Entered according to Act of Congress, in the year 1880, by J. B. LIPPINCOTT & CO., In the Office of the Librarian of Congress at Washington. LIPPINCOTT'S PRESS, PHILADELPHIA. THE HE patient before you this morning is named George W., æt. 38 years; was admitted to the hospital September 9, 1879. Type-maker by trade; of good family history; denying any form of syphilis, but acknowledging the excessive use of alcohol for many years. Six weeks ago he had an attack of what he called asthma, but very mild in its manifestations, amounting only to shortness of breath, with coughing. A week before his admission the dyspnoea increased, his voice began to be hoarse, and at intervals he lost the power of speech. September 15, he had a most terrible paroxysm of dyspnoea, with all the attendant phenomena of asthma, but the suffocative symptoms were far more severe than in most cases of asthma. The pulse was very weak and irregular; the surface of the body was blue and clammy, even the arms becoming purple. The paroxysms lasted until it was thought death would follow, when he slowly began to revive, although the spasm of the bronchial tubes appeared to persist as before. September 18 and 19, he had similar paroxysms, perhaps not quite so violent. There is much difficulty experienced by him in swallowing both solids and liquids, but no pain. This morning, the 20th, he had another paroxysm at six o'clock, which passed away leaving him in the condition of dyspnoea above described. The important symptoms to remember as a group are, the recent date of the first attack, the character of the dyspnoea, the dysphagia, and the impairment of voice. Finally, it will be well for you to recall the expression of the patient's face, as unlike that of an asthmatic individual. If you had casually glanced at our patient in the ward, you might have supposed him to VOL. X.-I be suffering from a simple asthmatic seizure; but important differences from ordinary asthma are easily recognized. There are three varieties of asthma which we clinically confront; one of these is the common variety of asthma often asSociated with or preceded by emphysema and bronchitis, and which is attended with spasm of the bronchial tubes and other familiar phenomena, but its etiology is yet an unsolved problem. Is our patient the victim of ordinary asthma? I think not, because, in the first place, the initial paroxysm occurred only six weeks ago, while previously he had enjoyed excellent health. The paroxysms also at first were very light,-merely noticed by him as spells of shortness of breath; but they have rapidly increased in severity and frequency, till at present they occur almost daily. In the intervals of the attacks he has dyspnoea, with whistling respiration, although there is no bronchitis, while in the ordinary attacks of asthma, unless there is concomitant bronchitis and emphysema, the close of the paroxysm brings with it a marked remission or entire relief of the symptoms. Another variety is the asthma which is sometimes associated with Bright's disease of the kidneys, called uræmic asthma. This variety is dependent upon a spasm of the arterioles of the lungs, induced by the direct impression of circulating undepurated blood upon the controlling vaso-motor centres. This form is not associated with spasm of the bronchial tubes, for auscultation can furnish satisfactory evidence that air enters and passes from the bronchial tubes without hindrance. without hindrance. It is very easy to exclude this species of asthma, for there is no dropsy or other evidence of Bright's disease, and the urine is normal. But we also have asthma with spasm of the bronchial tubes from the pressure of a tumor upon the pneumogastric nerve or its branches. We are taught by physiology that the tenth nerve contains both accelerator afferent fibres and inhibitory afferent fibres, the accelerator fibres predominating. Rosenthal declares the respiratory centre to be the seat of two forces of conflicting nature, the one laboring to generate respiratory influences, the other tending to offer re sistance to the generation of these impulses, the alternate victory of the one over the other leading to rhythmic discharges of force and the regulation of respiration as we find it in health. We also know that the superior recurrent laryngeal nerve is composed mainly of inhibitory afferent fibres, by the stimulation of which respiration can be brought to a stand-still, the respiratory apparatus remaining as at the close of expiration. This effect can also be produced by first exhausting (so to speak) the neurility of the accelerator afferent fibres of the main trunk of the pneumogastric nerve, which permits the inhibitory fibres to obtain the controlling influence, and thus reduces or stops the respiratory action, just as when the superior laryngeal branches are stimulated. Now, if pressure is brought to bear on the pneumogastric nerve or its branches which supply the bronchial tubes, as happens in some cases of tumors within the chest, it appears to me we can have two effects,-first, a continued irritation of the afferent nerves, and a continuous spasm of the tubes in consequence; which implies, secondly, deficient aeration of the blood. The accelerator fibres are, in common with the whole nerve, excessively sensitive to the influence of the non-aerated blood; therefore we can understand that there must be continuous over-stimulation of the accelerator fibres. It seems to me, therefore, that at intervals the neurility of these fibres will become exhausted, and thus will be brought about a paroxysm which may end in almost absolute asphyxia through the temporary ascendency of the inhibitory fibres. This does not prevail in simple asthma to the same extent, because the attacks cease with the relaxation of the bronchial tubes, and the symptoms of suffocation in cases of pressure arise from the prolonged deficient aeration of the blood. In the case before us there has been constant spasm of the bronchial tubes since his admission to the house, but at times he has seemed about to die; he becomes cyanosed, cold, and respiration almost ceases, due, I believe, to the inhibitory influence I have attempted to describe. If it is possible to explain these symptoms by pressure, can we find in our patient any evidences of pressure? Physical examination tells us that there is a tumor situated between the second and the fourth rib on the right side, at the point The tu of their union with the sternum. mor extends laterally three and one-quarter inches to the right side from the median line of the sternum, as demonstrated by percussion. The right side of the chest measures eighteen inches, the left sixteen inches, at the level of the second rib. The cardiac dulness appears to begin as usual, but cannot be defined accurately, because it is covered with emphysematous lung-tissue; but the apex-beat can be felt in the sixth interspace, three-quarters of an inch to the left of the nipple, indicating hypertrophy. There is also a pulsation in the second interspace, at the seat of tumor, which is heaving in character. The radial pulses occur later than the femoral,—an important sign of aneurism of the arch of the aorta. There is also a systolic murmur to be heard over the base, but more distinct at the tumor; it is low and prolonged in character; it is transmitted into the arteries of the neck, but is faintly heard at the apex, and at the ensiform cartilage is nearly lost. There is no murmur in the femorals or down the aorta posteriorly. The variations in murmur in aortic aneurism are, perhaps, familiar to you, from your studies of Walsh and from the demonstrations in the ward classes; time forbids me to enter upon their discussion in this case. A tumor situated as I have described is very suggestive of aortic aneurism, the symptoms of which are often dependent upon the direction of growth of the tumor. In this case we have dysphagia, but the difficulty is as great when there is an attempt to swallow liquids as solids, and is not associated with pain, but merely with the sense of choking, which the act of swallowing induces by causing the patient to hold his breath. Therefore I decide that he has no pressure on the oesophagus. He has aphonia at intervals; this implies irritation of the recurrent laryngeal nerve, which supplies all the muscles of the larynx except the crico-thyroid, and by rendering it possible to approximate the vocal cords, and also to render them tense, is principally concerned in phonation. There is, I believe, simply irritation, not direct pressure on it, because at intervals his voice is distinct. We should not, indeed, expect that the recurrent laryngeal should suffer pressure, because it is only on the left side that it curves under the aorta. But if it is not pressed upon, and if the paralysis of the vocal cords induced by irritation is only temporary, we must seek elsewhere for the explanation of the symptoms of dyspnoea, from which our patient suffers so much torture that his life is threatened. For this explanation I refer you to the views mentioned in the early part of my lecture upon the effects of pressure on the pneumogastric nerve. Indeed, from but one other source could the symptoms arise (I allude to the possible pressure of the tumor on the bronchial tubes); but there is no evidence of pulmonary collapse, and everywhere we hear vesicular murmur. Have we evidence from his history that we can use to support the diagnosis of aneurism? There is no syphilis to which we can trace arteritis,— as so often can be done,—but we have his acknowledgment of a life spent in the free indulgence of the passion for alcohol. What more potent cause of arteritis? For you must agree with those who consider this the antecedent to aneurism, because in your daily experience you see individuals constantly engaged in lifting or carrying (ie., placing an undue strain. upon their arterial system) with impunity, while in others much less exertion sows the seeds of aneurism. We have no evidence of heart-disease or its result, dropsy; so that we may, I think, consider that the evidence points in one direction only. It is true that I have seen an abscess the result of caries of bone point in this situation, as well as abscess from softening gummata. But, although our patient received a kick in the chest, I can detect no evidence of local injury, and, as I have said, there is no admission of syphilis, nor, indeed, are there any symptoms indicating suppuration. The comparatively short period since he noticed any departure from health militates against malignant or other new growth; nor is there any distention of the superficial veins of the chest, as would be the case if this tumor had its origin in the mediastinum. ous pressure-symptoms present. Pending a decision on this point, we must have recourse to the antispasmodic treatment employed in asthma in order to alleviate the paroxysms. Upon this class of remedies I wish to address you later in the winter. A ORIGINAL COMMUNICATIONS. CASE OF BONE-SYPHILIS IN AN INFANT, ACCOMPANIED BY PSEUDO-PARALYSIS AND A PECULIAR INTERMITTENT LARYNGEAL SPASM. BY ARTHUR VAN HARLINGEN, M.D., Chief of the Skin Clinic, Hospital of the University of Pennsylvania. ΤΗ Pauline Vivien H., a colored infant, was born of parents both of whom had been under my care for syphilitic disease during more than a year previously. The child, though fat and well nourished at birth, displayed mucous papules about the anus, in connection with catarrh of the nasal passages, about the beginning of the second week. No other symptom of disease appeared for several weeks, at the end of which time a certain progressive falling off in flesh began to be observed. When the child was about seven or eight weeks old, the mother noticed, one day, that the left leg had become suddenly powerless, and that there was a certain amount of swelling about the knee-joint. This seemed to pass away spontaneously, but a few weeks later the left arm also became similarly affected, the fingers only being moved, and the limb hanging down as if paralyzed. When the arm was raised at the shoulder the child I regret to say that I fear nothing can be done to relieve our patient permanently. Tracheotomy is not to be thought of, as the obstruction is not in the larynx. Indeed, electrolysis seems to be the only operation capable of giving succor, for, if successful, the layers of fibrine will probably gradually contract as they accumulate. All other modes of treatment will be too slow to be trusted, in the face of the seri- Young Children. New York, 1875. Syphilitic Lesions of the Osseous System in Infants and † Clinical Lectures on Diseases of Bone. London, 1878. |