The Chairman called attention to the relief of symptoms, particularly the optic neuritis which had been observed by Horsley after trephining. Later History.-On November 8th, the patient was operated upon, a portion of occipital bone was removed with a trephine, and the dura mater was felt to be very tense, more especially on the right side. The skin flap was then loosely sutured with silk-worm gut, thus completing the first stage of the operation. Patient said he had not as much pain in the eyes as before the operation. On November 13th, the second stage of the operation was performed. The dura mater was incised. Brain tissue seemed abnormally soft. No tumor was located. After this stage of the operation he complained of pain in the occipital region and could not be restrained from pulling off the dressings on his head, thus getting the wound infected, and on November 20th died of septic meningitis, the temperature for the past two days being over 105 deg., and pulse over 130. At autopsy over the right posterior part of the brain was seen a purulent discharge. On making sections of the brain. there was found a diffuse glioma about the size of a hen's egg, involving both frontal lobes, but was much larger in the right frontal lobe than the left. The cerebral convolutions were flattened from pressure. GOUT. Dr. Geo. Strathy, of the House Staff, presented a patient suffering from gout, giving the following notes: Complaint.-1. Swelling, agonizing pain and tenderness on pressure in the joints. 2. Small joints of hands and feet stiff, irregularly enlarged and deformed. 3. Deposits of chalky lumps in and about the joints and along the tendons. 4. Bleeding piles. 5. Slight cough. Duration.-Began 25 years ago; much worse during past five years. Family History.-F. D., aged 68, gout; M. D., aged 65, dropsy; 2 B. L. and W. (although 1 B., aged 65, has lumbago); 3 S. L. and W. Father's father died of gout. No gout on mother's side. Personal History.-Patient aged 55. Born in England, came to Canada 25 years ago and lived near Muskoka until one year ago, when he became a resident of Toronto. All his life he has been a clerk at indoor work, leading a sedentery life For the past and getting very little active bodily exercise. four years he has been unable to do any work. He has never been exposed to lead poisoning. He claims to have been always a very moderate eater as to amount, but has been accustomed to having meat three times a day. He uses three cups of tea per meal, smokes one ten-cent package tobacco per week, has not chewed tobacco for the last year, but all his life has indulged "not wisely, but too well," in fermented liquors, using as much as twelve dozen glasses of port wine or one dozen glasses of beer daily. He is not married. Previous Illness.--Had no children's diseases. Age, 13. Typhoid fever lasting three months. Recovery complete. Age, 21, gonorrhea, lasting six weeks. Glands swollen, but no rash. No sore throat and falling out of hair. Recovery complete. Age, 30, rheumatism (?) Started suddenly one afternoon in right knee and remained in that joint for two weeks. History of Present Illness.-Without any cause which the patient can assign, this trouble began 25 years ago, suddenly one afternoon, with severe pain in the right knee. The knee quickly swelled up to double its normal size, was very hot, tense and tender. During this attack, which lasted two weeks, the patient was restless, irritable and troubled greatly with dyspepsia. Two years later he had a similar attack, lasting one week, and the same knee alone was involved. One year later he had another recurrence, this time the metatarsophalangeal joint of the right big toe being involved. Next, his right ankle was affected. Then a similar process of involvement followed on the left side and accompanied by an attack of sciatica and lumbago. The above conditions have been gradually growing worse, the attacks becoming more frequent and of longer duration. Eight years ago his hand became involved, and the patient. noticed little lumps like chalk appearing first in the first interphalangeal joint of the right hand, and then gradually coming in various places in and about the small joints of the hands and feet. These lumps break down and ulcerate, leaving a yellowish surface behind. Four years ago the hand became deformed. Two years ago these chalky lumps appeared in the helix of the ear. The larger joints have escaped so far. The patient says he has been greatly benefited during the previous attacks by a prescription containing wine of colchicum, tincture of gentian and potassium iodide. When the swelling subsides, after an acute attack, the skin. desquamated. During an acute attack the patient suffers more at night. Attacks now occur 3, 4, 5 times a year, and last from two days to two weeks, usually four days. Present Condition.-Patient is very bright mentally, though suffering greatly. He is lying motionless in bed with his legs drawn up and all the joints flexed. He is unable to use his hands and feet on account of their stiffness and pain. Height, 5 ft. 1034 in., weight averages 175 lbs. says he loses about 15 lbs. with each acute attack.) Development and nutrition, fair. Expression, anxious. Complexion, florid. Over the nose and malar bones the vessels are prominent. (Teliangectasis). Skin moist and somewhat (Patient cyanosed. Over the temporal region and sides of face is milletseed sized papulo-vesicular eruption. There are tophi in the helix of the ear, alae nasi and along the tendons on the backs of the hands. There are two scars of old ulcers on the external surface of the right shin. Glands nowhere enlarged. Respiration is labored. Slight hacking cough. Temperature 101 3-5 deg. Muscles are very flabby. Hands. Markedly deformed. Flexed at metacarpo-phalangeal joints and also at the distal inter-phalangeal joints. Marked ulnar deflection. All the inter-phalangeal joints are ankylosed, and there are tophi on their exterior surfaces. The joints are swollen, hyperemic, glazed, tense, reddish-purple color, and vessels prominent. There are yellowish-white deposits on the exterior aspects which vary greatly in size. Joints are very tender. On the second inter-phalangeal joint of the index finger of the left hand is a large yellow vesicle, the size of a five-cent piece, which is soft and tender. Smear from its contents shows pus cells and needle-shaped crystals of sodium biurate. The little finger of the left hand shows remnants of a similar lesion, which has ruptured, leaving a yellow, dried-up deposit behind. On the ring finger of the left hand is an ulcer, small, shallow and smooth, with a yellowish discharge, which leaves a white chalky deposit on the surrounding skin. Joints, toes, ankles, knees, elbows, show similar change to a much less marked degree than in the hand. There is no pain in the sterno-clavicular joints and shoulders. Bones.-Nil. Eyes. No burning or itching-no episcleral congestion. Sclerotics show jaundice. There is an arcus senilis. Digestive System.-Subjective.-Appetite very poor. Bad taste in mouth. Vomiting. No pain in stomach. Great thirst. No belching. Bowels free. Bleeding Piles, No sore throat. Objective. Teeth badly stained. Gums pale. Pyorrhea alveolaris present. Tongue coated. Breath offensive and heavy. High palate. Abdomen is full and there is some bulging in the flanks. On percussion there is a highly tympanitic note everywhere except in the flanks. Stomach.-Greater curvature is two inches above umbilicus. No splashing. Liver.-Upper border at the lower border fourth rib. Lower border at the costal margin (in the mammary line). Spleen. Not palpable. Circulatory System.-Subjective. Shortness of breath. Swelling of ankles. No palpitation nor precordial pain. Objective.-Pulse 100 per min., rhythm regular. Vessel walls sclerosed. Tension, high. Tension, high. Volume only fair. Force, good. Rise and fall abrupt, and maintenance not well sustained. Heart.-Inspection.-Apex beat not visible. No bulging. Palpation.-Apex beat, a mere flicker in the fifth interspace four inches from middle line. No thrills. Percussion. Right border 1/2 in. external to the right border of the sternum in the fourth interspace. Left border 1/4 in. outside nipple line. Apex in nipple line in fifth interspace. Auscultation. The heart sounds are very faint and indistinct. First sound is weak and the second aortic sound is accentuated. No adventitious sounds. No murmurs. Blood Examination.-Feb. 7, 1907. R. B. C., 4,500,000; Hbg., 70 per cent.; W. B. C., 8,000. Respiratory System.-Cough expectoration. Dyspnoea. No pain in chest. No night sweats. Objective. Inspection.-Barrel-shaped chest. Poor expansion. Abdominal type of breathing. Palpation.-Expansion, poor. Vocal fremitus diminished. Percussion.-Hyperresonance everywhere. Auscultation.-Breath sounds are broncho-vesicular below that level. Rales and rhonchi present, but constantly changing positions. Sputum Examination.-Amount, small. Color, greenishyellow. Consistency, thick and tenacious (lumps of mucus). Stain used, carbol fuchsin and methyline blue. R. B. C., none. W. B. C., pus cells present. Epithelial cells, desquamated squamous. Crystals, no uric acid crystals. Bacteria, staphy loccus, streptococcus, diplococcus, rod-shaped bacillus. Spirals, none. Genito-urinary System.-Subjective. Frequency in mieturition. No worse at night. No pain. Red sediment in urine which adhered to the chamber. Never passed any calculi. Objective. Kidneys, not palpable. Urinalysis. Transparent, light amber-colored urine, with light sediment of both brick dust (urates) and cayenne pepper (uric acid) deposit. Odor is strong. Specific gravity, 1012. Reaction. Faintly acid. Quantity in 24 hours not known. Chemical.-Urea, 0.2. Albumen, none. Sugar, none. Bile, none. Phosphates, present. Urates, present. Chlorides, pre sent. Microscopical.-Epithelium, present. W. B. C., none. R. B. C., absent. Casts, absent. Made Feb. 7, 1907. Crystals (1) Uric Acid. (2) Oxalates. Amorphous (1). Urates. (2) Feathery Phosphates. System.-Subjective.-Headache. Nervous Hot feet at night. Cramps in calf and abdominal muscles. Sweating. Objective. Patient is very intelligent, and is not suffering from hallucinations, delusions, nor torpor. His comprehension and utterance of speech is good. Memory, excellent. Attention, good. Sleep fair, when pain of joints does not keep him awake. Motor Functions.-Voluntary power not much impaired. State of nutrition, fair. Irritability, all right. Reflexes, pupil normal. Plantar, normal. Ankle clonus, abCo-ordination, nothing abnormal. sent. Knee, normal. Sensory Functions. Subjective. No numbness, tingling, formication nor abnormal sensation of heat and cold. Objective. Sensations of pain; touch, temperature, are normal. Special Sense.-Sight, smell, taste and hearing normal. Cranial nerves all normal. |