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(2) Borderland cases of insanity are at times more apparent than real. A consideration of such cases may show that the obscure symptom is really an early manifestation of a psychosis, which can be classified.
(3) Medical men when testifying in "borderland cases" should invariably give their reasons for their opinion, and should not, if there is not sufficient proof, attempt to isolate the symptom and refer it to a named psychosis.
(4) The degree of responsibility in some of these cases, considering our present knowledge, cannot be accurately determined. Every case. is a study in itself, and must be determined on its merits.
(5) Expert testimony should be given only by experts. If this rule was strictly adhered to medical expert testimony would be better appreciated.
(6) Inability to pass upon a case should be frankly acknowledged. In cases of doubt, we are justified in giving our testimony, and leaving the real decision of responsibility to the court and its representatives.
CLINICAL SOCIETY OF THE UNIVERSITY OF MICHIGAN.
STATED MEETING, DECEMBER 15, 1905.
THE PRESIDENT, ROGER S. MORRIS, M. D., IN THE CHAIR.
REPORTS OF CASES.
DOCTOR GEORGE DOCK: I wish to describe a case of cardiac aneurysm. The patient was a farmer of fifty-two years, of intemperate habits, and with a scar suggestive of syphilis but denial of history of infection. From the age of eighteen the patient complained of neuralgic pain in the pit of the stomach and of pain and tenderness in the heart region. Two years before death he had a slight paralysis of the right side, lasting only three hours. For the last four months of life pain in the heart region was more severe, paroxysmal, and sometimes radiating down the left arm. Unlike most patients with angina pectoris, the man became almost maniacal, running around the room, screaming, declaring that the pain would kill him, but without having the oft-described feeling of impending death. For the last two months the pain in the heart was almost continuous. There was dyspnea; edema coming on first in the lower extremities, then becoming general. Physical examination showed all the evidences of incompensation, the heart dilated
and hypertrophied, with a blowing systolic murmur at the apex. The second aortic was accentuated; the radial arteries tortuous, thick, slightly uneven; the liver reached to the navel line; urine-specific gravity 1015, one-fourth bulk albumin, few hyaline casts. For several weeks he had not been able to sleep. Under the influence of morphine, diuretin and salt-free diet the patient improved markedly, so that by the second day of treatment he was able to sleep lying down. In four days the edema was gone and the heart became smaller. Eight days after beginning treatment, against positive orders to the contrary and with a prediction of sudden death in the event, he ate a large meal, started out for a walk, but after going a block, fell over and was found to be dead. Autopsy showed adhesions over the front part of the left ventricle; the heart enlarged, containing an aneurysm at the end of the left ventricle, and in the septum, containing a thrombus partly old and partly recent. There was relative insufficiency of the mitral valve, slight thickening of aortic flaps, coronary sclerosis, with obliteration of the anterior coronary in the lower part. The other organs showed congestion, slight atrophy, with moderate parenchymatous and interstitial changes.
Doctor Dock gave a critical summing-up of the case with reference to symptomatology, diagnosis, prognosis and treatment. He also called attention to some of the points of interest in connection with the subject of sudden death, and gave a detailed account of the history of cardiac aneurysm from the time of Lancisi. His remarks were illustrated by a number of old and modern works on heart disease, including Corvisart, Laennec, Cruveilhier, Carswell, and also some of the more important articles in medical periodicals illustrating the development of our knowledge of cardiac aneurysm.
OVARIAN CYST WITH TWISTED PEDICLE.
DOCTOR CHRISTOPHER G. PARNALL: Gynecological case number 1408 was admitted to the University Hospital on September 21, 1905. Age forty-two; married nineteen years.
Personal History.-Had all the ordinary diseases of childhood with good recoveries. For many years she has had attacks of headache. Patient says she has never been real well.
Menstrual History.-Menses appeared at age of twelve. Last period seven weeks before admission. Very irregular, one to two months. Duration, one to two days. Amount scanty, one or two napkins for whole epoch. No pain. Moderate vaginal discharge.
Marital History.-No children. No history of abortions.
Present Trouble.-It began about three years ago with pain in both groins, worse on left side. The abdomen increased in size very slowly. The enlargement seemed to be general and not confined, even at first, to either side. At the last menstrual period there was severe pain in the lower abdomen beginning on the right side and extending to the
left. There is a history of a number of attacks similar to the above except that the pain was not so severe. No nausea nor vomiting. Patient does not think she had fever.
Examination.-There is a great development of adipose tissue, patient weighing two hundred and thirty pounds. Otherwise the general examination is negative. There is a marked abdominal enlargement extending from the pubes upwards to the epigastrium. This swelling is dome-shaped. Lineæ albicantes marked. There is a deep suprapubic transverse furrow, above which the tumor is dome-shaped, smooth and symmetrical. It is sensitive and somewhat movable. Percussion note is dull over the tumor, tympanitic in the flanks. No fluid wave. Vaginal examination shows the uterus retroverted. Appendages not palpable. Nothing can be made out in the fornices of the vagina.
On the day after admission the examination of the urine revealed a positive test for sugar. On a so-called carbohydrate-free diet the sugar disappeared. The patient was kept on diabetic diet for a week preceding operation, during which time there was no reappearance of the glycosuria.
Diagnosis. Ovarian cyst. On account of the sensitiveness and history of sudden attacks of pain, it was thought probable that a twist` of the pedicle would be found, possibly with adhesions of the cyst wall to the surrounding peritoneum, and infection of the contents.
Operation. On September 25, 1905, by Doctor Peterson. The abdomen was opened by an incision thirteen centimeters long, in the median line. The subcutaneous fat was six and one-half centimeters in thickness. On opening the peritoneum it was found that the cyst wall was adherent to it for a radius of about ten centimeters. The adhesions were thin and vascular. They were loosened by sweeping the hand between the cyst wall and the peritoneum. About nine liters of muddy-colored fluid were removed by the trocar. The cyst was then easily removed by clamping the pedicle, which was twisted counterclockwise for half a turn. The left ovary was enlarged and cystic and was removed. The uterus was held forward by ventro-suspension. Four days after operation sugar again was found in the urine and did not entirely disappear under diabetic diet. The wound healed satisfactorily and convalescence was uninterrupted.
This case is of interest from the standpoint of diagnosis. Twist of the pedicle of an ovarian cyst is not uncommon, still the condition often goes unrecognized.
The torsion may be acute, resulting in severe sudden symptoms, or chronic, with less marked changes. In the first variety there is a sudden cutting off of the blood supply, particularly on the venous side, and hemorrhage into the cyst. Acute torsion may resemble in many ways the rupture of an ectopic gestation sac. There is usually sudden severe pain coming on after exertion, movements of the bowels, or urination. The patient may faint and present signs of internal hemorrhage.
In the chronic form the torsion is slow, the circulation in the tumor is interfered with only gradually, and adhesions often form between the cyst wall and the neighboring pelvic organs or the parietal peritoneum. The cyst may thus obtain a large share of its blood supply through these adhesions.
The temperature is usually not much elevated, generally 100° to 102° Fahrenheit. The pulse in acute torsion is frequently very rapid, . ranging from 100 to 160 per minute. When there is a marked adhesive peritonitis vomiting is a prominent symptom. Intestinal obstruction may occur as a result of the inflammatory changes involving the cyst and intestines or from pressure of the tumor. Palpation in uncomplicated cases of ovarion cyst is accomplished without causing even discomfort. In case of adhesions involving the serous membranes there is abdominal rigidity and marked sensitiveness. A small right-sided adherent cyst may indeed be easily mistaken for appendicitis or periappendical inflammation.
A CASE OF ACUTE CHOREA.
DOCTOR THEOPHIL KLINGMANN All the facts which have been gathered by the pathological anatomist and the physiological chemist in the study of chorea offer no explanation of the defects that give rise to the condition. No constant lesions have been found. Although certain organic changes are often associated with the disease, it is not infrequent to observe cases that are truly functional and give support to the view that chorea is an expression of functional instability of those nerve centers which have assigned to them the office of controlling the motor apparatus. Of the actual nature of this derangement we know little or nothing; whether the fault is primarily in the cortical cells or whether the impulses are secondarily disturbed in their course down the motor path. Hereditary influence is discoverable in many cases of chorea. A neuropathic heredity has been found. in one-sixth of the cases. Frequently a double relationship of the disease can be traced to acute rheumatism on the one hand and to various nervous disorders on the other.
The case in question, a patient of good general appearance, twentyfour years of age, gives evidence of hereditary influence. The father of the patient has had rheumatism. We must not, however, lay too much stress upon this fact, as rheumatism is so common that it is only significant when the family tendency is very strong, or when the subject has endured much suffering from the disease. The mother of the patient died at the age of thirty-six, of pulmonary tuberculosis. One sister died of the same disease at the age of thirty. Another sister had chorea for several months at the age of fourteen, but recovered completely. The patient's health was good until her eighteenth year, when she became somewhat nervous and fretful and complained of forgetfulness. She recovered from this condition without treatment, however, and was quite as well as ever until the present affection began. She experienced her first attack of chorea three years ago, when she
was twenty-two years of age and four months past her third confinement. Her first pregnancy terminated prematurely at seven months; the second four years ago at full term; the third and fourth pregnancies also being at regular time. The nervous condition at first manifested itself in severe headaches and marked irritability, which was followed by involuntary muscular movement in the face, the tongue, and later in the upper and lower extremeties. This continued for about two months and ended in complete recovery. One year later she had a second attack. This siege was much less severe and lasted but a short time. She became pregnant soon after this attack and remained well until five months after confinement, when a third, the most severe attack, developed.
The patient came to the University Hospital in November, 1905. She had suffered from chorea since August without intermission. While her general appearance is fairly good she has lost about thirty pounds since the beginning of this attack. There is no apparent cause for this loss of weight except continual worry and anxiety together with annoyance incident to constant involuntary muscular contractions. Her sleep is very much disturbed. There is no disturbance of digestion. The appetite is good. The patient is not anemic. In fact there is no evidence of organic disease in any organ except the heart, and the lesion indicated gives the patient no discomfort. There is considerable muscular weakness present. The spontaneous movements and incoordination are most marked in the arms and hands, but the face, and, to some extent, the lower extremities, were likewise affected. The movements are very irregular as to time as well as in character and degree. Sensibility is not disturbed and there is no pain or tenderness in any part of the body. The mental state is normal. The cardiac symptoms, which are the only evidence of organic disease in the case, are of great importance. The frequency of organic disease of the heart is less in childhood than in youth. In chorea, developing late, as it did in this patient, the cardiac symptoms are usually those of organic disease and frequently mitral regurgitation. It is reported. that in nine out of every ten fatal cases the cardiac valves are diseased. Statistics in the various clinics show that distinct organic disease. either preceding or developing during the course of chorea was found in thirty-two per cent of the cases. What part this plays as a causative factor cannot, with our present knowledge of the disorder, be ascertained. The changes which have been found after death afford no clear indication that the circulation is primarily deranged. In the majority of cases of the common form of chorea the heart lesion gives the patient little or no discomfort, even though it persists after the involuntary muscular movement has entirely ceased. The same is true of other pathologic conditions occurring before or during the course of the disease. It seems more likely that one common cause disturbs the functions of the various organs of the body, as well as the functions of the nerve centers in the brain. This cause may possibly be found in some toxin which accumulates in the organism. This is borne out