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weak vocal fremitus on the left side while the patient was lying down, becoming stronger on sitting up. This fact, however, led to the suspicion of aneurysm or other tumor pressing on the bronchus, and further examination showed a tracheal tug and delayed pulse in the left radial. The skiagraph revealed a great enlargement in the region of the arch of the aorta and the fluoroscope showed that this underwent pulsation synchronous with the pulse. A diagnosis was accordingly made of aneurysm involving the whole arch of the aorta and pressing on the left bronchus.

The patient was put on potassium iodid and given directions regarding mode of life. He lived without notable symptoms until the end of November, when he was taken with grip, which was soon followed by signs of pneumonia of the left lower lobe. From the beginning there was a good deal of blood in the sputum, but the symptoms subsided and the patient seemed to be doing well until at the end of two weeks, when he sat up in bed, had a copious hemorrhage and died within two minutes.

Through the efforts of the attending physician, Doctor Shumaker, of Butler, Indiana, an autopsy was made and the specimen forwarded. This shows a dilatation of the whole arch of the aorta from just above the valves to a point about the same level in the thoracic part. The arch is uniformly and considerably dilated, the wall thin and exceedingly calcified in thin plates. The innominate is also dilated. In the posterior part of the descending arch the wall is torn where it was closely adherent to the vertebra. At the bottom of the arch is a large old clot, partly adherent, and beneath this an opening, about a centimeter in diameter, leading into the left bronchus. The thickening of the mucosa around the opening suggests that there was pressure there for some time.

The case is especially interesting in connection with the other intrathoracic tumors we have had recently in the hospital, and especially one in the ward now, where there is a very similar skiagraphic picture. But in this latter, one of secondary carcinoma, we have the picture of venous pressure, in contrast to the obstruction of the bronchus in the present case, and also in contrast to the neuralgic pain so prominent in another woman recently in the ward.

A CASE OF SYDENHAM'S CHOREA.

DOCTOR THEOPHIL KLINGMANN: The case I am about to describe and demonstrate presents two interesting features. First, that the patient exhibits himself when the incoordinate movements are no longer constant and appear only when voluntary effort is attempted; and second, that this phase of the disease has been more prolonged than usual.

The history contemplates a man, aged twenty-six, American, civil engineer, single. His parents are both living and well, and the family history is negative except that one brother had two attacks of rheu

matic fever and father had spinal meningitis. Both made good

recovery.

The patient was admitted to the University Hospital, September 21, 1906. He was healthy as a child, suffering only from the usual diseases of childhood. Seven years ago he had an attack of rheumatic fever from which he made complete recovery. He remained well until December, 1905, when he suffered from a severe attack of tonsillitis, and within a few days of the onset of this affection he developed pain, swelling, and redness in the wrists, elbows, knees and ankle-joints. The diagnosis of rheumatic fever was made by the attending physician. During a period of several weeks he had marked elevation of temperature with occasional remissions. His physician stated that it was of a typhoid character but patient exhibited no positive evidence of this. He also stated that his heart was affected. The patient was confined to bed for six months, and became much emaciated and exhausted. For a short time he had some difficulty in swallowing. He developed two bed sores the size of a dollar in the sacral region. After the fever subsided he began to have involuntary incorordinate movements of the hands, arms, feet and legs which were so marked that it was impossible to take the patient's pulse at the wrist or to take the temperature in the axilla. The movements continued for several weeks and then gradually subsided but reoccurred whenever the patient made voluntary efforts. There was some mental enfeeblement.

At the time of my first examination, September 26, 1906, I found the patient well-nourished, musculature well-developed, and absence of atrophy. There were marked irregular incoordinate movements in the hands, arms, feet and legs brought on by intentional effort and subsiding a few moments after the patient became quiet. There was muscular weakness in the upper and lower extremities and inability to maintain steady contraction. The dynamometer registered 37 in the right and 39 in the left hand. He was easily exhausted and the difficulty increased by prolonged intentional effort. The gait was not ataxic but unsteady. There was much interference with standing and walking, owing to the spasmodic movements. Romberg's sign was not present. Knee-jerks slightly increased, ankle-jerks normal, no clonus, no Babinski reflex. With the exception of a slightly delayed sense of touch on the outer side of both feet, there were no sensory disturbances. No disturbance was observable in the perception and judgment of active movements of the extremities. The organic reflexes were normal. The cranial nerves were not involved. There was a systolic murmur, with greatest intensity at the apex. The patient was quiet and unemotional, he presents no mental characteristics, psychic stigmata, nor sensory stigmata. The eye examination made by Doctor Parker showed but a slight contraction of visual fields, no inversion of color-fields, and nothing characteristic of psychoneurosis.

After observing the patient for some time it became evident that the

possibility of an organic lesion could be eliminated and I made the diagnosis of Sydenham's chorea based upon the following facts:

(1) The irregular, unwilled but conscious movements in the upper and lower extremities.

(2) Inability to maintain steady contraction of the muscles of the upper and lower extremities.

(3) The actual loss of power in the muscles involved.

(4) The association of these symptoms with arthritis and possibly endocarditis.

Hysteria being so closely allied to chorea, the possibility of this condition must not be overlooked. Hysteric patients occasionally suffer from general spasmodic movements which may resemble those of true chorea. A patient suffering from chorea may also suffer from hysteria, but in the absence of all the characteristic stigmata of the latter, the irregularity of the incoordinate movements and the escort of attending symptoms in the former differentiate the conditions.

About ten days ago the patient developed an acute condition. He had a temperature of 101.5°, sore throat and a general soreness in the shoulders, back and extremities, respiration was very rapid, pulse weak and rapid. This all subsided within a few days.

PROBABLE HEPATIC CANCER.

DOCTOR DON D. KNAPP: A man, aged forty-eight, farmer, German. There is no history of previous trouble in any way bearing on present disease. On Christmas, 1905, patient had feeling of fulness after eating and then would wake up at night to find sour-tasting mucus running from his mouth, which at times contained food particles. He also vomited at times. In latter part of February he called on physician because of feeling of fulness in stomach and abdomen, with dull pain in these regions, sharper at times, and radiating to back and shoulders. Patient vomited after nearly every meal that summer and lost twenty pounds in weight. In September he was told by a physician that his liver was enlarged.

Patient entered hospital in this condition December 5, 1906. On physicial examination, the abdomen was found two fingers' breadth above level of ensiform in epigastrium and somewhat lower at level of umbilicus. About four fingers' breadt below level of navel the fulness sloped away rather abruptly. The upper right quadrant was somewhat fuller than the left. On deep inspiration, the epigastrium raised four fingers' breadth above the level of ensiform. On the right about half way between umbilicus and ensiform there was a small elevation which descended about one and one-half inches on deep breathing. On palpation, the abdominal wall was thin and moderately lax. There were no painful points. A firm resistant mass filled the right side as far down as the crest of the ilium in the anterior axillary line. In the median line, its lower margin was about one and one-half inches below navel, and on the left it extended upward and outward to meet rib margin at

about nipple line. The surface was hard, smooth, and covered with. rounded elevations with depressions. The lower edge was rounded and regular, feeling slightly nodular on right. The mass descended one and one-half inches on deep inspiration. No fluctuation could be detected in the abdomen nor was edema present in the extremities.

Rectal examination showed a small soft prostate. On inflation of colon the abdomen became fuller below the mass rising high up in front below the navel and covering the mass for a distance of two inches. The distension pushed the liver up one inch. The lower edge was not palpable. Stomach distension showed fulness and tympany below mass in median line and to left. On inserting the needle for aspiration into one of the elevated masses the top of the tumor felt as hard as tendon for about one-eighth inch, nipping needle very tightly; beyond the tissue was firm, resembling liver in consistency. There was nothing obtained on aspiration.

Occult blood was found in the stools at every examination.

Blood: Hemoglobin, sixty per cent; white cells, 8,000; red cells, 2,760,000.

Stomach examination revealed absence of free hydrochloric acid. Total acidity averaged about 20. Streptothrix were present in large numbers, mucus in excess, a few small blood clots, and no pepsin. Some hypermotility was also present.

With the previous history of the case and the nature of the tumor, carcinoma or gumma are the most probable. A history of syphilis is entirely lacking. A carcinoma on the other hand may be primary in the liver-a rare occurrence, or secondary to carcinoma of the stomach or gall-bladder.

MASTOIDITIS AND FURUNCULOSIS IN EXTERNAL AUDITORY MEATUS.

DOCTOR MARSHALL L. CUSHMAN: I wish to present two cases, not on account of their rarity but rather because of their frequent occurrence, and the fact that the differential diagnosis between them is often attended with some difficulty. Each of these cases presents the typical signs and symptoms of their condition, but nevertheless in each case was there made a wrong diagnosis by the attending physician.

Case I-A German, male, age thirty-eight, comes to clinic on account of pain and swelling "in left ear." Trouble began three months ago with an earache which "gathered and broke," discharging on and off until one week ago, when pain increased, discharge stopped, and swelling appeared behind ear. Patient complains of some buzzing and deafness, thickness of lips and stiffness of left side of face.

Examination showed the following:

Left ear.-Membrane red and bulging, some drooping of posterior and superior canal wall in the depth. Signs of old perforation in membrane. Canal dry, no pus present. Auricle prominent and postauricular fold obliterated. Some edema over mastoid and tenderness

for radius of about two inches behind canal, especially marked above. Temperature and pulse normal. Leucocytes, 10,180.

HEARING TEST.

Right ear.
10/21

normal
normal

Right ear.
normal

Voice
Weber

Rinnè

High notes

Low notes

+ normal normal

Case II.-An American, female, age twenty-three, comes to clinic with diagnosis of acute mastoiditis. Two weeks ago patient had pain in left ear which was very severe. She was somewhat dizzy and once lost consciousness and fell to floor. The condition was diagnosed as acute suppurative otitis media. The ear began to discharge and continued to do so for two days, during which time pain was absent or very slight. The discharge stopped four days ago but returned this morning. During first attack there was some postauricular swelling.

Examination showed the left ear more prominent. The area of tense swelling is in region of mastoid tip, which is red and tender to pressure. Tragus tender to pressure. No tenderness over antrum and no obliteration of postauricular fold. Canal narrowed by swelling of superior, posterior, and inferior walls. Probe enters floor and passes through periosteum to bare bone in region of middle ear. Pus in opening. Membrane red, thickened, not bulging and covered with creamy. pus. No drooping of posterosuperior canal wall at fundus. Leucocytes, 15,000. Temperature and pulse normal.

HEARING TEST.

Left ear.
1/2/35

+

Voice

Weber

Rinnè

High notes

Low notes

normal

normal

Left ear.
10/21

+

+

normal

normal

Here, then, we have two cases that present points of marked similarity, a careful examination, however, easily differentiating them, the former being, of course, an acute mastoiditis, and the latter a furuncle ⚫ of the external canal.

Both cases were operated upon and made uneventful recoveries with the exception that in the former case a slight eczema auris occurred which promptly disappeared upon changing from iodoform to plain gauze dressings.

The facial paralysis in the former case well illustrates one type that is occasionally seen, that resulting probably from pressure incident to the increased tension in the tympanum present during the middle ear suppuration.

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