small quantity, epithelial and granular casts in large 
 quantity. 
 
 Circulatory System : Suhjective Phenomena. — Since the 
 beginning of his illness, three months ago, he has noticed 
 palpitation on exertion, and dyspnoea ; no pain. On physical 
 examination the heart was found enlarged. The apex-beat 
 was between the seventh and eighth ribs, If in. to left of 
 nipple line, and there was marked epigastric pulsation. The 
 right border of the heart at the level of the fourth costal 
 cartilage was made out by percussion 1 in. to the right of the 
 right border of the sternum. On auscultation, a faint systolic 
 murmur was made out at the mitral area, and equally faint 
 systolic and diastolic murmurs at the aortic. Accompanied 
 by the faint diastolic murmur at the aortic area the second 
 sound was heard accentuated. Pulse-rate, 108, regular in 
 time and strength ; its beat was forcible, but a very slight 
 water-hammer character was perceptible. The walls of the 
 radial artery were thickened and hard. 
 
 Bes^piratory System. — Eespirations, 24 per min. ; no pain ; 
 no cough. On physical examination the chest was found 
 emphysematous, and impairment of the percussion note was 
 made out at both bases posteriorly, especially on the left side. 
 On auscultation, some weakening of the respiratory murmur, 
 
34 CASE OF EENAL AND CARDIAC DISEASE. 
 
 with coarse crepitation, was found at both bases, mostly over 
 the left. 
 
 Alimentary System. — Appetite and digestion fairly good ; 
 no thirst ; bowels regular ; tongue rather flabby and furred. 
 On physical examination of the abdomen it was found to be 
 enlarged, measuring at the level of the umbilicus 38 ins. By 
 percussion in varying positions the presence of ascites was 
 ascertained. The liver was found enlarged, its vertical 
 dulness in the right nipple line amounting to 9| ins. The 
 splenic dulness could not be precisely ascertained, owing to 
 the dulness at the left base, but the organ did not appear to 
 be enlarged. 
 
 Nervous System and Integumentary System are practically 
 normal, except that for some weeks his sleep has been some- 
 what disturbed, and that oedema of the skin and subcutaneous 
 tissue is markedly present. 
 
 In this case the history of a severe wetting, the occurrence 
 of rheumatic symptoms, and the supervention after some 
 weeks of dropsy of legs, genitals, abdomen, lung bases, and 
 face, with diminution in the quantity of the urine, and the 
 presence in it of albumen and casts, pointed to an acute 
 nephritis. But we had found also affecting the patient, 
 emphysema, a greatly dilated and hypertrophied heart, with 
 mitral, and probably also aortic valvular disease, and athero- 
 matous arteries. All these latter symptoms might reasonably 
 be ascribed to the single fact of his being a blacksmith of 
 about 40 years of age. 
 
 "We remembered also that the emphysema and the cardiac 
 and vascular conditions were certainly of some duration, and 
 that although on inquiry we could not elicit evidence that 
 symptoms showing weakened action of the heart had existed, 
 we believed that there must have been some tendency to 
 backward pressure, and that this in the case of the kidneys 
 meant an increased liability to acute nephritic attacks. 
 
 But the question occurred to us, Had there been previously 
 
CASE OF EENAL AND CARDIAC DISEASE. 35 
 
 any possibility of the existence of cirrhotic kidneys ? We 
 know that this morbid condition is often associated with the 
 cardiac and vascular changes found in this patient, and that 
 often, too, the renal condition is the primary one. Are we 
 to suppose, then, that this condition of kidney has been 
 present, and has taken its share in inducing the cardiac and 
 vascular changes which we have found, or are we to suppose 
 that in connexion with his circulatory system we are to recog- 
 nise the foundation of the whole mischief ? At the time 
 when the patient came into hospital we were inclined to take 
 this latter view; we felt sure that the big heart and hard 
 arteries had been there for some considerable time, we could 
 not say the same of the renal trouble. 
 
 But I wish now to consider with you more in detail the 
 reasons for and against this opinion, because such a considera- 
 tion will, in the first place, show you that we cannot be so 
 absolutely sure as we might think ; and, in the second place, 
 because it may help you to form an opinion in other cases of 
 a similar kind. When the symptoms of cirrhotic kidneys are 
 well marked, the condition is very easily recognised ; but the 
 diagnosis is often difficult in the earlier stages, and, of course, 
 you want to be able to diagnose it in as early a stage as 
 possible. 
 
 From the etiological standpoint nothing definite can be 
 elicited. He is at the age about which cirrhotic kidney becomes 
 common ; he has a history of hard work and of exposure, 
 and of rheumatism. But all these, it may be said, apply as 
 etiological factors as cogently to the state of his circulatory 
 system as to his renal organs. Prolonged muscular exertion 
 leads to dilatation and hypertrophy of the left ventricle and 
 sclerosed arteries, as well as does contracting kidneys. It 
 may be asked here, — To what extent can the aortic and 
 mitral valvular disease of themselves account for the large 
 heart ? To this I would answer that, as indicated mainly by 
 the pulse, these lesions are slight, so that for an explana- 
 
36 CASE OF RENAL AND CARDIAC DISEASE. 
 
 tion of this we must look rather to increased arterial 
 pressure. 
 
 Then as regards symptoms, — whilst dyspnoea, palpitation, 
 and disturbed sleep are symptoms of cirrhotic Bright's disease, 
 their occurrence in this case may well be explained in other 
 ways. The hard pulse, so characteristic of the kidney trouble, 
 is slightly modified in this case as the result of the valvular 
 lesions, but still the heart-beat is strong. With the rigid 
 artery, however, it might easily be accounted for on the 
 theory of a primary cardiac and vascular morbid condition. 
 Headaches, giddiness, and disturbed digestion, all of which 
 are common symptoms of cirrhotic kidney, he has not com- 
 plained of, and had he done so they also might readily be 
 explained by the cardiac condition. The liver is markedly 
 enlarged, evidently from congestion ; and whilst the con- 
 sideration of its size makes us wonder that symptoms of 
 disturbed digestion have not been more prominent, it shows 
 that there must have been great backward pressure, and that, 
 therefore, the kidneys being similarly congested would be very 
 liable to an attack of inflammation. Failing vision and the 
 characteristic changes in the retina he presents no evidence 
 of. In the absence, therefore, of any of the general symp- 
 toms of cirrhotic kidney, we pass now to a more detailed 
 consideration of the urinary system itself, and to this let me 
 now direct your attention. 
 
 We first inquired as to the quantity of urine which he had 
 been passing previous to his illness, and he stated that he had 
 never noticed any increase in its quantity or paleness in its 
 appearance, and what is, as we shall see, of great consequence, 
 that he never had to get up to micturate during the night. 
 We also made out that he had never noticed any puffiness 
 about his eyes in the mornings previous to his acute attack. 
 We therefore, as already stated, were inclined to believe that 
 his attack was one of acute inflammation, occurring in a 
 patient with practically normal though congested kidneys 
 
CASE OF RENAL AND CARDIAC DISEASE. 
 
 37 
 
 and valvular and arterial disease. But we made up our 
 minds to watch him during the satisfactory recovery which 
 we anticipated would occur, and to see if we could make 
 ourselves more certain of his renal condition as time went 
 on. We advised rest in bed, plenty of hot bottles and 
 blankets to favour the action of the skin, a non-nitrogenous 
 diet, attention to the action of the bowels, and a mixture of 
 quinine and iron, with a small dose of digitalis thrice daily. 
 
 At once improvement began to show itself, with rapid 
 increase in the quantity of urine, the dropsy disappeared, and 
 the albumen and blood after a few days could no longer be 
 detected. But it is to the condition of the urine that I now 
 wish to direct your attention, and the points to which I wish 
 specially to direct your attention are shown in the Tables. 
 
 Table I. shows the total quantity of urine passed since his 
 admission each day, and since October 22 the proportion 
 passed during the day and night. The day urine is the quan- 
 tity passed between 8.30 a.m. and 8.30 p.m., and includes the 
 quantity passed before the patients are supposed to be going 
 to sleep ; the night urine is the quantity passed between 8.30 
 P.M. and 8.30 a.m., and includes the quantity passed before 
 the ward is cleaned in the morning. 
 
 Table I. 
 
 
 Total. 
 
 Day. 
 
 Night. 
 
 
 
 TotaL 
 
 Day. 
 
 Night 
 
 Oct. 14, .. 
 
 .... 25 
 
 
 
 Oct. 
 
 25, .. 
 
 .... 66 
 
 18 
 
 48 
 
 15, .. 
 
 .... 3.S 
 
 
 
 
 26, .. 
 
 .... 65 
 
 21 
 
 44 
 
 16, .. 
 
 .... 42 
 
 
 
 
 27, .. 
 
 .... 61 
 
 32 
 
 29 
 
 17, . 
 
 .... 74 
 
 
 
 
 28, .. 
 
 .... 46 
 
 24 
 
 22 
 
 18, . 
 
 ....129 
 
 
 
 
 29, .. 
 
 .... 69 
 
 29 
 
 40 
 
 19, . 
 
 ....104 
 
 
 
 
 30, .. 
 
 .... 65 
 
 21 
 
 44 
 
 20, . 
 
 ....117 
 
 
 
 
 31, .. 
 
 .... 41 
 
 12 
 
 29 
 
 21, . 
 
 ....149 
 
 55 
 
 94 
 
 Nov. 
 
 1, .. 
 
 .... 57 
 
 28 
 
 29 
 
 22, . 
 
 ....110 
 
 38 
 
 72 
 
 
 2, .. 
 
 .... 56 
 
 24 
 
 32 
 
 23, . 
 
 .... 93 
 
 26 
 
 69 
 
 
 3, .. 
 
 .... 49 
 
 24 
 
 25 
 
 24, .. 
 
 .... 80 
 
 35 
 
 45 
 
 
 
 
 
 
 Table II. shows for the five days ending October 26, in 
 
38 
 
 CASE OF RENAL AND CARDIAC DISEASE. 
 
 addition to the quantity of day and night urines, the specific 
 gravity and the proportion and amount of urea. For the 
 analysis and construction of this Table I have to thank Dr 
 Boyd. 
 
 Table II. 
 
 
 Amount — 
 
 Amount — 
 
 Urea- 
 
 Urea — 
 
 Specific 
 
 Total Urea in 
 
 Date. 
 
 Day. 
 
 Night. 
 
 Day 
 Per- 
 centage. 
 
 Night 
 
 Gravity. 
 
 Grammes. 
 
 Oct. 
 
 Ozs. 
 
 C.c. 
 
 Ozs. 
 
 c.c. 
 
 centage. 
 
 Day. 
 
 Night. 
 
 Day. 
 
 Night. 
 
 
 
 
 
 
 
 
 
 
 22 
 
 38 
 
 1078 
 
 72 
 
 2044 
 
 1-4 
 
 •9 
 
 1020 
 
 1013 
 
 15-06 
 
 18-39 
 
 23 
 
 26 
 
 738 
 
 69 
 
 1902 
 
 2-4 
 
 1-2 
 
 1030 
 
 1020 
 
 17-71 
 
 22-82 
 
 24 
 
 35 
 
 993 
 
 45 
 
 1277 
 
 1-6 
 
 1-4 
 
 1022 
 
 1020 
 
 15-88 
 
 17-87 
 
 25 
 
 18 
 
 511 
 
 48 
 
 1362 
 
 1-9 
 
 1-85 
 
 1028 
 
 1022 
 
 9-70 
 
 24-59 
 
 26 
 
 21 
 
 596 
 
 44 
 
 1249 
 
 2-4 
 
 2-85 
 
 1030 
 
 1030 
 
 14-30 
 
 35-59 
 
 From these Tables it will be seen— (1.) That the total 
 quantity of urine passed by this patient ran up rapidly after 
 his admission, and is now returning to what we may con- 
 sider the normal amount. (2.) That the specific gravity and 
 amount of urea are keeping high — indeed, rather above the 
 normal. Neither of these, it is evident, indicate that 
 cirrhotic kidneys have pre-existed or exist in this man ; for, 
 of course, were this so, the quantity of urine would, we 
 should expect, have remained high and the specific gravity 
 low, whilst the urea — though as regards total quantity 
 perhaps equalling the average — would, corresponding to the 
 increased amount of water, have been proportionately less 
 than the average. 
 
 But notice that (3) the amount of the night urine is nearly 
 always higher than that of the day. This is, I believe, an 
 important point; and because, in my opinion, a sufficient 
 amount of importance has not been directed to it in medical 
 teaching, I propose to devote a little time to its consideration. 
 My attention was directed to it some years ago when work- 
 ing as Assistant Physician in Prof Greenfield's wards, and 
 my friend Dr Claud "Wilson, who was then Eesident in 
 
CASE OF RENAL AND CAEDIAC DISEASE. 39 
 
 Wards 23 and 24, made some observations in connexion with 
 it which were published in the Lancet of June 29, 1889. 
 
 In health the proportion of urine passed during the day 
 hours is very much greater than that passed during the 
 night. Eoberts, for example, with a total daily quantity of 
 30 ozs. 6 drs. of urine, gives for the sixteen hours of waking 
 30 ozs. 2 drs., and for the eight hours of sleep only 4 drs. 
 This gives as the amount of the secretion per hour, for the 
 day a little less than 2 ozs., and for the night about | dr., or 
 splitting the total quantity into two, one representing the 
 amount passed between 8 a.m. and 8 p.m., and the other the 
 amount passed between 8 p.m. and 8 A.M., this would give for 
 the day quantity about 27 ozs. and for the night about 
 3|- ozs. 
 
 Eemembering that the quantity of urine varies greatly in 
 health and disease in different individuals, and also that our 
 patient is lying in bed all day as well as all night, we cannot 
 yet fail to be struck by the greatly altered ratio of the noc- 
 turnal to the diurnal excretion. On only one occasion is the 
 nocturnal amount less than equal to the diurnal, in most 
 cases it is much greater, on two occasions it is more than 
 twice as much. Further, although the total amount of urine 
 is diminishing, the excessive quantity of night urine still 
 seems to hold. 
 
 Dr Claud Wilson, from his observations, came to the 
 following conclusions as regards the proportionate quantity 
 of diurnal and nocturnal secretion — " That in debility, how- 
 ever produced, the diurnal and nocturnal rates approximate 
 to each other, that this is specially marked in cases of 
 cardiac disease, and more so still in organic disease of the 
 kidney. One case is especially interesting, in which the 
 approximation between the day and night rates of excretion 
 was sufficient to make me strongly suspect organic (waxy) 
 disease of the kidney, though there was no noticeable 
 polyuria nor any albumen. This patient died two months 
 
40 CASE OF EENAL AND CARDIAC DISEASE. 
 
 later, when he was found to have extensive waxy disease of 
 both kidneys as well as of other organs, although no albumen 
 had been detected in his urine until a week before his death, 
 and then only a trace." 
 
 With what Dr Wilson has said I can certainly agree, with 
 one little qualification which I shall mention directly. I 
 have known of cases where contracting kidney was diagnosed 
 mainly by noting the altered diurnal and nocturnal excretion 
 rate, and I have known of cases where the diagnosis was 
 missed by failing to inquire into this. The little qualification 
 which I referred to was as regards the altered rate in cardiac 
 cases. I think that the cardiac cases to which Dr Wilson 
 referred were cases like that of the patient whom we are now 
 considering, and that in them, as in this patient, we cannot 
 be sure that some renal mischief was not existent. Let me 
 therefore impress upon you the importance of inquiring as 
 to the diurnal and nocturnal excretion rate. Of course, 
 alterations can occur in other morbid conditions, and even 
 occasionally in health, but when it occurs habitually, and 
 cannot be explained as due to other morbid causes, it may 
 enable you earlier than any other symptom to contemplate 
 the onset of organic renal disease. 
 
 To revert now to our patient W. He is going on favour- 
 ably ; he is now allowed a certain proportion of nitrogenous 
 food, and in a few days he will, taking every precaution by 
 clothing, etc., to protect him from cold, be allowed to get up 
 and go about. We shall from time to time, however, make 
 inquiries as regards his diurnal and nocturnal rates of urine 
 excretion. If with a total quantity of 40 or 50 ozs. of urine 
 we find that the nocturnal proportion shows a marked 
 diminution, this will certainly influence us to believe that 
 the kidneys have as yet suffered no fibroid change. 
 
 We shall also look to the specific gravity of the urine. 
 Of course, if any such change is going on we expect that 
 the specific gravity will diminish, but we shall note specially 
 
CASE OF EENAL AND CARDIAC DISEASE. 41 
 
 if this diminishing is more marked in the case of the night 
 urine. We shall also examine for casts. Up till now 
 hyaline casts are still being detected from time to time. 
 
 And now, can any reason be given for the increased flow 
 of urine during the night found in this and other such cases ? 
 I believe that it can, and to better explain it I would ask 
 you to remember another feature of chronic Bright's disease, 
 and that is the dropsy. 
 
 Corresponding with the large flow of urine the dropsy is 
 slight, but what is of special importance is that it is marked 
 about the eyes, and mostly in the mornings. That is to say, 
 the dropsy about the eyes is occurring during the night when 
 the patient is secreting the largest proportionate amount of 
 urine. Further, if a patient with contracting kidneys falls 
 asleep during the day, let us say in his chair or on the sofa, 
 he will usually notice that his eyes are puffy when he wakes, 
 and if you inquire you will often find evidence that during 
 his sleep he has been secreting a considerable amount of 
 urine. 
 
 The explanation of all this lies, I think, in the theory that 
 along with the lowered metabolism of the night hours, or 
 hours of sleep, there is a lessened lymphatic absorption. 
 Without, in the light of Heidenhain's recent work,^ accepting 
 in its entirety the Ludwig theory, viz., that the urine 
 secretion is in part a process of filtration and in part of osmosis, 
 we may yet believe that between the filtered fluid in the 
 tubules and the contents of the lymph spaces in the con- 
 nective tissue of the kidney a certain amount of interchange 
 will occur. At the time when lymphatic absorption is 
 active this may, as Ludwig states, result in a diminution in 
 the quantity, and possibly also in an increase in the specific 
 gravity of the urine, — that is to say, in its concentration. 
 When, however, the activity of lymphatic absorption is 
 
 '• " Versuclie unci fragen zur Lehre von der Lymplibilclung. " Heid- 
 enliain, Archiv f. d. ges. Phys., Bd. xlix. 
 
42 CASE OF EENAL AND CARDIAC DISEASE. 
 
 lessened, a larger quantity of urine, with possibly lowered 
 specific gravity, will flow downwards into the bladder. 
 Similarly in the tissues generally, with lessened lymphatic 
 absorption, these will contain a greater proportionate amount 
 of fluid. Thus, in a locality where the tissues are lax, as in 
 and about the eyelids, there will be an oedematous condition, 
 which will disappear when the absorption process is more 
 active. 
 
 Hence there will be remarked oedema about the eyes, 
 most noticeable when the patient awakes in the morning, 
 associated with a nocturnal flow of urine increased pro- 
 portionately to the diurnal. Also a lessening of this oedema 
 as the day wears on, associated with a diurnal flow of urine 
 diminished proportionately to the nocturnal. 
 
 Of course, another explanation of this dropsy which has 
 been brought forward is gravity and the position of the patient 
 during the night.^ Were gravity, however, the main cause, 
 we should expect at the same time a corresponding dropsy 
 of the ankles at night as the result of the patient walking 
 about during the day. This, however, in cases of contracting 
 kidneys such as we are referring to, we usually do not 
 get. 
 
 1 L'alhuminurie. Lecorclie et Talamon. Paris, 1888. 
 
CASE OF PRIMARY CONTRACTING KIDNEY. 
 
 Gentlemen, — The case which I propose to consider with 
 you to-day is one, I believe, of primary contracting kidney. 
 
 W. R, aged 52, a photographer, was admitted to Ward 30 
 on December 23, 1893, complaining of defective eyesight. 
 
 Family History. — Parents both dead, father at 42, mother 
 older, causes of death unknown ; two brothers dead, causes of 
 death unknown ; four sisters and one brother living ; has had 
 five children, all dead ; two died, aged 20 and 25, from con- 
 sumption. 
 
 Personal History. — Has always had a good home and been 
 in comfortable circumstances ; his work is for the most part 
 indoors, but he gets plenty of leisure for outdoor exercise ; 
 has taken beer rather freely, but seldom drinks spirits ; has 
 had gonorrhoea, not syphilis. 
 
 Had no illness until three years ago, when he had an 
 attack of influenza, which confined him to bed for two weeks.- 
 For a year after this he had a rather severe cough, but this 
 was accompanied by but little expectoration, by no night- 
 sweating, and by no loss of weight. He has always had a 
 slight cough since this attack, but otherwise, he said, he has 
 been as well as he was before. Six or seven weeks ago he 
 found that his sight was failing, especially for near work, and 
 during the past six weeks he tells us that it has gradually 
 been becoming worse, but that some days he notices it more 
 
44 CASE OF PKIMARY CONTRACTING KIDNEY. 
 
 than others. He also tells us that since the attack of 
 influenza he has been troubled with headaches. These at 
 times are very bad, especially at night, and he states that he 
 often goes to bed feeling all right, and is awakened during 
 the night by the headache. This headache seems to be 
 usually occipital, but sometimes it is frontal. He distinctly 
 states that there has been no exacerbation of the headaches 
 during the past six weeks, — that is to say, since his eyes 
 became affected. The headaches also never cause vomiting. 
 
 State on Admission. — He is a man of under middle height, 
 but fairly well proportioned, and of fair muscularity. There 
 is a slight fulness under the lower eyelids, with a semi- 
 circular hollowing below, which seems to indicate that this 
 fulness has at one time been more marked. 
 
 Alimentary System. — His mouth is rather dry ; he is more 
 thirsty than he used to be, and his tongue is somewhat 
 coated. Beyond a slight tendency to constipation, there is 
 no further abnormality. The liver and spleen are normal. 
 
 Circulatory System. — There are no subjective phenomena. 
 Pulse is 90 per minute, regular in force and rate. The 
 tension is high, the pulse wave is small, and the arterial 
 walls are somewhat sclerosed and tortuous. 
 
 Heart. — Apex-beat can be felt in the fifth interspace, in 
 the nipple line. Owing to the presence of emphysema, the 
 percussion of the heart is a little difficult, but the left border 
 can be made out distinctly to the left of the nipple line. 
 On auscultation the first sound is reduplicated in all the 
 areas, and the second sound is accentuated, and presents the 
 " pump-valve " character in the aortic area. 
 
 Respiratory System. — He states that for the past two 
 months he has noticed himself more short of breath than 
 formerly. He has a slight cough with muco-purulent 
 expectoration. His chest is distinctly emphysematous, but 
 the physical signs of bronchitis are very slightly marked 
 indeed : the breath sounds, somewhat feeble, all over show a 
 
CASE OF PEIMARY CONTRACTING KIDNEY. 45 
 
 slight inspiratory harshening. There are no crepitations 
 anywhere. 
 
 Urinary System. — He states that for the past seven weeks 
 he has had to get up two or three times at night to pass 
 water, and that he has been passing a considerable quantity. 
 Since his admission the quantity has varied between 50 and 
 90 ozs. It is light in colour, acid in reaction, and has a 
 specific gravity of about 1010. It also contains a small 
 quantity of albumen, "2 per cent. ; a trace of globulin, and a 
 few hyaline casts. The amount of urea is about 300 grns. 
 in the twenty-four hours. 
 
 Integumentary System. — The skin is usually rather dry, 
 and he sweats very little. There is some oedema below the 
 lower eyelids, as stated previously, and he says that this is 
 most noticeable in the mornings, and that it disappears as 
 the day wears on. He did not complain of oedema of the 
 feet, but on careful examination a little pitting over the shin 
 bones at the ankles could be detected. 
 
 Nervous System. — Except the headache and failure of eye- 
 sight, as previously mentioned, he has no abnormal sensations. 
 
 Examination of Eyes. — His left eye shows a scar over the 
 lower part of the cornea. This, he says, was due to an 
 accident with a chisel, which he sustained when he was 17 
 years of age. Ever since that time the sight in the left eye 
 has been impaired, but this did not trouble him. In both 
 eyes vision has been failing for the past six or seven weeks. 
 He states that for about two weeks before his admission he 
 has also noticed coloured rings around any object he looked 
 at. Sometimes there were several rings of different colours ; 
 at other times stars appeared. He saw no flashes of light 
 when in the dark, and he stated that he could see better by 
 gaslight than by daylight. He also complains of severe pain 
 above the eyes. This pain sometimes comes on suddenly, 
 like lightning pains. These phenomena occur in connexion 
 with both eyes, but specially with the right. 
 
46 CASE OF PRIMAEY CONTRACTING KIDNEY. 
 
 On examination the movements of the eyeballs were found 
 unimpaired. The pupils are equal and regular in outline ; 
 they react readily and equally with accommodation, but 
 scarcely at all to light. With the ophthalmoscope both optic 
 discs appear blurred, but the vessels are not obscured. 
 Numerous white patches of well-marked radiating white 
 lines of albuminuric retinitis in both eyes. These changes, 
 however, are more marked in the right. 
 
 Beflexes. — Superficial : Appear normal. Beep : Both knee 
 and ankle jerks are well marked in both legs. No clonus 
 can be elicited. Organic : All the organic reflexes are normal, 
 with the exception of the bladder, for he tells us that some- 
 times he is suddenly seized with a desire to pass water, and 
 can scarcely check it. 
 
 Cerebral and Mental Functions are normal, except that his 
 sleep is not good, and is apt to be disturbed by dreaming. 
 
 The diagnosis which we have arrived at is that we have 
 to deal with a case of primary contracting kidney, with the 
 associated thickening of the arterial coats and hypertrophy 
 and dilatation of the heart, and with its frequently con- 
 comitant emphysema. And now let us consider in detail the 
 etiology and symptomatology of this complaint as manifested 
 by our patient. 
 
 Etiology. — As you are all well aware, the etiology of con- 
 tracting kidney is rather obscure, but foremost among the 
 conditions which act as etiological factors are the three, — 
 alcohol, lead poisoning, and gout. Now, in our patient you 
 will have remarked there is no distinct history of any of 
 these to be elicited. Of course gout is a very wide term, 
 and in the sense in which it is used in connexion with primary 
 contracting kidney it covers a multitude of conditions ; but 
 when we try to elicit from our patient any history of 
 dyspepsia or such like — of symptoms which might be classed 
 as gouty — we find ourselves baffled, for up to the attack of 
 influenza which he suffered from three years ago, he states 
 
CASE OF PRIMARY CONTRACTING KIDNEY, 47 
 
 that lie has had no ailments whatsoever. To understand this 
 matter better, however, let us first try to understand how such 
 clearly-defined factors as alcohol and lead produce contracting 
 kidney, and see if from this consideration we can get any 
 light. One explanation of this is, that as the result of blood 
 containing alcohol or lead circulating through the kidneys 
 for months or years, a chronic irritation is set up, resulting 
 in the infiltration of the interstitial tissue with leucocytes, 
 and in the formation there of new fibrous tissue, which, 
 contracting, leads to shrinking of the organ as a whole, with 
 consequent pressure upon and obliteration of its tubules 
 and glomeruli to a greater or less extent. This is chronic 
 interstitial nephritis. Others look for an explanation of 
 contracting kidney in " nothing but a simple degenerative 
 atrophy of the renal parenchyma, and in a corresponding 
 gradual increase of the interstitial connective tissue," ^ — that 
 is to say, they believe that, just as fibroid change takes place 
 along certain tracts of the spinal cord when they are shut 
 off from the influence of their trophic realm, so in the kidney 
 when from one cause or other the nutritive power fails, a 
 similar disappearance of the normal structural elements and 
 an appearance of fibrous tissue will occur. Just as sclerotic 
 changes in the spinal cord mean that the more complex and 
 specialized elements, viz., nerve cells and nerve fibres, are 
 from defective nutritive power no longer able to reproduce 
 themselves in their more complex and specialized form, but 
 disappear and are replaced by the less complex and less 
 specialized fibrous tissue, so in the kidneys an exhausted 
 nutritive power will mean more or less disappearance of the 
 specialized elements, viz., the renal tubules and epithelium, 
 and a proportionate increase in the less specialized, viz., the 
 connective tissue. Between chronic inflammation on the one 
 hand and degeneration on the other it is impossible to draw 
 a line, but I think you will see that, looked at in this way, 
 ^ Strumpell, Text-book of Medicine, p. 856. 
 
48 CASE OF PRIMARY CONTRACTING KIDNEY. 
 
 the effects will be the same. Now, it seems to me that to 
 look upon primary contracting kidney as a degenerative 
 rather than an inflammatory process is to take a most 
 reasonable view. 
 
 It will explain the occurrence of the senile kidney — the 
 contracted granular kidney which is found in old people, 
 as being the result of slow failure of nutritive power — and 
 it will account for the contracting kidney of the alcoholic 
 or the lead worker, as being, as it were, a senile kidney 
 brought on prematurely as the result of the overwork which 
 the efforts to withstand the effect of the alcohol or lead have 
 thrown upon it. It will also, as readily as any other theory, 
 explain why the gouty or the rheumatic individual — or one 
 who is dyspeptic as the result of long-continued over-eating, 
 over-working, or mental worry — should be liable to suffer 
 from contracting kidney. In all these we know that faulty 
 metabolism in the organs or tissues will lead to the presence 
 of products more or less irritating in the blood and in the 
 kidneys, and that this, acting like alcohol or lead, will not 
 fail to produce a premature wearing out or senility of the 
 renal parenchyma. 
 
 Further, just as we know that the duration of life of an 
 individual depends not only upon the wearing out to which 
 he is subjected, but upon the amount of vitality with which 
 he is endowed at birth, or, to be more correct, at conception, 
 so with the kidneys. The innate vital power of these organs 
 varies much in different individuals. Wear and tear which 
 in one will be successfully borne for eighty or ninety years, 
 will in another cause what may be termed senile kidneys 
 and death at 35 or 40. Contracting kidney is markedly 
 hereditary. 
 
 If we now apply these considerations to our patient, who 
 at the age of 52 presents definite indications of contracting 
 kidney, all that we can say is — (1), that from the fact that 
 his father died at the age of 42, he may possibly, as regards 
 
CASE OF PRIMAEY CONTRACTING KIDNEY. 49 
 
 his kidneys, be hereditarily rather below par ; (2), that his 
 attack of influenza three years ago may also have aided in 
 the using up of their nutritive energy ; (3), that he may 
 possibly have been taking too much alcohol, and that, as the 
 result of faulty dieting, exposure, etc., some morbid material 
 may have been circulating through his kidneys, and pre- 
 maturely have used up their trophic power. 
 
 One thing seems certain, and that is, that there is no 
 evidence of any parenchymatous nephritis, which might, as it 
 often does, set the fibroid change in action. This is a case of 
 ^primary contracting kidney. 
 
 Symptomatology. — Notice here that what brought our 
 patient to the Infirmary was impaired eyesight. This 
 exemplifies what you will often find, viz., that this disease is 
 frequently first diagnosed by the ophthalmic surgeon. But 
 this exemplifies also something even more important, and 
 that is, that the disease in its earlier, and therefore more 
 remediable, stages is to be recognised by objective signs rather 
 than by subjective symptoms. The main explanation of this 
 is that the impaired function of the kidneys is compensated 
 for by extra work in other tissues and organs, notably in the 
 circulatory system, and that, therefore, with practically entire 
 absence of symptoms, we may have, if we remember to look 
 for them, distinct evidence of the existence of the disease in the 
 presence of cardiac and vascular changes. This, however, will 
 be best understood by discussing the various systems in detail. 
 
 Circulatory System.. — Here the only symptoms of derange- 
 ment are that, on inquiry, we find that he has noticed 
 himself for the past few months more easily put out of 
 breath than formerly. He has no giddiness or other 
 evidence of weak cerebral circulation, and no palpitation 
 nor cardiac pain. On examination, however, we find his 
 heart enlarged, a reduplicated first sound heard over the 
 ventricles, and a loud " pump-valve " second sound, heard 
 loudest in the aortic area. 
 
 D 
 
50 CASE OF PRIMAEY CONTRACTING KIDNEY. 
 
 The cause of the reduplicated first sound and of the pump- 
 valve second sound I believe to be the abnormally high 
 pressure in the left ventricle and aorta. Normally, as you 
 know, the pressure in the left heart is supposed to be three 
 times greater than that in the right ; but in our patient, 
 although we believe the right heart to be somewhat dilated 
 and hypertrophied as the result of the emphysema, we 
 believe that the left heart is proportionately still more so. 
 The extra tension in its cavity, therefore, is the cause of the 
 reduplication of the first sound, because it induces asyn- 
 chronism in the systolic contraction, and in the sudden tension 
 of the valve cusps and cordee tendinis of the two ventricles. 
 The extra tension is also the cause of the pump-valve aortic 
 second sound, because of the greater pressure in and probably 
 also dilatation of that tube. The high arterial tension is shown 
 very well by sphygmographic tracing ; and with the sphyg- 
 mometer the pressure on his admission was found to be about 8. 
 
 But, now, what is the cause of the hypertrophied heart, 
 the high tension, and the rigidity of the vessels ? On this 
 subject a great many theories have been brought forward. 
 Johnson ascribed it to the morbid material in the blood 
 stimulating the vasomotor nerves, and so exercising a " stop- 
 cock " action on the small vessels, the result of which would 
 be to induce heightened blood-pressure, hypertrophied heart, 
 and thickened vessels. Traube's theory, as modified by 
 Cohnheim, is that in the condition of renal inadequacy there 
 is a hindrance to the circulation through the kidney, and that 
 this will react and cause increased blood-pressure in the entire 
 arterial system, and so induce hypertrophied heart, etc. But 
 the view which I think will occur first to you is a simple one. 
 It is, that the kidneys being inadequate, noxious materials 
 are retained in the blood, and that thus the give-and-take 
 interaction between blood and tissue is disturbed. The 
 tissues will thus less readily assimilate their nutritive material, 
 and the blood will therefore require more force to drive it on. 
 
CASE OF PEIMARY CONTEACTING KIDNEY. 51 
 
 Thus can be explained the hypertrophy of the heart. The 
 thickened vessels might be explained in the view that the 
 extra pressure brought about by the hypertrophied heart 
 entails strengthening of the arterial walls. Further, we can 
 suppose that, just as in the heart the compensatory hyper- 
 trophy is apt to be followed in time by fibroid or fatty change 
 in its wall, so in the vessels the hypertrophied elastic or 
 muscular coat is apt in time to show degenerative fibroid or 
 sclerotic changes. But note that, in whatever way induced, 
 this hypertrophy of the heart and high arterial tension is 
 compensatory, and consequently salutary. As cell after cell 
 of renal epithelium is destroyed, as patch after patch of 
 secreting tissue becomes fibrosed, and as, consequently, the 
 renal inadequacy becomes more and more marked, all this is 
 more and more compensated for by the forcing of an extra 
 quantity of blood through the kidneys, and so long as the 
 heart is equal to the extra work, and the vessels to the extra 
 strain, no trouble is caused and no symptoms are induced. 
 Sooner or later, however, the strain begins to wear out the 
 machinery somewhere, but this will be better referred to 
 later on. 
 
 Another symptom which comes for consideration under the 
 circulatory system is the ansemia. This is a common symp- 
 tom in contracting kidney, but it is not present in our patient ; 
 for in him the corpuscles were found to be close on the 
 5,000,000, and the hseraoglobin about 60 per cent. When we 
 reflect that one cause of the anaemia so common in these cases 
 is the loss of albumen by the urine, and that another is the 
 disturbed appetite and digestion, we can understand that our 
 patient should not present ansemia ; for the amount of albu- 
 men in his urine is very small, and his appetite and digestion 
 are fairly good. 
 
 Besinratory System. — A prominent symptom here is dyspnoea 
 on exertion, and the usual causes of this dyspnoea are weakened 
 action of the heart, and probably also ansemia. Among other 
 
52 CASE OF PRIMARY CONTRACTING KIDNEY. 
 
 causes is irritability of the nerve centres ; and in our patient 
 the slight dyspnoea on exertion which he complained of may 
 possibly be ascribed to this, for, as you have seen, his ankle 
 and knee jerks are specially well marked. But a further 
 cause is doubtless the emphysema, which is specially common 
 in cases of contracting kidney, and which is markedly present 
 in our patient. The slight cough which he occasionally suffers 
 from will be due to the emphysema inducing from time to 
 time attacks of bronchial catarrh. 
 
 Digestive System. — In our patient the dyspeptic symptoms, 
 which are so often troublesome in contracting kidney, are as 
 yet markedly absent. His tongue is perhaps slightly furred, 
 but all he complained of was a rather dry mouth, increased 
 thirst, and constipation, all of which can be explained by the 
 large quantity of urine which he is passing. 
 
 Urinary System. — The urine presents, as stated, the charac- 
 ters of contracting kidney : it is large in quantity, pale in 
 colour, low in specific gravity, and it presents albumen and 
 casts. The large quantity is, of course, compensatory, and 
 persists in these cases till a failing heart lowers the arterial 
 tension and increases the venous. With the large quantity 
 of urine the amount of urea per ounce is below the average, 
 although the patient may be excreting the normal amount in 
 the twenty-four hours. In this patient the amount of urea 
 in the twenty-four hours is about 300 grains. 
 
 In such cases, further, the flow of urine per hour at night 
 is specially great, hence increased frequency of micturition at 
 night is often an important symptom. In cases of primary 
 contracting kidney the amount of albumen is usually small, 
 and it is important to remember that it may be absent alto- 
 gether from beginning to end. In this patient it was on his 
 admission about "2 per cent., but it has completely disappeared 
 since. Casts are always to be looked for, and corresponding 
 with the atrophied and degenerated condition of the renal 
 epithelium they are hyaline or granular in character. 
 
CASE OF PRIMAKY CONTRACTING KIDNEY. 53 
 
 Integumentary System. — His skin is dry, and he has noticed 
 that he has not been sweating for a time. As regards dropsy, 
 it is slight, corresponding with the large quantity of urine 
 which he has been passing. As already stated, he has himself 
 observed only a little puffiness of his eyes in the mornings 
 on waking, and we on his admission observed as well a very 
 slight tendency to pitting about his shins and ankles. An 
 interesting question crops up here as to why in such cases 
 the dropsy is observed only about the eyes and only in the 
 mornings ; and this latter phenomenon is all the more interest- 
 ing when it is remembered that, showing itself in the morn- 
 ings, it must have been occurring during the night hours 
 when the flow of urine per hour is apt to be specially great. 
 This point, however, I have referred to in a previous lecture.^ 
 
 Nervous System. — As you all know, symptoms referable to 
 the nervous system are very common in contracting kidney. 
 This can be understood when we remember that any impurity 
 in the blood must readily affect the sensitive nervous tissues. 
 Hence result headaches, neuralgias, sleeplessness, Cheyne- 
 Stokes breathing, etc. Further, we have to remember that 
 alterations in the blood-supply — either too high pressure when 
 the compensation is complete, or too low when it fails — will 
 affect brain metabolism, and cause giddiness, tendency to 
 faintness, etc. In our patient only headaches and disturbed 
 sleep are complained of; but it is of interest to notice that his 
 ankle and knee jerks are distinctly increased, as indicating 
 that his nerve centres are rather more irritable than normal. 
 
 Again, you know that, as the result of the same cause, the 
 mental functions are apt to be affected, — moroseness and 
 irritability of temper are common associates of this condi- 
 tion of renal inadequacy. Our patient, happily, appears to 
 be unaffected in this way ; but one sometimes sees distinct 
 mental impairment, and maniacal attacks supervene in such 
 cases, specially towards the termination. 
 
 * " On a Case of Eenal and Cardiac Disease," p. 32, 
 
54 CASE OF PRIMAKY CONTRACTING KIDNEY. 
 
 [I cannot refrain here from alluding to a patient, L., who 
 was in Ward 30 in December last. This man had been a 
 soldier in India, and some of you will remember him from 
 the fact of the marks shown on his left breast, viz., two double 
 D.'s and a B. C. Though quite quiet and orderly in the ward, 
 he had evidently been, to use a vulgar term, a bad lot in the 
 army; and you will remember we believed we had an 
 explanation of this in the fact that he had had an attack of 
 acute nephritis at the age of 17 years, before he had enlisted ; 
 and that all his symptoms evidenced the existence of 
 secondary contracting kidney, dating from that time. The 
 reading of his case at the clinique forcibly recalled to my 
 mind Eudyard Kipling's story In the MoMer of a Private. 
 Kipling here describes how a certain private Simmons passes 
 into an attack of male hysteria, how he shoots his comrade 
 Losson and also his major, and how he keeps shooting right 
 and left in the barrack square till he is at length overpowered 
 and taken. He is, of course, hanged in hollow square of the 
 regiment ; and then Kipling tells us that the colonel says it 
 is drink, and the chaplain says that it is the devil, but that 
 no one thinks that it is hysteria. Well, in our patient L., I 
 have no doubt that his misdoings in his regiment would be 
 similarly ascribed to drink and to the devil, but I have as 
 little doubt that they were mainly due to renal inadequacy.] 
 
 But a most important symptom which our patient presents 
 is the albuminuric retinitis. This, or rather the disorder of 
 vision which it entailed, was indeed what brought him to 
 hospital. Albuminuric retinitis is said to occur in from 10 
 to 20 per cent, of the cases of contracting kidney, but as 
 regards its cause we have little precise knowledge. We 
 know that it occurs in chronic cases, and often when the 
 general symptoms of kidney disease are slight, hence it is 
 probably due to some morbid material in the blood. It does 
 not seem to be so much due to the consequent cardiac and 
 vascular changes, because we know that hypertrophied heart 
 
CASE OF PRIMARY CONTRACTING KIDNEY 55 
 
 and thickened vessels existing without albuminuria do not 
 induce it. Further, in cases of albuminuric retinitis the 
 prognosis is, as we shall see, very unfavourable, hence we 
 may conclude that it is, at any rate, associated with some 
 defective trophic power on the part of the nerve tissues. 
 
 Prognosis. — In contracting kidney the prognosis is always 
 bad. The disease is progressive, but with care cases may 
 last and work may be done often for many years. Sooner or 
 later, however, changes occur — 
 
 1. Cardiac compensation may fail, and death occurs with 
 symptoms of backward pressure, lung congestion, diminution 
 of the quantity of urine, dropsy, etc. 
 
 2. Cardiac compensation remains good, but a vessel gives 
 way in the brain, and the patient dies from cerebral hsemor- 
 rhage. 
 
 3. Pleurisy, pneumonia, peritonitis, or acute nephritis may 
 occur. 
 
 4. Uraemia may occur. 
 
 5. The fatal issue may result from sudden oedema of the 
 glottis or of the lung, or pulmonary apoplexy. 
 
 In our patient the favourable points are that the specific 
 gravity of the urine is fairly good, and that the heart shows 
 no marked sign of failing compensation, but the albuminuric 
 retinitis makes the prognosis grave. It has been stated 
 again and again that the duration of life in such cases is not 
 over two years. 
 
 Treatment. — As regards diet, non-nitrogenous foods seem 
 to be indicated in those cases, but you have to remember 
 that if the patient is weakly, and more especially if there is 
 any tendency to anemia, some nitrogenous food should be 
 allowed. The patient's feelings are often a good guide in 
 this matter. If he feels an appetite for such, and if he can 
 digest them, the probability is that good will result. 
 
 As regards regimen, care should be taken to keep the 
 skin in proper working order. Flannel should be worn, and 
 
56 CASE OF PRIMARY CONTRACTING KIDNEY. 
 
 occasional baths should be employed, — hot-water or vapour, 
 if Turkish seem too risky. For the bowels, laxatives have 
 usually to be employed. In addition, articles of food which 
 have an effect in this way may be selected, such as fruit, 
 etc. You all know the risks of constipation. Patients with 
 contracting kidney often succumb to cerebral hsemorrhage as 
 the result of straining in the W.C. 
 
 As regards drugs, a combination of the bromide and iodide 
 of potassium often does good ; and for the anaemia, iron, if it 
 can be borne, may be employed. Our patient is getting the 
 bromide and iodide, and we found his general condition and 
 headaches relieved by occasional doses of nitro-glycerine, and 
 by occasional hot-air baths. His headaches have also been 
 relieved by blistering behind the ears. 
 
A CASE OF HYDRONEPHROSIS TREATED 
 BY ASPIRATION, 
 
 Gentlemen, — James W., aged 46, a shoemaker, residing in 
 Edinburgh, was admitted to Ward 30 on January 14, 1896. 
 His complaints were of a burning pain in the left side and 
 across the small of the back, and he drew attention to a 
 swelling in the left side of his abdomen. 
 
 His family history is very good, and as regards personal 
 history, he has always been of temperate habits, and has 
 lived in a comfortable home. When a child he had scarlet 
 fever and small-pox. In 1868 he had an attack of what he 
 calls dysentery. As he has never been out of the country, 
 his diagnosis of this illness is not likely to be correct ; but 
 he seems to have been ill for several months, to have had 
 diarrhoea and tenesmus, with pain in the left side of the 
 abdomen, and to have passed mucus and blood. In 1879 
 patient attended St Mary's Hospital in London, for a com- 
 plaint which he considers in every way similar to that from 
 which he now suffers. He was treated for eight weeks, at 
 the end of which time all his symptoms had disappeared. 
 In 1894 he was ill for three months with what he calls 
 "kidney trouble." He had severe back pain, swelled legs, 
 dyspepsia, and he was very weak. He soon, however, 
 recovered, and the only other points in his personal history 
 are, that he has always suiTered from constipation, and that 
 when young he used to suffer considerably from having to 
 
68 A CASE OF HYDRONEPHROSIS TREATED BY ASPIRATION. 
 
 retain his water for a long time, owing to no convenience 
 being at hand. 
 
 Present Illness. — On December 28 last, patient had occa- 
 sion to be out of doors a good deal, and got a severe chill. 
 He had to keep his bed during the next few days, and 
 had fits of shivering. On the night of January 2, whilst in 
 bed, he felt a burning pain in his left lumbar region. This 
 pain gradually increased for a week, and then became less 
 severe. It was at the end of this week that the patient first 
 noticed the swelling in his abdomen. No improvement 
 occurring, he came to the Eoyal Infirmary and was admitted 
 as above. During the twelve days before his admission, 
 patient suffered from sleeplessness; he could not lie on his 
 right side owing to the pain, and he found relief by 
 sitting in a doubled-up position. He told us also that 
 for ten days previous to his admission the water which he 
 passed was of a red colour, and in quantity much less than 
 normal. 
 
 State on Admission. — Height, 5 ft. 6 ins.; weight, 8| stones; 
 muscularity, poor ; face, sallow ; pulse and temperature, 
 normal. 
 
 Alimentary System. — No subjective phenomena, with the 
 exception of constipation and occasional flatulence. 
 
 Aldomen. — On the left side of the abdomen a swelling is 
 seen, its most prominent point being half an inch directly to 
 the left of the umbilicus. In the nipple line the swelling 
 extends from the costal margin above to the iliac region 
 below. Viewed posteriorly, there is a distinct bulging on the 
 left side. On palpation the swelling is felt to be tense and 
 elastic, of a rounded shape, and about the size of a child's 
 head. It can be moved slightly in the antero-posterior 
 direction. Pressure on it at any part causes slight pain. On 
 percussion all over it a dull note is obtained. In front the 
 dulness extends close up to the umbilicus, so that the 
 tumour, in growing, has pushed the descending colon towards 
 
A CASE OF HYDRONEPHROSIS TREATED BY ASPIRATION. 59 
 
 the right side. Otherwise the abdominal viscera are normal, 
 as are also the circulatory, respiratory, and nervous systems. 
 
 Urinary System.. — Urine averages 50 ozs., pale, acid, and 
 of a specific gravity of 1010. It contains no blood or 
 albumen, and of urea about 5 grains per oz. 
 
 In this patient we came to the conclusion that we had a 
 hydronephrosis of the left kidney, and believing that it was 
 possible that it might in time empty itself along the ureter, 
 as it had done previously in 1879, and as his symptoms 
 presented nothing urgently requiring interference, we deter- 
 mined to give him some days' rest in bed, and wait to see if 
 on this occasion also a similar fortunate development might 
 not occur. "We gave him a placebo, therefore, and watched 
 him every day to see if we could ascertain any diminution 
 in the size of the renal tumour, with any increase in the flow 
 of the urine. We tried to aid this by a little gentle sham- 
 pooing downwards in the direction of the ureter. No change, 
 however, occurring, we determined to interfere, and on 
 January 24 we aspirated. We used a small needle, and 
 punctured rather behind the posterior axillary line, choosing 
 this point because here the parietes are thin, and because 
 here we should best avoid the peritoneum. During the 
 aspiration process we kept up steady pressure all over the 
 front of the tumour, and we drew off 22 ozs. of a fluid 
 resembling port wine in colour, but rather turbid, and having 
 a specific gravity of 1012. This fluid was urine — evidently 
 dilute urine — mixed with blood, the deposit showing micro- 
 scopically red blood-corpuscles, many of them more or less 
 broken down. 
 
 After the tapping, the patient expressed himself as feeling 
 much relieved, but it was noticed immediately that the urine 
 was now coloured and contained blood-corpuscles. Thus 
 we recognised that the hydronephritic sac with its bloody 
 urine was now communicating with the bladder. 
 
 Only to a certain extent, however, for as day succeeded 
 
60 A CASE OF HYDRONEPHROSIS TREATED BY ASPIRATION. 
 
 day we observed that though the blood-stained urine con- 
 tinued, the sac was again distending. Further, with this 
 re-accumulation in the sac, the amount of blood-staining 
 in the urine seemed to be lessening. This we explained 
 in the following manner : — With the sac distended as at 
 A, the ureter was compressed, and so no escape of the sac 
 contents occurred. With the emptying of it by aspiration, 
 the ureter became patent as at B, and so the urine con- 
 tained blood, etc. But the fluid collected again, and the sac 
 again began to compress the ureter, until a condition much 
 like that of the original one had been established. 
 
 On February 8 the tumour appeared to be about as large 
 as it had been before, and although we realized from the 
 condition of the urine that the sac was still discharging into 
 the bladder to some extent, we judged it best to aspirate again. 
 This we did on February 9, and evacuated 26| ozs. of fluid, 
 of sp. gr. 1002, and containing blood and urea as before, but 
 rather lighter in colour. Since then there has been practi- 
 cally no further accumulation, and the urine is perfectly 
 clear. In amount it is about 50 ozs., and in sp. gr. 1015. 
 We therefore believe that the sac is now collapsed, and that 
 although this kidney is, owing to the effects of the hydro- 
 
A CASE OF HYDRONEPHROSIS TREATED BY ASPIRATION. 61 
 
 nephrosis, probably to a large extent destroyed, any urine 
 which it is secreting is passing readily down to the bladder. 
 
 But, now, what is the cause of the hydronephrosis in this 
 patient? The commonest cause in such instances is calculus 
 blocking up the ureter ; and notice, that to produce a hydro- 
 nephrosis the ureter block must not be complete. Sudden 
 complete obstruction by a calculus leads to obstruction 
 behind and rapid dilatation, but this is followed by subse- 
 quent atrophy of the kidney. It is only when the obstruc- 
 tion is incomplete that the kidney can go on secreting 
 sufficiently to produce sacculation, so that if there is a cal- 
 culus in this case, it has not been producing complete 
 obstruction. Other causes are, narrowing of the ureter, by 
 tumours or cicatricial contraction after inflammation. 
 
 In our patient there is no history pointing to renal 
 calculus, and on the two occasions on which we punctured 
 the sac we watched carefully to find if the needle grated 
 against anything like a calculus, but it did not do so. After 
 each tapping we also carefully palpated to see if a stone 
 could be felt, but without success. Then in our patient 
 there is no evidence of tumour, pelvic or abdominal, press- 
 ing on the ureter. A point of some importance, however, is 
 that in 1868 he is said to have had an attack of dysentery. 
 During this attack he seems to have been seriously ill, and 
 to have passed mucus and blood in considerable quantity, 
 and to have had straining. As dysentery is rare in this 
 country, we think it possible that there may have been 
 some enteritis and consequent ulceration about the colon or 
 sigmoid flexure, and we believe it possible that the cicatricial 
 contraction after this may have to some extent constricted 
 the left ureter. What had been the cause of the aggravation 
 of the resulting dilatation in 1879, and again in January last, 
 it is difficult to say. We can easily understand, however, 
 that with a ureter considerably obstructed either from 
 calculus or constriction, some practically accidental cause, 
 
62 A CASE OF HYDKONEPHEOSIS TREATED BY ASPIRATION. 
 
 such as movement or twisting of the body, may have pro- 
 duced aggravation of the obstruction. Then, with the sac 
 being distended more and more, bleeding was likely to have 
 occurred, so that on aspiration we found urine mixed with 
 blood. 
 
 The effects of treatment in this case have been very 
 satisfactory. Any obstruction that there may be in con- 
 nexion with the left ureter is not now causing dilatation, and 
 this affected kidney, and the right kidney which is probably 
 hypertrophied, are together efficiently discharging urea and 
 other urinary products. He was discharged on March 11, 
 1896, feeling quite well and ready for work; and palpation 
 of the left lumbar region revealed neither tenderness nor 
 swelling. We have advised him to wear an abdominal 
 bandage, and we trust that with care to avoid sudden move- 
 ment or twisting, and care also as regards cold, he may keep 
 fairlv well. 
 
ON DIABETES MELLITUS. 
 
 Gentlemen, — We have had in our Ward lately a number 
 of cases of diabetes mellitus, distinctly greater than usual, 
 and we find on inquiry that a similar experience has fallen 
 to the physicians in other parts of our Infirmary. On 
 inquiring of Dr Gillespie, our Medical Eegistrar, I found 
 that for the last seven years the numbers of cases treated for 
 this disease in the hospital have been as follows : — 1888-89, 
 16; 1889-90,17; 1890-91,23; 1891-92,27; 1892-93,32; 
 1893-94, 42 ; 1894-95, 30. It will therefore be seen that 
 there has been a very considerable increase in the number of 
 cases admitted during the last three years. Dr Gillespie has 
 further pointed out to me that there were three periods 
 during which these cases were specially numerous, viz., 
 October and November 1891, December and January 1892- 
 93, and February and March 1894. It is noteworthy that 
 each of these periods coincides with or follows periods 
 during which epidemic influenza was noted to be specially 
 prevalent. Eemembering the depressing effect of influenza 
 on the bodily nutrition, we are not surprised at such results. 
 Doubtless influenza has left other affections in its train, and 
 doubtless also certain of our cases of diabetes mellitus can 
 be shown to be ascribable to other etiological factors, but the 
 special frequence of diabetes during late years, and its asso- 
 ciation, as regards time, with influenza, are well worthy of 
 remark. 
 
 The case of diabetes mellitus which I propose to discuss 
 
64 DIABETES MELLITUS. 
 
 with you to-day is that of a man, T. L., set. 50, a labourer, 
 who was admitted to the Infirmary on 31st October 1895. 
 His complaints were that he was always hungry and very 
 thirsty, and that he had to make water with great frequency. 
 
 His family history is fairly satisfactory, showing no ten- 
 dency to diabetes nor to any other constitutional complaint. 
 He has had the ordinary illnesses of childhood, and has had 
 measles twice, the second attack being when he was 20 
 years of age. When 27 years of age he had an attack of 
 gonorrhoea, and a year later, at which time he was serving 
 as a soldier in India, he had an attack of jungle fever. For 
 the last fifteen years he has been working as a labourer in 
 Leith. He describes himself as having been a moderate 
 drinker, and he states that his surroundings at home and at 
 work have been fairly comfortable. 
 
 His present illness seems to have begun about twelv e 
 months ago. After what was apparently a slight attack of 
 influenza, he remarked a gradual increase of thirst and 
 appetite, and increasing frequency of micturition. He tells 
 us that about every twenty minutes he had to leave his work 
 for the double purpose of obtaining drink and making water. 
 He noticed that he was especially thirsty after meals, and 
 says that it was no uncommon thing for him to drink as 
 much as a quart of water after breakfast. If he had of 
 necessity to do without drink, his mouth had a sticky sensa- 
 tion and his tongue grew hot and dry. During the course of 
 his illness he has been habitually constipated, the bowels 
 being moved at intervals of three or four days. He has also 
 noticed that he has been rapidly losing weight. Twelve 
 months ago he weighed 13 stones 2 lbs., three months ago 
 his weight was 10 stones 12 lbs., at present it is only 10 
 stones Ij lbs. Although not compelled to give up his work, 
 he has been feeling himself grow weaker, and so has sought 
 admission to the Infirmary. 
 
 Present Condition. — Patient is 5 feet 8 inches in height, 
 
DIABETES MELLITUS. 65 
 
 and his weight, as stated, is 10 stones 1^ lbs. He has the 
 appearance of having been a well-developed man, but his 
 muscles are now comparatively small and flabby. 
 
 Alimentary System. — Patient has lost six teeth ; those 
 remaining are nearly all more or less carious, and he states 
 that he has noticed that his teeth have been decaying more 
 rapidly during the past twelve months. His tongue is red 
 and dry, and somewhat furred posteriorly. The oral secre- 
 tion gives a markedly acid reaction with test paper. His 
 appetite is voracious and his thirst insatiable. His digestive 
 power is very good, and he volunteered the information that 
 previous to his illness he could not have eaten or digested 
 what he can do now. Bowels are somewhat constipated. 
 On physical examination of the digestive organs the only 
 noteworthy point is that the liver is slightly enlarged. Its 
 percussion dulness in the nipple line is over 8 inches, and it 
 can be distinctly recognised by palpation below the inferior 
 costal margin. 
 
 Hcemopoietic System. — No enlargement of the lymphatic 
 glands or of the spleen can be detected. 
 
 Circulatory System. — He has no subjective phenomena, 
 except that he feels more easily tired and more easily put 
 out of breath than formerly. Examination of the blood 
 shows its specific gravity to be 1056 (Eoy's method), with 
 6,100,000 red corpuscles, and 106 per cent, of hsemoglobin. 
 The heart is of normal size, and shows no evidence of 
 valvular disease. His pulse is 70 per minute, regular, soft, 
 and compressible. The radial artery is somewhat tortuous, 
 and its wall slightly thickened. 
 
 Respiratory System. — He has no subjective phenomena, 
 and careful examination of the lungs fails to reveal anything 
 abnormal. 
 
 Integumentary System.— Hi^ skin is harsh and dry. There 
 are no eruptions, but over the metatarso-pharyngeal joint 
 of each thumb there are slight scabs. He states that these 
 
66 DIABETES MELLITUS. 
 
 are the results of a slight injury inflicted some weeks ago, 
 and he states that he has noticed that slight injuries to his 
 hands take a longer time to heal now than they did formerly. 
 There is no apparent oedema, hut if we press firmly with 
 the point of the finger on the shin hone near the ankle, 
 we find a very slight amount of pitting. This indicates 
 that in spite of his polyuria there is a slight tendency for 
 the transudation of serum into his tissues at the dependent 
 parts. 
 
 Urinary System. — The patient has balanitis and some 
 pain and irritation on micturition. This began twelve 
 months ago with his present illness. There is increased 
 frequency of micturition, both night and day. Urine, amount 
 250 ozs., pale and slightly opaque. It has an odour some- 
 what like that of sour milk, its reaction is acid, and specific 
 gravity 1032. It contains sugar to the extent of about 8000 
 grains per day. The addition of caustic potass in the first 
 stage of Moore's test causes a cloud, showing that the 
 phosphates are abundant. There is no albumen or other 
 abnormal constituent. 
 
 Nervous System. — His cerebral and mental functions are 
 normal, but he states that he has noticed that his eyesight 
 has been failing for the last three years, and specially so 
 during the last year. The cutaneous reflexes — plantar, 
 cremasteric, and abdominal — are very well marked. The 
 deep reflexes, knee and ankle, are not present. There is 
 no impairment of motion or sensation. His temperature 
 is as a rule subnormal. Such being the phenomena which 
 our patient presents, let us now consider his case in a little 
 more detail. 
 
 Etiology. — Diabetes mellitus is, as you know, more frequent 
 in men than in women, and our patient is rather above the 
 age at which the disease is most prone to show itself. In 
 our patient there is nothing in the family history indicating 
 diabetes, or any other debilitating condition. This, however. 
 
DIABETES MELLITUS. 67 
 
 is not surprising. Although diabetes is markedly hereditary, 
 he is beyond the age at which heredity plays its most im- 
 portant role. Thus, for example, of the last twelve cases of 
 diabetes in my ward, only two showed heredity as regards 
 this disease, and these were aged respectively 15 and 17 
 years, the average age of the others being over 40 years. 
 Excluding heredity, therefore, we must look for something 
 in his personal history which has so lowered his nutrition 
 as to allow the diabetes to supervene. Here the points that 
 call for remark are — that first as a soldier, and later as a 
 labourer, he must have gone through a great deal of wearing- 
 out work, and have suffered many exposures. Probably also 
 he has taken more alcohol than he believes he has. There 
 is no doubt that in a very large proportion of our Infirmary 
 cases of diabetes an alcoholic history is obtainable, and we 
 know that alcohol, like morphia or chloroform, is very apt to 
 produce glycosuria. We know that drinking bouts are often 
 accompanied by temporary glycosuria, and if drinking bouts 
 become common, we can easily understand that the glycosuria 
 may become permanent. Farther, you will remember that 
 in another case of diabetes which we had in our wards 
 lately, the symptoms of diabetes were distinctly noticed to 
 have followed the last of a series of drinking bouts. 
 
 Hard work, exposure, and alcohol have all therefore had 
 their share in inducing his disease. But I think we are 
 right in saying that the attack of influenza which he suffered 
 from about a year ago has been, as it were, the " last straw," 
 and that it has precipitated the onset of the diabetes. 
 
 Symptoms. — A good general idea of the symptoms of 
 diabetes mellitus can be obtained from the analogy of the 
 process of osmosis. Thus the blood, owing to the large 
 amount of glucose in it, will be continuously drawing in to 
 itself fluid from the alimentary canal and from the tissues, 
 and in this way may be explained the thirst, the dryness of 
 the mouth and of the tissues generally, and the usually 
 
68 DIABETES MELLITUS. 
 
 present constipation. Then the glucose, with the fluid which 
 it draws to itself in the blood, can filter readily, and hence 
 may be explained the polyuria and glycosuria. Further, as 
 fast as the glucose is being eliminated by the kidneys, more 
 of it is being sent into the blood, and as fast as fluid is being 
 absorbed from the alimentary canal and tissues, more of it is 
 being ingested by drinking, and so the process goes on. 
 All the symptoms of diabetes cannot be explained in this 
 mechanical way, but many of them can. This we shall 
 understand best by considering them in detail as they occur 
 in connexion with the various systems. 
 
 Digestive System. — The dryness of the mouth and thirst 
 need no further reference; but we find in our patient, as we 
 invariably find in diabetes, that the secretions of the mouth 
 are markedly acid. It has been said that in diabetes the 
 saliva is acid, but this is not so. In this patient, as in all 
 our other cases, we have found that if we produce a copious 
 flow of saliva by stimulating the tip of the tongue with the 
 faradic current, the reaction of the pure fluid is alkaline. 
 The acid reaction of the secretion in the mouth, therefore, 
 is not due to acid saliva, but probably to some acid decom- 
 position. To this acidity is ascribed the rapid caries of the 
 teeth noticed in this disease. In diabetes the appetite is 
 voracious, a symptom which we can readily understand when 
 we remember the enormous loss of oxidizable material which 
 the glycosuria entails. Associated with this, the digestive 
 power is specially good. Our patient tells us that he can 
 now eat and digest quantities of food in a way which he 
 could not have done previous to the onset of his illness. 
 Further, we have had patients who, previous to their 
 diabetes, suffered from dyspepsia even though they attended 
 carefully to their diet, and who, after the disease had 
 supervened, could eat and digest, as they expressed it, any- 
 thing. In this we can recognise one of the many examples 
 of the "vis medicati'ix natu?-ce"; the great loss of sugar 
 
DIABETES MELLITUS, 69 
 
 rendering the ingestion of more food necessary, Nature 
 improves the appetite and digestive power accordingly. 
 The slight enlargement of the liver which this patient 
 presents is common in diabetes, and is probably due simply 
 to hypersemia. 
 
 Hcemopoietic System. — This is apparently normal ; we find 
 no enlargement of lymphatic glands or of the spleen. 
 
 Circvjlatory System. — In most cases of diabetes, as in our 
 patient, examination of the heart and bloodvessels shows them 
 to be fairly healthy. The pulse may be slightly quickened 
 and slightly more compressible than in health, explicable on 
 the theory that the heart as well as the other tissues of the 
 body suffers from a lowered nutritive power. But in con- 
 nexion with the circulatory system in diabetes, the condition 
 of the blood is specially important. In our patient the number 
 of red corpuscles is 6,100,000, and the haemoglobin is 106 
 per cent. N"ow, this extra richness in corpuscles and hsemo- 
 globin which is frequent in this disease is explained by many 
 as being due to a concentration or a thickening of the blood, 
 the result of the polyuria. But were this the case, the 
 specific gravity of the blood would be correspondingly in- 
 creased, and, further, we should find that the specific gravity, 
 the number of corpuscles, and the percentage of haemoglobin, 
 should vary greatly with the amount of food and specially of 
 water ingested. On this subject we have been making some 
 observations during the session. I need not give you the 
 results in detail, but I shall tell you what we have found in 
 this patient (L.), and in the other diabetic (A.) whom we 
 have at present in the ward. This will be sufiicient for my 
 purpose. 
 
 In these men we have examined the blood on several 
 occasions between 5 and 6 a.m., and again between 10 and 
 11 A.M. At the earlier period they had had no food nor 
 water for several hours ; at the latter they had had breakfast 
 and had drunk copiously of water. 
 
70 DIABETES MELLITDS. 
 
 The following gives an idea of the results : — 
 
 Between 5 and 6 a.m. 
 
 (L.) Corpuscles 6,232,000. Hsemoglobin 110 per cent. Sp. gr. 1058. 
 (A.) „ 6,316,000. „ 100 „ „ 1053. 
 
 Between 10 and 11 a.m. 
 
 (L.) Corpuscles 6,100,000. Hasmoglobin 106 per cent. Sp. gr. 1055. 
 (A.) „ 5,056,000. „ 100 „ „ 1050. 
 
 These results show that after ingestion of food and a large 
 quantity of water, a slight diminution alike in the specific 
 gravity, corpuscles, and haemoglobin is remarked, but the fact 
 which stands out prominently is that without any marked 
 alteration from the normal in the specific gravity of the blood 
 the proportion of corpuscles and of haemoglobin remains speci- 
 ally high. I am therefore in the habit of ascribing this charac- 
 teristic of the blood in diabetes again to the " vis tnedicatrix 
 naturce." The amount of oxidizable material being lessened 
 by the enormous loss of sugar in the urine, IsTature tends to 
 compensate for this by increasing the oxidizing elements 
 in the blood, viz., the corpuscles and hsemoglobin. Some- 
 thing analogous seems to occur in other conditions, notably 
 in starvation. If an animal be completely deprived of food, 
 the nutrition of the more important tissues of the nervous 
 system and the heart is obtained by the using up of the less 
 important, e.g., the fat, muscles, glands, etc. ; and with a rapid 
 diminution of the body-weight as a whole, the blood seems 
 to show little diminution either as regards corpuscles or 
 liEemoglobin. 
 
 It must not be forgotten that in certain cases of diabetes 
 a lessening in the richness of the blood will be found. I 
 think, however, I am right in saying that in the earlier cases, 
 and in cases which have still some vigour left, it will be found 
 the rule to meet with no diminution, but even a distinct 
 increase in this respect. Such at least has been my experi- 
 ence ; and when I recall to your minds the pink cheeks and 
 
DIABETES MELLITUS. 71 
 
 red lips which even the emaciated of the diabetics lately in 
 our wards have presented, you will, I think, agree with me 
 in regarding anaemia as anything but a common associate of 
 this disease. 
 
 Bespiratory System. — This in our patient is practically 
 normal. As you all know, lung phthisis and inflammatory 
 affections ending occasionally in lung gangrene are regarded 
 as being of no infrequent occurrence in diabetes, and have 
 been ascribed either specially to some disordered condition 
 of the trophic nerves of the pulmonary organs, viz., the vagi, 
 or to a general lowering of nutrition. This association is 
 shown in the table at page 76 ; here all that need be said 
 is that out of 50 fatal cases of diabetes, 16 died of phthisis 
 and 6 of pneumonia or lung gangrene. But this is not all, 
 for of the 24 cases out of the 50 which died of coma, in at 
 least 8 was there distinct evidence of the existence of chronic 
 or acute lung disease. 
 
 Integumentary System. — Our patient does not complain of 
 itching of the skin, nor are there any boils or carbuncles. 
 But the skin feels harsh and dry, and in the scabs over his 
 knuckles we see indications that skin wounds or abrasions 
 are taking a longer time to heal now than they did formerly. 
 This we shall refer to more fully when we consider the 
 trophic condition of the tissues in diabetes. 
 
 Urinary System. — The balanitis present in this case is due 
 to the sugar in the urine irritating the mucous membrane 
 over which it flows, and is a common feature in diabetes. 
 The increased frequency of micturition, whilst probably also 
 in part due to this irritation, is mainly, of course, the result 
 of the large quantity of water secreted, some 250 ozs. This, 
 supposing that the ordinary capacity of his bladder is 12 or 
 14 ozs., means that it must be emptied some eighteen or 
 twenty times in the twenty-four hours. Usually in diabetes, 
 as in health, the amount of urine passed per hour is distinctly 
 greater during the day hours than during the night hours, 
 
72 DIABETES MELLITUS. 
 
 this being accounted for by the food and water ingested 
 during the day period. With this we usually find that the 
 specific gravity of the urine and the amount of glucose and 
 urea excreted is greater during the day hours. But it is 
 not to be forgotten that the proportion per hour of day 
 urine and night urine is markedly altered from that of health. 
 In a certain number of our cases of diabetes the proportion 
 of urine passed per hour during the night has been as great 
 as that passed during the day, in some indeed distinctly 
 greater, resembling in this respect what we so often find in 
 the polyuria of contracting kidney. Further, in such in- 
 stances the differences between night and day urine as 
 regards specific gravity and amount of sugar and urea we 
 have again and again found to be not very great, all of which 
 observations seem to indicate that in the production of the 
 polyuria and glycosuria of diabetes mellitus other factors 
 than those of simple osmosis must be at work. 
 
 In our patient the following represents the state of the 
 urine before and after the administration of diabetic diet : — 
 
 1. Average for six days on ordinary diet. 
 
 Quantity. Specific Gravity. Sugar. Urea. 
 
 256 ozs. 1040. 8154 grs. 1101 grs. 
 
 Mghest, 292 ozs. liigliest, 1044. Hghest, 13,206 grs. highest, 1916 grs. 
 
 lowest, 204 ozs. lowest, 1032. lowest, 5313 grs. lowest, 549 grs. 
 
 2. Average for six days on diabetic diet. 
 
 Quantity. Specific Gravity. Sugar. Urea. 
 
 96 ozs. 1038. 1886 grs. 1170 grs. 
 
 highest, 120 ozs. highest, 1043. highest, 2316 grs. highest, 1400 grs. 
 
 lowest, 72 ozs. lowest, 1032. lowest, 1680 grs. lowest, 756 grs. 
 
 Here it will be noticed that the main difference in the 
 urine before and after the diet is in its quantity and in the 
 amount of sugar. Less glucose passing into the blood from 
 the food means less to be excreted by the urine, and means 
 
DIABETES MELLITUS. 73 
 
 also lessened osmosis, so that there will be less thirst and 
 less urine passed. But the large amount of nitrogenous food 
 explains why the amount of urea should not be diminished 
 after the administration of diabetic diet, and this and the 
 lessened amount of water in the urine accounts for the 
 persistence of the high specific gravity. We have found 
 also, as stated previously, that in our patient the phosphates 
 seem increased, and this both before and after the diet was 
 employed. We have tested for acetone with Lugol's test 
 — a few drops of nitroprusside of sodium and caustic soda 
 — but the red colour did not give place to the purple on 
 the addition of acetic acid. 
 
 Reproductive System. — The lessening of the sexual desire 
 which is common in diabetes does not seem to have 
 occurred in this patient, and in this connexion it is inter- 
 esting to note also that his cremaster reflex is specially 
 well marked. 
 
 Nervous System. — Our patient is by no means dull or 
 apathetic. His superficial reflexes — plantar, cremasteric, 
 abdominal, and epigastric — are all well marked; but his 
 deep reflexes — i.e., the knee and ankle jerks — are absent. 
 This presence of, or perhaps increase in, the superficial 
 reflexes, and lessening of the deep, we have found to be 
 very common in our diabetic cases. There is no evidence of 
 peripheral neuritis. On looking up my notes, I find that 
 of the 15 cases of diabetes which we have had in our wards 
 lately, only one had peripheral neuritis. This affected only 
 the left leg, and you will remember that we explained this 
 limitation as being probably the result of an old injury 
 sustained by that limb. 
 
 Our patient's sight is fairly good, his accommodation is 
 very good for his age, and there is no evidence whatever of 
 cataract. Here you may ask, What are the causes of the 
 diabetic cataract and of the neuritis ? Both of these have 
 been ascribed directly to the sugar in the blood,— the cataract 
 
74 DIABETES MELLITtrS. 
 
 to its causing drying of the lens by osmosis, the neuritis to 
 its giving rise to the development in the blood or tissues 
 of toxic substances, acet-acetic acid or crotouic acid, or 
 whatever they may be, and thus producing neuritis, just as 
 alcohol or lead or other toxic substances can produce it. 
 Probably, however, the causation of these is not so simple, 
 and this leads us to the consideration of the trophic condition 
 in diabetes. 
 
 Trophic Condition. — That there is great disturbance here 
 is evidenced by the rapid loss of weight. This is associated 
 with the drain upon the body from the glycosuria and in- 
 creased excretion of urea. The impairment in this trophic 
 power is also indicated in our patient by the fact that 
 wounds or abrasions of the skin of the hands have been 
 noticed to take a much longer time to heal than they did 
 formerly. In this connexion we had two cases in our wards 
 lately, which showed this impaired nutritive condition to a 
 much greater extent than this patient does. One of these 
 was a patient, M., who was sent to us from the surgical 
 house. He had gone there to be treated for deep-seated 
 inflammation and suppuration in the palm of his left hand, 
 which he believed had been due to a poisoned wound. The 
 effects of treatment in the surgical house being most unsatis- 
 factory, his urine was tested, and found to contain sugar. 
 When he came down to us in Ward 30 we had little 
 difficulty in making out that the diabetes had been existent 
 for months, although unknown to himself, and that the 
 inflammatory changes and absence of healing power in his 
 hand were to be ascribed to this disease rather than to 
 anything of the nature of a poisonous substance having been 
 allowed to enter his tissues. The second case occurred in 
 my ward two years ago, and illustrates even better than 
 this how diabetes mellitus may reveal its presence by 
 trophic disturbance. A man, E., aged 30, had been knocked 
 over in the street by a van, and one of the wheels either ran 
 
Diabetes mellitus. 75 
 
 over or bruised his right thigh. He was brought at once 
 from the street where the accident had occurred into the 
 Infirmary to the surgical wards. There it was found that 
 no fracture had occurred, and the injury appeared to be 
 simply a bruise, which it was expected would be recovered 
 from in a comparatively short time. After a few days, 
 however, it was noticed that inflammatory and suppurative 
 changes were occurring at the seat of the injury. Incisions 
 were made into these, but the evacuations of pus brought 
 about no improvement. In the course of a few days 
 inflammatory and suppurative changes were noticed to be 
 extending up and down the thigh, the pus burrowing 
 between the muscles and in the subcutaneous tissue, so that 
 the skin over the greater part of the anterior and inner 
 aspect of the thigh sloughed. The urine was then exa- 
 mined, and found to contain sugar, and he was sent down 
 to our ward, where after about two weeks he died. On 
 careful inquiry we found that this man had noticed in- 
 creased urination and increased thirst for some six months 
 before his accident, and taking everything into consideration, 
 we came to the conclusion that in causing this patient's 
 death the diabetes was the more important factor. Lastly, 
 in connexion with the trophic condition, we have to re- 
 member the liability of diabetics to such diseases as phthisis, 
 pneumonia, lung gangrene, and erysipelas. 
 
 Fatliologij of Diabetes. — In a clinical lecture, a detailed 
 consideration of the pathology would be inappropriate, but I 
 think that some good general ideas on this subject can be 
 brought to your minds by regarding the pathological con- 
 dition as being to a large extent the result of one or other 
 or all of these three main factors : — 
 
 1. That the starchy and saccharine constituents of the 
 food, transformed by the digestive process into grape sugar, 
 are carried by the portal system to the liver. There, 
 instead of being transformed into glycogen and stored up, 
 
76 DIABETES MELLITUS. 
 
 this grape sugar is allowed to pass unchanged by the 
 hepatic vein and inferior cava to the heart and arteries. 
 
 2. That the starchy and saccharine constituents of the 
 food, transformed by the digestive act into grape sugar, 
 are carried by the portal system to the liver. There this 
 grape sugar is transformed into glycogen, but this glycogen 
 is retransformed into grape sugar in more than normal 
 rapidity and degree, and sent as such by the hepatic vein 
 and vena cava to the heart and arteries. 
 
 3. That the starchy and saccharine constituents of the 
 food, transformed by the digestive process into grape sugar, 
 are carried by the portal system to the liver and trans- 
 formed into glycogen. This glycogen is retransformed into 
 grape sugar in normal degree, and sent in normal amounts 
 by the hepatic vein and vena cava to the heart and arteries. 
 But the tissues, owing to a general defect in their nutritive 
 powers, are unable to assimilate this grape sugar, and so it 
 accumulates in the blood and produces the symptoms of 
 diabetes. 
 
 Now it must not for a moment be supposed that this com- 
 prises all the pathological factors of the disease. G-lycosuria 
 can occur on a flesh diet, and can be induced artificially in 
 animals when completely deprived of food, thus showing 
 that grape sugar can be formed from flesh food and from 
 proteid tissue metabolism. But if you ask me to which of 
 the three factors I ascribe the most importance, I unhesi- 
 tatingly say, to the third. It seems to me that diabetes is 
 a disease not so much the result of disordered function of 
 one oro-an, the liver, as of some disordered trophic condition, 
 affecting the tissues generally. I am aware that destruction 
 of one organ, the pancreas, can produce glycosuria; I am 
 aware that in this case the onset of the disease can be 
 explained on the theory that the resulting cessation of the 
 internal secretion of the pancreas renders the tissues unable 
 to assimilate the sugar brought to them by the blood ; and 
 
DIABETES MELLITUS. 
 
 77 
 
 I am aware that a like cessation of some internal secretion 
 of the liver may have a similar effect. But I think that 
 a study of the etiology of the disease, its marked heredity, 
 and its tendency to occur when, as the result of some 
 innate or acquired conditions, there is impairment of the 
 nutritive power as a whole, all point to some more general 
 pathological cause. 
 
 Prognosis. — In our patient the immediate prognosis is 
 fairly favourable, but the ultimate prognosis is bad. His 
 age and good general condition are in his favour, but the 
 loss of sugar and urea is great, and the effects of diet are 
 not proving of any great avail, so that we cannot but 
 prognosticate unfavourably for him in no long time, prob- 
 ably within the next two years. How is his case likely 
 to terminate ? To form an idea on this point I give you a 
 summary of the causes of death in 50 cases of diabetes as 
 detailed in the pathological records of the Edinburgh Eoyal 
 Infirmary, and from these you will, I think, be able to 
 draw your own conclusions. 
 
 No. of 
 Cases. 
 
 Cause of Death. 
 
 Males. 
 
 Females. 
 
 Average Age 
 of Males. 
 
 Average Age 
 of Females. 
 
 24 
 
 Coma. 
 
 17 
 
 7 
 
 31 
 
 25 
 
 16 
 
 PhtMsis. 
 
 12 
 
 4 
 
 31 
 
 24 
 
 6 
 
 Pneumonia or 
 gangrene of lung. 
 
 All 
 
 
 36 
 
 
 4 
 
 Erysipelas or 
 gangrene of exter- 
 nal parts, tlie result 
 of accident or opera- 
 tion. 
 
 3 
 
 1 
 
 
 
 This shows that coma is the commonest cause of death, 
 and that next follows phthisis, the ages being in each case 
 much the same. Pneumonia and gangrene of the luno- are 
 less frequent causes, and tend to occur at a rather later age. 
 Other causes of death are what might be called accidental. 
 I cannot refrain at this stage from mentioning that in 
 
78 DIABETES MELLITUS. 
 
 the pathological reports of the Infirmary for the year 1851 
 I find that in two cases of diabetes which had died of coma, 
 atrophy of the pancreas is noted to have been found by the 
 then pathologist, Dr W. T. Gairdner. This is, of course, 
 interesting in connexion with the more recent investigations 
 as regards pancreatic diabetes. 
 
 Treatment. — Our patient has been put upon diabetic diet, 
 and we are doing what we can to keep his skin function in 
 good order. Warm flannel clothing is of course essential 
 for this, but hot baths, or even for patients who can stand 
 it, Eussian or Turkish baths at intervals, may be employed. 
 As regards drugs, with the exception of opium or codeia, we 
 do not know of any which have a marked effect on the 
 glycosuria, but we know that with such treatment as cod- 
 liver oil, and with arsenic in increasing doses, we often get 
 general improvement, and these drugs we are now giving 
 to our patient. We have seen cases which did remarkably 
 well on milk alone, and I had a patient lately who seemed 
 to be improved by euonymin, which I gave him on the 
 theory that whatever affected beneficially the biliary func- 
 tion of the liver might have a like effect on the glycogenic. 
 Then we must remember that whatever improves the mental 
 and general condition has a beneficial effect on the disease, 
 and so we must endeavour to arrange that diabetic patients 
 be shielded from all business cares and worry, and that they 
 should have all the good which change of air and scene 
 alone can give. 
 
 If in time the patient declares that he can no longer 
 eat and digest the gluten bread and almond cakes, or if 
 the craving for wheaten bread and potatoes can be no longer 
 resisted, the best form in which to give these is toasted. 
 In such circumstances we not infrequently find that the 
 allowance of a little toasted bread or chip potatoes may 
 appear to be rather beneficial. In time, too, opium or some 
 of its derivatives may be required, but these should only be 
 
DIABETES MELLITUS. 79 
 
 used with caution. For the coma, when it occurs, little can 
 be done. On the theory that it is due to the liberation 
 of some acid, the injection into a vein, or subcutaneously, 
 of a 3 per cent, solution of sodium bicarbonate has been 
 advised. So also has the inhalation of oxygen, but neither 
 of these has been found to be of much use. 
 
TWO CASES OF LIVER CIRRHOSIS IN 
 CHILDREN. 
 
 ' Gentlemen, — Cases of cirrhosis of the liver in children 
 are distinctly uncommon. Thus, whilst in the post-mortem 
 records of the Eoyal Infirmary I find in 710 adult cases there 
 were eight of liver cirrhosis, in the same records of the Sick 
 Children's Hospital I find that in the same number of cases 
 there is not one of this disease. Yet within the last year we 
 have had in the ward two examples of this affection. In both 
 of these, as we shall see, there were indications of tubercular 
 mischief, and inasmuch as in other cases of this disease in 
 children which have been reported there have frequently 
 occurred manifestations of tubercle, and as in children the 
 disease cirrhosis presents certain important peculiarities, I 
 have thought that we might, with profit, spend our time to- 
 day in the consideration of those cases. 
 
 The first is that of a little boy, James C, aged 6, from 
 Cowdenbeath, who was admitted to Ward 30 on March 16, 
 1895. His complaints on admission were swelling of and pain 
 in the abdomen, and occasional diarrhoea, and it was stated 
 that he had been ill for about two years. His family history 
 was good ; his father and mother are both healthy looking. 
 There are three other members of the family, all of whom are 
 in good health, and no family history of tubercular disease 
 can be elicited. 
 
TWO CASES OF LIVER CIRRHOSIS IN CHILDREN. 81 
 
 Personal History. — He was not weaned until after twelve 
 months old, and from this period onwards he has been in the 
 habit of taking much the same kind of food as his parents. 
 Up to the time of his being taken ill the house in which he 
 lived was dry and healthy. 
 
 Present Illness. — This dates from an attack of measles two 
 years before his admission (1893). This left the patient 
 decidedly weaker, and about eighteen months before admission 
 swelling of the abdomen was first noted. This swelling 
 became more and more marked, but no other symptom seems 
 to have appeared until New Year 1895, when diarrhoea set 
 in. The stools were noticed to be greenish in colour, and had 
 a fcetid odour. About this time, also, slight pains, referred 
 to the epigastrium, but not particularly associated with the 
 ingestion of food, were complained of. The pains got worse 
 as time went on, till at last the patient was caused to cry out 
 with them, and was kept awake at night. As he continued 
 to get worse, he was recommended to come to the Infirmary, 
 and was admitted as above. 
 
 State on Admission. — He is fairly well grown for his age, 
 but is lacking in muscularity, and his thin arms and legs 
 contrast markedly with the large abdomen. The conjunctivEe 
 show a distinctly yellow tinge. His temperature is normal; 
 his pulse is usually about 90. He presents at present none 
 of the appearances of suffering ; indeed, he looks bright, con- 
 tented, and happy. 
 
 Alimentary System. — The tongue is clean and pink in 
 colour. He is always keen for his food ; in fact, he has no 
 sooner finished one meal than he wants to know when he is 
 going to get the next. He has occasionally some pain in the 
 epigastric region, but this pain bears no relation to the taking 
 of food. He has no vomiting, and at present the bowels are 
 regular. The fgeces are fairly well coloured. 
 
 On examination, the abdomen is large and globular in 
 shape. Branches of the internal mammary and epigastric 
 
82 TWO CASES OF LIVER CIRRHOSIS IN CHILDREN. 
 
 veins are seen to be distended, and to be coursing upwards 
 over the abdominal wall. At times a transverse ridging 
 (Wyllie's " ladder pattern "), due to coils of rather distended 
 intestine, can be made out on the thinned abdominal wall, 
 and slight peristaltic movements occasionally show. 
 
 On palpation the abdomen is found to be soft and elastic, 
 and no pain can be elicited anywhere, even on firm pressure. 
 The enlarged liver can easily be detected by palpation. Its 
 lower border is felt rather sharp and hard, but here and there 
 over the edge and upon the anterior surface of the organ 
 distinct nodulation is to be felt. By percussion, deep liver 
 dulness is found to begin in the nipple line, about the third 
 rib, and to extend one inch below the costal margin. In the 
 nipple line, therefore, the extent of liver dulness is about 
 5| inches. In the middle line the lower border of the liver 
 extends 2 inches below the lower border of the xiphisternum. 
 The spleen is markedly enlarged. It can be palpated in the 
 left hypochondriac and upper lumbar regions. On percussion, 
 its extent in its long diameter is found to be over 6| inches. 
 
 Hmmo^poietic System. — ISTo distinctly enlarged lymphatic 
 glands can be felt in the mesentery or elsewhere. 
 
 Circulatory System. — This is practically normal. The pulse, 
 however, is small, and of rather low tension. 
 
 Respiratory System. — Practically normal. 
 
 Urinary System. — No subjective phenomena. The urine 
 is dark amber in colour, acid in reaction, and sp. gr. 1022. 
 Except a trace of bile, it contains no abnormal constituents. 
 
 In the ward this boy was dieted at first on milk and starchy 
 food ; afterwards he got a little fish, chicken, and pudding. 
 As to drugs, we gave him TT{,5 liq. hydrarg. perchlor. with 
 TTL3 liq. morphias for the first two weeks. After this he 
 got simply the liq. hydrarg. We also, during the last few 
 weeks he was in hospital, rubbed in little pieces, the size 
 of a pea, of the unguentum hydrarg. every night over the 
 abdomen. During his stay in hospital he was bright and 
 
TWO CASES OF LIVER CIRRHOSIS IN CHILDREN. 83 
 
 happy, and free from pain ; but in his condition we remarked 
 no distinct improvement. His weight remained very much 
 as it had been on admission, i.e., 3 st. 3 ]bs. His abdomen 
 remained large, and there was no alteration in the size of the 
 liver and spleen. He left the hospital on July 16, and the 
 doctor who was in attendance now informs me that since his 
 return home he got gradually weaker, that ascites supervened, 
 and that he died in the end of last December. 
 
 The next case is that of the patient I show you, Bridget G-., 
 aged 10, a schoolgirl, residing in Edinburgh, and who was 
 admitted 18th January 1896, complaining of swelling of the 
 abdomen, occasional pains in the right side, and troublesome 
 cough and spit. 
 
 Family History. — Her father died of heart disease; her 
 mother is alive and healthy. She has two sisters and two 
 brothers alive and well. One brother died after vaccination, 
 and there was one child still-born. 
 
 Personal History. — Although her home is fairly comfort- 
 able, her food has all her life been not very good. She has 
 had none of the ordinary diseases of children, but her mother 
 states that she has had a cough practically all her life. 
 
 Present Illness. — According to her mother's statement she 
 has been delicate ever since a fall down the stairs which she 
 had when she was two years of age. This accident seems to 
 have weakened her, and the next important point is that 
 about a year after this, when she was three years of age, she 
 awoke one night with severe pain in the right side. Hot 
 fomentations were applied, and the pain subsided, but in the 
 morning it was noticed that she was jaundiced. This jaundice 
 does not seem to have been very bad, for, on her being taken 
 next morning to the Children's Hospital, she was treated 
 there as an out-patient. Although apparently not seriously 
 ill, she has remained weakly ; she has had cough in the winter 
 months, and frequent spitting of blood. Two years ago, as 
 
84 TWO CASES OF LIVER CIKllHOSIS IN CHILDREN. 
 
 she was feeble, and as the jaundice seemed rather worse, she 
 was brought to the Royal Infirmary, and admitted to Ward 
 24. After staying some weeks there, she was discharged 
 improved, but she was still weak, and the slight jaundice 
 had never completely gone. Last winter her cough was 
 specially severe, and she brought up larger than usual 
 quantities of blood. It was then that the enlargement of the 
 abdomen seems to have been remarked"; her mother states that 
 her clothes were tight one day and loose the next. She was 
 treated at the Dispensary, and with the advent of summer 
 she improved, and was able to go to school. As the winter 
 came on she got ill again ; she complained of occasional pain 
 in the right side. Her cough became worse, and so she 
 was brought to the Infirmary. 
 
 StaU on Admission. — She is a dark-haired, dark-eyed, 
 rather gipsy-looking girl. She is thin and anaemic, and her 
 skin is dry and earthy-looking. There is slight yellow 
 coloration of the conjunctiva. The pulse and temperature 
 are practically normal. 
 
 Alimentary System. — Her appetite is variable ; at times 
 she can eat great quantities, at other times very little. The 
 tongue is clean, and the lips and gums are well coloured. 
 She complains of no discomfort after eating. Bowels are 
 regular; fseces are coloured. Inspection of the abdomen 
 shows that it is enlarged. The branches of the internal 
 mammary vein in the epigastric region are specially distended, 
 but there are enlarged veins also in the hypochondriac, lumbar, 
 and hypogastric regions. There is no evidence of ascites. 
 The liver is distinctly enlarged. In the nipple line, deep 
 dulness begins above at the fourth rib, and extends down- 
 wards 2| inches below the costal margin. In the middle 
 line, the liver dulness extends 2| inches below the xiphi- 
 sternum. The liver can be palpated easily ; it is very firm in 
 consistence, and over its surface, and at places on its otherwise 
 sharp edge, little nddulations can be felt. The spleen is 
 
TWO CASES OF LIVEK CIKRHOSIS IN CHILDREN. 85 
 
 much enlarged ; it can be felt in the left hypochondriac region, 
 and its anterior border can be traced to within an incli of 
 the umbilicus. 
 
 Circulatory Syste7n is normal, with the exception of a 
 soft blowing murmur, loudest at the mitral area (hsemic). 
 
 Respiratory System. — She has had a cough, spit, and 
 occasional heemoptysis. 
 
 Over the right apex, especially posteriorly, there is distinct 
 percussion impairment, a somewhat bronchial character of 
 breathing, and increase in the vocal resonance. 
 
 Since she came into the hospital she has had very little 
 cough and no spit, so that the examination of the latter for 
 the tubercle bacillus could not be carried out. 
 
 Urinary System. — No subjective phenomena. Urine amber 
 in colour, acid, sp. gr. 1023, shows a slight trace of bile. 
 
 In these two patients we believe that we have examples 
 of cirrhosis of the liver. Now, one of the first considerations 
 which will strike you is that in both of them there is not 
 only no diminution of the liver, but a distinct increase in its 
 size. In this connexion it is to be remembered that this is 
 the rule in liver cirrhosis of children. The explanation of 
 this we shall defer until we are considering the course and 
 prognosis of the disease. But although this sign is absent, 
 we have, in the indications of portal obstruction which our 
 patients present, distinct grounds for our diagnosis. 
 
 Let us now consider these signs of portal obstruction. 
 These are, first of all, the enlargement of the spleen, explained 
 by the great increase of pressure in the portal system. In 
 both of our patients the splenic enlargement is marked. The 
 notches or nicks which one looks for on the anterior border 
 are, however, not distinctly felt. Next we have to notice 
 the enlargement of the veins on the abdominal wall. This 
 is due to the portal blood finding an obstacle to its passage 
 through the liver, and so forming an anastomosing circulation 
 
8b TWO CASES OF LIVER CIREHOSIS IN CHILDREN. 
 
 through the systemic veins. This anastomosis is mainly — in 
 the stomach, between portal branches and oesophageal veins ; 
 in the liver, through the falciform ligament and perihepa- 
 titic adhesions between^portal branches and diaphragmatic, 
 internal mammary, and epigastric veins ; in the mesentery, 
 between portal branches and lumbar veins, and at the lower 
 end of the intestinal tube, between the hsemorrhoidal veins 
 and branches of the iliac and hypogastric veins. 
 
 In this way, in a well-marked case of cirrhosis of the 
 liver we can see enlarged and often tortuous veins all over 
 the abdominal wall. When these, as is sometimes seen, 
 form a distinct ring round the umbilicus, the term " caput 
 medusae " is applied to the condition. 
 
 The importance of this anastomosis is very great, for it per- 
 mits of the return of portal blood to the heart when through 
 increasing obstruction in the liver the circulation through 
 that organ is becoming interrupted. In this way we can 
 explain the very striking improvement which we sometimes 
 meet with in such cases. Thus some of you may remember 
 the man L., who occasionally comes up to our ward. Over 
 twenty years ago this man w^as in the Infirmary with ascites, 
 and other symptoms of cirrhosis of the liver. He was then 
 tapped nineteen times, some 400 ozs. of fluid being removed 
 on each occasion. He then began to improve, and since 
 then, although his liver is smaller than it was, and though 
 he is thin and feeble, he has had alsolutely no fluid in his 
 abdominal cavity, and has been able to move about in a 
 quiet way. 
 
 Ascites is, as you can understand from what we have just 
 been saying, a very common symptom of cirrhosis of the 
 liver. In neither of our two patients has it been present to 
 any appreciable extent whilst they were in the hospital. 
 
 In the little boy, however, as we are told by the doctor 
 who attended him, it was present towards the end, requiring 
 tapping. 
 
TWO CASES OF LIVEK CIRRHOSIS IN CHILDREN. 87 
 
 Other symptoms of portal obstruction are gastro-intestinal 
 catarrh, due to congestion of the mucous membrane of the 
 alimentary tract, and as the result of this congestion 
 haematemesis and meleena may occur. In neither of our 
 cases is there any history of haematemesis or melsena, but in 
 both there have been indications from time to time of gastro- 
 intestinal catarrh. 
 
 Jaundice, which is not a common symptom of cirrhosis in 
 the adult, is very common in the cirrhosis of children, and is 
 probably due to a spread of the duodenal catarrh into the 
 bile ducts. It is not usually severe ; in our two cases there 
 is only a slight coloration of the conjunctiva, and a slight 
 trace of bile in the urine. The skin is hardly tinted, and the 
 fseces are fairly normal as regards colour. 
 
 Pain in cirrhosis is not often very acute. The slight 
 pains felt over the liver are probably due to perihepatitis. 
 In the little boy patient the severe pains felt over the 
 abdominal wall were, I believe, due to colic, the result of 
 some tubercular enteritis. In the girl, the occasional attack 
 of severe pain in the region of the liver, followed by slight 
 jaundice, seemed to indicate some obstruction of the ducts, 
 probably from inspissated bile. The emaciation which our 
 patients show can easily be explained. We can readily 
 understand that with portal obstruction the elaborating 
 ejffects of the liver on nutritive material derived from the 
 food will be interfered with. 
 
 Etiology. — The main cause of cirrhosis is some irritant, 
 carried to the liver capillaries by the blood, and causing 
 there an increased growth of the less specialized fibrous 
 tissue, and corresponding disappearance of the more 
 specialized liver parenchyma. Now, the blood going to the 
 liver is of two kinds — portal blood and hepatic artery blood 
 — and so the irritant may be carried by either of those 
 channels. But it is evident that portal blood and hepatic 
 artery blood are constantly intermingling, and so, although 
 
88 TWO CASES OF LIVER CIRRHOSIS IN CHILDREN. 
 
 we may be permitted to say that, for example, in alcoholic 
 cirrhosis the irritant is carried mainly by the portal blood, 
 and in syphilitic cirrhosis mainly by the hepatic artery blood, 
 we yet must recognise this intermingling, and remember that 
 in a large number of cases we cannot say definitely through 
 what channel the irritant is carried. Alcohol, which is 
 probably the most common cause of the disease in the adult, 
 is also unfortunately a not uncommon cause of it in children. 
 We are sure, however, that in neither of our cases has it 
 been the factor, although, curiously, I find that in a case of 
 cirrhosis in a girl lately in Dr Af&eck's ward it has been 
 undoubtedly the cause. In our cases also we have excluded 
 syphilis, and in neither have we any ground to ascribe it to 
 malaria. 
 
 But in dyspepsia of all kinds, and from any cause, we can 
 readily understand that an important factor may be recog- 
 nised. As the result of it, some abnormal and consequently 
 irritating products will be ca,rried by the portal system to 
 the liver, and these will in time induce the disease. In the 
 case of the boy there was, I believe, tubercular enteritis. 
 In the case of the girl there was a history of long-standing 
 dyspepsia. But, further, in the girl's case also there was 
 distinct suspicion of tubercular lung mischief; and it is 
 interesting to remember that the association in children of 
 liver cirrhosis and tubercular disease has been again and 
 again remarked. 
 
 To fevers the onset of liver cirrhosis in children has also 
 been ascribed, the pathological explanation of this being the 
 cell infiltration which takes place in kidneys, liver, and other 
 organs during fever. In this connexion it is important to 
 remember that in the boy patient the illness seemed to date 
 from an attack of measles. 
 
 Taking all these etiological elements into consideration, I 
 am inclined to think that in both of our cases the tubercular 
 factor has been the most important. "Whether, however, it 
 
TWO CASES OF LIVER CmRHOSIS IN CHILDREN. 89 
 
 has acted indirectly through dyspepsia, or more directly 
 through changes induced in the liver substance (tuberculous 
 cirrhosis), I cannot say. 
 
 The course of liver cirrhosis in children is eminently 
 unsatisfactory. There is little doubt that in cases which are 
 slightly advanced recovery may readily occur if the cause 
 can be removed. But when the portal obstruction has 
 become so marked as to cause great enlargement of the 
 spleen, ascites, or the establishment of a well-marked anasto- 
 motic venous circulation, the prognosis is very unfavourable. 
 In time the patient gets more and more emaciated and feeble, 
 and ascites, requiring repeated tapping, establishes itself. 
 The direct cause of death may be some complication like 
 peritonitis or pneumonia, or coma due to the presence of 
 some toxin in the blood. A most noteworthy point is that 
 in children the diminution in the size of the liver, so marked 
 in adults, has very seldom been observed. This is explained 
 on the ground that the course being more rapid in children, 
 the organ has not in them sufficient time to contract. 
 
 As regards treatment, this is mainly dietetic and hygienic. 
 Our patients were dieted on milk and starchy foods, with a 
 little fish or chicken. "When necessary, laxatives are indi- 
 cated to relieve portal congestion. Both of our cases 
 seemed to be improved by small doses of mercury ; and in 
 the boy's case, as already stated, we made use also of 
 mercurial inunctions. 
 
A CASE OF DYSENTERY TREATED BY 
 DEEMETINISED IPECACUANHA. 
 
 Gentlemen, — John M., aged 29, a labourer, formerly a 
 soldier, born and residing in Edinburgh, was admitted to 
 Ward 30, on October 19, 1895, complaining of dysentery, 
 and stating that he had been ill for six weeks. His family 
 history is very good, and his home is comfortable, but as a 
 labourer he is exposed to all sorts of weather. As regards 
 previous illnesses, he had had scarlet fever as a child, and 
 an attack of acute Bright's disease at the age of 20. He 
 recovered from this completely, and then enlisted. As a 
 soldier he went to India, and at Umballa he had an attack 
 of dysentery which lasted for one month. After this he had 
 ague several times, but his general health seems to have kept 
 good, and he left the army about a year ago and took to 
 work as a labourer. 
 
 Present Illness. — This began six weeks ago with diarrhoea, 
 pain in the bowels, loss of appetite, and vomiting. The 
 bowel evacuations were very frequent, eight or nine evacua- 
 tions during the day, and often more at night. There was 
 great straining, and the motions show mainly mucus and 
 blood and a very little fsecal matter. Finding himself getting 
 worse, he came to the Infirmary. 
 
 State on Admission. — Height, 5 ft. 6|- in. ; weight, 8 st, 
 5 lbs. ; used to weigh about 10 st. He looks thin and 
 
A CASE OF DYSENTERY, ETC. 91 
 
 anxious, and is very anasmic. He has little or no appetite ; 
 and after eating or drinking, vomiting usually comes on. He 
 complains much of abdominal pain, and there is great tender- 
 ness on pressure over the descending colon and sigmoid 
 flexure. With the diarrhoea there is great tenesmus, and a 
 burning pain in the rectum. The dejections consist mainly 
 of small quantities of muco-pus and blood, with little or no 
 faecal matter. We have repeatedly examined them for the 
 " amoeba dysenterise," but we have not succeeded in seeing it. 
 The liver and spleen cannot well be percussed out, but we 
 are of opinion that they are both slightly enlarged. 
 
 His circulatory, respiratory, urinary, and other systems are 
 normal ; his pulse is usually about 70 per minute, and his 
 temperature about 99°. Here, then, is a case of dysentery, 
 and we recognise what we often find in dysentery and in 
 ague, — the tendency to recurrence as the result of some 
 depressing cause. When we questioned our patient closely, 
 he told us that although his health up to the commencement 
 of his present illness had been very good, yet that when 
 exposed more than usual he would have slight ague-like 
 attacks, especially during the night, and also that his present 
 dysenteric attack came on after a specially severe exposure 
 to cold. 
 
 His progress and the modes of treatment employed can 
 best be related by the following excerpts from the case- 
 book : — 
 
 " On admission patient was put on milk and a little 
 farinaceous food, and tinct. coto., 111,10, every four hours, 
 was prescribed. As this in three days had not in any 
 way modified the diarrhoea, bismuth subnit., 30 grs., thrice 
 daily, was substituted ; and large injections (3 or 4 pints) of 
 warmed weak boracic solution were ordered to be given twice 
 daily. The injections occasioned such severe pain that their 
 administration had to be preceded by the introduction of 
 ■J gr. morphia suppository. 
 
92 A CASE OF DYSENTERY 
 
 " Novemher 8. — The treatment had not in any way affected 
 either the character or frecjuency of the stools, the patient 
 being called eight or nine times daily to pass, after much 
 painful straining, a small quantity of bloody muco-pus. The 
 bismuth was stopped, and pulv. ipecac, 5 grs., thrice daily, 
 was prescribed. A douche of nitrate of silver (| gr. to the 
 oz.) was ordered to replace the injections of boracic solution, 
 each douche to be preceded by the introduction of | gr. 
 cocaine suppository. Two or three pints of this solution 
 were allowed to pass into the rectum, the patient's pelvis 
 being raised by a pillow, and care being taken to allow the 
 fluid to pass in very slowly. 
 
 "November 13. — Very slight improvement in the diarrhoea. 
 The patient still complains of pain in the abdomen, and great 
 tenderness on pressure, especially over the sigmoid flexure 
 and descending colon. The dose of ipecac, was increased to 
 10 grs. thrice daily. 
 
 "November 16. — As the administration of the ipecac, caused 
 severe nausea and vomiting, which was not modified by 
 giving previously % 20 of liq. morph., it was stopped, 
 and 111^ 40 of tinct. koromiko were given three times a 
 day. 
 
 "December 2. — Since the ipecac, was stopped there has 
 been a slight increase in the diarrhoea. The nitrate of 
 silver douche and the tinct. koromiko, which had been 
 increased to 5J. thrice daily, had little good effect. There 
 has been no change in the character of the stools, and 
 the abdominal pain and tenderness is much the same as 
 before. Pulv. ipecac, sine emetina, 10 grs., thrice daily, was 
 ordered. 
 
 "December 6. — Little change as regards the diarrhoea, but 
 the abdominal pain is not so severe, and tenderness on 
 pressure is less marked. Dose of pulv. ipecac, sine emetina 
 increased to 15 grs. thrice daily. 
 
 "December 9. — Patient feeling much better and anxious to 
 
TKEATED BY DEEMETINISED IPECACUANHA. 93 
 
 get up. The diarrhoea is not so severe, four or five stools 
 daily. Abdominal tenderness hardly marked at all. 
 
 "December 11. — Patient was allowed to sit up, but felt very 
 weak. Dose of pulv. ipecac, sine emetina increased to 20 grs. 
 thrice daily. 
 
 "Decemter 18. — Patient feeling much better. Diarrhoea 
 much improved, two or three stools a day, and showing a 
 little fsecal matter. N'o tenderness on the abdomen. Patient 
 to get a little beef- tea and fish. 
 
 "DeceiTiber 26. — Improvement still maintained. Stools two 
 or three daily, distinctly fsecal in character. Little or no 
 blood. 
 
 "Decemher 30. — Patient has only one motion in the 
 twenty-four hours, the stool being well formed. He feels 
 much better and is gaining in weight (8 st. 8 lbs.). The 
 dose of ipecac, decreased to 15 grs. thrice daily. 
 
 "January 9. — On January 3 the nitrate of silver douche 
 was stopped. Next day patient complained much of pain in 
 the abdomen, and had four motions, the stools being watery 
 and blood-stained. A return was at once made to the nitrate 
 of silver douche, the patient was ordered to keep his bed, 
 and the dose of ipecac, sine emetina was increased to 20 grs. 
 thrice daily. 
 
 "January 19. — Patient is very much better. The bowels 
 are moved once or twice daily, the stools being of normal 
 colour and consistence. He is getting ordinary diet and is 
 going about in the ward. With the exception of a slight 
 remission on January 23, probably the result of exposure, 
 patient's progress towards convalescence was very satis- 
 factory. He was discharged on February 4, his weight 
 being 8 st, 12 lbs. He was recommended to take a holiday 
 in the country, to continue taking the ipecac, powders in 
 10-grain doses twice daily along with a tonic, and to report 
 himself in two or three weeks," 
 
 There has been some difference of opinion as regards the 
 
94 A CASE OF DYSENTEKY, ETC. 
 
 value of deemetinised ipecacuanha. By some it has been 
 found of such slight efficacy that it has been asserted that 
 the antidysenteric effects of ipecacuanha are mainly due to 
 the emetina. In the hands of others, however, it has been 
 found of very great value (Kanthack and Caddy, Practitioner, 
 June 1893). In our patient there is no doubt as to its 
 having been of the very greatest use. 
 
AORTIC ANEURISM; 
 
 WITH SPECIAL KEFEKENCE TO SENSITIVE AEEAS 
 ON THE SKIN. 
 
 History and Description of a Case. 
 
 Gentlemen, — D. E., aged 64, a joiner, formerly a soldier, 
 was admitted to Ward 30 in the Eoyal Infirmary on March 
 9, 1895, complaining of pains in the chest and back. 
 
 His family history was fairly good, and indicated no 
 tendency to any particular disease. In early life he had 
 been a soldier, and he had gone through all the hardships of 
 the Crimean War ; in later life he had been a joiner, and had 
 had occasional heavy lifts. With the exception of specific 
 disease in his soldier days, he had had no previous illness. 
 He had always been very temperate, well fed, and well 
 housed. His present illness began about eighteen months 
 ago, when he noticed that he was subject to a dull aching 
 pain in the back of his neck. About six months ago he 
 noticed also a pain in his chest. Those pains were of a dull 
 boring character, and were always brought on by exertion. 
 Eecently he had also noticed some loss of power in the 
 right arm. In spite of these pains the patient had been 
 able to continue his work till a week ago, when they became 
 very severe. Applying for relief to a medical man, aortic 
 aneurism was diagnosed, and he was recommended for 
 admission to the Eoyal Infirmary. 
 
 His height is 5 feet 6 inches, his weight 10 st. 7 lbs., but 
 
96 AORTIC ANEURISM, ETC. 
 
 he states that he used to weigh over 11 stones. His develop- 
 ment and muscularity are fairly good for his age, and, with 
 the exception of slight oedema of both ankles and of the 
 right wrist, there are no very obvious morbid appearances. 
 His appetite is good, and he states that he has no difficulty 
 in swallowing. His digestion is also good, but when the 
 chest pain is severe he states that he is troubled with 
 flatulence. On physical examination his digestive organs 
 appear normal, except that the liver is slightly enlarged. 
 
 He makes no complaint of dyspnoea, but states that he 
 has slight palpitation now and again. He has pain over the 
 precordia and in the upper part of the chest generally, 
 specially on the right side. He has also some pain in the 
 back. As already stated, these pains are all apt to be 
 brought on by exertion. On physical examination the heart 
 is found to be enlarged, its impulse beat being in the sixth 
 interspace, three-quarters of an inch external to the nipple 
 line. Over the manubrium sterni and over the first inter- 
 space on either side of it, but more especially on the right 
 side, pulsation can be made out. On palpation over this 
 area the pulsation is recognised as expansile, and very 
 heaving and powerful. Each beat directly follows that of 
 the heart, and a distinct diastolic impulse can be made out. 
 Percussion reveals great enlargement of the heart and 
 marked dulness over the manubrium and parts adjoining, 
 where, as already stated, pulsation can be seen. On 
 auscultation over the base of the heart and over the pulsating 
 area a slight systolic murmur is heard, and the second sound 
 is pump-valve in character. The pulse, about 70 a minute, 
 varies in character in the two radials, as seen in the tracings. 
 It is noted that the right carotid is also weaker than the 
 left. 
 
 The breathing, 22 a minute, is costo-abdominal in type. 
 There is no cough, no hoarseness of voice, no stridor. 
 Physical examination of the lungs reveals nothing abnormal, 
 
AORTIC ANEURISM, ETC. 97 
 
 but "tracheal tugging" is very well marked, aDcl careful 
 examination shows slight displacement of the trachea towards 
 the right side. 
 
 Fig. 1. 
 
 Left radial. 
 
 Right radial. 
 Sphygmographic tracing from case of D. E. 
 
 The integumentary and urinary systems are normal. As 
 regards the nervous system and special senses, all that need 
 be said here is that the right pupil is much larger than the 
 left. Both pupils, however, react readily to light and 
 accommodation. 
 
 In this case we had no difficulty in diagnosing aneurism of 
 the aorta, with enlargement of the heart, especially of the 
 left ventricle. Any valvular disease we believed, if present, 
 to be very slight. The aneurism seemed to involve mainly 
 the ascending and transverse parts of the arch. Although 
 pulsation and dulness were present to the left of the sternum, 
 we did not believe that the descending part of the arch was 
 involved to any extent, because there was no dulness in the 
 left interscapular region. The enlargement of the heart we 
 associated with the aneurism. We could not ascribe it to 
 any aortic valvular disease, as the pump-valve second sound 
 negatived regurgitation, and the absence of any marked 
 systolic murmur, and the well-filled arteries of the left side, 
 negatived obstruction. Some authorities hold that aneurism 
 per se entails extra work upon the heart, and so causes hyper- 
 trophy ; others deny this ; but whether or not, we may be 
 
98 AOETIC ANEUEISM, ETC. 
 
 sure that the conditions which lead to aneurism, namely, 
 atheroma, strain, etc., lead also to cardiac enlargement. You 
 all know that in a case of difficulty of diagnosis between 
 aneurism and mediastinal tumour, an enlarged heart is a 
 point strongly in favour of the former. 
 
 As to pressure symptoms, we believed, in the first place, 
 that there was no pressure upon the gullet. The slight 
 oedema of the legs, the enlargement of the liver, and the 
 slight oedema of the right arm, might be ascribed to pressure 
 on the vena cava and the right innominate vein, but the 
 absence of distinct venous dilatation anywhere precluded the 
 idea of the existence of any marked pressure here. As 
 regards the trachea, we believed that the fact that it was 
 slightly pushed towards the right, and the marked " tracheal 
 tugging," indicated that it was involved, but in the absence 
 of stridor, etc., we thought that it itself was not to any extent 
 compressed. There were, however, in the smallness of the 
 right radial, brachial, and carotid pulses distinct indications 
 of involvement, and in connexion also with the nervous 
 system there was distinct evidence of pressure. To these I 
 wish now to refer in some detail. 
 
 The Difference in the Pulses. 
 
 The small pulses of the right side might be due to 
 the innominate artery either being pressed upon by the 
 aneurism, or to its being partially closed by a clot at its 
 origin from the aorta. The more sloping upstroke, curved 
 summit, and gradual downstroke, shown by the sphygmo- 
 graphic tracing, with the almost complete disappearance of 
 the predicrotic and dicrotic notches, could be explained on 
 the theory that the dilated and expansile aneurismal sac 
 acted like the elastic indiarubber bag of a spray producer. 
 
 But, you will ask, if the ascending and transverse portions 
 of the arch in this patient were dilated and formed a large 
 elastic sac like the bag of a spray producer, why did not the 
 
AORTIC ANEURISM, ETC. 99 
 
 tracing from the left radial show similar appearances ? At 
 the time I thought that this might be explained by supposing 
 that the aneurism sprang from the arch at a part close to the 
 origin of the innominate artery, and that the greater part of 
 the transverse portion of the arch was not dilated. But a 
 post-mortem examination (the man died from slow rupture 
 into the pericardial sac three days after his admission) 
 showed that the whole of the ascending part of the arch out- 
 side the pericardium and the whole of the transverse portion 
 were involved, and that the left subclavian arose from a part 
 as dilated as was that from which the innominate arose. 
 Hence the marked difference in the character of the tracings 
 from the right and left radials is to be ascribed to the opening 
 of the innominate being narrowed by a clot, and that of the 
 left subclavian being perfectly free. 
 
 The Nervous Symptoms. 
 
 As regards nerve structures involved, we have seen that in 
 this patient the right pupil was dilated, indicating pressure 
 upon the sympathetic on the right side, and irritation of the 
 fibres which pass up to the pupil from the cilio-spinal region. 
 There were no indications of involvement of either of the 
 recurrent laryngeals, there was no hoarseness, and the vocal 
 cords moved freely. But I wish specially to refer to the 
 parts where pain, numbness, or other disturbances of nerve 
 function were felt. 
 
 As you are aware, the pains about the chest, down the 
 arms, etc., which are so often complained of in aneurism, are 
 usually ascribed to pressure of the aneurism upon branches 
 of the brachial plexus and intercostal nerves, but they are 
 much more appropriately to be referred, as Mackenzie,^ and 
 notably Head,^ have shown, to peripheral irritation of the 
 various segments of the spinal cord. 
 
 * Medical Glironide, August 1892. 
 2 Brain, vol. xvi., 1893. 
 
100 
 
 AORTIC ANEURISM, ETC. 
 
 In this patient we had hardly time, owing to his rather 
 sudden demise, to mark out the painful and sensitive areas 
 sufficiently carefully, but we have two other patients with 
 aortic aneurism in the ward, and in them we have done so. 
 I shall first, therefore, refer to them, and postpone alluding 
 to this case till afterwards. 
 
 Fig. 2. 
 
 Thus Fig. 2 represents a patient D., at present in the ward. 
 The area (A) represents the position of his aneurism as demon- 
 strated by percussion. The shaded areas represent the parts 
 where pain is specially felt, and where the skin can be shown 
 to be specially sensitive to the prick of a needle. In this 
 case we believe that the painful areas in the front of the 
 chest, and the specially sensitive spots at the elbows, corre- 
 spond to irritation of the first dorsal segment ; that the 
 painful areas along the inner aspects of the upper arms corre- 
 spond to irritation of the second dorsal segment, whilst that 
 the painful spot in the right interscapular region posteriorly 
 corresponds to irritation of the third dorsal segment. In this 
 case the aneurism mainly involves the ascending arch and 
 innominate, and, as seen, the tender areas are on both sides 
 anteriorly. 
 
 In the second case, E., Fig. 3, in whom the aneurism (A) 
 seems to involve mainly the transverse part of the arch, the 
 
AOKTIC ANEUKISM. ETC, 
 
 101 
 
 painful chest area is anteriorly on the right side alone, and 
 seems to correspond with the third dorsal segment. But 
 the left arm shows, in addition to the specially sensitive spot 
 at the bend of the elbow, an area of tenderness along its 
 entire inner aspect. This extends right down to tlie fingers, 
 
 Fig. 3. 
 
 where it corresponds to the distribution of the ulnar nerve? 
 and indicates irritation of both first and second dorsal 
 segments. Posteriorly there is a large area, symmetrical 
 on either side. It is specially painful and sensitive, and 
 seems to correspond with the second, third, and fourth dorsal 
 segments. 
 
 In the patient D. E., the subject of this lecture, we had 
 not, as already stated, time to mark out those areas carefully. 
 It was noted, however, that in addition to painful areas on 
 the anterior and posterior aspects of the thorax, in addition to 
 complaints of pain down his arms, and of occasional loss of 
 power in his right arm, he complained of a painful spot at 
 the back of his neck, about the vertebra prominens. This 
 seemed to correspond with the posterior distribution of 
 nerves from the first dorsal segment. In studying those 
 areas in all those cases we endeavoured to discover if any 
 
102 AORTIC ANEURISM, ETC. 
 
 precise connexion existed between the locality of the 
 aneurism on the arch and the painful or sensitive areas. 
 We could not, however, come to any more definite conclusion 
 on this matter. 
 
 Treatment. 
 
 Our cases of aneurism are being treated by absolute rest, 
 low diet, and large doses of iodide of potassium, with the 
 addition of a little chloral if iodism tends to show itself. As 
 regards the mode of action of the iodide of potassium in such 
 cases, there is great difference of opinion. According to 
 some, it acts by lowering the blood-pressure ; according to 
 others, by increasing the secretions, inspissating the blood, 
 and so promoting clot formation ; whilst a third view is that 
 it acts by causing thickening and contraction of the sac. As 
 to its power of lowering the blood-pressure, all our observa- 
 tions negative this. With the sphygmomanometer we have 
 found that no marked lowering of the pressure occurs as the 
 result of the use of large doses of iodide of potassium, and 
 you will remember the case of the man X. (specific disease), 
 in whom we gradually increased the dose of the iodide till he 
 was taking between two and three drachms a day, and in 
 whom careful sphygmomanometric examination showed no 
 lowering of the blood-pressure. 
 
 The view that iodide of potassium causes inspissation 
 of the blood we also do not feel inclined to accept, for 
 in several of the patients in our ward who are taking 
 iodide of potassium we have tested this, and we found 
 that the specific gravity of the blood was not increased. 
 Whether or not, however, the iodide has a special effect 
 in causing the blood to clot more rapidly we are unable 
 to say. 
 
 Lastly, as regards the view that the benefit of the iodide is 
 to be ascribed to its affecting the wall of the aneurismal sac. 
 It is evident that as the main effect of the drug is supposed 
 
AORTIC ANEUKISM, ETC. 103 
 
 to be to promote absorption, any beneficial effect which it 
 exercises in aneurism mnst be the result of its tending to 
 remove whatever causes the sac wall to yield, and not of its 
 tending to increase what might cause the sac wall to contract. 
 Hence some hold that the iodide is useful only in specific 
 aneurisms, but on this point we cannot speak with any 
 certainty. 
 
A CASE OF EPILEPSY PRESENTING SOME 
 PECULIAR FEATURES. 
 
 GrENTLEMEN, — E. J., aged 13, a schoolboy, residing in Edin- 
 burgh, was admitted to Ward 30 on January 17, 1893, 
 complaining of fits, from which he has suffered for the last 
 eighteen months. 
 
 History: Family. — He is one of a family of five. His 
 parents are both alive and well, and the only points which 
 seem noteworthy are that his father seems to be a rather 
 nervous man slightly addicted to alcohol, and that there is 
 a phthisical tendency in the father's family. 
 
 History: Personal. — His mother states that he has had 
 no ilhiesses previous to his present one. We asked if he 
 had had any convulsive attacks in infancy during dentition, 
 but found he had had none. 
 
 Present Illness. — Eighteen months ago, when playing in 
 Leith Street, he was knocked down by a passing cab, the 
 shaft striking him on the forehead above the left eye. He 
 states that he was stunned, and that when he came to his 
 senses he found himself in a chemist's shop. He then walked 
 home. This took place on a Thursday. On the morning of 
 the following Saturday he took his first fit, and felt very ill 
 all that day. About a fortnight afterwards he had another 
 fit, and he states that they were occurring at similar inter- 
 vals till three weeks ago. Since then he has been having a 
 fit every night about ten o'clock, just as he is dropping off 
 
CASE OF EPlLKPSY PRESENTING PECULIAR FEATURES. 105 
 
 to sleep. Last Friday night (January 13) he had five fits, 
 but he was able to stop three of them by grasping his leg 
 in the manner described below. He describes the fits as 
 follows: — He is made aware that one is coming on by a 
 tickling feeling in the ball of the great toe of the left foot. 
 He cries out directly the tickling comes on, and says he 
 cannot help crying out. He grasps the leg above the knee 
 with both hands as tightly as he can, and often he has got 
 his brother, with whom he sleeps at night, to grasp it too. 
 At times he is able in this way to prevent the tickling 
 passing up the leg, and so to prevent the fit coming on. At 
 other times he is unable to do this ; the tickling extends up 
 to his head, and he becomes unconscious, and remembers 
 nothing more till he awakes from sleep some hours afterwards. 
 He has never bitten his tongue, or at least it bears no marks 
 of having been bitten; and he has never observed blood 
 about his mouth or on his pillow in the mornings. From 
 his mother's description, however, we had no doubt from the 
 first that the fits were distinctly epileptic, and since his 
 admission we have had the opportunity of seeing him in 
 several paroxysms, so that we have no doubt upon this point. 
 Let us, however, in the meantime confine ourselves to the 
 phenomena which we met with in his case on his admission. 
 
 State on Admission. — Height, 4 ft. 10 in. ; weight, 6 st. 
 9 lbs. He is a well nourished and developed boy, of good 
 muscularity. A small abrasion can be seen about two 
 inches above the left eye, which he says has been there 
 since his accident. His temperature and pulse-rate are 
 normal. His expression is happy and contented, and he 
 has a stammer in his speech, which has, he says, always 
 affected him. 
 
 Nervous System. — Voluntary motor functions normal. 
 Skin sensibility to touch, temperature, and the faradic 
 current is normal all over. On the left leg or foot it shows 
 little, if any, difference from the right, the only point worthy 
 
106 CASE OF EPILEPSY PRESENTING PECULIAR FEATURES. 
 
 of note being that, when testing the sensibility of the sole 
 of the foot by tickling that part, the patient cried out on 
 one or two occasions, and grasped his leg, feeling, as he 
 expressed it, the twitching which is apt to pass into a fit. 
 
 SHn Befiexes. — On admission, the plantar, cremasteric, 
 epigastric, abdominal, and scapular reiiexes were all found 
 to be well marked, — it was thought, on the whole, rather 
 more on the left side. 
 
 Deep Befiexes. — The knee-jerk was found distinctly more 
 marked than usual in both legs ; and in both ankles, on 
 tapping the tendo Achillis, distinct reflexes could be elicited, 
 and a slight tendency to ankle clonus could be made out. 
 With the deep reflexes, as with the superficial, we were 
 careful to test if any relative increase could be made out on 
 the left side, but we could not altogether satisfy ourselves 
 that it was so. More, however, will be said about this 
 by-and-by. 
 
 Another reflex which we examined on his admission was 
 the faucial reflex. As you all know, on tickling the fauces 
 a reflex contraction of the parts results, more or less marked 
 in different individuals. Now, it has been said that this 
 reflex is well marked in epileptics, corresponding to the 
 increased irritability of the nerve centres existing, or 
 supposed to exist, in that disease, and that the reflex 
 irritability of the parts there may be useful as a guide to 
 the efficiency of the bromide of potassium.^ That is to say, 
 that with the administration of the bromide the number of 
 the fits and the reflex irritability of the fauces will be found 
 to diminish together. Here, then, was a case in which a 
 knowledge of the reflex irritability of the fauces would be 
 specially interesting, for the fits had been becoming more 
 and more frequent, and the patient had not been taking 
 any bromide. On examining into it, however, we found 
 that it was conspicuously absent ; as one of our students 
 1 Compare Osier, Principles and Practice of Medicine, p. 956, 
 
CASE OF EPILEPSY PRESENTING PECULIAR FEATURES. 107 
 
 remarked when this was demonstrated, our patient would 
 make a splendid subject for laryngoscopic examination. 
 This absence of the faucial reflex was, however, quite what 
 I expected. In most cases of epilepsy whicli I have exa- 
 mined I have found it so, whether the patients have been 
 taking the bromide or not. 
 
 Special Senses. — These are all normal. With the ophthal- 
 moscope no abnormality can be discovered in the fundus. 
 
 Mental Functions. — These also are normal. His mother 
 states that he is an average boy as regards his school lessons, 
 and that she does not think that he has suffered there from 
 overpressure. He has a stammer in his speech, but this 
 has been present all his life. 
 
 Urinarij System. — About 50 ozs. daily, acid; sp. gr. 1020 ; 
 no abnormal constituents. 
 
 Such, then, is our case. You will, I think, agree with me 
 in considering that it presents many interesting features. 
 These I now propose to consider in detail, and I shall begin 
 by discussing with you the "aura" of which this case presents 
 so distinct an example. Epileptic aurse may be sensory, 
 motor, special sense, psychical, or visceral, but in this case 
 our only difficulty seems to be to decide whether the aura is 
 sensory or motor. He tells us, as you will remember, that 
 it begins by a tickling sensation in the ball of the left great 
 toe, which spreads up the leg. In this way it might be 
 regarded as a sensory aura. But he tells us — what, indeed, 
 we have had the opportunity of observing since his admission 
 — that it is associated with a twitching and contraction of 
 the muscles of the foot and leg, and so we might believe that 
 it was a motor aura, and that the tickling sensation may be 
 due to muscle rather than cutaneous sensibility. Which of 
 the two it is we cannot well say, but there is no doubt that 
 sensory impressions tend to excite it. It will be remembered 
 that tickling the soles of his feet, so as to test the sensibility 
 or excite the plantar reflex, was found by the clerk who took 
 
108 CASE OF EPILEPSY PKESENTING PECULIAR FEATURES. 
 
 the case to arouse the aura. Further, although now in our 
 visits to his bedside in the ward we find that acting in this 
 way does not so readily induce the aura sensation, Dr Baines 
 informs me that if at night he awakes our patient and tickles 
 the sole of the foot, especially about the ball of the great toe, 
 the aura sensation is at once induced so strongly that the 
 patient feels that it is only by a timely and firm grasp of 'his 
 leg that a true paroxysm can be prevented from coming on. 
 It is interesting to remember that many cases presenting 
 similar peculiarities as regards the nature of the aura and 
 the effect of skin irritation in provoking an epileptic 
 paroxysm have been reported. As examples of these I 
 quote the following from a paper by Dr Ogle^: — 
 
 A man, aged 21, who had had syphilis, but who had had 
 epilepsy before the syphilis, was having several attacks in 
 the day, and noticed that each attack was preceded by an 
 aura, a sensation as of blood rushing up from the left side of 
 the chest and left arm to the head. Dr Ogle found that 
 suddenly jerking the left arm, or roughly handling the left 
 shoulder, or pinching the skin of these parts, could at 
 once induce an attack. He also observed that to induce an 
 attack a second time, it was necessary that an hour or two 
 should have elapsed after the first one, as if to permit an 
 accumulation of force. 
 
 Another case, also reported by Dr Ogle, was that of a boy 
 who had a fatty tumour over the upper part of the right 
 scapula. Whenever the tumour was handled, however lightly, 
 the boy became unconscious, and his body assumed the posi- 
 tion of intense episthotonus, this position being maintained 
 for half a minute, or longer if pressure were continued. 
 
 These observations remind us at once of the " epilepto- 
 
 genous" areas first discovered and described by Brown- 
 
 Sdquard. As you know, in the case of the guinea pig 
 
 rendered epileptic artificially — i.e., by section of portions 
 
 1 Lancet, 1874, vol. i., pp. 615 and 651. 
 
CASE OF EPILEPSY PRESENTING PECULIAR FEATURES. 109 
 
 of the spinal cord, etc., — it has been shown that the epilepto- 
 genous area is for the most part the skin about the angle of 
 the jaw. What has caused the " epileptogenous area " in our 
 patient to be the skin over the ball of the left great toe we 
 cannot well say. We have tested the parts carefully for any 
 indications of altered sensibility as regards touch, temperature, 
 and the faradic current, also for any indications of altered 
 trophic function, but beyond what has been already described 
 we have discovered nothing. 
 
 Next, I wish to say a little as regards the spread of the 
 aura. As already stated, the boy tells us that if he is unable 
 to stop the tickling sensation by firmly grasping the leg, it 
 (the sensation) rapidly passes up to his head, and then he 
 loses consciousness. On questioning, however, more closely, 
 he tells us that after he feels it in his head it seems to pass 
 to his left arm and then to his right arm, after which he 
 knows nothing; and he does not know when his right leg 
 becomes affected. 
 
 Eemembering, however, that the aura is simply a part of 
 the epileptic paroxysm, we have obtained further information 
 on this point by observing the sequence of events during the 
 onset and course of a paroxysm. When, for example, he has 
 found that grasping his leg has been of no avail, he lets go 
 his leg with a sort of cry, and we notice that his muscles are 
 all contracted in the so-called tonic stage. We do not get 
 much information from this ; but if we watch for the onset 
 of the clonic stage we can discover that it begins first in the 
 legs, then spreads to the arms, and, lastly, to the face. I am 
 therefore disposed to believe that the spread of the epileptic 
 nerve disturbance in this case is the usual one, viz., from the 
 leg to the thigh, then to the opposite limb, then to the arm 
 of the same (left) side, then to that of the opposite (right) 
 side, and, lastly, to the face and head. 
 
 As regards the meaning of the cry, so often present in 
 epilepsy, there is a difference of opinion among physicians. 
 
110 CASE OF EPILEPSY PRESENTING PECULIAR FEATURES. 
 
 One theory is that it is in a way voluntary, indicating fear or 
 surprise ; while another is that it is, like the aura, a part of 
 the fit, and caused by a convulsive contraction of the thorax 
 and narrowing of the glottis. It has been argued against the 
 first theory that patients have no recollection afterwards of 
 having cried out, or experienced fear or surprise ; but the 
 upholders of this theory point out that after a paroxysm the 
 patient's memory of its immediate antecedents is apt to be 
 obscured. Probably, however, the other theory is the better, — 
 the associated contraction of the thorax and narrowing of the 
 glottis being the result of the epileptic nerve disturbance 
 involving the phonation centre in the cerebral cortex. In 
 our patient the fits have, since his admission, been usually 
 accompanied by a cry, but he does not seem to remember 
 about this afterwards. 
 
 The attacks themselves in this case present no very unusual 
 features. We notice during the tonic stage the powerful, and, 
 as it were, steady contraction of the muscles, the initial pallor 
 of the face, the converging of the eyes, the dilating of the 
 pupils. Then follows the dusky suffusion of the face by the 
 respiratory stoppage, and the clonic stage manifesting itself 
 by the jerking of the limbs, the convulsive twitchings of the 
 muscles of the face, the frothing at the mouth, etc. As com- 
 pared with average epileptic paroxysms the attacks are not 
 severe ones ; he does not bite his tongue, his recovery is rapid, 
 and the flea-bite-like petechial hsemorrhages, — the indications 
 of intense venous congestion, — which one so often finds on 
 the forehead after a paroxysm, have never been seen. Shortly 
 after the fit he passes, however, a large quantity of rather 
 high-coloured urine. On several occasions we have examined 
 this; we found it acid, with a specific gravity of 1022, and 
 clear. 
 
 Eemembering that temporary albuminuria or glycosuria 
 may follow an epileptic paroxysm, we have tested it for 
 albumen and sugar at those times, but have found none. On 
 
CASE OF EPILEPSY PKESEXTING PECULIAR FEATUEES. Ill 
 
 adding to it a little caustic potash, however, we have observed 
 that this post-paroxysmal urine shows a distinctly greater 
 cloudiness (phosphates) than the urine passed at other times. 
 
 Let me next draw your attention to the fact that in our 
 patient the paroxysms are mainly nocturnal. As you are 
 aware, this is the case with many epileptics ; and, as Dr Fere 
 states,^ this fact has served the upholders of the theory that 
 epilepsy is associated with congestion of the nerve centres, as 
 well as those who believe that it is associated with ansemia, 
 with what they have regarded as evidence, — the partisans of 
 the congestion theory pointing to the prone position, the 
 partisans of the an£emia pointing to the physiological con- 
 dition of the nerve centres during sleep. 
 
 In the case of our patient the attacks, as just stated, came 
 on for the most part during sleep at night, but it is interesting 
 to remember that on one occasion (23rd January), when the 
 nurse, finding him even more mischievous than usual, had 
 sent him to bed, he had between the hours of 4 and 10 p.m. 
 eight attacks of the aura. ISTone of them, however, passed 
 into a regular paroxysm, and, of course, in such circumstances 
 it is impossible to decide how much what is understood as 
 " free will " had to do with their production. It is note- 
 worthy, however, that he has never had a paroxysm when up 
 and going about. 
 
 But what is no less interesting is the time of the night at 
 which paroxysms are most apt to occur. Dr Fere, from a 
 great number of cases, has shown in a most interesting manner 
 that their occurrence is most frequent about 9 o'clock at night, 
 or 3, 4, or 5 o'clock in the morning, — that is to say, about the 
 times which follow going to bed or precede getting up. As 
 you will remember, these are precisely the times when sleep 
 is least likely to be profound, and when dreams, the results 
 of partial cerebral activity, are also most frequent. In our 
 patient the fits came on before his admission, as he explained 
 ^ Les Epilepsies et les Epileptiques, Dr Ch. Fere, p. 312. 
 
112 CASE OF EPILEPSY PRESENTING PECULIAR FEATURES. 
 
 it, just as he was going off to sleep ; since his admission they 
 have occurred mostly about 2 or 3 a.m. 
 
 In our patient we have further endeavoured to obtain 
 information as regards the state of his nervous system during 
 the intervals, and we have carefully looked for any alterations 
 in this at the period preceding and succeeding a paroxysm. 
 As you can understand, information of this kind would be of 
 great value in helping us to a knowledge of the pathology of 
 epilepsy, and careful investigations of this kind would well 
 repay the trouble. What we have been able to do at present 
 has not been very much ; but such as it is, let me now 
 describe it to you. 
 
 At certain regular periods, viz., at 10 a.m., 2, 6, and 10 p.m., 
 and at 2 and 6 a.m., and when opportunity offered during the 
 pre- and post-paroxysmal states, we ascertained the pulse- 
 rate, temperature, voluntary muscular power by the dynamo- 
 meter, the state of the cutaneous and deep reflexes, and the 
 state of the electro-sensibility and electro-contractility to the 
 faradic current in the legs and feet. 
 
 We found the pulse-rate and temperature to show great 
 regularity. No difference in them have been noticed in the 
 pre-paroxysmal stage, but a rise has been noticed in the tem- 
 perature immediately after the fits. Thus in one instance 
 when the fit occurred at the usual time, 2 a.m., and when, as 
 his chart shows, the temperature is about its lowest,^ his 
 temperature was found to be 99° F., pulse 64, and respirations 
 24 ; whilst an hour after, the temperature was 97°, pulse 88, 
 and respirations 16. 
 
 As is known, the voluntary motor power, as ascertained by 
 the dynamometer in the hands, is diminished in the post- 
 paroxysmal stage. Our patient, whilst ordinarily registering 
 70 E. and 50 L., after the attack usually registers about 45 E. 
 and 35 L. 
 
 ^ Compare Fere, Les Epilepsies et les Epileptiques, p. 313 ; also Bevan 
 Lewis, Med. Times and Gazette, March 1876. 
 
CASE OF EPILEPSY PRESENTING PECULIAR FEATURES. 113 
 
 As regards reflexes,^ our observations seem to indicate a 
 slight increase in the pre-paroxysmal, and diminution in the 
 post-paroxysmal stage, and as regards electro-sensibility and 
 contractility a diminution in the post-paroxysmal stage. 
 
 Diagnosis. — On this subject, what we have now to do is to 
 make up our minds whether we are dealing with a case of 
 idiopathic epilepsy, — of an epilepsy in which, supposing we 
 had at present an opportunity of examining the nerve centres, 
 we should find practically nothing to account for it,- — or a 
 case in which, as one of the results of the injury, we should 
 find some gross lesion. Eemembering that our patient received 
 a severe injury to his head some eighteen months ago, and 
 that his mother dates his epilepsy from this time, and remem- 
 bering also that each attack begins with a distinct aura in 
 the left foot, we might not unreasonably suppose not only 
 that there existed such a lesion, but that it existed at a certain 
 part of the brain. 
 
 I have come to the conclusion that there is no gross 
 lesion, however, for the following reasons : — No trace of 
 injury nor tenderness can be detected on examining the head 
 at any part ; and although the aura always begins in the ball 
 of the left foot, a careful examination of the limb shows no 
 alterations — motor, sensory, reflex, or trophic — such as one 
 might expect with a gross lesion. I have also known of 
 other cases in which as distinct a peripheral aura was 
 present as exists in this case, and no gross lesion of the brain 
 was found. He has, further, no headaches nor vomiting, 
 and the examination of his eyes by the ophthalmoscope 
 reveals nothing abnormal. Lastly, epilepsy due to a localized 
 lesion is more frequently a partial than a general one, as is 
 the case with our patient. 
 
 [Concerning the value of these two last considerations, 
 let me remind you, however, that we cannot speak very 
 
 ^ Compare "F^r^, Les EpilejJsies et les Einleptiqiies, p. 1 57 ; also Beevor, 
 Brain, April 1882. 
 
 H 
 
114 CASE OF EPILEPSY PEESENTING PECULIAE FEATURES. 
 
 confidently, — more especially since, as many of you will 
 remember, we have had in Ward 30 two cases illustrative 
 of the opposite of this. One was the case of a man, B., who 
 had developed attacks of general epilepsy as the result of a 
 rapidly-growing sarcoma of the left cerebral hemisphere, and 
 in whom repeated ophthalmoscopic examination revealed no 
 changes whatever in the retina. The other was the case of 
 the man, S., admitted for hemiplegia of the right side — face, 
 arm, and leg — and in whom we diagnosed a syphilitic 
 thrombosis in the left internal capsule. This man, shortly 
 after his admission, developed epilepsy, which we recognised 
 as post-hemiplegic, and as being due to the irritation of the 
 area of softening in the internal capsule. Although the 
 lesion was a localized and not a very extensive one, the 
 epilepsy was general. Many other examples could be given, 
 but these are sufficient to demonstrate that the absence 
 of optic nerve changes does not negative the presence of 
 gross cerebral lesions, and that the fact that the epileptic 
 paroxysms are general does not in any way negative the 
 existence of a localized brain lesion.] 
 
 But now that we have concluded that there is no gross 
 lesion in this case, what importance are we to assign to the 
 injury in connexion with the causation of the disease ? 
 Eecognising that an injury such as this boy received must 
 certainly have had a prejudicial effect, I am yet inclined to 
 think that the main factors in the production of his epilepsy 
 have been constitutional ones. In his father's family there 
 is a marked phthisical tendency, and his father seems to be 
 a nervous and irritable man, inclined at times to alcoholism. 
 
 Further, the boy's mental organization is certainly not a 
 very sound one. Nurse tells us that she has great difficulty 
 in keeping him out of mischief in the ward, and his mother 
 told me that he has all along at home been in the habit of 
 receiving severe and frequent thrashings from his father. 
 Whether, for such a state of affairs, the nervous organization 
 
CASE OF EPILEPSY PRESENTING PECULIAR FEATURES. 115 
 
 of the boy or of the father is the more to blame, we need not 
 concern ourselves; we have ample grounds for concluding 
 that our patient is to be regarded as neurotic. Again, we 
 have to remember that the age at which the disease began is 
 that of ordinary idiopathic epilepsy, and, lastly and most 
 important, that there is a distinct history of an "aura" 
 having been observed at a date antecedent to his accident.^ 
 I am therefore inclined to ascribe his illness mainly to con- 
 stitutional causes ; these in the absence of his injury would 
 probably have produced the epilepsy, whilst the accident, 
 without the constitutional predisposition, would probably 
 have had no such effect. 
 
 Prognosis. — Although we may reasonably hope that our 
 patient will live for years, and that periods of freedom from 
 attacks will from time to time show themselves, we cannot 
 but admit that as regards the disease itself we cannot speak 
 very favourably. Had we been able to ascribe it more to 
 injury and less to constitution, we could, of course, have 
 hoped for more from time and care. As you know, frequency 
 rather than severity of paroxysms gives the graver prognosis, 
 and in our patient the attacks, up to the time of his 
 admission, have been increasing in frequency. By many 
 physicians the markedness of the aura is looked upon as 
 favourable ; and there is no doubt that when, as in our 
 patient, its occurrence gives an opportunity for arresting the 
 fit, it is a still more favourable sign. Nocturnal attacks are 
 by some regarded as more favourable than diurnal, as being 
 less likely in time to induce that impairment of the intelli- 
 gence so common in epileptics. 
 
 Treatment. — This may be divided into the treatment — {a) 
 of the paroxysm, and (&) of the interval. 
 
 {a.) For the paroxysm we provided our patient on his 
 admission with a strap round his left leg above the knee, 
 
 1 This information we obtained some days after his admission, as the 
 result of careful inquiry. 
 
116 CASE OF EPILEPSY PRESENTING PECULIAE FEATURES. 
 
 which he could tighten when he felt the aura. He has dis- 
 carded this, however, as he says that he has discovered that he 
 can do better by grasping the leg tightly with his hands. If 
 a scientific explanation were asked for this, it might be said 
 that powerfully grasping his leg has a derivative effect on 
 the nerve force which is being generated, and prevents an 
 explosion of epilepsy ; just as firmly grasping the arms of 
 the dentist's chair has a derivative effect on the nerve force 
 generated by a painful tooth-extraction, and prevents explo- 
 sions of other kinds. 
 
 [Such modes of arresting a fit are not uncommon. Forced 
 flexion, forced extension or twisting of a limb, pinching a 
 finger or toe, or the skin of the ear, etc., have all been found 
 in certain cases to act more or less efficiently.] 
 
 In such a case the nitrite of amyl inhalation might be 
 tried when the aura is felt, but hitherto we have not used it. 
 
 The attack having recurred, we let him work through it. 
 We do not require to put any protecting body between his 
 jaws, as he does not bite his tongue, and we let him sleep 
 after the fit, recognising that its occurrence means exhaustion 
 of the nerve centres, and a need for rest. 
 
 (&.) In the intervals he has been taking the bromide of 
 potassium in 20-gr. doses thrice daily, and the result is that 
 the fits are much less frequent. We propose in the mean- 
 time to continue this. 
 
A CASE OF SPINAL INJURY. 
 
 Gentlemen, — D. G., aet. 28, a miner, was admitted to Ward 
 30 on November 6, 1893, complaining of muscular weakness, 
 and of a feeling of coldness and numbness in the legs, dating 
 from a severe injury to his back sustained on December 6, 
 1892. 
 
 History : Family. — His father, aged 59, is a healthy man, 
 but has suffered at times from dropsy. His mother died of 
 cholera ; and he has six brothers and one sister, all alive and 
 well. He has always had plenty of good food, and has never 
 drank so much as to prevent him going to his work. He used 
 to smoke as much as 6 ozs. in the week, but for the last five 
 years has not smoked more than 2 ozs. At home he is quite 
 comfortable, but he is much exposed when at work, especially 
 as latterly he has worked in a Welsh mine at a very great 
 depth. He has always been strong and healthy, and had no 
 accident till the one now to be referred to. This happened 
 on December 6, 1892, when, just as he was beginning work, 
 a large mass of coal fell on his back, and he remembers 
 nothing till he recovered consciousness nine days afterwards. 
 On the tenth day after (December 16) he was admitted into 
 Llanelly Hospital, where he was told he had broken his back, 
 and that three of his ribs had also been broken. At that time 
 he states that he suffered intense pain over the small of his 
 back, which shot down both his legs and up to his head, and 
 also a severe headache, which lasted for months. He had also 
 lost power completely in his legs, and he had no feeling in 
 
118 A CASE OF SPINAL INJURY. 
 
 them, nor, indeed, from his waist downwards. He states also 
 that his arms were paralysed, and that his breathing was very 
 laboured. He had no loss of feeling in his arms ; he could 
 eat his food fairly well, but he experienced a difficulty in 
 speaking, and he noticed that his sight was not so good as it 
 had been. He had complete loss of control over his bladder 
 and rectum. He remained in hospital at Llanelly for three 
 months, during which period he made some improvement. 
 The power in his arms returned after about a month, and about 
 this time also he recovered control over his bladder and 
 rectum. He then returned home, and was treated with the 
 faradic current, v/hich he says relieved considerably the pain 
 in his back, and seemed to restore the feeling in his legs to 
 some extent. In May last he came back to Scotland, at 
 which time his legs were still paralysed. On one day in 
 August last he noticed that there was more feeling in his 
 right leg, and he found that he could move his right thigh on 
 his abdomen. At this time he was taking strychnia by advice 
 of his doctor, and he seems on one occasion to have taken an 
 overdose by some mistake of his own. He described to us 
 how, immediately after he had swallowed this, he experienced 
 the most terrible tremors through his body, — his jaws were 
 locked, and he lost both vision and the power of speech, 
 though his mind was quite clear. Emetics were adminis- 
 tered, but did not make him vomit, and gradually his bad 
 symptoms improved, but he says that ever since he has had 
 tremors through" his muscles from time to time. He, how- 
 ever, continued gradually to improve, and the power in the 
 left leg returned sufficiently to enable him to walk with the 
 aid of two sticks. He says, however, that trying to walk 
 always causes pain over the lower part of his back and down 
 his left side. About four months ago he had severe pain in 
 his stomach, which caused him to vomit ; he also had severe 
 palpitation and giddiness after taking food. About this 
 • time, too, he noticed a feeling of formication on the front of 
 
A CASE OF SPINAL INJURY. 119 
 
 his right leg, and this has occurred several times since. He 
 then sought admission to the Infirmary, and was taken into 
 Ward 30. 
 
 State on Admission. — Height, 5 ft. 4 ins. ; weight, 8 st. 
 11 lbs., used to be 10 st. 4 lbs. Development good, though 
 muscles are soft and flabby. The muscles of the legs appear 
 the most reduced. The spine of the first lumbar vertebra is 
 prominent, and there is pain on pressure over it, and, indeed, 
 over all the lower dorsal, lumbar, and sacral spines. 
 
 ISTervous System : Sensory. — He has an aching pain over 
 the lower part of his spine and left side, and a feeling of 
 coldness, specially over the sacrum. There is a feeling of 
 numbness over the front of the left thigh, disappearing over 
 the front of the knee, but becoming marked again over the 
 front of the leg and the dorsum of the foot. It is also 
 marked over the dorsum of the right foot and the front of 
 the right leg. The sensibility to touch, pricking, and tem- 
 perature is lost over these parts, and careful testing shows 
 that over the lateral and posterior aspects of both legs these 
 sensibilities are also impaired. But it is noteworthy that the 
 sensibility in the soles of the feet is much better marked than 
 in the legs. 
 
 Motor. — Voluntary motor power over the muscles of the 
 thighs is fairly good ; over the muscles of the legs, on the 
 other hand, it is markedly lost. This can be seen very well 
 when the patient sits on the edge of his bed with the legs 
 allowed to hang down. It is then seen that, although the 
 muscles of both limbs are much smaller than normal, the les 
 muscles are much more reduced than those of the thigh, and 
 that when he is asked to move the foot on the leg at the 
 ankle joint, little or no movement occurs, while when he is 
 asked to move the leg on the thigh at the knee, the move- 
 ments, both of flexion and extension, are briskly performed. 
 In cases like this it looks almost as if these latter movements 
 were more briskly performed than in a normal individual, as, 
 
120 A CASE OF SPINAL INJURY. 
 
 indeed, the thinned leg must be lighter to move, and so give 
 specially easy vsrork to the thigh muscles to perform. When 
 we examine these weakened leg muscles more particularly 
 we find that the tibialis anticus and peroneus longus and 
 brevis are specially affected, in consequence of which he 
 cannot dorsiflex, abduct and adduct his foot. But the 
 muscles of the back of the leg are also affected, his power 
 of pointing the foot being limited. These voluntary motor 
 impairments are most marked on the left leg. 
 
 Befiexes : Superficial. — Plantar are present on both sides, 
 specially on the right. Cremasteric are also present, and 
 abdominal are well marked. Deep. — The ankle-jerks are 
 well marked on both sides, and on both sides clonus can be 
 elicited. The knee-jerks are markedly absent on both sides, 
 and there is not the slightest trace of clonus, either on 
 tapping the patellar tendon with the leg semiflexed, or on 
 suddenly and forcibly drawing down the patella when the 
 legs are straightened out. 
 
 Electric Irritability of Muscles. — Whilst the muscles of the 
 thighs respond fairly well to the faradic current, the muscles 
 of the legs, specially those just named, require a very power- 
 ful current, and respond very feebly. This is specially the 
 case with the tibialis anticus in both legs. With the galvanic 
 current very strong currents are required, and the polar reac- 
 tion is the normal one, — that is to say, K C C is greater than 
 A C C. There is thus no reaction of degeneration. 
 
 Cerebral and Mental Functions. — Intelligence is good, but 
 he has a feeling of torpor, which often lasts all day, and gets 
 worse at night. On trying to go to sleep he experiences a 
 feeling as if he were dreaming, and he then feels as if he 
 were going to faint. This causes him to rouse himself with a 
 start, and so he often does not sleep all night, and never 
 sleeps more than three hours on end. His memory, specially 
 during the torpid states, is very much impaired, and he 
 notices that he remembers events of his childhood more 
 
A CASE OF SPINAL INJURY. 121 
 
 easily tlian recent events, — that is to say, than events which 
 have happened since the accident. He states also that his 
 hand is very shaky, and causes him difficulty in writing. 
 
 Special Senses : Sight. — Since his accident this is impaired 
 for distant objects ; he cannot tell the time on the clock at 
 the other end of the ward. For near objects his sight is 
 good enough, but he says his eyes water greatly. On exa- 
 mination his pupils are found to react normally to light and 
 in accommodation, and no changes can be detected with the 
 ophthalmoscope. His other special senses are normal. 
 
 Locomotory System. — He can walk with the aid of a stick, 
 but the feet hang down, and he has to raise them high to 
 keep the toes off the ground. On standing with his feet 
 together he sways considerably, but on shutting his eyes 
 this swaying is not increased. 
 
 Alimentary System. — Teeth are bad ; tongue fairly clean 
 and moist ; no tremors to be noticed. He has a sticky 
 feeling in his mouth, and thinks there is less saliva than 
 formerly. Appetite poor, and often feels thirsty. After 
 taking food he is much troubled with pain in the stomach, 
 and with flatulence. Used to vomit much after food, but not 
 for the last ten days. Bowels confined, and has constantly 
 to be taking medicine ; says that if stools are not loose he 
 has great difficulty in expelling them. Physical examination 
 of the abdominal viscera shows nothing abnormal. Except 
 that he suffers occasionally from palpitation, the circulatory 
 system is normal, as is also the respiratory system. 
 
 Integumentary System. — His skin always tends to be moist, 
 and he states that this is especially the case over the anses- 
 thetic areas of the leg. 
 
 Urinary System. — Normal ; no increased frequency of, or 
 trouble in, micturition. 
 
 The diagnosis at which we have arrived is that there has 
 been an injury to the vertebral column and spinal cord about 
 
122 A CASE OF SPINAL INJURY. 
 
 the lower dorsal and upper lumbar regions, and that this has 
 resulted in gross changes in the cord at the part, and in less 
 marked changes above. To understand this properly I shall 
 ask you to consider with me — (1), the injury; (2), the 
 changes in the cord at the part and below ; (3), the changes 
 in the cord and parts above. 
 
 (1.) The Injury. — This I believe to have been one of fracture 
 with dislocation : you can understand that, locked together 
 as the vertebrae are by their articular processes, these two — 
 fracture and dislocation — almost certainly occur together. 
 
 Observe next that the locality where this fracture and 
 dislocation have occurred is a very usual one, viz., about 
 the last dorsal and first lumbar vertebrae. This you can 
 understand when you remember the nature of the injury. 
 The man was standing, stooping somewhat, when the weight 
 fell on his shoulders and back. Now the dorsal vertebrae, 
 together with the ribs, sternum, and intercostal tissues, form 
 a sort of hollow cylinder, a very strong structure, and so can 
 well resist a strain. Hence the effects of such will fall upon 
 the nearest point in the comparatively weak and small column 
 below, viz., the first lumbar vertebra. 
 
 [For the same mechanical reason you can understand how 
 another part of the vertebral column, viz., the lower cervical 
 vertebrae, are also specially liable to suffer from injury in a 
 similar manner. This is the weak part immediately above, 
 as it were, this strong hollow cylinder.] 
 
 As the result of this displacement the spinal cord may 
 have been injured in various ways. It may have been 
 pressed upon and narrowed by the lower fragment. There 
 may have been some tearing of the dura, although this seems 
 to be rare; there may have been haimorrhage from parts 
 around the cord, or, with more or less laceration of the cord 
 itself at the part, there may have been haemorrhage into its 
 substance. Of whatever nature it may have been, it must 
 have been a very severe lesion. 
 
A CASE OF SPINAL INJUKY. 123 
 
 As further indicating the severity of the injury, we find 
 that the patient was insensible for nine days, but that when 
 he recovered consciousness, not only had he paralysis and 
 anaesthesia from the seat of the injury downwards, with loss 
 of power over bladder and rectum, but he had loss of power 
 over his arms, and difficulty in breathing, lasting for about 
 a month. 
 
 These latter symptoms, I believe, were due to concussion. 
 We know that cases have occurred where paralysis and loss 
 of consciousness followed injuries in which there had been 
 no fracture or dislocation of the vertebrae at all, and in 
 which, on post-mortem examination, no lesions of cord or 
 brain could be discovered. In such cases we may suppose 
 that as the result of the shock all nerve functions had been 
 suspended, — just as, as Eeynolds has put it, a piece of iron 
 can be demagnetised by a heavy blow. In this case the 
 shock must have been a specially severe one, abolishing his 
 cerebral functions for nine days, and his spinal for about a 
 month. 
 
 (2.) Changes in the Cord at the part and below. — It is 
 certain that the injury to the cord which had caused 
 abolition of function by shock above, must also have caused 
 similar abolition below, and the return of control power 
 over bladder and rectum after about one month's time might 
 possibly be regarded as indicating that the lost power over 
 these viscera had been due to shock rather than to direct 
 injury to their centres and connexions in the cord. 
 
 It is almost certain, further, that as the result of the 
 injury directly, or of a myelitis which is apt to follow such 
 an injury, some sclerotic changes have occurred, and the 
 question now is as to where these will be. 
 
 Are they in the grey matter ? I do not think so to any 
 extent. The bladder, rectal, and genito-spinal centres are 
 intact, and the centres for the ankle-jerk and plantar reflexes 
 are so also. Further, there is no muscle degeneration nor 
 
124 
 
 A CASE OF SPINAL INJUKY. 
 
 tendency to bed-sores. Are they in the white matter, the 
 connecting part of the cord ? I think so certainly. 
 
 Looking at the subject theoretically, it is evident that we 
 have to deal with a lesion which interferes with both motion 
 and sensation, and probably the best way to explain this 
 condition will be to invite your attention to the accompany- 
 ing Diagram. This is intended to represent a longitudinal 
 
 section of the spinal cord. In it A A represent the tracts 
 to the muscles of the thigh, with b b as the muscle sensory 
 nerves corresponding, whilst c c represent the motor tracts 
 to the muscles of the leg, with d d as their corresponding 
 muscle sensory nerves. It is clear that a lesion in the 
 region of the shaded area L would cause the motor and 
 reflex phenomena which our patient presents, for it would 
 leave his voluntary motor power over the muscles of the 
 thigh unimpaired, and deprive him of voluntary motor 
 power over the muscles of his leg; whilst it would at the 
 same time explain the increased ankle-jerk and ankle clonus, 
 and the absence of knee-jerk and knee clonus. 
 
 Similarly with sensation. To represent this diagrammati- 
 cally a somewhat complicated diagram would be required ; 
 
A CASE OF SPINAL INJURY. 
 
 125 
 
 but remembering that the skin sensory fibres do not remain 
 long in the white matter, but having entered the grey 
 matter pass from it back again into the white, and are 
 conducted upwards in the posterior or lateral columns, we 
 can easily imagine that a lesion in the position of the 
 shaded area might cut the sensory fibres from the legs or 
 thighs, and at the same time miss the sensory fibres from 
 the feet. In our patient, as has been stated, sensation in 
 the soles of the feet is not much impaired, whilst in both 
 legs and in the front of the left thigh it is more or less 
 abolished. Eef erring now to Gowers' table, the required 
 portion of which I append, — 
 
 (nerves.) 
 
 LI 
 
 Lumbar 
 muscles 
 
 Peroneus, 1. 
 
 Flex, of 
 ankle, Ext. 
 
 of ankle. 
 
 ' 2 -> Cremaster 
 >Flexors of hip 
 
 H 
 
 [-Extensors of knee 
 4^ Adductors of liip 
 
 '1' 
 
 Ext. & abduct, of hip 
 
 -Flexors of knee 
 q -[J 
 "^ ^ Intrinsic muscles of 
 
 n f foot 
 
 Perinfeal and anal 
 
 A I muscles 
 
 5 
 Co. 
 
 \ Groin and Scrotum 
 I (front) 
 
 3! i 
 
 [ Thigh ] front 
 
 outer side 
 
 J 
 
 , inner side 
 
 5 Leg, inner side 
 
 -. I r Buttock, lower 
 
 I part 
 2 I -| Back of thigh 
 
 I Leg \ except 
 o J 1^& foot / inner part 
 
 4 VPerinseum and anus 
 5 
 
 Co. 
 
 1 Skin from coccyx to 
 / anus 
 
 Cremasteric 
 
 S-^ y Knee-jerk 
 
 clonus 
 
 we are disposed to put such a lesion in the cord some- 
 where about the cord-centres for the third or fourth lumbar 
 nerves, — that is to say, about a point opposite the junction 
 of the last dorsal and first lumbar vertebrae. Of course 
 other possible explanations of the symptoms might be given, 
 notably the possibility of some lesion of the " cauda equina," 
 but we need not trouble ourselves further with what could 
 be only hypothetical. 
 
 (3.) Changes in the Cord and parts above. — In the cord 
 
126 A CASE OF SPINAL INJUKY. 
 
 above there are probably some changes of the nature of 
 ascending sclerosis, but what I wish to draw your attention 
 to now is his complaints of torpor, disturbed sleep, impaired 
 memory, impaired sight, headaches, pains in the back and 
 side, palpitation, etc. These are all symptoms which one 
 meets with after concussions, and they are interesting, 
 because they remind us of the train of symptoms which we 
 hear of and see in the so-called cases of railway spine. As 
 you know, after railway collisions it is common for a number 
 of people, who of course have not been killed or have not 
 lost limbs, but who have been simply " shaken," to develop 
 such symptoms weeks or months after the accident, and 
 presenting no objective signs of disease in brain cord, 
 special senses, nerves, muscles or viscera, to declare them- 
 selves injured for life, and to claim compensation. Such 
 individuals are apt to be looked upon as malingerers; but 
 in our patient there is no inducement to malingering, and 
 these symptoms are present. Their cause is not at all known. 
 For the back pain, some irritation about the nerve roots 
 has been suggested. It is evident that in an accident such 
 as this man has sustained, the parts around must have been 
 injured, hence we might expect pains here, as after fractures 
 or severe bruises elsewhere. 
 
 As regards Prognosis. — The prognosis in injury to the 
 spine is always better than in disease, as myelitis, lateral 
 sclerosis, etc., and a further favourable point in this case is 
 that improvement has occurred. But although I think we 
 may expect some further improvement, I do not take a very 
 hopeful view of the case. The presence so markedly of the 
 so-called concussion symptoms seem to indicate that the 
 severe injury has, as it were, taken so much out of him 
 that we cannot expect him to present much recuperative 
 power. 
 
 Treatment. — He is being treated by massage and elec- 
 tricity, galvanic and faradic, to his muscles. He is advised 
 
A CASE OF SPINAL INJURY. 127 
 
 to walk about as much as possible, short of fatigue. For 
 the back pain we are trying the application of the 
 faradic current, as we do in lumbago. Were it to be- 
 come very severe I should have no hesitation in using 
 the cautery. He is getting strychnia and nerve tonics 
 internally. 
 
A CASE OF FRIEDREICH'S ATAXY. 
 
 Gentlemen, — J. B., eet. 26, single, a soapboiler, was 
 admitted to Ward 30 on October 17, 1893, complaining of 
 weakness in the legs. 
 
 History : Family. — He is the fifteenth of a family of 
 sixteen children, eight of whom died when young from causes 
 unknown to him. Of the remaining eight, four are dead, 
 two (sisters) of phthisis, and the others of causes which he 
 cannot ascertain. His parents are both alive, — the father in" 
 good health, the mother suffering from rheumatism. No 
 history of paralysis or of fits is in the family. 
 
 Personal. — Up till his present illness, which, according to 
 his own account, began about six years ago, his health has 
 been very good. He has never had syphilis. At work he 
 has been, however, much exposed to sudden changes of tem- 
 perature, and for the last seven years he admits having been 
 in the habit of drinking to excess on Saturday nights. His 
 present illness seems to have begun six years ago. At that 
 time his speech became so affected that he had difficulty in 
 making himself understood. According to his own account, 
 this speech impairment came on rather suddenly, and without 
 cause. After six months his speech seems to have improved 
 somewhat, but has been since, and is now, markedly impaired. 
 Three years ago he noticed for the first time that he was apt 
 to stagger when walking. This was whenever he was in the 
 dark, and he had then to guide himself with his hands in 
 
A CASE OF FEIEDKEICH's ATAXY. 129 
 
 order to prevent himself falling. Six months later he noticed 
 that his hands trembled when he used them. The staggering 
 in walking and trembling in the hands have both been 
 gradually getting worse. He has been under treatment, in 
 hospital and out of it, by massage, electricity, nitrate of silver, 
 etc., but, he states, with no beneficial result. 
 
 Present Condition. — Height, 5 ft. 7| ins. ; weight, 9 st. 
 7 lbs. He used to weigh about 11 stones, but his general 
 nutrition and muscularity are still fairly good. On examin- 
 ing him when stripped, some patches of chloasma M'ere 
 observed on the chest and abdomen, and a distinct lateral 
 curvature of the spine was detected. On careful inquiry as 
 to this, we found that it had probably been in existence about 
 eight years. He himself had no idea that his spine was 
 curved ; but when we asked him how long his right shoulder 
 had been noticed to be lower than his left, he stated eight 
 years as the probable time. 
 
 ISTervous System : Sensory Functions. — At present there 
 are no abnormal sensations except an occasional aching, not 
 severe, in the loins. A fortnight aw he states that he felt 
 for the first time a slight feeling of formication in both feet. 
 Sensibility to touch, pain, and temperature is everywhere 
 unimpaired. As regards special senses, sight is not impaired 
 either for near or distant vision, and there is no diminution 
 of the visual field in either eye. Colour vision is normal. 
 The pupils are equal, and react readily to 'light and in accom- 
 modation. There is no paralysis of any of the ocular muscles, 
 but when the patient is asked to look at an object placed to 
 the extreme right or left there is some slight lateral nystag- 
 mus, affecting chiefly the eye that is directed outwards. 
 With the ophthalmoscope no morbid changes can be detected. 
 Hearing, smell, and taste seem normaL His muscular sense 
 (sense of weight) is little, if at all, impaired, but his sense of 
 locality is distinctly faulty. Thus, when with eyes closed he 
 
130 A CASE OF FKIEDKEICH's ATAXY. 
 
 is asked to bring his index fingers together, or to touch the 
 point of his nose with one or other index finger, or to touch 
 some point on one leg with the toe of the other foot, etc., he 
 is invariably wide of the mark. 
 
 Motor Functions. — Voluntary motor power is rather im- 
 paired both in arms and legs. With the dynamometer the 
 right hand registers 35 and the left 30, but . whether the 
 rather low grip-power is due to impaired conduction on the 
 part of the voluntary motor nerve tracts, or to feeble muscu- 
 lature, it is difficult to say. This impairment of voluntary 
 motor power seems to exist equally in arms and legs. The 
 legs are, of course, much stronger than the arms, but propor- 
 tionately their loss seems about the same. On testing the 
 relative power of the flexors and extensors of the fingers and 
 wrist, we found that in the former the power was about twice 
 as great as in the latter. [Gowers says that " the flexors 
 suffer more than the extensors, and the weakness in the 
 flexors of the ankle may permit some degree of talipes to 
 occur."] In our patient there is as yet no evidence of talipes. 
 The electro-contractility in the muscles of his arms and legs 
 showed no difference from that of health. 
 
 Befiexes. — The plantar and cremasteric are fairly well 
 marked and equal. The abdominal and epigastric can 
 hardly be elicited. The knee-jerk is absent on both limbs, 
 and there is absolutely no trace of ankle-jerk or elbow-jerk 
 or of clonus. As regards organic reflexes, — micturition, defse- 
 cation, generative power, respiration, and deglutition are 
 normal, though he states that about a month ago he noticed 
 temporarily a tendency to choke on swallowing hurriedly ; 
 this has not troubled him to any extent since. 
 
 Equilihration and Locomotion. — If he attempts ta stand 
 with his feet together and his eyes closed, he sways about 
 for a little and then falls. It is worth while here to notice 
 that it has been stated by some observers that the equilibra- 
 tion disturbance of Friedreich's disease is fundamentally 
 

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A CASE OF FRIEDREICH'S ATAXY. 131 
 
 different from that of ordinary tabes. Thus — here I quote 
 from Ladame^ — "Whilst in tabes closure of a patient's eye 
 makes him lose his equilibrium, because he has no longer 
 notion of the position of his limbs, in Friedreich's disease it 
 is in consequence of choreiform instability. The patient 
 sways whether his eyes are opened or closed ; but in the 
 latter case, having lost the control of vision, the swaying 
 movements easily pass the limits of equilibrium, and he falls, 
 although he may have preserved the notion of the position of 
 his limbs." Of our patient I do not think this statement 
 holds at all, and a tracing with the taxograph bears this out 
 (tracing a). With his eyes open the lines are fairly even, 
 and with them closed the undulations are exactly like those 
 of an ataxic patient. In locomotion there is difficulty ; the 
 feet are lifted high, thrown forwards and outwards, and the 
 heels brought down heavily on the floor. The gait is dis- 
 tinctly ataxic in character. When asked to walk backwards, 
 he fixes his eyes on some object in front of him, and walks, 
 however, better than we expected he should. When the 
 patient is standing or moving about, a jerking and choreiform 
 tendency can be seen in the arms when they are made to 
 perform any movement. He can usually, however, when 
 asked, hold his hands out quite steadily, but he has some 
 difficulty in buttoning his clothes, in writing, or in picking 
 up a pin. When standing on his feet or raising himself in 
 bed his head is also seen to perform slight jerking nutatory 
 movements. 
 
 Cerebral and Me7ital Functions. — Giddiness has always been 
 a prominent symptom. His intelligence is good ; he under- 
 stands readily what is said to him. His memory is good, 
 and he sleeps well. Speech is impaired ; there is hesitation 
 in getting out the words, but he says that this symptom is 
 better than when he noticed it first, six years ago. The 
 tongue, when protruded, shows some slight fibrillar contrac- 
 ^ Brcdn, vol. xiii. p. 467. 
 
132 A CASE OF FRIEDREICH'S ATAXY. 
 
 tions, but there are no tremors about the lips when he 
 speaks. "With the exception of the heart, which shows some 
 increase of its area of duluess to the left, and the possible 
 existence of a slight amount of aortic valvular mischief, the 
 other viscera are perfectly healthy. [It is interesting to note 
 that heart troubles are very common associates of Friedreich's 
 disease, and this point, and the possible connexion between 
 the morbid appearances in the spinal cord and the vascular 
 and cardiac lesions, have been drawn attention to in an 
 interesting way by ISTewton Pitt.^] 
 
 In this patient we have, I believe, an example of Fried- 
 reich's ataxy. At first sight, when we observed his ataxic 
 gait in walking, his inability to stand with his eyes closed, 
 and his absent knee-jerks, we for a moment thought of 
 ordinary locomotor ataxy. But the absence of the charac- 
 teristic initial lightning or girdle pains, of any impairment of 
 tactile, temperature, and other sensations, of bladder trouble, 
 of the Argyll Eobertson pupil, and the presence of speech 
 impairment and of jerking movements of the head and eyes, 
 convinced us that it did not correspond with that disease. 
 
 "We next thought for a moment of multiple cerebro-spinal 
 or disseminated sclerosis. Certainly this disease, presenting 
 great diversity in different cases as regards the amount of 
 sclerosis and the localities where the sclerosis may exist, 
 offers an anatomical explanation adequate enough for the 
 symptoms which he presents. Some sclerosis of the postero- 
 external column of the cord would account for the absent 
 knee-jerks ; some slight sclerosis of the direct and cross 
 pyramidal tracts would account for any little loss of voluntary 
 motor power in the arms and legs, and possibly also for the 
 jerking character of their movements ; a sclerosis of the 
 cerebellar tracts in the cord and of their continuing fibres in 
 the cerebellum would account for the equilibration disturb- 
 ances and the giddiness, whilst sclerosis higher up in pons or 
 1 Guy's Hosjntal Reports, vol. xliv. p. 392, etc. 
 
A CASE OF FKIEDEEICH's ATAXY. 133 
 
 crus would account for the impairment of speech, the jerking 
 movements of head, and the nystagmus. But although it is 
 interesting to note that by two such observers as Bourneville 
 and Charcot, Friedreich's ataxy was likened to a combination 
 of this disease and tabes, the clinical features are not those at 
 all characteristic of multiple sclerosis. The speech impairment 
 does not present the slow stacatto character, the nystagmus 
 is not so marked, the movements of the limbs, when move- 
 ment is performed, have a jerky character rather than the 
 tremblings of multiple sclerosis, and there is an entire absence 
 of the apoplectiform attacks seen in this disease. Again, the 
 deep reflexes are lost in our patient, and not increased, as 
 they are so markedly in cases of multiple sclerosis. 
 
 We have, therefore, concluded that the case is one of 
 hereditary ataxy or Friedreich's disease, or, as Gowers prefers 
 to call it, hereditary ataxic paraplegia. ISTow, here the first 
 consideration which will occur to you is that to the term 
 hereditary no great value is to be applied, because we have 
 had no evidence of heredity in the case of our patient. This 
 is certainly the case, and it would as certainly have made 
 our patient appear to be a mere typical example of the dis- 
 ease had we been able to elicit evidence of heredity. But, 
 as we remembered the other day when taking his case, it 
 does not follow that the heredity or family tendency is not 
 present. We can easily understand how a man in the posi- 
 tion socially of an Infirmary patient may not be possessed of 
 very complete or correct information as to the health of his 
 relatives, and more especially when he has come in, as it 
 were, at the fag end of a family of sixteen. 
 
 We have only to remember that, although this may not be 
 altogether true here, in this disease the tendency to run in 
 families is so well marked that the term hereditary has 
 been applied to it. Perhaps the best illustration of this is 
 the fact that sixty-five cases reported by one observer 
 occurred in nineteen families. 
 
134 A CASE OF Friedreich's ataxy. 
 
 As regards age, this affection shows itself at an earlier a e 
 than does ordinary ataxy, the second dentition and puberty 
 being about the commonest periods for it to appear. Our 
 patient is now 26, but he gives six years ago as the time 
 when the speech became affected, and eight years ago as the 
 time when the spinal curvature was first noticed. As this 
 spinal condition is due to muscular weakness, and may be 
 regarded as a symptom of this disease, it would give 18 as 
 the age at which it first developed in our patient. 
 
 As regards sex, all that need be said is that it seems rather 
 more common in men ; and as regards other points in the 
 etiology, we have to remember that, being so distinctly due 
 to congenital causes, a history of excessive exertion, exposure, 
 alcohol, and syphilis, so common as etiological factors in 
 other nervous affections, does not play such an important 
 role in this disease. 
 
 The symptoms of hereditary ataxy as they have been 
 described in other cases are markedly present in our patient. 
 With absence of lightning pain or girdle pain, his cutaneous 
 sensibility to touch, pricking, temperature, etc., are unim- 
 paired, and with regard to his special senses nystagmus is 
 the only abnormality. His knee reflexes are entirely absent, 
 but his visceral reflexes — bladder and rectum — are absolutely 
 normal. His equilibration in walking and standing is that 
 of an ataxic patient, and the impairment of the co-ordinating 
 power in his upper limbs is a prominent feature. Lastly, 
 the jerking movements of the head and neck, the disturbance 
 of speech, and the giddiness, which are all symptoms of 
 Friedreich's ataxia, he presents in a marked degree. 
 
 The mode of onset of the symptoms in our patient presents 
 some peculiarities. Ordinarily, though some nystagmus may 
 be an early occurrence, the legs are first affected, then follow 
 the arms, and then the speech disturbances. Our patient, 
 however, states very definitely that his speech trouble was 
 the first symptom, and that the legs and arms were not 
 
A CASE OF FHIEUREICH's ATAXY. 135 
 
 affected till three or four years later. Further, as we have 
 already seen, he told us that the lateral curvature of the 
 spine had been noticed some two years earlier than his 
 speech trouble. Now this spinal curvature, due as it is to 
 weakness of the spinal muscles, is usually one of the later 
 symptoms. Hence, as regards onset of symptoms, this case 
 presents peculiarities. [In a case reported by Topinard, 
 which Ladame regards as a typical example of Friedreich's 
 disease, lateral curvature seems to have been one of the 
 earliest symptoms, for in describing the case we read, — 
 "Towards the age of 11 years, at La Pitie, M. Michon 
 proposed an operation to remedy a sinking of the left 
 scapula."] 
 
 As regards morbid anatomy, the principal deviations from 
 the normal in such cases seem to be that, with the whole 
 spinal cord somewhat smaller in section than usual, there is 
 well-marked sclerosis of the postero-median columns, and 
 sclerosis in varying intensity of the postero-lateral columns, 
 of the cerebellar and ascending lateral tracts, and of the 
 pyramidal tracts. That there should be sclerosis of these 
 tracts we can easily understand from the evidence of the 
 interference in these cases with the transmission upwards 
 of those sensory impulses which are necessary for muscular 
 co-ordination and equilibration. But that the sclerosis 
 of the postero-median columns should exist, and exist so 
 markedly, is noteworthy, for, as you know, the impulses of 
 tactile impressions have been supposed to pass up in these 
 tracts as well as those of muscular sensibility. 
 
 Inasmuch as in cases of Friedreich's disease tactile 
 sensibility, and, indeed, cutaneous sensibility of all kinds, is 
 unimpaired, this consideration would seem to indicate that 
 the postero-median columns are, like the cerebellar and 
 antero-lateral ascending tracts, more especially concerned in 
 the transmission upwards of those impulses which are 
 required for muscular co-ordination and equilibration. 
 
136 A CASE OF FRIEDKEICH's ATAXY. 
 
 Are we to believe that in this patient the pyramidal tracts 
 are much affected ? Here we have to remember that in 
 similar cases in which opportunities for post-mortem exa- 
 minations had been obtained, changes in these tracts were 
 not very marked, although existent. I believe that in our 
 patient they are not blocked to any extent. The voluntary 
 motor power is still considerable, and the hand-grip with 
 the dynamograph shows a fairly even line (tracing h). But 
 I think it extremely probable, however, that in the ordinary 
 progress of the disease the involvement of these tracts may 
 become more marked, so that the affection may become a 
 mixture of postero-lateral sclerosis and tabes, as Gowers has 
 described it. Ordinarily, as you know, in cases of postero- 
 lateral sclerosis the increased knee-jerk is an indication of 
 the affection of the pyramidal tracts, but of course this help 
 cannot be expected in Friedreich's disease. 
 
 The giddiness, nodding movements of the head, and the 
 speech impairment indicate some — probably slight — sclerotic 
 changes in the medulla and pons, and possibly also in 
 the cerebellum, such as have been described in similar 
 cases. 
 
 As regards pathology, it is believed that this disease is 
 mainly due to an innate defective nutritive power. Its 
 tendency to occur in families, and to show itself at an early 
 age, before excesses of any kind have had time to bring 
 about a premature wearing-out of the nerve machine, seem 
 to indicate defective endowment rather than excessive 
 expenditure. 
 
 On the question of prognosis all that need be said is that 
 the disease is progressive, but slow, and may last for many 
 years. 
 
 As far as we are at present able to judge in this individual 
 case, it seems to be rather more rapid than usual, and the 
 statement he vouchsafes, that he has lately at times felt 
 some tendency to choke in swallowing, is of some importance 
 
A CASE OF Friedreich's ataxy. 137 
 
 in connexion with possible involvements of parts in the 
 bulb. The precise cause of this deglutition difficulty has 
 been said to be an ataxy of the tongue. 
 
 For treatment, attention to the general health, massage, 
 electricity, arsenic, phosphorus, and nitrate of silver have 
 all been recommended. The tendency to contractions should 
 also be remembered and guarded against. 
 
 Eefeeences. 
 
 Brain, vol. xiii. p. 467. Dr P. Ladame. 
 Brain, vol. xv. p. 250. Dr Sanger Brown, with Discussion 
 by Dr Ormerod and Professor Bernhardt. 
 
 Guy^s Hospital Reports, vol. xliv. p. 369. Dr Newton Pitt. 
 
ON A CASE OF 
 
 COMBINED PARALYSIS OF THE NERVES 
 OF THE ARM DUE TO INJURY. 
 
 Gentlemen, — S. R, aged 24, a mason, born in and at 
 present residing in Edinburgh, was admitted to Ward 30 
 on 7th December 1892, complaining of weakness of the left 
 arm, the result of a fall. 
 
 History. — Family history good. Patient has been in the 
 habit of taking occasional drinking bouts, but is, on the 
 whole, moderate as to alcohol. Has always had a comfortable 
 home, and never too hard work. Had measles in childhood, 
 and whilst in Calcutta in 1887 had a slight attack of dysen- 
 tery. Has had a few falls at his work, but none of them 
 serious until the present one. This he met with whilst work- 
 ing at the window of a church in Newport, Rhode Island, 
 U.S.A., on the 27th September last. From the window he 
 fell a heio'ht of 12 feet, landing on his left slioulder and on 
 the left side of his head. He states that when picked up 
 inimediately after the accident he w^as quite unconscious ; 
 that his left arm was found to have been folded under his 
 body, — he was lying on his back ; that his left ear and cheek 
 were cut, but that there were no other serious injuries to his 
 head. He was at once removed to the Newport Hospital. 
 He regained consciousness some tliree and a half hours after 
 the accident, and then discovered that he had lost completely 
 
- COMBINED PAEALYSIS OF THE NERVES OF THE AEM, 139 
 
 the power of motion and sensation in his left arm. Some 
 four days afterwards he states that he noticed a gradual 
 return of both, and he remembers that sensation returned 
 first, and that the power of motion returned first in the 
 fingers, and then in the hand and wrist. He states, also, that 
 during the return of sensation his arm was so painful that he 
 could not sleep at night, the pain being of a stinging charac- 
 ter. He remained in the hospital for two weeks, and was 
 treated with massage and electricity (faradic). After leaving 
 he attended daily as an out-patient for six or seven weeks, 
 but finding that the improvement in the condition of his arm 
 did not continue, he came home to Edinburgh, and was 
 admitted, as above stated, on 7th December 1892. 
 
 State on Admission. — Height, 5 ft. 6 ins. ; weight, 9 st. 3 lbs.; 
 well developed and fairly muscular. The left arm all over is 
 slighter and feels more flabby than the right, and when asked 
 to move the arm or forearm the loss of power becomes very 
 marked. The flattening of the left shoulder caused by the 
 wasting of the deltoid is specially apparent. There are no 
 other obvious morbid appearances. The pulse and tempera- 
 ture are normal, and, with the exception of the condition of 
 the left arm, he is a healthy, vigorous man. Let us now 
 investigate more carefully this left arm. 
 
 Observe, in the first place, that the paralysis is associated 
 with atrophy and absent reflex irritability of the muscles. 
 Concerning this more will be said by-and-by, but at present 
 this is sufficient to show that the lesion is either one of the 
 peripheral nerves, or one of the cord involving the nuclei of 
 origin of certain of the motor nerves in it. 
 
 Let us first consider the several muscles in detail. 
 
 Deltoid. — Its paralysis is shown by the fact that the patient 
 cannot abduct the arm at the shoulder-joint, and its atrophy 
 by the marked flattening of the shoulder. 
 
 Siqyrasjnnatus. — This muscle acts like the deltoid, hence 
 when it is paralyzed along with tlie deltoid its loss of function 
 
140 COMBINED PARALYSIS OF THE NERVES OF THE ARM. 
 
 cannot well be demonstrated by a corresponding loss of move- 
 ment. In this patient, however, its involvement is well seen 
 by the wasting which it shows. It is worth mention that 
 Growers states that when the supraspinatus is paralyzed along 
 with the deltoid, the head of the humerus falls away from the 
 acromion far more than when the deltoid is paralyzed alone. 
 This is illustrated in this patient to some extent. The head 
 of his left humerus is distinctly lower than that of the 
 right. 
 
 Infraspinatus. — This rotates the humerus outwards, a 
 movement which this patient cannot perform, but the con- 
 dition of this muscle is also best shown by the atrophy. 
 
 Teres minor. — This has a similar action to the infraspinatus, 
 and is probably also involved in this case, although this can- 
 not be demonstrated. 
 
 Siibscapularis. — This rotates the humerus inwards, and is 
 apparently not involved in this case. As you see, the patient, 
 when asked, can rotate his humerus inwards, and you see also 
 that the pectoralis major, trapezius, and latissimus dorsi are 
 evidently unaffected. 
 
 The rJiomhoids are involved, as shown when the patient 
 draws back his shoulders. The flattening in the left inter- 
 scapular region is then well marked. 
 
 The serratus magnus is also involved. In this case its 
 paralysis can best be seen when the patient tries, as it were, 
 to push himself backwards with his hands. On the right 
 side the digitations of the muscle can then be seen to stand 
 out powerfully as compared with those of the left. 
 
 The teres major draws the humerus to the scapula, aiding 
 the pectoral muscles. It is probably not affected in this case. 
 
 Triceps is not affected, as shown by its well-nourished con- 
 dition and by its extensive power. When I flex his left arm 
 and ask him to extend it, he does so with considerable force. 
 
 Biceps is markedly involved. He cannot flex the elbow, 
 nor can he supinate the forearm when pronated. 
 
COMBINED PARALYSIS OF THE NERVES OF THE ARM. 141 
 
 Brachialis anticus is probably also involved, though this 
 cannot well be demonstrated. 
 
 Supinator longus is certainly involved. This is well seen 
 when he attempts to flex the elbow or to supinate the hand 
 when it has been pronated. 
 
 The pronators and the extensors and flexors of the wrist 
 and fingers seem all to work well. We were for a time not 
 quite sure of the extensor carpi radialis longior, but we have 
 now concluded that it is acting normally. 
 
 Next notice that these affected muscles show the reaction 
 of dec^eneration. With the faradic current to their motor 
 points we find no reaction on the affected side, whilst on the 
 healthy they respond readily. The unaffected muscles of the 
 left arm also respond readily to the faradic current. On the 
 other hand, with the galvanic current to the affected muscles 
 they respond quite readily, and the so-called " qualitative " or 
 " polar " change is marked. That is to say, while 
 
 KCIC ^Q^ KOC 
 
 is the order on the healthy side, we found that on the affected 
 side there occurred in at any rate some of the muscles, 
 
 AGIO KCIC. 
 
 But this patient also presents some important sensory 
 disturbances. There is, first of all, a well-marked area of 
 ansesthesia over the deltoid muscle, corresponding with the 
 distribution of the sensory fibres of the nerve to that muscle, 
 viz., the circumflex nerve. Higher up on the shoulder, and 
 over the supraspinatus muscle, is an area where anaesthesia 
 is present, but to a less degree. Lastly, over the forearm 
 there is an area of ansesthesia corresponding to the distribu- 
 tion of the subcutaneous fibres of the musculo-cutaneous 
 nerve. 
 
 These anaesthetic areas can be shown very well by touching 
 the skin over them, and noting where the sensibility becomes 
 
142 COMBINED PAKALYSIS OF THE NERVES OF THE ARM. 
 
 normal. They are well shown in the illustrations, which are 
 taken from photographs. Thermal sensibility is also affected, 
 as you see the hot and cold test-tubes applied to these areas 
 cannot be distinguished. 
 
 Further, with the faradic current we find that whilst over 
 the normal side the stimulus is felt when the approximation 
 of the secondary to the primary coil reaches 15 mm., over the 
 ansesthetic areas the stimulus is not felt till the approxima- 
 tion reaches 10 or 11 mm. With this diminution of sensibility 
 to touch, temperature, and the faradic current, we find, further, 
 a marked hyper-sensibility to painful impressions. Thus a 
 pinch or a tap which, over the anaesthetic areas of his left 
 arm and shoulder, causes the most apparent wincing, on his 
 normal side has no effect whatever. There is anaesthesia with 
 hyperalgesia. 
 
 In connexion with these areas of diminished sensibility, we 
 also endeavoured to discover if, with the galvanic current, an 
 altered polar reaction occurs similar to what occurs in muscles 
 when degenerated. In some such cases we know that a sensa- 
 tion is produced by ACi current more readily than by KCl 
 current. In this patient we have found some evidence of this 
 change, — only, however, over the deltoid area of the affected 
 side. 
 
 Here, then, we have a case where, as the result of a fall on 
 the shoulder some three months ago, we have paralysis of the 
 following muscles :— Ehomboids, supra- and infraspinatus, 
 probably teres minor, serratus magnus, deltoid, biceps, and 
 probably brachialis anticus, supinator longus. 
 
 In addition, we have areas of anaesthesia over the shoulder, 
 due to involvement of the sensory fibres of the circumflex, and 
 over the radial surface of the forearm, due to the involvement 
 of the sensory fibres of the musculo-cutaneous nerve. The 
 area of impaired sensibility over the suprascapular region is 
 probably due to involvement of some of the sensory branches 
 of the cervical plexus. 
 
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COMBINED PAKALYSIS OF THE NEKVES OF THE ARM. 143 
 
 Thus, then, we have a lesion involving the nerve to the 
 serratus, the nerve to the rhomboids, the suprascapular nerve, 
 the circumflex, and certain of the fibres of the musculo- 
 cutaneous and musculo-spiral nerves, viz., those to the biceps, 
 brachialis anticus, and supinator longus and its sensory fibres. 
 Noting that thus certain nerves and certain fibres are, as it 
 were, picked out, we have to endeavour to find a locality 
 where a lesion could possibly produce these effects. 
 
 In connexion with this, let me first draw your attention to 
 the experiments of Ferrier and Yeo and the relations of vari- 
 ous movements of the arm to the spinal nerve-roots. For 
 example, on stimulating the 4th cervical root in the monkey, 
 they found that the movements were elevation and retraction 
 of the arm and flexion and supination of the forearm, by 
 the rhomboids, supra- and infraspinatus, biceps, brachialis, 
 and supinators. 
 
 On stimulating the 5th cervical root the movements were 
 " similar to the last, but without retraction of the arm, and 
 with extension of the wrist and first phalanges, by the deltoid, 
 serratus, flexors of elbow, extensors of wrist, and long exten- 
 sors of fingers." That is to say, that, with the exception of 
 the extensors of the wrist and fingers, stimulation of the 4th 
 and 5th cervical roots causes contraction of all the muscles 
 which are picked out by the paralysis in this case. 
 
 Again, Growers, in treating of the combined paralysis of the 
 nerves of the arm, refers to the fact pointed out by Erb, that 
 injuries to the neck sometimes cause a combined paralysis of 
 the deltoid, supra- and infraspinatus, biceps, brachialis anti- 
 cus, and supinators. On this subject Gowers goes on to say, — 
 " Erb found that there is one spot between the scaleni, corre- 
 sponding to the 6th cervical nerve, at which electrical stimu- 
 lation puts all those muscles in motion." 
 
 Hoedemaker, who has described two cases of this palsy, 
 finds the motor point in a line drawn from the sterno-clavicular 
 articulation to the 7th cervical spine, 1-5 cm. from the edo-e 
 
144 COMBINED PARALYSIS OF THE NERVES OF THE ARM. 
 
 of the trapezius. The palsy is apparently dependent on 
 disease of the 5th and 6th cervical nerves, and the 5th, it will 
 be remembered, receives a twig from the 4th. 
 
 In our patient there is, as we have seen, involvement of 
 certain sensory as well as motor fibres, and as the former of 
 them, viz., those of the circumflex and of the musculo-cutane- 
 ous nerves, seem to have been traced to the 4th and 5th 
 cervical spinal nerve-roots, I am inclined to think that these 
 are the nerve-roots involved. From the fact that there is 
 some appearance of change in the order of reaction of the 
 sensory nerves to the galvanic current, it may, I think, be 
 supposed that the spinal nerves have been injured outside the 
 junction of the motor and sensory roots, and, of course, out- 
 side the ganglion on the sensory ones. 
 
 As regards prognosis, this is so far favourable. The nerve 
 affection has been due to injury. It has not yet lasted too 
 long to preclude recovery. The muscles have not lost their 
 irritability to galvanism, some return of power has been 
 noticed in the supination and flexion, and the supinator longus 
 and biceps now show some tendency to respond to the faradic 
 current. Further, the sensibility is improving. 
 
 Treatment. — This consists mainly in galvanism to the 
 muscles and faradism to the affected areas of skin. Eecently 
 the faradic current has been also applied to the supinator 
 longus and biceps. Massage to the affected limb is being 
 applied daily. He is getting strychnia internally, and we 
 shall use strychnia hypodermically if we think it necessary. 
 To prevent stiffening at the shoulder he daily gives a little 
 exercise to the joint by holding on by his hands to a horizontal 
 bar which we have fixed up for him in the ward. Possessing 
 good power in his fingers and hands, he can hold on quite 
 easily, and the result has been that after about a week a 
 threatened stiffening of the shoulder has disappeared. 
 
A CASE OF PONS LESION. 
 
 G-ENTLEMEN, — The case which I am about to bring before 
 you to-day is one which illustrates in itself some very inter- 
 esting features, and which contains others which may be of 
 value to you in the diagnosis of nerve lesions. 
 
 The patient is a man, E., 57 years of age, who was 
 admitted June 20, and examined on June 21 and following 
 days. 
 
 He complains of giddiness and difficulty in walking, and 
 general weakness, of twelve months' standing ; of numbness 
 and loss of feeling on the left side of face, arm, leg, and 
 trunk, of four months' duration ; of inability to open the 
 mouth widely, three months' duration ; and of loss of power 
 on the right side of the face, with double vision during the 
 past seven weeks. 
 
 Family History is fairly good. His father died at the age 
 of 55 of some chest complaint. His mother died of " old 
 age" at 88. Three other members of the family died respec- 
 tively from heart trouble, inflammation of the bowels, and 
 small-pox. Others are alive and well. 
 
 Patient has had seven children, all alive and healthy. He 
 has always had a comfortable home and good food, and is 
 moderate in the use of alcohol. 
 
 At his work (a mason) he is often exposed to the weather. 
 
 Previous Health. — Tliere is no history of syphilis. He 
 seems to have been perfectly well till thirteen years ago, 
 when after some heavy work and exposure to cold, he states 
 
146 A CASE OF PONS LESION. 
 
 that he came home one night suffering from lioarseness of 
 voice and uneasiness in the throat. Next day he went to 
 work as usual, and the hoarseness became worse. At night 
 his voice was gone entirely. He consulted a doctor, and his 
 throat was painted and some local remedy applied, but after 
 about a month, finding himself no better, he came to the 
 Eoyal Infirmary, and was admitted to Dr Brakenridge's 
 Ward. 
 
 His condition was diagnosed as paralysis of the left vocal 
 cord, and it was thought probable that it was due to a small 
 aneurism of the aorta involving the left recurrent laryngeal 
 nerve. He was told to be careful in his living, and was sent 
 out a little better. He comes back again to us after thirteen 
 years, and, as we shall see, he still has paralysis of the left 
 vocal cord. 
 
 From this time (thirteen years ago) he remained in good 
 health until a year ago, when he began to be troubled with 
 giddiness in walking, causing him to stagger as if drunk. 
 
 He noticed that he was obliged to keep his eyes fixed on 
 the ground in front of him to prevent himself from staggering. 
 The tendency to stagger was most marked towards evening; 
 it was not so obvious in the morning. 
 
 As a result of this giddiness he once fell while stooping to 
 lift a block of stone at his work. 
 
 He gradually became worse, and next he noticed that his 
 general health was becoming somewhat enfeebled. 
 
 Shortly after this giddiness began — that is to say, about a 
 year ago — he had an attack of vomiting which came on with- 
 out any known cause. This lasted a week, was of consider- 
 able severity, and during it all food was rejected immediately. 
 
 Since then he has occasionally had slighter attacks of 
 vomiting. They come on in the morning generally before, 
 or it may be after, breakfast, and are preceded only by a 
 slight feeling of nausea. 
 
 About this time also he noticed that he was troubled 
 
A CASE OF PONS LESION. 147 
 
 with headaches, which, however, were not of a very severe 
 form. 
 
 About four mouths ago he became aware of, as he describes 
 it, a "numbuess, tiugling, and coldness, and sense of strange- 
 ness," on the left side of the face and body and on the left 
 arm and leg, and a little later than this he noticed that in 
 touching things with those parts he could not feel them so well. 
 
 A month after this he found difficulty in opening his 
 mouth widely. His attention was drawn to this by the fact 
 that he was obliged to use a smaller spoon than formerly. 
 
 Seven weeks ago he noticed a loss of power in the muscles 
 of the right side of the face, and then he began also to see 
 double, indicating a paralysis of some of the eye muscles. 
 With the paralysis of the muscles of the right side of the face 
 he noticed that his right eye did not close properly. He 
 says he noticed this, because, when lying in bed with his eyes 
 shut, as he supposed, he still saw light. 
 
 He states also that the vomiting and the feeling of weak- 
 ness have been getting worse during the last four weeks. 
 
 He was seen about a month ago, prescribed for, and told 
 to return in a month. This he did, and was admitted to 
 Ward 30. 
 
 Present Condition. — The patient is a man 5 ft. 6J in. in 
 height, and at present weighs 10 st. 4 lbs., but he used to be 
 about 12 St. when in health. His muscles are soft and flabby. 
 Tiie right half of his face is absolutely motionless. There is 
 no wrinkling of the forehead, and no reflex closure of the lid 
 on touching the conjunctiva of the right eye. The eye is 
 widely opened, and the conjunctiva is slightly inflamed. 
 The lower lid is also a little removed from the globe, but not 
 much. 
 
 There is also evident hollowing in the right temporal fossa, 
 due to paralysis and wasting of the right temporal muscle. 
 
 Alimentary System. — The tongue is not in any way para- 
 lyzed, but can be moved freely in any direction. He 
 
148 A CASK OF PONS LESION. 
 
 complains of dryness of the mouth, especially on the right 
 side. This is important, because with the portio dura, as you 
 know, you often have the chorda tympani involved, and so 
 salivation affected. 
 
 During mastication the food tends to collect on the 
 affected side of the mouth in the hollow of the cheek, 
 and he has to clear it out with his finger. The palate 
 shows some indications as if its right side were a little 
 lowered, but this is not very well marked. There is no 
 difficulty in swallowing. 
 
 The bowels are very constipated. 
 
 Physical examination of the abdomen reveals nothing 
 worthy of note. 
 
 Hcemopoietic Systetn is normal. 
 
 Circulatory System. — Pulse 88, strong and full. The 
 vessels are a little thickened, but tliere are no indications 
 of aortic aneurism. 
 
 Respiratory System. — There is a slight cough and spit. 
 The left vocal cord is quite paralyzed, as already stated. 
 
 Integumentary System. — This is normal, except that there 
 is a slight tendency to oedema of the legs. 
 
 Urinary System. — Patient has generally to rise once at 
 night to pass water. Tlie act of micturition is at times 
 slightly delayed, not sufficiently to be of importance. 
 
 Sp. gr. of urine, 1020 ; no albumen ; no sugar, 
 
 Nervous System {Sensory). — Patient complains of coldness, 
 numbness and tingling, as if the parts were "asleep," in the 
 left arm and leg, and on the left side of the body and face. 
 This is specially marked on the arm and front of the chest. 
 There is some impairment of feeling all over these parts. 
 The area of incomplete ana3thesia is limited by the middle 
 line of the body. There is no hyperassthetic part. 
 
 On the right side sensation is perfectly normal, at any rate 
 as regards the trunk and limbs. On the right side of the 
 face there seems to be a little hypera^sthesia, but it is difficultj 
 
A CASE OF PONS LESION. 149 
 
 if not impossible, to determine this, since we have only the 
 defective side to compare it with. 
 
 Sensation of locality is impaired on the left side. He 
 cannot say exactly where you have touched him. 
 
 There is also some impairment of sensation in the left 
 conjunctiva and in the mucous membrane of the nose and 
 cheek on the left side. Ammonia held to the nostrils 
 stimulates the right more than the left. 
 
 Sensibility to weight is not affected. 
 
 Temperature sense is impaired on the left side also. Cold 
 is often mistaken for hot, but hot is never mistaken for cold. 
 
 Sensibility to electric current on the left side is also 
 diminished, and also sensibility to pain. 
 
 Eate of nerve conduction on the left side is diminished. 
 
 Muscular sense on the left side is not much affected. 
 
 Special Senses: Smell. — The sniffing movement of the 
 right nostril is not well marked, but he smells such a 
 substance as clove oil equally well on each side. As just 
 stated, ammonia is perceived better on the right side, not so 
 well on the left, since it stimulates the nerves of common 
 sensibility. 
 
 Hearing. — He hears constant noises in the right ear, and 
 loud sounds are sometimes painful. But the ticking of a 
 watch is not heard so well with the right ear as it is with the 
 left. 
 
 Sight. — The right eye points over to the left, and is com- 
 pletely paralyzed with respect to the external rectus. 
 
 The left eye moves well enough to the left, but only a 
 little to the right. Hence there is modified paralysis of the 
 internal rectus of this eye. 
 
 Dr Sym examined the eyes, and the following is his 
 report : — 
 
 "There is paralysis of the right movement of both eyes. 
 It is rather a paralysis of movement than of muscles. 
 The internal rectus of the left side makes no effort to con- 
 
150 A CASE OF PONS LESION. 
 
 tract when the patient is asked to look at an object moving 
 to the right, but it feebly contracts when he is told to 
 converge for a near object. The other muscles are free. 
 There is homonymous diplopia. Fundus seems healthy. 
 Disc is a little grey. There is no appearance of former 
 neuritis. Field of vision is fairly good. Pupils are of 
 medium size, and contract to light and accommodation. 
 This erroneous projection leads to great giddiness in standing 
 or walking." 
 
 Taste. — We have had some considerable difficulty in 
 satisfying ourselves as regards the condition of taste in this 
 case. In the first place, the patient cannot open his mouth 
 very widely, so it is difficult to get at the back part of the 
 tongue. In the second place, we have to contemplate the 
 possibility of the existence of lessened common sensibility 
 on tlie left half of the tongue, and of this causing some 
 confusion. But all our observations go to indicate that on 
 the whole of the right half of the tongue, front and back, 
 there is a diminution both of taste and of common sensi- 
 bility. Wlien, for instance, a little quinine, or sugar or salt, is 
 applied to the tongue, or taken into the mouth, he distinctly 
 tells us that he feels the taste only on the left side, and 
 all over it. Similarly, when the tongue is touched or pricked 
 with a needle, he tells us that he feels it distinctly better on 
 the left side. This is not altogether what we should have 
 expected, but it certainly is what he says he feels. 
 
 Motor. — Organic reflexes are quite normal. Skin reflexes 
 do not in any way deviate from health, but the conjunctival 
 reflex is, of course, absent on the right side. 
 
 With regard to the voluntary muscles, there is nothing 
 very noticeable, except with regard to the muscles of mas- 
 tication. The masseter and temporal are paralyzed and 
 atrophied on the right side, and they, with the facial muscles, 
 show the reaction of degeneration. As regards the pterygoids, 
 we find that the lower jaw is moved slightly over to the 
 
A CASE OF PONS LESION. 151 
 
 right side wLeu it is depressed, and that the patient cannot so 
 well perform a lateral movement of it to the left side. This 
 indicates paralysis of the right external pterygoid muscle. 
 
 Co-ordination. — Tlie patient performs movements, such as 
 buttoning his coat, perfectly well. 
 
 He can stand with his eyes shut and his heels together 
 without swaying. When walking with his eyes open he 
 tends to go to the left, and in attempting to correct this he 
 staggers. He has great difficulty in going up and down stairs, 
 on account of the confusion arising from his double vision. 
 
 With one or both eyes shut, he walks nmch better, and 
 can even walk backwards fairly well. 
 
 So much for the symptoms and morbid appearances. 
 What we have to do now in connexion with the considera- 
 tion of the case is to make up our minds first as to the 
 locality, and secondly as to the nature of the lesion. 
 
 Let us take first of all the paralysis of the I'ace. This 
 paralysis of the face, you can see at once, must be due to a 
 lesion of the nerve itself, or of its nucleus. It is not due to 
 a lesion above the nucleus. 
 
 We are inclined to think that it is the nucleus of the 
 facial nerve that is affected, 
 
 I think witli these rough diagrams (see pp. 152 and 153) 
 you will be able to follow me. 
 
 The nucleus of the portio dura or facial nerve (F) lies in 
 the lower part of the pons Varolii, and we believe that we 
 have a lesion somewhere at the lower part of the pons 
 involving this root. But a lesion involving the root of the 
 facial must be quite close to the root of the sixth nerve (VI.), 
 and it is very likely to involve it as well, and this would 
 explain the paralysis of the right side of the face, and the 
 paralysis of the external rectus of the right eye. 
 
 But what about the left eye ? This may be explained by 
 the connexion of the sixth nerve on one side with the third 
 nerve on the opposite side, so that such a lesion is apt to 
 
152 
 
 A CASE OF PONS LESION. 
 
 interfere with the co-ordination of the sixth and tliird nerves. 
 Dr Sym's report, as we have seen, indicates this as the 
 explanation. 
 
 Further, a lesion here will also be very near the motor 
 nucleus of the fifth (Vm.) nerve which supplies the muscles 
 of mastication. Hence the paralysis of these muscles can 
 also be explained. 
 
 Diagram of section of the lower part of the pons, sho^\^ng the connexion of the facial, sixth, 
 and motor fifth nerves (mastication). 
 
 F. Facial nerve. VI. Sixth. Vm. Motor of fifth. 
 
 As regards the giddiness. Notice that this may be 
 explained as being due to the disturbed w^orking of eyes. It 
 may be entirely due to this, but it is possible that it may be 
 due in part also to some of the fibres of the portio mollis 
 being involved. Thus we know that from a little lower down 
 than the positions of the facial, sixth, and motor fifth nuclei 
 the portio mollis or auditory nerve arises, and we know also 
 that in connexion with it there are two nuclei of origin. We 
 know also that whilst one of these nuclei seems to be mainly 
 
A CASE OF PONS LESION. 
 
 153 
 
 connected with fibres from the cochlea, and so to be con- 
 cerned in hearing, the other is mainly connected with the 
 semicircular canals and vestibule, and is supposed to be 
 concerned in equilibration. In the diagram they are both 
 indicated by the area marked Au, and it is evident that a 
 lesion involving the facial, the sixth, and the motor fifth is 
 very likely to involve this nucleus also. In this way, there- 
 fore, might be explained in part the giddiness. No doubt it 
 and the equilibration disturbance are largely due to the eye 
 conditions, but he tells us that even when he sits quietly with 
 his eyes closed he still feels the giddiness to some extent. 
 
 Diagram showing the relative position of the nerve nuclei below the floor of 
 the foiirth ventricle. 
 
 F. Facial. VI. Sixth nerve. Vm. Motor of fifth. 
 Au. Portio mollis. GP. Glosso-pharyngeal. 
 
 Hearing. — As you are aware, in paralysis of the facial 
 nerve hearing is often affected owing to the action of the 
 stapedius muscle being interfered with. In this case we have 
 also, as just stated, to take into consideration the possibility 
 of the auditory nucleus itself being involved. 
 
 Next, as regards the loss of sensation on the left side of 
 the head, trunk, and left arm and leg. 
 
 The sensory nerves from the left leg, arm, and side of 
 
154 A CASE OF PONS LESION. 
 
 the trunk pass into the posterior part of the cord, and having 
 decussated either in the cord or in the medulla, pass through 
 the tegmentum of the pons, up the crus to the brain. We 
 can understand, therefore, that a lesion here may affect these 
 and account for the hemi-ansesthesia. 
 
 Further, to account for the impairment of sensation on the 
 skin and mucous membranes of the left side of the face, we 
 have to suppose that the lesion on the right side of tlie pons, 
 while leaving unaffected the sensory part of the fifth nerve 
 on that side (Va, diagram, p. 152), is in one way or other 
 interrupting the continuity of the fibres which convey 
 impulses from the sensory part of the fifth on the left 
 side, upward to the right side of tlie brain. 
 
 2\iste. — As regards taste, we liave seen that in our patient 
 not only is this special sense impaired over the right half of 
 the tongue, but that common sensibility appears to be also 
 impaired in this situation. The loss of taste is explained by 
 the view that the glosso-pharyngeal is the sole nerve of taste, 
 and that it supplies the back of the tongue through its main 
 trunk, and the front part through the pars intermedia and 
 chorda tympani. Hence in our patient we must suppose 
 that the glosso-pharyngeal nucleus or fibres of origin are 
 involved (diagram, p. 153). 
 
 But how can we explain the impairment of common sensi- 
 bility on this right half of the tongue with no other evidence 
 of lesion of the sensory fifth nerve on that side ? Explana- 
 tions might be hazarded, but they could only be conjectural. 
 
 Larynx. — As regards this the question might be asked, Can 
 the paralysis of the left vocal cord — which was noticed thir- 
 teen years ago, and which is now very much as it seems to 
 have been then — be a part of his present disease ? I believe 
 not. Neither do I think that it is due to aneurism. Prob- 
 ably it is due to some inflammation of a rheumatic nature, 
 which has led to adhesions between the left arytenoid and 
 parts around. 
 
A CASE OF PONS LESION. 155 
 
 As regards locality of the lesion in this patient, therefore, 
 I believe it to be situated in the right side of the lower 
 part of the pons, involving the nuclei of origin of the facial, 
 sixth, and motor fifth nerves, extending downwards so as to 
 implicate to some extent the nuclei of the glosso-pharyngeal 
 and portio mollis, and upwards so as to implicate the sensory 
 fibres which have crossed from the left side of the head, 
 trunk, and limbs. 
 
 Nature of the Lesion. — This is obscure ; but since the condi- 
 tion has been going on steadily for twelve months, I think 
 that probably it is of the nature of an infiltrating glioma. It 
 is of slow growth, and although there is some headache and 
 vomiting, there is no distinct optic neuritis. Still I think it 
 is of this character. 
 
 Treatment. — It is not necessary to say much about this. 
 We are giving him the iodide and looking after his general 
 health. This is all we can do at present. 
 
CASE OF ADDISON'S DISEASE. 
 
 Gentlemen, — A. C, aged 52, an upholsterer, born and 
 residing in Edinburgh, was admitted to Ward 30 on January 
 27, 1893, complaining of great weakness and brown colouring 
 of his skin. 
 
 History. — Family : father died of inflammation of the lungs 
 at the age of 39, and from the patient's account this seems to 
 have been acute pneumonia. Mother died at 83, and was 
 always a strong, healthy woman. He has one sister only, 
 and she is rather weakly, although evidently not phthisical. 
 Patient is married, and has been the father of a family of 
 seven, of which four are dead. — one at the age of 6 years, of 
 water on the brain. 
 
 Habits as to Food and Brink. — He gives a strong alcoholic 
 history, and states that he has also taken tea in excessive 
 quantities. 
 
 General Surroundings. — At home he has only one room for 
 himself and his family, and he says his house is damp. At 
 work his surroundings are also unfavourable. He is much 
 engaged making mattresses, and so is constantly in a very 
 dusty atmosphere. This, he says, makes him cough, and 
 causes his spit to become black for weeks at a time. His 
 average day's work is nine hours. 
 
 Previous Illnesses. — Had measles when a child. He says- 
 he is very liable to catch cold, and that he always gets a 
 cough when winter comes on. He gives no history of 
 venereal disease. 
 
Case of Addison's Disease. 
 
 Portion of the Anterior Abdominal Wall, showing at j^arts the arrangement of the 
 sjaots in rows and their ring-like character. 
 
Case of Addison's Disease. 
 
CASE OF Addison's disease. 157 
 
 Time, Mode of Origin, and Cause of Present Illness. — He 
 states that he was feeling well enough, and was quite fit for 
 work till three years ago. He then noticed that he was 
 becoming weaker. He noticed, too, that he had a hard 
 cough, and that he sweated a good deal, especially at night. 
 Sometimes, when the cough was specially severe, he would 
 spit up a little blood. He also noticed that he was losing 
 flesh, and that if he sweated much his skin used to itch a 
 great deal. 
 
 He kept on in this condition until five months ago, and 
 then attention was attracted by his wife to a brown colora- 
 tion at the back of his neck. This discoloration was uniform 
 over an area about the size of the palm. It was not spotted, 
 but a few days after this he noticed a number of spots on his 
 chest. These gradually increased, and he next noticed the 
 legs becoming coloured, and then the arms. 
 
 Since the discoloration began, he states that he has noticed 
 himself becoming very much weaker ; he has been troubled 
 at times with pain across the loins, and his stomach has given 
 him a good deal of trouble. 
 
 Stale on Admission. — Height, 5 ft. 7 in.; weight, 8 st. 
 1 lb., used to be 9A- st. ; his muscles are flabby, and his face 
 presents the appearances of anaemia. 
 
 Integumentary System. — "When stripped, the brown dis- 
 coloration of the skin can be seen widely distributed over the 
 body and limbs. Over the neck, the greater part of the 
 trunk, and tlie greater part of the limbs the brown discolora- 
 tion is fairly uniform, but at some parts, and notably the 
 anterior abdominal wall, this is not the case ; but its appear- 
 ance is one of a multitude of spots, round in shape, and about 
 "I of an inch in diameter. These are much more numerous 
 on the left side of the lower part of the abdomen, where they 
 are arranged as if in regular rows right up to tlie middle line, 
 where they abruptly cease. These spots can be made out 
 very distinctly over the other parts of the trunk and limbs ; 
 
158 CASE OF ADDISON'S DISEASE. 
 
 l)ut, of course, where they have become so numerous as to 
 merge into one another, the appearance of the parts has 
 changed. 
 
 If the spots are examined more carefully, they are in many 
 cases seen to be ring-like, — that is to say, to present a dark- 
 brown margin and a lighter-coloured centre. In many cases, 
 too, their centre shows a hair, whilst in other cases the spots 
 seem to encircle a sweat-gland. This latter point we have 
 satisfied ourselves upon by examining them carefully after he 
 has been sweating, for then many of them show, in their 
 lighter-coloured centres, a raised and somewhat sodden 
 appearance of the epidermis. 
 
 As previously stated, the face, though somewhat sallow, 
 does not show the pigment ; but the darkening is fairly well 
 marked in the external genitals. The axillae and the nipples 
 cannot, however, be said to be more pigmented than the sur- 
 rounding skin. Over the non-discoloured areas, specially of 
 the abdomen, the skin appears to be — and in this we are 
 corroborated by the patient's own statement — rather whiter 
 than normal, and on each arm small spots, about half an inch 
 or so in diameter, of leucoderma can be seen. The palms and 
 soles show no pigmentation. Over the outer aspect of the 
 left elbow joint there is an area, oval in shape and about one 
 inch in length, where the skin is slightly reddened and not 
 pigmented. The patient tells us that tlie skin had been 
 browned here ; but that a lew weeks before his admission he 
 had knocked his elbow against a wall and skinned it at the 
 part, and that when he took the scab away he had noticed it 
 white. 
 
 The hair of the patient's head and beard is uniformly 
 white, but he says that he began to turn grey at the age of 
 36 years. He believes, however, that the marked whiteness 
 has existed only for the last three years, — i.e., since he has 
 noticed his illness coming on. 
 
 On examining the hairs of the body, notably about the 
 
CASE OF Addison's disease. 159 
 
 pubes, we noticed that on the left side, or wherever the 
 pigmentary coloration of the skin is more marked, the hairs 
 also seem to be more pigmented. This is not always the 
 case, for though on close examination we observe that the 
 hairs emerging from the centre of brown spots are more 
 frequently brown than those emerging from a non-coloured 
 area of skin, we find many brown spots giving origin to 
 white hairs, and many pale areas of skin giving root to 
 brown hairs. 
 
 The nails in our patient show, as is usual in Addison's 
 disease, no discoloration ; but they are markedly thickened, 
 specially those of the thumbs, and index, middle, and ring 
 fingers. The toe nails are apparently unchanged. 
 
 As regards the mucous membranes, the lips show patches 
 of brown pigmentation, mostly along their line of contact ; 
 the hard palate shows also patches most markedly, and the 
 inner surface of the cheeks to a less extent. The mucous 
 membrane of the tongue does not appear to be affected. 
 
 Respiratory System. — With the history of cough, of night 
 sweats, and of slight haemoptysis, we carefully examined the 
 chest, and found some impairment of the percussion-note at 
 the left apex posteriorly, with slight harshening of the 
 respiratory murmur, prolongation of the expiration, and 
 increase in the vocal resonance. The at present scanty muco- 
 purulent and rather frothy spit has been examined, but no 
 bacilli have been found. It shows however, curiously, the 
 pneumococcus. 
 
 Circulatory System. — When at rest he has no symptoms 
 of circulatory disturbance, but if excited he is liable to 
 palpitation, and though he never has fainted, he is apt to 
 feel faint on making any sudden movement. Dyspncea, 
 also, he does not complain of, except as the result of exertion. 
 
 Physical examination shows the heart to be slightly 
 enlarged (dilated), its left border being a little outside the 
 nipple line. With the exception of a hsemic bruit at the 
 
160 CASE OF Addison's disease. 
 
 apex, and a slight " bruit de diable " in the veins of the neck, 
 there are no murmurs. 
 
 Pulse is 110 per minute, very soft and compressible, 
 although regular, and the low tension is shown well by the 
 sphygmographic tracings. 
 
 The blood when examined showed the red corpuscles to 
 number 3,500,000 per cmm., and amount of haemoglobin to 
 be 45 per cent. 
 
 Dr Muir has kindly examined some specimens of it for us, 
 and his report is as follows : — 
 
 " The red corpuscles show considerable variations in size, 
 many being undersized. There were also a few irregularly- 
 shaped corpuscles. The corpuscles are pale, and form 
 rouleaux somewhat imperfectly. The blood - plates are 
 markedly increased in number. The leucocytes are also 
 somewhat increased, specially the large variety. 
 
 "The blood thus shows nothing characteristic, the changes 
 being such as are generally met with in cachectic conditions." 
 
 Alimentary System. — His appetite is fairly good, and he is 
 rather thirsty, but he has now — i.e., since his admission — 
 no vomiting. He used to suffer from vomiting and pyrosis. 
 His bowels are usually confined ; and he says that every 
 fortnight or so he is apt for two or three days to be attacked 
 with vomiting and diarrhoea. He says also that he some- 
 times takes a rather severe pain in the epigastrium. 
 
 Physical Examination reveals no enlargement of liver or 
 spleen, nor any other abnormality. 
 
 Geyiito- Urinary System. — Urine : Quantity has varied 
 between 36 and 80 ozs., colour rather pale, reaction acid, 
 specific gravity 1014 to 1020, no albumen nor sugar. On 
 several occasions we have estimated the quantity of Urea, 
 but found no marked decrease. Neither have we found any 
 increase of indican. 
 
 Hcemopoietic System. — Some slightly enlarged glands in the 
 groins and axillse can be detected. 
 
CASE OF ADDISON'S DISEASE. 161 
 
 Such, then, is our case. We have concluded that we are 
 dealing with an example of Addison's disease, — of a disease in 
 which some morbid condition of the suprarenal capsules is 
 the main lesion. But our patient presents some rather 
 peculiar and very interesting features, which I wish now 
 particularly to draw your attention to. 
 
 In the first place, as regards etiology. This disease is, of 
 course, more frequent in men, but notice that our patient 
 is rather older than the average. Next, as you will 
 remember, the most frequent disease of the capsules in this 
 malady is a tubercular one ; it is interesting to note that 
 although in his family history there seems to be no very 
 marked phthisical tendency, he has had a cough and 
 haemoptysis. A point which has been adverted to by some 
 of those who have written on the subject of Addison's 
 disease is, indeed, that the disease is not more common in 
 the phthisical. 
 
 Another factor in its etiology which has been instanced 
 is injury to the back. In our patient we have, however, no 
 evidence of this, but he has had to do hard physical work in 
 unhealthy surroundings. 
 
 As regards symptomatology, the first point to which I 
 wish to direct your attention is, that in our patient the one 
 special symptom of the disease, viz., the debility, preceded 
 the other, the bronzing of the skin. He tells us that he has 
 been feeling weak and ill for some three years, whilst that 
 the bronzing of the skin was not noticed till some four 
 months ago. In the Croonicm Lectures for 1875 Dr Green- 
 how states that the number of cases in which the bronzing 
 is preceded by the debility and in which the debility is 
 preceded by the bronzing are about equal, and cases seem 
 also to have occurred where these two main symptoms were 
 noticed to have occurred together. 
 
 The localities where the pigmentation shows itself is also 
 important. As you are aware, it tends for the most part to 
 
162 CASE OF Addison's disease. 
 
 affect first and most markedly the exposed parts — face, neck, 
 and hands, and also those parts which normally contain most 
 pigment, viz., the axillee, nipples, umbilical region, external 
 genitals. As you will see, this is not altogether the case 
 with our patient. Although he reports the coloration as 
 having been first seen on the neck, you will see that it, with 
 the face and hands, is not so dark as the trunk at many 
 parts, and that though the external genitals are pigmented, 
 the axillae, nipples, and umbilical region are not specially so. 
 As is usually the case, the palms of the hands are distinctly 
 less coloured than the dorsal surfaces, and although the finger 
 nails are thickened in the manner already described, we can 
 see that their matrices are not discoloured. 
 
 Another point worthy of note is that abrasions of the skin 
 may be followed by an excess of, or by an absence of pigment. 
 As you will remember, our patient has a small spot of a pale 
 colour on his left elbow which has followed an abrasion, and 
 he distinctly tells us that before he received this injury the 
 skin was dark in colour.^ It would seem as if the absence 
 or excess of pigment depended on the depth of the injury. 
 Where this has been deep the resulting scar will be white ; 
 where superficial, it will be much darker than the surround- 
 ing portions. Examples of the latter have been quoted 
 following the application of a blister, and similar darkenings 
 have been observed to follow the slight skin irritation caused 
 by garters. A case very interesting from this point of view 
 was reported by Mr Nicholson in 1872, of a baker lad who 
 presented on his shoulders dark stripes, corresponding to 
 the bands by which the basket he carried was slung at his 
 back. 
 
 The transition from the darker to the lighter areas of skin 
 is also to be noticed. As a rule it may be said that this is 
 never abrupt, the darker merging gradually into the lighter 
 
 1 Since his admission we have noticed fresh brown spots appearing 
 over this whitened area. 
 
CASE OF Addison's disease. 163 
 
 apparently normal areas. An exception to this is met with, 
 as is often the case, where there is leucoderraa, as shown well 
 in plate xi. of Addison's monograph, and the small spots of 
 leucoderma on our patient show well a similarly abrupt 
 margin. Still at many parts a merging of the dark into the 
 normal coloured areas can be made out. 
 
 But now let me draw your attention to the peculiar spotted 
 appearance which in our patient this discoloration presents. 
 As already stated, he tells us that the first discoloration 
 noticed was on the back of his neck, and that this was a 
 large, uniformly diffused patch. Over the other parts of the 
 body and limbs the pigmentation seems to have begun as 
 spots rounded in shape, and by gradually becoming more 
 numerous, merging into one another to produce a uniform 
 browning. The occurrence of spots to some extent is not 
 unusual in Addison's disease. In one of the plates (x.) of 
 Addison's monograph several such are figured, and Greenhow 
 describes the " appearance of small, well-defined black specks, 
 like black moles or freckles, on already discoloured portions 
 of skin." It is evident, however, that the spots in our 
 patient, many of them presenting the appearance of small 
 rings with pale centres, are different altogether from what 
 Addison has figured and G-reenhow has described. 
 
 The arrangement of these spots, specially on the lower 
 part of the left side of the abdomen, is very curious. As has 
 been stated, some seem to be connected with hair follicles 
 and others with sweat glands. Their curious distribution 
 suggesting some nerve influence, we have tested the skint 
 sensibility to touch, pricking, and temperature, comparing 
 the spots with the surrounding skin, but have been unable to 
 detect any difference. 
 
 As regards the mucous membranes, the appearances are 
 the usual ones of Addison's disease. The conjunctivse are 
 white, the lips show pigmentation mostly at the line of 
 contact of the one with the other, and the hard palate and 
 
164 CASE OF ADDISON'S DISEASE. 
 
 inner surface of cheeks show several small dark-coloured 
 areas. 
 
 As regards the epidermal appendages, the thickening of 
 the thumb and finger nails has been already referred to, and 
 we have already also referred to the tendency for the body 
 hairs to be dark when emerging from a pigmented, and 
 blanched when from a non-pigmented spot. 
 
 Further, the general symptoms, — the extreme debility and 
 sense of weakness, the lumbar and epigastric pain, the 
 dyspepsia and vomiting, the feeble and somewhat quickened 
 pulse, all contrasting with the patient's showing no great 
 emaciation and no great loss of subcutaneous tissue, — are 
 just what we expected in such a case. 
 
 Since he has come in our patient has improved very much 
 in condition, as the result probably of rest. He has gained 
 weight (6 lbs.), he feels much better, and his pulse is now 
 about 70, and of much better tension. In this connexion we 
 have to remember that, although the disease is practically 
 uniformly fatal (one case of recovery only is reported), 
 remissions are frequent, and it may last for years. In these 
 remissions the general health improves ; and, what is more 
 interesting, the skin-coloration lessens. I cannot help 
 thinking that a lessening of the colour has occurred to a 
 slight extent in this case. 
 
 As regards the modes of death in such cases. This is 
 usually by asthenia, the mind remaining clear to the last in 
 spite of the tremendous nervous prostration. Sometimes, 
 when so very weak, a syncopal attack ends the scene, and in 
 other cases death is preceded by coma. It is interesting to 
 know that in one example of the latter mode of termination 
 acetonuria was present, and it is important to remember that, 
 like diabetes, this also is a disease which may be treacherous. 
 G-reenhow gives several examples of Addison's disease in 
 which severe constitutional symptoms developed suddenly, 
 and proved fatal in a few days. 
 
CASE OF Addison's disease. 165 
 
 The treatment of the disease is closely bound up in the 
 pathology, so concerning this a few words are necessary. 
 
 As you are aware, this association of intense prostration 
 and bronzing of the skin was shown first by Addison to be 
 connected with disease of the suprarenal capsules. Since 
 Addison's time much work has been done in connexion with 
 the subject, although we still have a great deal to learn. 
 
 We know, however, — 
 
 (1.) That in this disease the pigment is deposited mainly 
 in the cells of the rete, as is the case in the dark races of man, 
 but that it may be found to some slight extent more deeply 
 in the fibrous tissue of tlie cutis. 
 
 (2.) That although in patients suffering from cancer, 
 tubercle, lymphoma, etc., and in whom the suprarenal cap- 
 sules have been unaffected, areas of skin pigmentation are 
 not infrequent, such cases are to be regarded as being alto- 
 gether distinct from Addison's disease. 
 
 (3.) That it has been observed that with diseased capsules 
 there may exist the extreme debility without the bronzing of 
 the skin, as well as the extreme debility with the bronzing. 
 Such instances have been explained on the theory that in the 
 former set of cases the medullary part of the capsules, i.e., the 
 part which contains the nerve structures, is alone involved, 
 whilst that in the latter set the cortical part, i.e., the part 
 concerned in pigment formation, is also diseased. In all the 
 cases, further, in which prostration alone existed, it is reason- 
 able enough to suppose that, had the patients lived lonfT 
 enough, bronzing might also have supervened. 
 
 (4.) That the semilunar ganglia are more or less involved 
 in suprarenal capsule disease, and that they may have to do 
 with the induction of the severe nerve symptoms. 
 
 We know, also, that the affection of the capsules is usually 
 a tubercular one ; that with other affections of these bodies, 
 e.g., cancer, pigmentation is not so frequent ; but we know, 
 too, that cases of Addison's disease have been seen where the 
 
166 CASE OF Addison's disease. 
 
 capsules seemed to have undergone atrophy, where, as has 
 indeed been stated, the capsules had undergone the same 
 change as does the thyroid in myxcedema. In such cases we 
 can conceive that the administration of the suprarenal capsule 
 of a sheep or ox would be as efficient as is that of the thyroid 
 of such an animal in myxoedema. If, on the other hand, there 
 exists tubercular or other disease of the capsule, we cannot, 
 of course, expect anything like so much. 
 
 Up till now our patient has been treated only by rest, diet, 
 and tonics, and, as you see, there has been very considerable 
 improvement. 
 
INDEX. 
 
 Addison's disease, 156. 
 Alcohol in diabetes, 67. 
 Aneurism, aortic, 95. 
 Arterial tension, 50. 
 Ataxy, Friedreich's, 128. 
 Anra, 105, 107. 
 
 Blood in Bright's disease, 51. 
 Blood in diabetes, 69. 
 
 Caput medusae, 86. 
 Combined paralysis, 138. 
 Concussion, 123. 
 Cry in epilepsy, 109. 
 
 Diabetes mellitus, 63. 
 
 Diabetes, blood corpuscles in, 69. 
 
 ,, cause of death in, 71. 
 Diplopia, 150. 
 Dropsy, 41. 
 Dysentery, 90. 
 
 Empyema, 1. 
 
 ,, exploratory puncture in, 9. 
 
 ,, pulsating, 10. 
 Epilepsy, 104. 
 Epileptogenous areas, 108. 
 Erb's spot, 143. 
 
 Faucial reflex, 106. 
 Fracture of vertebree, 122. 
 
 Heart, displacement of, 22. 
 
 ,, hypertrophy and renal disease, 
 51. 
 Hydronephrosis, 57. 
 
 Ipecacuanha sine emetine, 90. 
 Influenza and diabetes, 63. 
 
 Kidney, primary contracting, 43. 
 Knee-jerk, 53. 
 
 Liver ciiThosis, 80. 
 
 Micturition, frequency of, 37. 
 
 Phthisis, fibroid, 22. 
 
 ,, ab htemoptoe, 29. 
 Polyuria, 52. 
 Pons lesion, 145. 
 Potass, iodide in aneurism, 102. 
 
 Pienal and cardiac disease, 32. 
 Pietinitis, albuminuric, 54. 
 
 Skin, sensitive areas on, 95. 
 Smell, loss of, 31. 
 Sphygmographic tracings, 97. 
 Sphygmomanometer, 102. 
 Spinal curvature, 135. 
 Spinal injury, 117. 
 
 Taste, 154. 
 
 Taxograph, 131. 
 
 Tracheal tugging, 97. 
 
 Trophic condition in diabetes, 74. 
 
 Urea in diabetes, 71. 
 Ureter, compression of, 60. 
 Urine, diurnal and nocturnal, excretion 
 of, 32. 
 
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James 
 
 Royal Infirmary cliniques 
 
 RC66 
 
 J23 
 
 1896 
 
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