ous.

The organisms found in association with cholangitis are numerAmong them may be mentioned the staphylococcus pyogenes aureus (Netter, Martha, Dupré, Girode, Frankel), staphylococcus albus (Dupré and Klebs), streptococcus pyogenes (Dupré and Malvoz), pneumococcus and staphlycoccus albus (Girode and Gilbert), Typhoid bacillus (Gilbert, Girode and Dupré).

Dupré has also isolated a diplococcus, a diplobacillus, and an encapsulated bacillus, as yet unidentified, and the bacillus saprogenes liquefaciens. The bacillus coli conummis has frequently been found, and some writers uphold its causative influence very persis tently. Mayo Robson says it produces an exudative inflammation in the bile passages and abscess. We know that its virulence varies greatly; at one time it is harmless, at another it may produce a local abscess, and again a fatal septicemia.

Chauffard and others think it plays an important part in biliary infections, equal to that of the pyogenic cocci in infections of the genito-urinary tract. It is, however, such a widely distributed organism that its presence in pathological conditions is often looked upon with suspicion, and especially so in post-mortem work, now that so much is said regarding the invasion of the body by organisms during the death struggle. Then again, the work of Barbacci on perforative peritonitis shows the tendency of the colon bacillus to overgrow other bacteria that have originally been present.

The same controversy has arisen over the bacteriology of appendicitis, the colon bacillus being the chief infecting organism, according to some writers. In a series of cases I have found a variety of bacteria present, the number depending upon the duration of the disease--the earlier the case the greater the number of species found. In several cases a streptococcus was almost overlooked by reason of the small size of the colonies. In a small proportion the colon bacillus alone was found. The ease with which some organismsespecially the streptococcus-may be overlooked in the presence of one growing so luxuriantly as the colon bacillus, must be apparent, in all methods of isolation. The point is that we find the colon bacillus in purulent inflammations, and in many cases find it alone. As above stated, it can produce pathological conditions, so for the present we must abide by our findings.

The most important accompaniment of suppurative cholangitis is a general infection, said to be always fatal.

Endocarditis is frequent, and Netter and Martha have found the same organisms on the heart valves as in the bile ducts. LabadieLagrave speaks of purulent meningitis; Courvoissier, of pylephlebi

tis, phlebitis of hepatic vein, thrombosis of a branch of the hepatic artery with infarction, and perihepatitis with adhesion to surrounding viscera.

The abscesses secondary to cholangitis may vary from the size of a pea to that of a child's head (Frerichs). One the size of a hen's egg was present in a case complicating typhoid fever (Klebs). These may travel in almost any direction, and have been known to open into the peritoneum, stomach, colon, or duodenum, through the diaphragm into the pleural cavity, and into the abdominal wall. Of the cases due to lumbricoid worms, one opened into the lung, and another formed an abdominal fistula through which a worm was discharged.

In conclusion, I desire to thank Dr. H. B. Anderson for the privilege of studying this case.

Clinical Notes.

A CONTRAST OF TWO CASES OF TUBERCULAR
PLEURISY WITH EFFUSION.*

THE

BY H. H. OLDRIGHT, M. B. Tor.,
Assistant Surgeon St. Michael's Hospital, Toronto.

HE two cases of pleurisy which I will describe are of interest both on account of the individual peculiarities of each, and from a comparison of the physical signs, the symptoms and the duration of the pathological processes.

In the first case, one of fibrinous pleurisy, the patient, an hostler, was exposed to cold and wet, causing through the reflex nervous arc a point of weak resistance to the bacillus tuberculosis or the pneumococcus ; the former, I presume, as it is the most common cause, according to Strumpell, and also because there was no appreciable consolidation of the lung. The peculiarity in this case was that the vocal fremitus, bronchial breathing and vocal resonance could be felt and heard through the effusion which extended from the right nipple level to the base, and this may be accounted for by the compression of the lung as far as the bronchus, and the density of the fibrinous effusion, which clotted on being withdrawn, forming a firm greenish-colored jelly. The amount of fluid withdrawn was about three pints. This dense effusion transmitted the fremitus and breath sounds as readily as a consolidated lung.

We may eliminate pneumonia for two reasons, firstly the apex beat was displaced to the left of the left nipple line, and secondly, the amount of effusion would compress the lung up to the nipple level where the absolutely flat percussion note below this level ended, and the tympanitic zone and normal resonance above over the upper lobe began.

In the second case with serous effusion the peculiarity was in the paralysis of the right serratus magnus muscle, which came on some weeks after the last aspiration. (See page 153.)

*Read before the Toronto Medical Society.

The points of note in comparing these two cases are that in the first with the fibrinous effusion there was great pain, which was absent with the serous effusion, there was no return of the fibrinous effusion, probably due to immediate adhesion of the pleural surfaces, while the other required four aspirations, and lastly the difference in the physical signs.

2. Apex beat displaced beyond left nipple line.

3. Percussion note flat.
4. Cough.

5. Edema somewhat relieved by tapping and pulse normal after.

6. Fluid, straw-colored in first two tappings,and slightly tinged with blood in the last two. No coagulation in first, slight coagulation in last two.

7. Rales persisting, but improving. also dulness over left base and hindered movement of chest in same region improving, due to infiltration.

8. Duration of effusions two months. 9. Persistent dulness on right side from thickening of pleura. Paralysis of respiratory nerve of Bell, long thoracic. Serratus paralysis.

Case No. II.: Noticed paralysis of right serratus first three months after onset of illness and six weeks after last tapping. He had difficulty in raising right arm above the shoulder level without help from the left, and had to grasp something to maintain the elevated position with ease. Right serratus magnus atrophied. Scapula winged. All other muscles normal. My first impression was that mentioned by Treves, namely, that the lower angle of the scapula had escaped from under the latissimus dorsi. Strumpell

says it is common, and generally with porters and soldiers. Aetiology-trauma, cold (rheumatic), infectious diseases (typhoid), progressive muscular atrophy (one symptom.)

Prognosis-recovery tedious, several months-some cases in

curable.

Treatment-electricity.

In the discussion following this paper the members of the Society thought that a neuritis, resulting from puncture of the nerve, could

be eliminated, as the lesion must have been higher up than the seventh rib. Dr. H. Parsons suggested that there may have been extension of inflammation from the pleura, causing a neuritis in the long thoracic, analogous to that producing mastitis in cases of pleurisy, and this would seem to be the best explanation.

Case No. I. has entirely recovered from a slight cough following the pleurisy.

Case No. II. has fibroid phthisis and has gone south to Asheville, N. Carolina, from which place, I am sanguine, he will return recovered.