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as the following case is the only one in which he has yet had the opportunity of instituting a post-mortem examination, we give it in full:
M. Demay, a painter, aged twenty-eight years, came to consult Dr. Du chenne in May, 1858. He then ascertained him to be affected with ataxie locomotrice in the third stage-viz., double but incomplete paralysis of the sixth pair; characteristic boring and flying pains, recurring especially at night; integrity of the muscular force, contrasting with the complete loss of co-ordination of the lower limbs, which rendered walking impossible, even when assisted by the eyesight; formication and numbness of the two last fingers of each hand, of only a few months' date; sensibility in the feet and legs much diminished; electro-muscular contractility intact. The ataxie locomotrice dated back two years, and had followed the usual course. The apparent cause was a syphilitic disorder contracted in 1849, which had been treated with the protiodide of mercury, corrosive sublimate baths, &c. Dr. Duchenne advised him to go into the Charité, where he died in 1858, of an intercurrent affection. At the autopsy, the brain and spinal cord were examined with the greatest care, but presented no appreciable lesion whatever.
The author establishes three stages. During the first, the diagnosis is doubtful; spontaneous strabismus or diplopia is a common symptom of incipient ataxie, especially when associated with amaurosis; the blindness sometimes supervenes before the co-ordination of movement is disturbed to any great extent. Flying, circumscribed, boring pains, attacking all parts of the body, are characteristic; they sometimes precede the actual disease for several years. In the second and third stages, which the author does not clearly distinguish, the disturbance in the co-ordination of the movements makes its appearance; and, if following upon the indications belonging to the first stage, leaves no doubt as to its nature. The disease is generally of long duration.
VI. Case of Rupture of the Esophagus. By Dr. Jos. MEYER. (Preuss. Ver. Zeitung, N. F. i., 39-41, 1858; and Schmidt's Jahrbücher, Jahrg. 1859, No. 2.)
The following rare case occurred in Professor Schönlein's clinical wards. A shoemaker, aged thirty-eight, habitually intemperate, robust, suffered from occasional dysphagia in swallowing solids, brought on in childhood by the application of caustic alkali. The attacks gradually increased in frequency, and the last one occurred in February, 1858, when the patient was swallowing a piece of sausage. Violent attempts at vomiting failed to throw it up; a considerable quantity of blood was ejected; great anxiety and dyspnoea, and pain in the epigastrium, followed. An hour after the occurrence the right side of the face became tumefied. A surgeon administered several emetics, and introduced a probang without effect. The symptoms became more urgent, and on the following day he was admitted into the Charité. He was first seen sitting, bent forwards, with a pale, rather cyanotic complexion, cutaneous emphysema of the face, neck, and anterior half of the thorax. The auscultation of the heart and lungs was everywhere normal, except impaired vocal resonance at the posterior base; the pulse 142, small; respirations 40. There was severe pain extending from the xiphoid cartilage to the vertebræ, which was increased by the erect posture. A rupture of the œsophagus, with moderate pleuritic exudation at the right base, was diagnosed. In the course of the night all the symptoms increased; the emphysema spread over both arms; liquids could be swallowed, but only in small quantities, on account of the dyspnoea. Death ensued fifty hours after the commencement of the illness. The autopsy showed the esophagus to be healthy, except a patulous ulcerated surface, one and a quarter by three-eighths of an inch in dimension, on the anterior
walls of the oesophagus, three inches above the cardiac orifice of the stomach. The ulcer had perforated all the coats; the edges were sharply defined, and the surrounding parts healthy. Just above the cardiac orifice there was some narrowing, the muscular tissue being hypertrophied, but without cicatricial tissue. In front of the perforation there was a large accumulation of foul pus with necrosed tissue and the remains of food. To the right there was a less extensive purulent infiltration, mixed with gas, and from here there proceeded an extensive emphysematous distension of the mediastinum. The pleural cavities contained much discoloured fetid exudation, the pleure were invested with thick, fibrino-purulent masses; there were no adhesions to the healthy lungs, nor any lacerations of the latter. There could be no doubt that the perforation was quite recent, both from the appearance of the ulcer and the absence of thickened walls of an abscess. Dr. Meyer has only been able to find two analogous cases; one recorded by Boerhaave, the other by Dryden,t in both of which the symptoms were analogous to those recorded.
VII. Communications regarding some Cases of Laryngeal Disease, examined by means of the Laryngeal Speculum. By Dr. LUDWIG TUERCK. (Zeitschrift der Gesellsch. der Aerzte zu Wien, 1859, No. 11.)
We have on former occasions directed attention to the practical utility of the laryngeal speculum in the diagnosis and treatment of diseases of the larynx. The following are a few brief memoranda illustrative of the uses of the instrument, taken from the details given by Dr. Türck in the above memoir :
1. A girl, aged thirteen, after recovery from lupus of the upper lip and left cheek, was attacked with temporary aphonia and renewal of the labial ulceration. The free edge of the epiglottis was seen to be much thickened, its mucous membrane much tumefied, and of a pink colour; at the anterior edge there was a loss of substance; the mucous covering of the arytenoid cartilage was much swollen, and the true chorda vocales showed a white investment at their free edges.
2. A man, aged thirty-three, suffering from hoarseness and occasional aphonia. The chordae vocales remained separated at their middle part, and did not show the tremulous movement seen in the healthy subject, when he pronounced A (ah); in coughing, the arytenoid cartilages approached one another, and closed the false chorda vocales, a condition which the author has often observed in aphonia dependent upon laryngeal catarrh. The autopsy revealed diphtheritic (?) ulcers on the posterior surface of the trachea, on the parts of the larynx subjacent to the glottis, and between the arytenoid cartilages.
3. A pedlar, suffering from syphilitic aphonia, recovered from all his affections but the aphonia. The speculum showed no loss of substance in the epiglottis; the region of the left arytenoid cartilage was somewhat flattened. The true chorda vocales did not join properly, especially at the posterior angle, when A was pronounced, nor when the patient coughed. On deep inspiration the cords did not separate properly; the true and false chorda could only be distinguished on the right side."
4. A female, aged forty-seven, had been affected with complete aphonia for eight months. Frequent examination of the larynx never exhibited any catarrhal affection; in whispering A the chord vocales closed only at the anterior and posterior angle, and were wide apart in the remainder of their ex
Atrocis nec descripti prius morbi historia. Lugd. Batav., 1724.
+ See British and Foreign Medico-Chirurgical Review, Jan. 1856, p. 229; and Jan. 1859, p. 257.
tent, and did not exhibit the normal vibrations; in making a more powerful effort at pronouncing the A, the space between the chorda increased to from one to one and a half lines. In doing this the corpuscula Santorini at the apices of the arytenoid cartilages crossed one another, so that the right one came to lie in front of and below the other.
5. An artificial flowermaker, aged thirty, had suffered for many years from aphonia. At the anterior edge of the glottis the two chorda vocales were of normal appearance; behind them there was on both sides a pale red excrescence, nearly two lines long; a narrow third excrescence was occasionally projected between them by coughing; another growth of a similar kind was attached to the left cord as well as to the right, and the two last were considerably separated when the attempt was made to pronounce A.
6. A case of oedema glottidis in a young man, following typhus, giving rise to great dyspnoea, exhibited a perfectly smooth surface in the place of the upper and lower vocal chords, and at the inner sides of the arytenoid cartilages were two transparent bladders, which only left a linear slit between them.
7. A female, aged thirty-eight, suffering for three months from hoarseness and dyspnea, exhibited a translucent tumefaction almost covering the right chord as well as the ventricle; the inner surface of the right ary-epiglottic fold was also prominent; the same parts on the left side were normal.
For further particulars we refer to the original. The above may suffice to prove the diagnostic value of the speculum laryngis.
VIII. On Contraction of the Aorta on a Level with the Ductus Botalli. By E. LEUDET. (Gaz. de Paris, No. 4, 1858; and Schmidt's Jahrb., 1859, No. 3.)
After a review of the history of this rare malformation, the author relates the following case, in which a very unusual complication increased the difficulty of the diagnosis. F. G, aged thirty-seven, female, had been regularly menstruated till eighteen months before coming under observation, when the catamenia ceased suddenly; dyspnoea supervened, especially upon going upstairs, and also at night. A slight cedema of the inferior extremities disappeared under the use of purgatives. After twelve months the symptoms became more urgent; severe pains in the upper sternum and middle of left scapula supervened. A few months ago dysphagia and aphonia occurred; there was no pain in the course of the respiratory passages. The dyspnoea had increased, but there was no palpitation; there was no cough, little appetite, rarely vomiting, no diarrhoea, but such a loss of strength that the patient was obliged to intermit all work. There was oppressive headache on the left side of the forehead, there was no vertigo or pulsating headache. On admission there was no enlargement of the superficial veins, but on the middle and anterior surface of the thorax there was an enlargement of small arteries, as well as in the left intra-spinal fossa; numerous arterial branches were found at the posterior margin of the left armpit. The normal impulse of the heart was felt in the fifth intercostal space, a little to the left of the nipple; there was no purring tremor; the jugulars and carotids were normal, both radial arteries beat exactly alike; there was a slight systolic blowing murmur at the base of the heart on a level with the aortic valves, which did not extend to the left margin of the heart; it was increased along the course of the aorta, and attained its maximum on a level with the second rib. There was no impulse or enlargement. The abnormal bruits were not heard over the abdominal aorta. The beat of both femoral arteries was weak, but equal. There was marked dulness over the left lung, with diminished respiratory murmur and bronchophony, but no râles. Right lung normal. Urine pale, not albuminous. From
the 25th of July to the 3rd of August no change occurred; rigors, sweats, and cough then set in; the emaciation increased, and the dyspnoea became more urgent. The dulness of the left lung ascended up to the left intra-spinal fossa, and the respiratory murmur ceased posteriorly; the dulness anteriorly mounted up to the left clavicle, respiration being almost inaudible. Sudden severe hæmoptysis on the 16th of August proved fatal. Autopsy: larynx, trachea, and bronchi full of fluid blood. The left bronchus was adherent to an aneurysmatic sac of the descending aorta, with which it communicated by two openings. The left pleura contained about three pints of a serous, slightly opaque liquid. The whole left lung was in a scirrhous condition, and when cut showed a large number of small lobular masses, from which blood and pus exuded. There were traces of old pericarditis on the visceral layer of the pericardium. The heart somewhat enlarged: pulmonary artery and its branches normal; mitral and aortic valves healthy; the endocardium of the left ventricle somewhat thickened, the walls slightly hypertrophied. The ascending aorta was perfectly normal; the innominata somewhat enlarged, as well as the left carotid. The left subclavian was much dilated; the coats unaffected; immediately below the origin of left subclavian the aorta was constricted in a funnel-shaped form, so as to allow the passage of a common probe, but not of a female catheter; the coats contained no deposit, but were much hypertrophied, especially the middle and external coats. Below the constriction the aorta was enlarged aneurismatically, and the coats entirely degenerated. Anteriorly, and communicating with the left bronchus, lay a sacculated aneurism, the walls of which were incrusted with salts of lime. The descending aorta was in direct communication with the aneurism, but presented no peculiarity. The internal mammary arteries were dilated, and anastomosed with dilated branches of the epigastric artery. The lumbar arteries and posterior scapular arteries were double their usual size.
IX. On Thrombosis of the Ductus Botalli (Ductus Arteriosus); in Communications from the Pathological Institution of Professor Rokitansky. By Dr. KLOB. (Zeitschr. der k. k. Gesellsch. der Aerzte, 1859, No. 1.)
The closure of the ductus botalli takes place between the fourth and eighth day of life, by the formation on the inner coat of areolar tissue, with considerable nuclear growth, and the consequent contraction of these tissues. In the following case the involution appears to have been prevented by the formation of a thrombus in the artery, or by some previous morbid process which induced the latter.
A female infant, aged eight days, died in the Lying-in Clinical Wards; she was well developed, slightly icteric; brain normal, except some yellow coloured serum in the ventricles; thyroid gland small, tracheal mucous membrane pale; thymus gland rather small, both lungs slightly dematous and containing a frothy yellow serum. The pericardium contained about three drachms of clear pale yellow liquid; the heart of normal size and form, contracted; the tissue pale brown; the cavities and large vessels containing loosely coagulated blood; the endocardium and inner coats of the vessels were stained with blood. The ductus botalli was uniformly three lines in diameter. The orifice in the pulmonary artery was blocked up by a soft plug, dark red at its commencement, further on pale yellow, closely adhering to the coats of the vessel. At the aortic orifice the plug was abruptly broken off. There was no trace of contraction at the aortic orifice. The liver was dark red, the gall bladder contained brown bile. In the mesentery there were branched extravasations following the course of the arterial branches, and reaching as far as the attachment of the omentum to the intestine. The superior mesenteric artery was
found blocked up in its smallest divisions by minute particles of coagulated fibrin; from these points a thrombus had formed, extending towards the trunk; in some parts the internal and middle coat had got detached so as to resemble a dissecting aneurism.
Dr. Klob states that he has examined many infants of the same age, but has failed to discover the ductus botalli closed in the same way. He is of opinion that the thrombus was not the cause of the persistence of the duct, but that it was caused by a species of inflammatory process in its coats, which caused the contained blood to coagulate. The author is further of opinion that the blocking up of the mesenteric artery was caused by the breaking off of a portion of the plug in the duct at the aortic termination, which was carried along by the current of blood until arrested in the divisions of the mesenteric.
X. Case of Acute Miliary Tuberculosis running its Course in Thirty Hours. By C. A. WUNDERLICH. (Archiv für Physiologische Heilkunde, Jahrg. 1859, Heft 2.)
The learned professor relates this case as an instance of what he regards as a very acute case of miliary tubercle, its commencement and termination occurring in thirty hours, though he admits that it may also be interpreted as a case of acute tuberculosis which remained latent until shortly before death.
A type-founder, aged twenty, living in easy circumstances, had almost invariably enjoyed good health, never having shown symptoms of lead poisoning. At Christmas he had been poorly for a few days, and on the 6th of February of the present year he was also slightly indisposed, but was perfectly well afterwards. On the 11th of February he went to work as usual, and ate his dinner with a good appetite. After dinner he vomited once, but was able to do his work. At five P.M. he complained of vertigo, and on going to the water-closet became comatose. He was brought to the Leipzig Hospital in this state, was undressed with difficulty, and when put to bed lay on his right side doubled up; opened his eyes at times when spoken to, but did not answer questions. His face had the usual colour; the pupils acted well; there was a moderate blue line round the teeth. The front surface of the chest could not be examined. There was no dulness posteriorly. Respiration was vesicular throughout, except at the left scapula, where it was slightly bronchial. Respirations, twenty; pulse, ninety-two; heart-sounds normal. Nothing abnormal about the abdomen. General nutrition good. Insensibility persistent. Constant jactitations increased every half-hour paroxysmally, but without spasms or screaming. On the following morning the face was purplish, and the patient swallowed nothing. After a warm bath, with cold applications to the head at mid-day, he was attacked with universal convulsions, alternating with tetanic extension; the face became cyanotic; there was froth at the mouth. After an hour and a half's interval the attack was renewed; then after half an hour, and subsequently they returned every five minutes. The pupils now became contracted; coarse and fine mucous râles were audible over the lungs; respiration became irregular; the tracheal rattle supervened, and the convulsive paroxysms increasing in frequency; he succumbed to one at one A.M. the next night. Post-mortem: Cranium and dura mater normal; the meninges normal throughout, except that at the left posterior lobe there were a few small opaque spots, with two distinctly projecting, translucent, greyish, miliary tubercles. The left posterior lobe of the cerebrum was softer than the remainder of brain, but without extravasation or congestion; ventricles not enlarged, without serum; the septum pellucidum and fornix softened; the remainder of the brain healthy. Both pleura adherent. The right apex showed cicatricial contractions, and besides small, almost cylindrical, bronchial dilatations and old tuber