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Case of Diphtheria.--Sudden Death on the 13th Day.-Fatty
Degeneration of the Heart and Cardiac Thombus,
Under the care of Dr. Ross. Reported by Mr. IMRIE. E. A., æt. 11.—Is one of several children living in a tenement above a room where a child died of diphtheria about two
She was admitted into the Montreal General Hospital, under care of Dr. Ross, on the 16th January, 1879, having been sick with sore throat and severe feverish symptoms for three days. The whole entrance of the throat was seen to be dusky aud much congested. Tonsils swollen and covered with a pretty thick greyish-white membrane, which also extended freely upon the pillars of the fauces and the surfaces of the uvula. Breath very offensive; neck thick-looking and glands moderately enlarged ; temp., 104°; pulse, 120; no albumen in the urine. Two days later (18th January) we find that there has been very little, if any, extension of the membrane beyond the parts already mentioned. Swelling of glands persists ; also great fotor of breath, and commencing acrid discharge from the
Was somewhat delirious the past night, and the pulse is quick (140); urine contains a trace of albumen.
January 20th.— Temperature has not been above 101° ; no more delirium ; urine moderately albuminous—25 ounces in 24 hours; membrane coming away freely from the throat; no extension ; fetid discharge from nostrils considerable; glands still swollen and tender.
218t.-- Patient, the note says, seems“ much brighter."
22nd. There has been slight epistaxis; improvement continues; throat free from membrane, but raw and irritable; glands less swollen, and not tender ; albumen less; temp., 99°; pulse, 105.
24th.— Throat appears to be healing. There is a slight regurgitation of fluids through the left nostril, and the voice has a somewhat nasal character. Temperature normal.
25th.—Two p.m.—Not so well; is irritable and restless ; complains of pain and soreness in the back and legs. The skin of the legs, especially the fronts of the thighs, is markedly
hyperæsthetic. Throat and glands much improved, but patient is somewhat deaf in both ears. Slight regurgitation, and the nasal voice persists. The urine has been very scanty, only two ounces having been passed in the last 24 hours ; contains small amount of albumen. Temp., 98° ; pulse, 68.
From this time she continued rather fretful and complaining until 5:30 p.m., when she was raised by the nurse upon the bedpan, as she desired to have her bowels moved. She had been then sitting up but a few moments when she gave a long sigh, saying “ Oh dear !” and, falling back, expired instantly.
At the autopsy, the following conditions were found :—The larynx and trachea were entirely free from any exudation. The heart was moderately contracted. Its valves were healthy. The muscular substance appeared of good colour, not pale or streaky-looking, but under the microscope is seen to be in a state of advanced fatty degeneration. The right auricle contained a large white, pretty firm clot, which nearly filled its entire chamber and extended into the corresponding ventricle. It did not pass into the pulmonary artery. Part of this, at
any rate (if not the whole), was certainly formed before death. The kidneys were moderately congested.
Remarks by Dr. Ross.-Sudden death in severe cases of diphtheria is not altogether unexpected. It also occasionally occurs during the course of a diphtheritic paralysis. But it is not often that sudden death supervenes whilst the disease itself, never having been of a severe type, seems to have given way, and convalescence be about to begin. The foregoing case, however, well illustrates its possible occurrence.
In all these cases, paralysis of the heart, through the pneumogastric, no doubt plays the most important part ; but, doubtless, fatty degeneration of the heart muscle is a very common, if not constant, forerunner of the paralytic event. On this point Oertel says: “When the disease lasts long and is very intense, and especially in cases in which death is caused suddenly by paralysis of the heart, the muscle appears soft, pale, friable, broken by extravasations of blood, and on microscopical examination most
of its fibres are found in an advanced stage of fatty degeneration.” Now, in this case, we found at the autopsy the advanced fatty degeneration—indeed, hardly a singular muscular fibre could be found which was not largely converted into oil globules. But it differs from most others in the following respects :-Our patient died on the thirteenth day of the disease, and therefore it could not be said to have lasted long. The attack had not been intense, although it had been moderately severe. There was no decided paralysis, although we had observed a somewhat paretic condition of the velum palati. So that, although fully aware of the occurrence of sudden death and fatty heart under the condition of an intense and prolonged attack, especially if septic symptoms have been marked, or in the debilitated systemic condition indicated by the existence of some kind of paralytic affection, yet I was not prepared to meet with instantaneous death in this little girl under the apparently favorable circumstances which I 'bave related. We learn from the observations of this case that fatty heart may exceptionally be fully developed even after a short duration only of moderately severe diphtheria--that it will betray its presence by no symptoms, and may thus assist in causing death just when convalescence seems about to begin. . I say “ assist in causing,” because I do not think the fatal event is to be entirely attributed to the muscular degeneration. Tne record of the autopsy shows that there was found in the right chambers of the heart a large white fibrinous clot. Now, we should not have expected to find any such thing in the heart of a person dying from sudden cessation of the heart's action. Dr. Robinson Beverly, writing in the Lancet, 2nd November, 1872, has pointed out that the formatlon of heart clots (cardiac thrombosis) is to be recognized as a possible source of great danger in a certain number of cases of diphtheria—even in those apparently progressing very favorably. “Death,” he says, “ may occur either suddenly (immediately after the formation of the coagulum) or after the lapse of a period of anxiety and anguish, more or less prolonged.” In this case death must have occurred immediately after the formation of the thrombosis.
Caseous Degeneration of a Lung with Rapid Softening.
Death after Hæmoptysis. Under the care of Dr. Ross.
Reported by Mr. W. SUTHERLAND. G. R., æt. 26, a negro, was admitted into the General Hospital, under Dr. Wilkins, on the 22nd of August, 1878, complaining of cough, weakness and feverishness.
The only account of tubercular disease in his family is the death of one sister at 26 from ordinary pulmonary consumption. His father and mother are both alive and well.
He has always been a strong and robust man until the commencement of the present year, since when he has not been feeling so strong and able to work as previously. He has also been subject to coughs, but denies having had any persistent cough until quite lately. About three weeks prior to admission he got a severe wetting, and since that time has been feeling very ill. He soon began to cough, suffered from pains in his sides, felt feverish, and lost appetite and strength. No positive symptoms indicative of an attack of acute pneumonia of ordinary type can be found. He did not lay up, but attended as an outpatient for two weeks before coming into the wards.
During the month of September he had a persistently high temperature in spite of the administration of quinine ; coughed a great deal, with copious heavy perspiration ; rapidly lost flesh and strength.
On the 1st of October he was transferred to the care of Dr. Ross, and the following notes were then made of the physical signs :
Soft parts of chest much emaciated and clavicles prominent, especially the left. Expansion very deficient on the left side. Dullness over the whole of the left lung; the note is very
hard and toneless behind, particularly at the lower part, and the sense of resistance is very great—in front it has also a somewhat tubular character. A good percussion sound upon the right side. On auscultation, in front of left side, amphoric breathing, gurgling, and pectoriloquy-behind, a weak, faintlyblowing breath sound and moist râles. On the right side rough breathing, with bubbling râles, is found beneath the clavicle ; elsewhere, vesicular murmur is unaltered. Vocal fremitus much increased on left side.
These physical signs persisted till the end without special change, except the development of a very distinct cracked pot percussion sound beneath the left clavicle.
The temperature chart shows continuous fluctuations of body heat, fluctuating between 100° F. and 104° F. There was a daily expectoration of sometimes as much as a pint of heavy purulent and nummular sputa. The pulse continued very rapid, and progressively smaller and weaker. Emaciation and prostration quickly advanced. Ultimately, on the 19th October, he was taken with hæmoptysis and died on the following morning, without, however, having spat any very large quantity of blood.
Autopsy.—Left Lung-Pleura thickened ; covered also in places with flakes of recent lymph. Entire apex occupied by a large cavity, which contains clots and dirty reddish-yellow pus ; numerous trabeculæ cross it. The lower and outer portion is in a condition of rough, shaggy-looking ulceration. No small aneurisms are seen. The rest of the lung is firm, solid, and, with the exception of a small margin at the lower part-airless. On section, the tissue presents a uniform opaque white colour, looking as if the whole organ were in state of caseous degeneration. The section is perfectly dry, and here and there a few gelatinous-looking strands of tissue are seen. Right LungFull in volume ; crepitant, except part at the apex and posterior part of the middle lobes. Apex contains a small irregular cavity surmounted by infiltrated gelatinous-looking tissue. Lower lobe crepitant, contains a few caseous masses, and here and there are firm nodular bodies like miliary tubercles. The bronchi contain small clots of blood. Bronchial Glands.-Enlarged, tumid, moderately pigmented, not caseous, and contain no tubercles.
No tubercular disease existed elsewhere, and the other organs presented nothing worthy of note.