AN EMBRYOLOGICAL CURIOSITY.

636 and reacted to light but not perfectly during accommodation. Although he could see and recognise those about him he could only read with great difficulty. The knee-jerk wasabsent. His mind was perfectly clear and he was able to dictate a good business letter. There was no headache or other pain. Tactile sensation was perfect everywhere. The’ temperature was normal and the pulse was full and strongbut not accelerated. On the afternoon of the same day I’ found the general loss of power slightly increased, formication of the arms and legs persisted, and the temperature was; still normal. He passed a good night, but when I saw him early on the morning of the 9th (the second day of illness the symptoms were much intensified. He had now to be assisted to move in the bed. His tongue was slightly furred’ His sight was’ and the temperature had risen to 100’F. worse and the pupils no longer reacted to light. There was The brain now also a distinct difficulty in articulation. In the afternoon Dr. James remained perfectly clear. Taylor kindly saw the case with me. By this time it was apparent that the motor paralysis would soon becomeabsolute. The breathing was shallow and bulbar symptoms There was no nystagmus or were much more marked. tremor. The third nerve was involved, as shown by ptosis: and by paralysis of accommodation and of all the ocular There was also muscles. The optic discs were normal. paralysis of the soft palate with difficulty in swallowing. The Dr. James Taylor drew was still 100°. attention to the similarity of the condition to that caused bycurari poisoning and agreed that the condition was almost: hopeless. On the 10th (the third day of illness) the motor paralysis became absolute with the exception that the patient" could still move the head slightly from side to side. Any attempt to swallow set up spasms in the facial muscles ; the respiration gradually failed and he died at 4.30 P.M. There The nurse told me that the heart. were no bedsores. continued to beat long after respiration had ceased, but she did not notice whether abdominal or thoracic respiratory movements ceased first. The rectum and bladder were’ unaffected throughout and the urine was free from albumin: and sugar. The case was, no doubt, one of acute motor paralysis and* it is probable that the whole of the grey matter of the spina? cord was affected. The bulb and the course of the third’ nerve were also involved. The slight rise of temperature which occurred in this case is, I believe, not usually observed, but the absence of anaesthesia, bedsores, and’ paralysis of the rectum and bladder sufficiently differentiates: the disease from myelitis. The extremely rapid course of’ Newcastle-on-Tyne. the disease and the absence of any symptoms of gross change’ in the grey matter point to some virulent poisoning of thelatter structure and the analogy to curari poisoning lends LANDRY’S PARALYSIS. colour to the theory of some toxic agency. There was little: BY ARTHUR S. TAYLOR, M.D. CANTAB., F.R.C.S.ENG. time to adopt any treatment. At the outset iodide of potassium was given, and on the second day grain of CASES of acute motor paralysis rapidly proving fatal are so strychnine was injected hypodermically every three hours. this may explain the strong and persistent action of rare, especially in this country, that the following remark- Possibly the heart. The patient was fed by nutrient enemata. able case is of the greatest interest. I have classed it as Surbiton Hill. a case of Landry’s paralysis as it appears to me that the symptoms followed more closely the lines of that disease than those of any other lesion of the nervous system with AN EMBRYOLOGICAL CURIOSITY. which we are acquainted. The paralysis, however, was not as in the of and the course By J. ROSS MACMAHON, M.B., C.M. ABERD. cases, "ascending" majority of the disease was even more acute than in any I have seen diminished and when the patient was able to leave the at the end of August, it had quite ceased and the wound was healed. The patient has been seen lately and continues in all respects well. The foregoing cases are grouped together as examples of the method of re-establishing continuity of the bowels by lateral anastomosis. Case 1 exhibits the only instance in which any kind of clamp or support was made use of in effecting the junction, and in this case the cohesion effected by the pressure of the plates was not considered sufficient without the additional safeguards of a row of Lembert stitches and a wrap of omentum. When these additional measures are taken the saving of time effected by any form of button or clamp is seriously reduced. As a set off to the saving of time all such mechanical devices have the drawback that they restrict within very moderate limits the communication established between the two segments of intestine. It seems to be a matter of great importance, not only for the immediate relief of the symptoms but still more for the continuance of this relief, that the communicating opening should be exceedingly free ; and this can only be secured when the junction is made by The plan followed in the other four sutures alone. The two portions of bowel to be united cases was the same. were placed side by side and where the sides lay in apposition they were joined by a series of Lembert sutures for a length of rather more than 3 in. Then an incision was made into each segment of bowel in that part of the wall opposite the mesenteric attachment and just falling short of the ends of the row of stitches. By an overcast suture through all layers the two openings were next united. This suture began in the margins which were contiguous and as it passed round it was carried through the margin of one opening and then through the corresponding point of the margin of the other, so that when the suture was tightened these were drawn together. In this way one end, then the corresponding outer margins of the twoincisions, then the other end back to the point whence the suture started were united, and the openings in the two portions of bowel were converted into one large aperture of communication. To avoid puckering and narrowing of the opening the suture was tied off after each three or four stitches. Lastly, the cincture of Lembert stitches which was begun before opening the intestines was completed. Carried out in this way the suturing can be rapidly done, and as the anastomosis can be made as free as desired there need be no risk of future contraction.

hospital,

described. The patient was a man, aged forty-two years, who had been married twelve months. He had always enjoyed exceptionally good health and his life would have been accepted About as a first-class one by any life assurance company. six years ago he had a bad accident, being run over by an omnibus, but from this he completely recovered with the exception that he had a partially stiff left elbow-joint. He had been a good deal worried recently by domestic illness, but the cause had been removed and apparently he was not affected by it in any way. On August 7th, 1898, he went to bed in his usual perfect health. At seven o’clock the next morning he awoke to find his right arm tingling and numb. The left arm was affected similarly but to a less degree. He thought he had been "sleeping on his arm." When given a cup of tea he dropped it and on getting out of bed found that he had not the full power in his legs. There was a good strong grip with either hand. He could walk round the bed but was evidently afraid of falling. His pupils were equalI

all

temperature

THE case described in the following paper embodies St. number of points of great embryological interest. An alternative heading might have been, "Absence of Abdominal Wall, Bladder, and Anus, with a Semi-cloacal Condition and Bilateral External Genitalia, &c." The child, an eight-month one, was the sixth offspring of the mother and was not born alive. Throughout her pregnancy the mother exhibited relatively little abdominal protrusion and she averred that she was ignorant of her condition until about one month before her delivery. By, abdominal examination the child’s parts could easily be felt. Examination per t’yz’/M’ revealed the fact that the sacral region was the presenting part; in other respects matters were consistent with a normal condition. The labour only lasted three or four hours, very little liquor amnii escaped, and the ovum was delivered in toto. This circumstance was owing to the fact that the umbilical cord was represented by

687 condition which obtains about the beginning of the second really suggestive of a precursory duplex bladder and would .month of pregnancy. At this period the embryonic somato- seem to imply a bifid allantois. Into each area a ureter pleure (the part about to be folded in to form the body wall) could be traced, so far as could be made out, ending blindly a

is continued on beyond the embryo as the amnion (the
’The abdominal wall was deficient in a kite-shaped area the tail of which was situated at a point corresponding to the ensiform cartilage, and the sides of which ,gradually diverged to the -,videst point rather on the outside of the middle of either Poupart’s ligament, from which the dome-shaped head, passing beneath a point corre-

the right side (that of the hydronephrosis), but having a minute opening on the left side. The lower margin of the spaces formed most of the dome of the kite-shaped deficiency of the abdominal wall; below this skin formation commenced and passed along to the perineum. Situated at this point on either side and about an inch apart was a well-formed though diminutive penis. Each penis presented a glans, a prepuce and a closed meatus urinarius, and below them the skin was sacculate and thrown into loose folds so as to form a scrotum. The testes had not descended and were lying high up, where they were formed from the genital ridge. The duplex quasi-bladder corresponded well with the formation of two penes, but there was no communication between the penes and the bladders. On the under or dorsal side of each penis a distinct but comparatively faint raphé was observable, indicating the presence of two uro-genital sinuses at an earlier period. Before passing to perhaps the most interesting abnormality which was manifested in this case it may be opportune to observe that in normal pregnancies the cloaca in the human embryo exists up to the fourteenth week. Into it open the two Wolffian ducts, the two fused Miillerian ducts, the allantois, and the intestine. A vertical division of the cloaca from side to side, growing up from below in the form of an epithelial plate, divides it into an anterior or uro-genital opening and a posterior or anal opening. This involves the complete separation of the uro-genital system from the intestinal canal. The Wolffian ducts form the kidneys and ureters in both sexes, and the spermiduct, seminal vesicles, &c., in the male, and the connexion with the gut then vanishes. The Miillerian ducts fuse before entering the cloaca per the neck of the allantois. In the female they form the uterus, the vagina, the Fallopian tubes, &c. ; but in the male a remnant is retained in the uterus masculinus. In on

sponding to the absent pubic arch, completed the area. The boundary of this space represented the point where skin iformation ceased; beyond this the somatopleure, or body wall, passed on as in an early stage to become amnion. ’Through this gap the abdominal viscera protruded, the right kidney being rendered particularly prominent by a well-marked hydronephrosis as large as a duck’s The bladder was deficient, the left kidney occupy- egg. ing the site. It was indicated, however, by a very - curious state of things, which is all the more interesting when compared with extroversion of the bladder of congenital origin and the condition of the genitals usually Gconcomitant with that event. Bordering the middle line on the present case the anus was represented by a slight dimpling at the normal site, but no perforation had occurred and the gut ended in the middle line between the two bladder

areas.

The termination

was

abrupt

just in front of the skin of the perineum and it was quite patent. About 1 in. above the end of the gut, and communicating with it posteriorly, lay numerous coils of tube of varying circumference. These occupied a site behind the gut, and on a close inspection it could be seen that the mass really consisted of three and

was

situated

distinct and blind tubes all conductihg to the rectum. On the rectum with scissors the three openings could be The tubes were seen and a quill could be passed into each. arranged one on each side of a larger and central one. The two lateral tubes were of equal lumen and length and were placed symmetrically. The central one was much longer and of much greater circumference and it gradually tapered off at its blind end. A semi-cloacal condition of things was thus revealed. The central blind duct was doubtless the fused Miillerian ducts (the uterus, Fallopian tube, &c., in the female) which had remained instead of undergoing resorption and disappearing. The two lateral tubes were the remnants of the two Wolfflan ducts which had also failed to disappear. Some distance up the large intestine was a narrow strip of cicatricial-like tissue 2 in. long; it was flat and smooth and felt like a piece of parchment let into the long axis of the gut. This doubtless was the site of the closure of the yelk sac. Around this the bowel was gathered up in pleats and puckers which radiated outwards. Strangely enough there was absolutely no sign of an appendix vermiformis, but some inches above the closure of the yelk sac, and corresponding exactly to the site at which the appendix should come off, was an exact facsimile, in miniature, of the condition described at the closure of the yelk sac. The parchment-like longitudinal plateau, the puckering of the gut, &c., were all

slitting

A,

Talipes valgus. R, Umhilical vessels, c, Scrotum. D, Penis. E, Anal dimple. F, Ureter of left kidney. G, Penis. H, Scrotum. I, Pes varus. J, Hight kidney. x, Hydronephrosis. L, End of gut with quill passed through.

’either side an ill-defined leaf-shaped space was visible on the lower end of the body wall, and here, in contrast to the surrounding somatopleure, two layers could be felt and rolled over each other. The two areas were quite independent and their walls could be separated and dissected up to the middle line, where they fused. This condition is

represented. In reviewing the case I would suggest that the cause of the limb and spinal deformity was the dearth of liquor amnii. Pressure would be a consequence of this deficiency, and the position and deformities of the child were consistent with this theory. The idea might be carried further, and it would be reasonable to suppose that the scantiness of the liquor amnii, combined with the resulting position of the legs of the fcetus, exerted a combative influence against the normal evolution of the other parts. -

Kensington,

W.