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ON A CASE OF ULCERATION INTO THE TRACHEA AND INNOMINATE ARTERY.
The patient in this case was a fine and previously healthy little boy, aged one year and eleven months. I saw him first on Friday, the 25th of November, 1859; and learned from his mother that he had been ill for five or six days; that on the previous Saturday she noticed the eruption of chicken-pox, and on the following Monday he was observed to cough; but as the
matting together the trachea,
close to the bifurcation, with the arch of the aorta and the commencement of the large vessels given off from the arch. The portion of the diseased mass lying immediately in front of the trachea had softened and ulcerated backwards into the trachea, forming a vacuum in four rings of about the breadth of a penny token; and the same process, extending directly forwards and impinging upon the innominate artery, to which the diseased mass was firmly adherent, had perforated the innominate at the point at which it is given off from the aorta. The ulcerated surface between the trachea and innominate artery had a ragged edge, and was coated with. dark, grumous, slimy mucus. There was no appearance of’ aneurism. The vessels were dissected out, and found perfect, except at the point of ulceration. From appearances, the ulceration into the trachea had existed some time, whilst there was but a slight breach of surface of the artery. Possibly the fatal issue had been hurried on by rupture of the weakened, vessel from the effort of coughing.
and the child did not appear to be ill, he about as usual until the evening, when he pain in his leg just below the knee. He was now very feverish, and the part was hot and swollen. A practitioner, who, I am informed, is without any qualification, now visited him, and prescribed a cold lotion and some powders, at the same time sapiently observing, and with, I have no doubt, unwonted candour and truthfulness, that "the leg quite puzzled him." This individual continued to attend the case, notwithstanding that the little patient grew worse every day, and the leg became more and more " puzzling." No thoracic disease appears to have been either sought for or London Hospital, January, 1860. .treated; and when I first saw the child, about noon on the day above mentioned, he was dying, and beyond the possibility of recovery. He was lying on his back in his mother’s lap; his countenance was pale, pupils largely dilated, and surface THE HEART. OF RUPTURE cold; there was no pulse at the wrist, and the respiration was there was over the increased very laboured; praecordial region BY WM. T. HAMILTON, ESQ., M.R.C.S. dullness; the normal sounds of the heart were scarcely audible, but friction sound, although faint, was distinctly heard. Appropriate treatment was ordered, and after a lapse of four CASES of rupture of the heart being so exceedingly rare, and hours I again visited the child, and he died during my stay. the following so well exemplifying what might be expected to Post-mortem examination. -On opening the thorax, the pericardium was found to be very vascular, and much distended occur when that rupture is small, I feel desirous of communiby fluid; the sac was nearly full of yellow flaky serum, and its cating it to the profession, as I consider it one of great in. serous lining, throughout its entire extent, was coated with terest :rough, villous-looking lymph; on the pleura also, on both W. B-,aged sixty-three years; a shoemaker by trade;;: sides of the thorax where it covers the upper portion of the of moderate size and development, and temperate habits; had diaphragm, there were patches of coagulable lymph. always enjoyed good health to within the last two or three Taviton-street, Gordon-square, Jan. 1860. days, when he had complained of slight uneasiness or oppression at his chest, coldness of the extremities, and shiverings ON A CASE OF Having been employed to carry two small parcels, not weighing ULCERATION INTO THE TRACHEA AND more than seven pounds, to the house of his employer, he had not proceeded many hundred yards when he was observed to INNOMINATE ARTERY. fall down in the road in an unconscious state. He was speedily DEATH FROM HÆMORRHAGE. raised by a passer-by, to whom he expressed his wonder at what had occurred, walked over with a staggering gait to the BY J. S. CUMMING, ESQ. side of the road without any assistance, and then laid down. Happening to be passing at the time, the man presented all A LABOURING man, named Edward F-,aged forty-one, the appearances of being in a deep fainting condition, which it is unnecessary for me to describe; and in that state he con living at Poplar, whilst walking along the road by Limehouse tinued for a few minutes, his death being preceded by a slight Church, with his son, on Saturday, January 7th, was suddenly convulsion. Such is the brief history of the case. seized with profuse arterial hæmorrhage, which, according to Having received an order from the coroner to make a postaccounts, flowed in a stream from his mouth. He died almost mortem examination, to ascertain the cause of death, I proto do so. My attention being naturally directed to the immediately, in the surgery of Mr. Brunton, into which he ceeded heart and thorax, I examined them first. I found the external As the incident created consiwas carried by the passers-by. well covered with fat. On reflecting the sternum, integuments derable sensation in the neighbourhood, a careful autopsy was and to view the viscera of the chest, I was much bringing undertaken by Mr. Brunton and myself, at Limehouse. There struck with the great size and distension of the pericardium was no history of disease forthcoming, as the man had not which had something like the feeling of a distended bladder. been under medical attendance: it was simply stated by his A slight incision into it soon revealed the true nature of the being thrown up, followed by a more wife that he had complained of feeling ill; had been getting case: a jet of liquid blood and flow of the same, finally a tolerably thick layer of gentle thin; had thrown up some blood a year before; and the pre- coagulum, covering nearly the whole heart, made me feel sure vious night he had been troubled with harassing cough. that there had been a rupture of some portion of the heart. The body was well-nourished; no external appearance to be This, on removing that organ carefully, was discovered to exist noticed, other than the mouth being filled with clots of blood. on the left ventricle, near its apex, in the shape of a small On opening the chest, the lungs presented a remarkably fine opening, capable of admitting the insertion of a small blowand healthy appearance. There was no fluid in the pericar- pipe, appearing like a mere separation of the muscular fibres, a dium. ’1 he heart was empty. On removing the lungs, they slight patch of ecchymosis alone marking the spot where the fissure or rent existed. I feel unable to account for this state, were unexpectedly found perfectly free from tubercle or cavity; the apices were perfect. The heart was removed, as usual, by as the walls of the ventricle appeared otherwise quite healthy, cutting across the large vessels. On examining the stomach, retaining their natural colour, thickness, and strength. There it was found to contain about eight ounces of blood mixed with seemed no ramollissement or fatty degeneration, but a coating food, the blood apparently having been swallowed, as the walls of fat on the surface of the heart in various parts. This otherof the stomach were healthy, with no sign of ulceration. The wise appeared sound, and free from disease of the valves. I liver and other abdominal viscera were healthy, but pale. Up may remark, however, that the aorta, near its junction with to this period in the examination nothing had been found to the heart, gave a peculiar gritty feeling to the finger, as if account for the death; but on proceeding to dissect the air- there was a deposit of ossific matter going on there. The chief point for observation, and that which seems to me passages in sit12, an enlargement was felt at the junction of the neck and thorax; the arch of the aorta, the trachea, and the to invest this case with peculiar interest, consists in the unsurrounding structures, were apparently matted together. The usual length of time that the patient existed after so formidable whole mass with the larynx and oesophagus were carefully reo an occurrence to so important an organ; for I think we may moved for closer examination. It was now discovered that a safely infer it was contemporaneously with thefall in the road firm scirrhous mass, apparently of the cervical glands, was that the lesion occurred. The few cases on record of ruptured
eruption was slight, allowed to complained of was
run
88
matting together the trachea,
close to the bifurcation, with the arch of the aorta and the commencement of the large vessels given off from the arch. The portion of the diseased mass lying immediately in front of the trachea had softened and ulcerated backwards into the trachea, forming a vacuum in four rings of about the breadth of a penny token; and the same process, extending directly forwards and impinging upon the innominate artery, to which the diseased mass was firmly adherent, had perforated the innominate at the point at which it is given off from the aorta. The ulcerated surface between the trachea and innominate artery had a ragged edge, and was coated with. dark, grumous, slimy mucus. There was no appearance of’ aneurism. The vessels were dissected out, and found perfect, except at the point of ulceration. From appearances, the ulceration into the trachea had existed some time, whilst there was but a slight breach of surface of the artery. Possibly the fatal issue had been hurried on by rupture of the weakened, vessel from the effort of coughing.
and the child did not appear to be ill, he about as usual until the evening, when he pain in his leg just below the knee. He was now very feverish, and the part was hot and swollen. A practitioner, who, I am informed, is without any qualification, now visited him, and prescribed a cold lotion and some powders, at the same time sapiently observing, and with, I have no doubt, unwonted candour and truthfulness, that "the leg quite puzzled him." This individual continued to attend the case, notwithstanding that the little patient grew worse every day, and the leg became more and more " puzzling." No thoracic disease appears to have been either sought for or London Hospital, January, 1860. .treated; and when I first saw the child, about noon on the day above mentioned, he was dying, and beyond the possibility of recovery. He was lying on his back in his mother’s lap; his countenance was pale, pupils largely dilated, and surface THE HEART. OF RUPTURE cold; there was no pulse at the wrist, and the respiration was there was over the increased very laboured; praecordial region BY WM. T. HAMILTON, ESQ., M.R.C.S. dullness; the normal sounds of the heart were scarcely audible, but friction sound, although faint, was distinctly heard. Appropriate treatment was ordered, and after a lapse of four CASES of rupture of the heart being so exceedingly rare, and hours I again visited the child, and he died during my stay. the following so well exemplifying what might be expected to Post-mortem examination. -On opening the thorax, the pericardium was found to be very vascular, and much distended occur when that rupture is small, I feel desirous of communiby fluid; the sac was nearly full of yellow flaky serum, and its cating it to the profession, as I consider it one of great in. serous lining, throughout its entire extent, was coated with terest :rough, villous-looking lymph; on the pleura also, on both W. B-,aged sixty-three years; a shoemaker by trade;;: sides of the thorax where it covers the upper portion of the of moderate size and development, and temperate habits; had diaphragm, there were patches of coagulable lymph. always enjoyed good health to within the last two or three Taviton-street, Gordon-square, Jan. 1860. days, when he had complained of slight uneasiness or oppression at his chest, coldness of the extremities, and shiverings ON A CASE OF Having been employed to carry two small parcels, not weighing ULCERATION INTO THE TRACHEA AND more than seven pounds, to the house of his employer, he had not proceeded many hundred yards when he was observed to INNOMINATE ARTERY. fall down in the road in an unconscious state. He was speedily DEATH FROM HÆMORRHAGE. raised by a passer-by, to whom he expressed his wonder at what had occurred, walked over with a staggering gait to the BY J. S. CUMMING, ESQ. side of the road without any assistance, and then laid down. Happening to be passing at the time, the man presented all A LABOURING man, named Edward F-,aged forty-one, the appearances of being in a deep fainting condition, which it is unnecessary for me to describe; and in that state he con living at Poplar, whilst walking along the road by Limehouse tinued for a few minutes, his death being preceded by a slight Church, with his son, on Saturday, January 7th, was suddenly convulsion. Such is the brief history of the case. seized with profuse arterial hæmorrhage, which, according to Having received an order from the coroner to make a postaccounts, flowed in a stream from his mouth. He died almost mortem examination, to ascertain the cause of death, I proto do so. My attention being naturally directed to the immediately, in the surgery of Mr. Brunton, into which he ceeded heart and thorax, I examined them first. I found the external As the incident created consiwas carried by the passers-by. well covered with fat. On reflecting the sternum, integuments derable sensation in the neighbourhood, a careful autopsy was and to view the viscera of the chest, I was much bringing undertaken by Mr. Brunton and myself, at Limehouse. There struck with the great size and distension of the pericardium was no history of disease forthcoming, as the man had not which had something like the feeling of a distended bladder. been under medical attendance: it was simply stated by his A slight incision into it soon revealed the true nature of the being thrown up, followed by a more wife that he had complained of feeling ill; had been getting case: a jet of liquid blood and flow of the same, finally a tolerably thick layer of gentle thin; had thrown up some blood a year before; and the pre- coagulum, covering nearly the whole heart, made me feel sure vious night he had been troubled with harassing cough. that there had been a rupture of some portion of the heart. The body was well-nourished; no external appearance to be This, on removing that organ carefully, was discovered to exist noticed, other than the mouth being filled with clots of blood. on the left ventricle, near its apex, in the shape of a small On opening the chest, the lungs presented a remarkably fine opening, capable of admitting the insertion of a small blowand healthy appearance. There was no fluid in the pericar- pipe, appearing like a mere separation of the muscular fibres, a dium. ’1 he heart was empty. On removing the lungs, they slight patch of ecchymosis alone marking the spot where the fissure or rent existed. I feel unable to account for this state, were unexpectedly found perfectly free from tubercle or cavity; the apices were perfect. The heart was removed, as usual, by as the walls of the ventricle appeared otherwise quite healthy, cutting across the large vessels. On examining the stomach, retaining their natural colour, thickness, and strength. There it was found to contain about eight ounces of blood mixed with seemed no ramollissement or fatty degeneration, but a coating food, the blood apparently having been swallowed, as the walls of fat on the surface of the heart in various parts. This otherof the stomach were healthy, with no sign of ulceration. The wise appeared sound, and free from disease of the valves. I liver and other abdominal viscera were healthy, but pale. Up may remark, however, that the aorta, near its junction with to this period in the examination nothing had been found to the heart, gave a peculiar gritty feeling to the finger, as if account for the death; but on proceeding to dissect the air- there was a deposit of ossific matter going on there. The chief point for observation, and that which seems to me passages in sit12, an enlargement was felt at the junction of the neck and thorax; the arch of the aorta, the trachea, and the to invest this case with peculiar interest, consists in the unsurrounding structures, were apparently matted together. The usual length of time that the patient existed after so formidable whole mass with the larynx and oesophagus were carefully reo an occurrence to so important an organ; for I think we may moved for closer examination. It was now discovered that a safely infer it was contemporaneously with thefall in the road firm scirrhous mass, apparently of the cervical glands, was that the lesion occurred. The few cases on record of ruptured
eruption was slight, allowed to complained of was
run
88