its course again from the stage at which it was arrested, and duly proceed to its end."

ART. 68.-A Case of Pneumo-Pericardium.

By Dr. J. W. BEGBIE, Physician to the Royal Infirmary,
Edinburgh.

(Edinburgh Medical Journal, October, 1862.)

This case is one of malignant disease of the oesophagus, succeeded, first, by sudden pericarditis, and ultimately by pleuro-pneumonia with effusion.

CASE.-Mrs. W., æt. 43, mother of seven children, admitted to Ward XIII., 29th July, 1862. She had for several months previously been under the care of Dr. Hislop of North Berwick, from whom, at the time of her admission, I received the following brief account:-"She had been suffering from increasing difficulty in swallowing, at first considered to arise from spasm in the muscles of the oesophagus, an opinion which was strengthened by the relief she experienced after passing the probang on several occasions. A month or more ago, in attempting to pass the probang much greater difficulty was experienced, and its use was finally desisted from. She suffered much about the same time from vomiting, and once brought up some blood with mucus." Dr. Hislop added, "From the pain she feels in the back, the increasing difficulty in deglutition, and the general features of the case, I fear that the morbid deposit is of a malignant character. I have for some time been doing nothing but supporting the system."

State on Admission.-Patient presents an anxious expression of countenance, is very anæmic, without history of hæmorrhage or renal disease. No albuminuria. As far as can be determined, the only cause for her present condition is defective alimentation, on account of dysphagia, which, coming on gradually, has existed more or less for nearly two years. She has almost constant vomiting, or rather there occurs immediate rejection of the food before it has reached the stomach. Has little or no pain. On careful examination of the chest, no abnormal indication is furnished either by the lungs or heart. Abdominal organs apparently free from disease.

From the time of admission the opinion gradually gained weight that the patient laboured under malignant disease of the lower portion of the œsophagus.

22nd August.-Under a careful regulation of diet some improvement has resulted. The dysphagia and vomiting have greatly abated. Vespere.Has this evening complaint of headache and pain in the chest. 23rd. After the application of a sinapism the pain in the chest was relieved. On auscultation, a distinct to-and-fro pericardial friction sound is audible over the region of the heart. There is no increase of precordial dulness. In the evening the patient fainted, losing consciousness for a very brief period; but on her recovery from the swoon, remaining cold and collapsed in appearance, with almost imperceptible pulse. Brandy was administered, and warmth applied externally.

24th.-Remained very much sunk during the whole night; the surface of body covered with clammy moisture; at times becoming almost pulseless; when perceptible, the pulsations at wrist numbered 120. Brandy and aromatic spirit of ammonia were given freely. She is now-Noon-a little

stronger, free from pain and without dyspnoea. The friction sound over the heart has lost nothing of its distinctness.

25th.-Has continued in much the same state. The attrition sound with the heart is not quite so distinct, and now there exists a little increase of dulness on percussion, with appearance of slight fulness in the fourth and fifth left intercostal spaces near the sternum.

26th.-More sunk in appearance. Physical signs have undergone no change.

27th and 28th.-In much the same state.

29th. On auscultation to-day at visit, a very remarkable character of the heart's sounds was noticed. The friction is replaced by a guggling noise, a churning splash, audible over the whole cardiac region, and rendered more distinct when, for an instant, the patient holds her breath. This sound is not distinguishable at a distance from the chest. The dulness on percussion over the heart has vanished, and now a clear and nearly tympanitic note prevails, with increased fulness in precordial region. The patient's extreme weakness forbids any attempt to alter her position in bed; the effect of change of posture on the percussion note cannot therefore be determined. 30th.-Physical signs remain as yesterday. 31st.-Patient died at 9 A. M.

In endeavouring to explain the remarkable physical phenomena connected with the heart, which presented themselves during the closing days of this poor woman's life, I considered it probable that the pericarditis, of which, on the 23rd of August, the signs were perfectly distinct, was determined by the progress of the cancerous affection of the oesophagus to the posterior wall of the pericardium; and when, on the 29th, the friction sound over the heart was replaced by the guggling râle, limited to the cardiac region, and altogether unlike any sound connected with the heart's action previously familiar to me; and when, in addition to the evidence thus afforded, there had occurred an unmistakable alteration in the percussion note over the heart, dulness having yielded to clearness, I concluded that perforation of the oesophagus had taken place, and that, besides the presence of lymph and fluid in the pericardial sac, there was also afr. The diagnosis then formed and expressed was as follows:-Cancer, affecting the lower portion of the œsophagus where in contact with the pericardium; pericarditis with effusion from extension of disease in the former; finally, rupture of the oesophagus and passage of gas into the pericardium. The post-mortem examination, conducted on 1st September by Dr. Haldane, determined the correctness of this opinion in all essential particulars. I subjoin Dr. Haldane's report. "The body was much emaciated; the surface very pale.

"When the chest was opened, the pericardium, marked by the pressure of the ribs, bulged forwards, and on being punctured air escaped. There were no adhesions of the pericardium, but in its cavity were about three ounces of a dark-brown fetid fluid. Both surfaces of the serous membrane were coated with lymph of a yellowish grey colour, of leathery appearance, and evidently of some standing; there was also some softer and more recent lymph, which could be readily scraped off with the nail. When the heart, which was of natural size and structure, was removed, an irregularly circular opening admitting the point of the finger, and communicating with the œsophagus, was found in the posterior wall of the pericardium. On examining the œsophagus, its upper part was found healthy, but the whole of the lower part from about the middle of the thoracic portion was in a cancerous condition; about two inches and a half of its anterior wall was completely gone, and its cavity was here bounded by the back of the pericardium and by the inner margin of each lung. It was here that the

pericardium was perforated, and the pleura covering the lungs in this situation was dull and of a brownish colour, but the lungs were not opened into.

"While the liver was being removed, it was found that the back of its left lobe was adherent to the anterior wall of the stomach in a space about the size of half-a-crown. On separating the adhesions, an opening with sloughy margins was found in the stomach, but the firm connexion with the liver had prevented communication with the peritoneum. The whole of the lower part of the oesophagus, the cardiac extremity of the stomach, and the adjoining portion of its anterior wall were cancerous; the cancer was soft and fungating, and in several situations was in a sloughy condition. intestines were contracted. There was no other lesion."

The

Dr. Begbie adds a few remarks on the physical signs of pneumohydro-pericarditis. "Laënnec," he says, who probably exaggerated the frequency of the occurrence of gas in the pericardial sac, speaks of three signs upon which dependence is to be placed in the diagnosis of air and fluid in the pericardium:-1. Unusual resonance over the lower part of the sternum. 2. Fluctuation sound (bruit de fluctuation) audible with the action of the heart and on deep inspiration. 3. As specially relating to the diagnosis of pneumo-pericardium, the circumstance of the heart's sounds being heard at a distance from the chest. Upon this sign Laennec placed very considerable reliance. He states, indeed, that his observations respecting it were made some time after those already referred to as one, and two, and that he had not been able to determine whether it existed in connexion with these. Dr. Stokes, whose observations on pneumo-pericarditis are most instructive, noticed the fact of the heart's sounds being heard at a distance in the case which he has recorded. He remarks, however, that this sign was not present in either Dr. Graves' or Dr. M'Dowel's cases already noticed. I have mentioned that it did not occur in the instance now recorded, and Dr. Walshe has no doubt correctly observed that Laennec's expressed conviction, that in almost all cases (for he uses the expression presque tous les cas, and not simply occasionally) when the heart's action is heard at a distance from the body, the cause of the phenomenon is a temporary development of gas in the pericardium (often readily absorbed, and whose presence does not give rise to any serious result), cannot at the present day be received. In the remarkable case of pneumo-pericarditis related by Dr. Stokes, the following signs were observed. I give them in Dr. Stokes' own language. On examination a series of sounds was observable which I had never before met with. It is difficult or impossible to convey in words any idea of the extraordinary phenomena thus presented. They were not the rasping sounds of indurated lymph or the leather creak of Collin, nor those proceeding from pericarditic with valvular murmurs, but a mixture of the various attrition murmurs with a large crepitating and a guggling sound, while to all these phenomena was added a distinct metallic character. In the whole of my experience I never met so extraordinary a combination of sounds. The stomach was not distended by air, and the lung and pleura were unaffected, but the region of the heart gave a tympanitic bruit de pot felé on

percussion, and I could form no conclusion but that the pericardium contained air in addition to an effusion of serum and coagulable lymph.' The phenomena on auscultation and percussion thus recorded will receive farther value as indicating the existence of hydropneumo-pericarditis, if in addition there be noticed, as was done by Dr. Walshe in the 'singular case of traumatic communication between the oesophagus and pericardium,' referred to in his work on Diseases of the Heart, a dull or tympanitic sound elicited over the precordial region according to the position assumed by the patient. The extreme weakness of the patient in the instance I have recorded alone prevented our determination of the existence of this important sign: from the appearances presented after death, I have little doubt that, had it been in our power to alter the patient's position after the development of the peculiar auscultatory phenomena, we should have had this last indication also to guide us. Without it, however, and in default of a metallic character of the cardiac sounds, as noticed by Dr. Stokes, the diagnosis of pneumo-pericarditis with effusion may I think be made, from observing a guggling or churning splash sound with the heart's action limited to the cardiac region, with which more or less of tympanitic precordial resonance is associated. Still more reliable as signs will these phenomena be, if, as in the instance now recorded, the guggling has succeeded, after its continuance for a few days, a distinct friction sound, and the tympanitic replaced a dull percussion note."

ART. 69.-On Narrowing of the Aorta at the Point of
Entrance of Botalli's Duct.

By M. A. DUCHEK.

(Wochenblatt d. Zeitschr. d. k. k. Gesellsch. d. Aerzte in Wien, Sept. 10, 17, 24, 1862; and Medico-Chir. Review, Jan. 1863.)

At the conclusion of this interesting paper, one in which the literature, as well former as recent, is well worked up (no less than 51 recorded cases being referred to), the author has the following observations regarding the causes of death in cases of this kind. He observes that they may be well considered with reference to the age at which death occurred; with the exception of 9 cases, the details of which were not complete, and 3 cases which were still alive. Of 39 cases, those that died

Before the close of the 1st year of life, were 3 in number.
Between the 1st 10th

1

Exclusive of 11 cases, the particulars of which are deficient, the causes of death are indicated in 40 cases.

Firstly. In the first year of infancy, consequently soon after or during the process of the narrowing. The author remarks that the rarity of death at this period is not what might have been expected. In no case of this kind was there mention made of any enlargement of collateral vessels, and thus, he observes, death may be attributed to the rapid production of impediment. Even in the two cases narrated, where pneumonia or atelectasis of the lungs existed, the backward action of the obstruction on the smaller circulation of the lungs must be looked upon as having been concerned. The third case (that of a new-born child) cannot be considered one in which the cause of death was laid bare, inasmuch as nothing is declared respecting other organs.

Secondly. All the remaining 38 died after a longer continuation of the stenosis, the majority between the ages of 20 and 30, only a few between 30 and 60.

(a) Lacerations of the heart and large vessels occurred in 8 cases. Thus we have laceration of the right auricle in a man 35 years of age; of the right ventricle in a man of 57 years of age; of the ascending aorta in a patient 17 years old, in a man 23 years old, and in a man of "middle age;" of an aneurysm of the ascending aorta in a man of 21 and 24 years of age; of an aneurysm of the descending aorta in a patient 37 years old.

The author connects the stenosis and the ruptured heart and vessels, which so often occur, by supposing that a prematurely atheromatous and fatty condition is induced by the increased bloodpressure in the rear of the obstruction.

(b) In cases of a longer continuation of the disease, that is, in older men, dropsy and marasmus came on in 8 cases.

(c) In 3 cases death occurred quite suddenly, without any preexisting symptoms; attributed by the author to irregularity and confusion, so to say, of the circulation suddenly (as by muscular exertion, mental agitation) induced; no opportunity, owing to the obstruction, being allowed for compensation.

(d) In 16 cases, in which the disease causing death had apparently no connexion with the stenosis, it was noticeable that they all had relation to the organs of respiration, with the exception of 3 cases1 of jaundice after gall-stones, and 2 of tuberculosis. Thus, in 9 cases, pneumonia existed in patients of various ages, the youngest being twenty-two days, and the oldest fifty-seven years. In one case pleurisy, and in one atelectasis of the lungs existed. The author connects these conditions and their final result with the abnormal state of pressure in the smaller circulation which existed.

(e) Only one patient died from causes quite apart from the stenosis -viz., from marasmus senilis, at the advanced age of ninety-two years.

The general and final inferences drawn by the author are, that the stenosis of the aorta at the point of junction of Botalli's duct is almost always followed by important results; that these results are analogous to those which for the most part followed stenosis of the