are of an irregular serpentine form,-they are situated upon an indruated base, the borders of which are well defined-perpendicular-and surrounded by a carmine border; these characters very distinct in some subjects, are scarcely perceptible in others. In this case the diagnosis will present great difficulties, and it will be impossible to say whether the disease is tuberculous or syphilitic-moreover both affections may be met in the same individual.

In the second stage of laryngeal phthisis, suppurative phenomena are observed, which are always in relation to the number of ulcerations; in less severe cases pus is seen only at the ulcerative surfaces; at other times the whole mucous is bathed in an unhealthy liquid which saturates and softens the tissues, and thus becomes a source of aggravation in the course of the disease.

It is also in this stage of the disease, that the first signs of that condition of the larynx, described under the name "Oedema of the glottis" appear, and which is constituted by a serous or purulent infiltration into the cellular tissue, in the epiglottic and arytenoidean regions, and towards the aryteno, epiglottic and thyro-arytenoid folds; though it may be by a tuberculous infiltration and a sclerotic production. The cedematous phenomena are generally very pronounced in the last period of laryngeal phthisis. Swelling and tumefaction invade, at the same time, those portions of the larynx which are lined by a loose cellular tissue, or the oedema remains limited to one region only; the inferior vocal cords, where the mucous is very adherent to the subjacent fibrous tissue, ordinarily escapes this complication. Examining a tubercular attack of oedema glottis, by the laryngoscope, the first thing perceived is a complete deformation of the epiglottis, which is much increased in size, and may appear as a large cushion, rounded and projecting.

Both borders of the operculum being much tumefied may even come in contact; this is the condition which Isambert has described under the name phimosis or para-phimosis. The aryteno, epiglottic folds, and arytenoides are also the seat of swelling which tends to narrow the superior opening of the larynx; having produced these alterations, it is difficult to see the ventricular bands, with the mirror-they being hypertrophied and puffed, covering the inferior vocal cords. mucous membrane presents a color, at times pale and exsanguinated, at others greyish or slate colored, at others red or purple ; the latter condition is observed, when the inner membrane of the larynx is at the same time under an accelerated inflammatory state.

The

The consistence of the tissues is sometimes soft and at others hard. We also reject the denominati on of sclerosis, which M.M. Doleris and Gougueheim have wished to substi

tute for that of cedema. If it is true, that in certain subjects the tumefied parts are indurated, resisting pressure, present a dense and lardaceous state, that they have, in a word, been transformed by a veritable interstitial sclerosis, it is not a fact that these alterations may be observed in all cases of laryngeal phthisis; one should, however, allow a wide space to soft oedemas, to which we may evidently apply the name scleremia. We believe in the relative frequency of true cedema, in pharyngeal tuberculosis, produced by a aserous or purulent infiltration; we base this opinion on a large number of previous observations, particularly upon a series of seventeen patients whom we examined during the last three months, at the clinic of Dr. Fauvel, and in whom the soft consistence of the tissues. was manifest.

With Dr. Moure, we will continue to employ the word œdema, unless a more appropriate expression is proposed.

The third period of laryngeal phthisis comprehends those lesions which attack the deep structures, muscles, ligaments, cartilages and articulations; these alterations may be the result of the propagation of the ulcerative action in the subjacent tissues, but the destruction may also begin in the submucous layers. There is produced perichondritis, chondritis, and true white tumors in the small articulations of the larynx; abscesses are formed and show as pyramidal swellings under the microscope-an example of such a case was seen recently. At this time the tongue becomes a source of purulent matter; there are in every part of the cavity ulcerations, fungosities and floating shreds. The mucous is covered with a thick layer of infectious pus; the calibre of the trachea is considerably narrowed and may lead directly to death.

Let us now glance at the rational symptoms of laryngeal phthisis-examine the modifications of voice, characters of the cough and expectoration and speak a word of the pain dyspnoea and dysphasia. At the commencement of the disease, the alterations of the voice are sensibly the same as those observed in chronic laryngitis; there is hoarseness, the sounds become more hollow and deep, the voice failing after talking or singing much, becomes markedly changed-there is also dysphony. Following the ulcerous lesions, with partial destruction of the organ, or simply with swelling and tumefaction of the mucous, covering parts, the integrity of which is essential to phonation, aphonia may supervene, which in certain cases is produced by paralysis of the recurrent nerves; finally in the latter stages of laryngeal tuberculosis, the voice is whispering and almost extinct.

It is very difficult to determine exactly the part which the laryngeal phenomena take in the production of cough; the ordinary concomitant pulmonary lesions may be regarded as the preponderating cause of this symptom. We believe in the direct influence of laryngeal lesions in the developinent and

character of the cough. Congestion and inflammation excited in the laryngeal mucous will render it more frequent; cough is observed most often in those who present ulcerations or small vegetations in the arytenoidean region; in fact from lesions of the larynx, the cough becomes harsh and concealed; finally, in consequence of an insufficiency of the inferior vocal cords, in the last stage of the disease, it may become eructating. But it should not be forgotten, that cases have been cited where the patients might not cough, though they may present profound alterations of the larynx. We saw a fine example of this fact in an unfortunate equisena at Mont-Dore in 1878. In this man there was great loss of epiglottic substance, a loose shred at the level of the right ventricular band, and numerous ulcerations upon the left inferior vocal cord. The pulmonary lesion was in a stationary condition, a softened focus at the inferior angle of the right scapula-no cavity. This patient only had spells of coughing on awakening in the morning; he was by no means incommoded by this, which in certain subjects takes a painful and fatiguing form. It is true we never saw an individual presenting so slightly pronounced special sensibility of the laryngeal mucous-laryngoscopic examination and feeling the intra laryngeal parts were made with impunity, giving rise to but slight reflex movement or spasm.

There is nothing to notice, particularly, in reference to the expectoration, which at the beginning of the disease is wanting, or composed of mucous. Later the sputa becomes purulent and varied in quantity, according to the extension and gravity of the laryngeal lesions: but it is extremely difficult to differentiate this secretion from that furnished by the bronchi and lungs.

Is the blood contained in the sputa of those suffering from laryngeal phthisis always of pulmonary origin, or is it the result of alterations seated in the vocal organs? According to most authors, true laryngeal hæmorrhage is extremely rare outside of cancer; in the tuberculous it consists of light sanguineous striæ mingled with the sputa-not in great quantity. "It is always from the lungs," says Bordenave," that the blood comes,, when in any quantity ejected by cough or expectoration."

Fauvel, cited in the excellent thesis of Moure, gives a more precise opinion on this subject. "Never," according to this eminent practitioner, "is there any laryngorrhagia in the tuberculous. The blood seen in the larynx does not come from the laryngeal mucous, but is arrested there in its passage. This does not satisfy us-it would be going too far to deny in an absolute manner, the occurrence of laryngorrhagia of a tuberculous nature, and we wish to prove it by three cases that have been observed.

[TO BE CONTINUED.]

Translations from Dutch Journals for THE PHYSICIAN AND SURGEON.
BY J. VANDERLAAN, M. D., MUSKEGON, MICHIGAN.

TWO CASES OF HYPOSPADIA IN ONE FAMILY.

BY DR. L. VANDERHOEVEN.

A few months ago, a certain R. applied to the Hospital at the Hague for treatment of Eczema squamosum and genu valgum dextrum. His sister, who accompanied him, asked for a private interview, in which she stated that her brother, to use her own words, was "neither male nor female," and that she herself shared the same defect. They were the only remaining of ten children, eight of whom had died at an early period, and who were without any malformation.

By physical examination, two labia majora are seen, which unite above a penis, two centimeters long, with a prepuce and corpora cavernosa. The glans is entirely bare and is not pierced by the urethra. In either of the labia is a testicle with its epididymis, from which the funiculus spermaticus ascends to the inguinal canal. In this canal the vas deferens and plexus pampiniformis are easily felt.

The testicles are of the size of a pigeon egg, the right one rather firmer and larger than the left. Quite firm pressure upon these glands excites no pain. There is not a trace of labia minora.

Half a centimeter below the glans penis, the orifice of the urethra appears, through which an ordinary female catheter passes with ease. On either side of the urethral opening another orifice is seen, allowing a filiform bougie to pass for about two micro-milimeters. The converging labia unite at a point about two or three centimeters below the meatus urinarius, and thus enclose a shallow fossa somewhat resembling the fossa navicularis in the female. The mons veneris is free from hair, and the external genitals apparently resemble the vulva of a girl twelve or fourteen years of age.

By rectal examination-while the catheter remains in situ -the urethra is found to measure about five centimeters in length. Of Cowpers glands, prostrate, vesiculæ seminales, uterus, and ovaries, not a trace can be found. The perineum is long.

Patient has a soft female voice, is small for his age and delicately built. There is no beard; the hair of the scalp is short. Finally, he shows two well developed mammæ, the glands of which are well defined. No milk can be squeezed from the gland. Patient states that he never lost any blood from the genitals, and that he never experienced anything like an erection or ejaculatio spermatis. His morning urine, which

was examined every morning for four weeks, never contained any spermatazoa. Sexually, he seems perfectly neutral. The whole individual resembles more the female than the male type.

By physical examination of his sister (more correctly his brother) aged twenty-eight, it appears that the latter, as far as the genitals are concerned, exactly corresponds with the former.

All the organs, however, are better developed, and the mons veneris is covered with hair. She never menstruated or lost any sperma. Her breasts are larger and the glands better developed than her brother's, but there is no secretion of milk. She has no beard and wears long hair. There is not the slightest desire for coitus, either active or passive. In contrast with her brother, she is well developed and has a strong voice. She appears to be a man in female dress.

By interchanging their assumed sex, both of them, no doubt, would better correspond to the proper sex. The question involuntarily arises why the accoucheur ascribed to them different sex. The patient states that the malformation was not overlooked by the obstetrician at birth.

Since the glands determine the sex, both should be classed as males.

A similar case is described by Dr. Magitot, in the July number (1881) of the Revue de Chirurgie. This latter case of Magitot belongs, according to Geoffroy Saint Hilaire, to the imperfect hermaphroditismus bisexualis; but Magitot considers it, from an embryological point of view, a case of scrotal hypospadia, in which the scrotum is bifid, and the infundibulum representing the membranous portion of the urethra. Pozzi, who also examined this case (Dr. Magitot's), thinks it is one of complete scrotal hypospadia; while Fillaux is of opinion that, considering the female voice, the well developed mammæ, and the loss of blood from the genital organs (which in this case of Magitot's was present, in this respect differing from the two cases described above), hermaphrodism cannot with certainty be excluded. The uterus may be so much atrophied that it cannot be felt, and a postmortem may reveal ovaries.

The two cases are most likely hypospadia; but with absolute certainty this diagnosis cannot be made; first, on account of the well developed mammæ of both; and, secondly, the female voice and form of the one.

The urine of the so-called male patient contains considerable albumen, with renal epithelia and casts, and there is a possibility, therefore, that a postmortem will soon make the diagnosis certain. If ovaries shall be found, the case must be classed as one of hermaphroditismus bilateralis.-Nederlandsch Tydschrift.