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CASE OF DISEASE OF THE AORTA, AND HYPERTROPHY OF THE LEFT VENTRICLE OF THE HEART.
172 the under surface of the neck of the bladder, and by the large basis on which it is supported. The enlargement of the prostate may be either interstitialthat is to say, simple hypertrophy of the tissues-or it may depend on chronic inflammation of the organ. This latter form, I believe, is the one which usually presents itself in calculous patients, and hence two of the effects of inflammation-viz. suppuration and ulceration-are occasionally observed in the stone in the bladder. Abscess of the prostate is not very uncommon; it may occupy the substance of the gland, or commence in the excreting ducts. The external cellular membrane may also, in some cases, be the seat of the purulent collection. The symptoms are often obscure. The abscess itself may open into the urethra, the bladder, the rectum, or the perinseum. It is unnecessary to remind you, that any considerable tumefaction of the prostate must alter more or less the shape, direction, and calibre of the prostatic portion of the urethra, rendercatheterism difficult, and impede or render impossible the operation of lithotrity. These points, however, will be fully examined in my next lecture. That portion of an inflamed or tumefied prostate which projects backwards into the cavity of the bladder, is sometimes the seat of ulceration; but this very seldom takes place, except towards the termination of the disease. The sufferings of the patient from this complication are dreadful, and it exercises a most unfavourable influence on any operation to which we may
prostates of patients labouring under
have
the kidney, or the glandular structure has entirely disappeared, and the organ is reduced to a mere cyst. This wasting, however, generally arises either from the presence of a calculus in the kidney, or from the pressure of purulent matter confined in the pelvis. The body of the celebrated anatomist, Malpighi, presented an example of atrophy of the kidney. In addition to these lesions, which can be clearly traced to the influence of the vesical calculus, other morbid states have been met with in calculous subjects. Thus the kidney has been found reduced to a pulpy mass, resembling a spleen in its composition ; it is sometimes the seat of tumours of various kinds, and often contains hydatid cysts, occupying more or less of the substance of the organ. Such kinds of lesions may not perhaps depend essentially on the presence of stone in the bladder, for they are often found in the bodies of persons who never suffered from that complaint. As I have already observed to you, the symptoms of renal disease connected with or supervening on stone in the bladder are often of a very obscure kind, and apt to escape detection ; yet you must pay the closest attention to the condition of the kidneys in every patient whom you may have to treat for stone, whether by lithotomy or by lithotrity. The local signs of disease of the kidney are often extremely vague; the general symptoms may be readily referred to constitutional disorder from the calculous affection of the bladder, and not to the kidney itself; yet if you operate, the patient will almost certainly die, and the cause of the fatal result be attributable to the operator.
recourse.
Atrophy of the prostate gland has sometimes been found in calculous patients ; but it is impossible to connect this lesion with stone in the bladder as effect and cause. It is more probably CASE OF DISEASE OF THE AORTA, AND a coincidence depending on some other influence which escapes HYPERTROPHY OF THE LEFT VENTRICLE The prostatic portion of the urethra is widened our detection. OF THE HEART. in cases of this kind. The calculus often lies close on the neck WITH REMARKS. of the bladder; and if lithotrity be had recourse to, the fragments are very apt to become impacted in the vesical extremity of the BY JOHN TOPHAM, M.D. Lond.
urethra. The only pathological effects of vesical calculus which it remains for us to consider, are those produced on the ureters and kidneys. The ureters are seldom found in a completely healthy state when the bladder has been subject for any length of time to the irritation of a calculus; more or less dilatation of these tubes is the lesion ordinarily discovered, and its degree will depend on the obstacle offered to the free discharge of urine from the bladder, for I do not now include cases in which the ureters themselves may be the seat of calculi. I speak only of the effects of vesical calculus on these parts. The dilated ureter is often inflamed, though inflammation of the internal membrane may exist without any change in the calibre of the duct. The inflammatory action is usually propagated upwards from the bladder, which is itself in a state of subacute inflammation, and the latter often extends to the pelvis of the kidneys, and thence to the substance of these organs. For a more complete description of this complication, I would refer to a memoir on Pyelitis, which I published in the June number, this year, of the London Journal of Medicine. Inflammation of the mucous lining of the ureter or pelvis is almost always attended by a secretion of pus, which sometimes distends the pelvis to such a degree as to produce complete absorption of the substance of the kidney. The secreting urinary organs themselves often become implicated during the progress of calculous affections of the bladder, either directly by the upward extension of inflammation along the ureters, or by sympathy. These secondary diseases, gentle-
PHYSICIAN TO THE SOUTH STAFFORDSHIRE GENERAL
HOSPITAL,
WOLVERHAMPTON.
M. N-, thirty-one years of age, is employed as a labourer in the coal-mines, and from the nature of his occupation is continually exposed to mechanical injury, from the falling-in of portions of the roof of the subterranean galleries in which he works, and has from time to time received severe contusionf; about the thorax from this cause. He refers his present sensations to the consequences of a fall of coal upon his chest fifteen weeks previously to my first seeing him, as ever since that accident he has complained of difficulty of breathing, and has been sensible of a continual beating sensation in his chest, any act requiring great muscular exertion occasioning palpitation of the heart. During the last three weeks, violent cephalalgia and a slight cough have been added to the above symptoms. He is a married man, of temperate habits; has never had rheumatism; and the only severe illness he can recollect having undergone occurred three years ago, when he suffered from haemoptysis to a considerable extent, the blood expectorated being of a dark colour. Physical signs.-The thorax is well-formed generally but the there is an evident vaulting over the region occupied heart. A measurement of the chest made in the situation of the fifth and sixth ribs, demonstrates that the left exceeds the right side of the thorax in its dimensions by about three-fourths of an inch. (The patient is right-handed.) On the right side of the chest, in the region corresponding to the articulation of men, constitute a most important portion of our subject, for they the second and third ribs, there is a pulsation synchronous exercise more influence on the results of lithotrity than even with that of the heart; and a similar phenomenon is percepdirect lesions of the bladder itself; while, at the same time, they tible in front of the neck, between the sternal articulations of are of so obscure and. insidious a nature as to escape, in many the clavicles. There is dulness on percussion, extending from cases, the notice of experienced practitioners. In o!d cases of the left nipple downwards to the lower margin of the last true stone in the bladder, the kidneys are seldom found healthy; and rib, and laterally to the left margin of the sternum. Over all in other cases of shorter standing, they are very apt to become this space, the performance of the act of percussion occasions implicated by the disorder which already exists in the bladder. pain to the patient. The right side of the chest is naturally The lesions of the kidney thus connected with vesical calculus resonant, except over a portion of about an inch square, situated are numerous and of various degrees of intensity. The most over the sternal attachment of the second and third ribs. In ordinary are chronic degeneration or inflammation of the sub- this locality the fingers discover a pulsation coincident with stance of the organ. In the early stages the glandular structure that of the heart; the motion communicated is, however, becomes injected, more soft and vascular than is natural. As the double, the second impulse being longer in duration than the disease advances, we find the usual effects of inflammation; pus preceding one. A distinct frémissernent accompanies the is secreted at an early period, and often in a rapid manner; second of these pulsations. Upon placing the hand over thenumerous small abscesses are found under the peritonaeal coat, or cardiac region, a strong heaving impulse is felt. Auscultation disseminated throughout the substance of the kidney ; in rarer practised over the front of the thorax demonstrates tha cases, the pus is collected into one large abscess. respiratory sounds to be natural, save in the situations menThe kidney sometimes presents an appearance of hypertrophy. tioned as existing on either side; for in these places there is It is then uniformly enlarged, and is of firm consistence, but au absence of respiratory murmur. The first sound of the sometimes soft. In more rare cases we meet with atrophy of hearty unusually dull, and the second is accompanied bya
by
173 from its attachments, and thus two of its pouches were reduced to a single irregular one." When acting as house-surgeon to cular murmur observable in the back of the thorax, save a University College Hospital, London, an instance, occasioned slight bruit de 80ufftet to the left of the first dorsal vertebra. in a similar manner to the above, was shown to me by Mr. The murmur described as existing to the right of the sternum, Mercer, of Deal; and the precise nature of the disorder has is audible in both carotid arteries, and most so in that of the since been ascertained and described by my friend Dr.R.Quain, right side; it is also heard between the sterno-clavicular under whose care the man afterwards was placed. He lived articulations. for nearly two years (this was in 1843), and after his death, I had the patient admitted into the wards of the institutionI Dr. Quain had an opportunity of examining the organs conat which he had applied for relief (the Wolverhampton Dis- tained within the thorax, when it was found that " all the pensary) on the 26th of July, 1848; but he left at his own cavities of the heart were enlarged and filled with blood. The request at the expiration of three days. The diagnosis then arch of the aorta was somewhat dilated; the heart weighed made was aneurism of thoracic aorta, with hypertrophy of left twenty-two ounces. The chief disease was found at the ventricle. lIe came to see me at intervals until the 21st of entrance of the aorta; here it was noticed that the conjoined October, 1848, during which period there was little change attachments of two of the valves to the aorta had been observable in the physical signs, save that the inequality in separated from the wall of that vessel, and thus those valves the duration of the two cardiac sounds had to a great extent were allowed to drop below the level of the third, which redisappeared. He was enjoined to avoid all active pursuits as tained its connexions." When I saw the patient, the character far as possible, with all excesses in diet, and was ordered a of the lesion was plainly evident from the loud regurgitant mixture containing tincture of digitalis and sulphate of mag- aortic murmur which existed, and which was strongly audible, even along the course of the femoral arteries. This case, nesia. From October the 21st, 1848, until the time of his decease, with other similar ones, was submitted by Dr. Quain to the May 16th, 1851, he was entirely lost sight of, and the above Pathological Society of London, October 20th, 1846; and they history and observations are copied from notes made by me at are all recorded in the Itlont3cly Journal of 3fedical Science for December of that year. the time. The weight of the heart in the case now under consideration, .Pos< mor<6)M oppeafCtMCM.—An examination of the contents of the thorax was made on the night of the patient’s death. in place. of being eight ounces and a half, as is stated by Dr. The left ventricle of the heart was found to be greatly en- Clendinning to be the average in persons aged between thirty larged, the corresponding cavity on the opposite side remain- and fifty years, amounted to two pounds twelve ounces. It is ing of the natural dimensions. The wall of the dilated to be regretted that a microscopical examination of the ventricle was exactly one inch in thickness, measured near morbid deposit observed in the aorta was not made; but owing the septum ventriculornm; and the weight of the entire heart to some carelessness, the parts were mislaid before I had time amounted to two pounds twelve ounces. The division between to institute such an investigation. In respect to the physical signs observable during life, these two of the aortic sigmoid valves was destroyed, and the two fused, as it were, into one, so that an irregular, buttonhole- were such as to admit of no doubt as to the nature and seat looking orifice remained. Tite other valves of the heart were of the disease. The localization of these signs on the right of healthy. The aorta was greatly dilated from immediately the sternum, at the seat of articulation of the second and third above the situation of the semilunar valves to the giving off ribs, was sufficient to indicate that the ascending aorta was of the brachio-cephalic trunk. An inch above the aortic the part implicated. Besides the dulness on percussion and valves, on the posterior aspect of the vessel, there was an the impulse, the presence of two morbid sounds, neither of aneurismal pouch, about the size and shape of a chesnut. which existed prominently over the heart itself, (though there There was no rupture of any of the coats of the aorta, but its were most unequivocal signs of great disease of that organ,) inner surface was studded with cartilaginous-looking nodules. showed that the origin of these must be referred to something The pericardium was not adherent, but traces of former in- extraneous to the great organ of the circulation. The natural flammation of that membrane were shown by the presence of resonance on percussion of the right side of the thorax (save two white patches situated upon its visceral layer, upon the over the situation before indicated), went to prove that there left ventricle, the larger of these being two inches in length. was no tuberculization of the lung, since in that case the They were not raised above the surface of the heart. Each dulness would probably have extended up into the acromial of the lungs exhibited marks of extensive recent inflamma- angle, the- proper stethoscopic corner, as it is called by Dr. tion, the patient having succumbed to an attack of pneumonia C. J. B. Williams (" Library of Practical Medicine," vol. iii. after a short illness. p. 176). The necropsy demonstrated that there were no Remarks.-It must ever add to its interest upon our minds,, tubercles deposited in the lungs, and thus added another to when, after having lost sight of a case of disease for manyr the instances tending to show that pulmonary tuberculosis and months, or even for years, the subject of it is again unex- aneurism are not frequent concomitants. The haemoptysis pectedly presented to our observation, and the notes andt which had occurred three years previously, must be attributed remarks registered and made upon previous occasions are to some other cause than the disease now described; perhaps rendered capable of being compared, and the accuracy of the to that given by the patient-viz., unusual bodily toil, views then taken verified, as was enabled to be done in the3 occasioning rupture of some of the pulmonary tissues. instance under consideration. August, 1852. The complaint under which this patient laboured was probably referred to its true c <.use by the sufferer himself-that REMOVAL OF A CARIOUS OS CALCIS. of mechanical injury, coupled with a life passed in laborious exertion. A very parallel instance is thus related in the BY A. G. FIELD, M.R.C.S., L.S.A., graphic words of Dr. Latham:SURGEON TO THE ROYAL SEA-BATHING INFIRMARY. " A man passing through Spa-fields one night was unmercifully beaten and plundered; and thrown into a ditch, and left CASE.—Edward E-, aged seventeen, was admitted to the to die. Die, however, he did not, but lay there he knew not how long; for he was insensible. The next day he was found, Royal Sea-bathing Infirmary, with caries of the left os calcis. and taken home. He was disabled by the bruises he had re- There was an ulcer about an inch behind each malleolus as ceived, and by palpitation of the heart and dyspnoea, which he large as the top of the finger; through these a probe could be had never complained of before; and was never again able to passed directly on to so large an extent of diseased bone as return to his ordinary occupation. After some months he was to leave little doubt that the whole was affected; its removal admitted into St. Bartholomew’s Hospital, dropsical, and was therefore determined on. An abscess formed in the back bearing all the symptoms which denote hypertrophy and of the heel six days before the operation, but this was dilatation of the heart. He soon died, and his heart wasi opened immediately fluctuation could be detected, and the found of a size which was almost incredible. All its musculai. parts around it recovered sufficiently to form a flap. substance was enormously amplified, and all its cavities; Operation.-On the 26th of July, with the assistance of enormously dilated; its pericardium, and lining membrane , Messrs. Hoffman, Hunter, and Price, (consulting-surgeons to and valves free from disease." (" Lectures on Diseases oiF the Infirmary,) I proceeded with the operation in the followthe Heart,"vol. ii. p. 205.) ing manner :-The patient being placed well under the influIt has been proved, in various instances, that excessive ence of chloroform, the point of a scalpel was passed through muscular exertion is capable of occasioning immediate injur; the internal ulcer down to the bone, carried downwards and Thus in Dr. Latham’s forwards, across the sole, backwards and upwards to to the mechanism of the heart. admirable work, is a case communicated by Dr. Bence Jonef!, the ulcer described as situated behind the outer ankle; this n which one of the senta, of the aortic valves " was torn awa’I incision was behind the posterior tibial artery and nerve.
slight blowing murmur, so protracted, however, as to render this longer by one-half than the first sound. There is no vas-
.
.
.
prostates of patients labouring under
have
the kidney, or the glandular structure has entirely disappeared, and the organ is reduced to a mere cyst. This wasting, however, generally arises either from the presence of a calculus in the kidney, or from the pressure of purulent matter confined in the pelvis. The body of the celebrated anatomist, Malpighi, presented an example of atrophy of the kidney. In addition to these lesions, which can be clearly traced to the influence of the vesical calculus, other morbid states have been met with in calculous subjects. Thus the kidney has been found reduced to a pulpy mass, resembling a spleen in its composition ; it is sometimes the seat of tumours of various kinds, and often contains hydatid cysts, occupying more or less of the substance of the organ. Such kinds of lesions may not perhaps depend essentially on the presence of stone in the bladder, for they are often found in the bodies of persons who never suffered from that complaint. As I have already observed to you, the symptoms of renal disease connected with or supervening on stone in the bladder are often of a very obscure kind, and apt to escape detection ; yet you must pay the closest attention to the condition of the kidneys in every patient whom you may have to treat for stone, whether by lithotomy or by lithotrity. The local signs of disease of the kidney are often extremely vague; the general symptoms may be readily referred to constitutional disorder from the calculous affection of the bladder, and not to the kidney itself; yet if you operate, the patient will almost certainly die, and the cause of the fatal result be attributable to the operator.
recourse.
Atrophy of the prostate gland has sometimes been found in calculous patients ; but it is impossible to connect this lesion with stone in the bladder as effect and cause. It is more probably CASE OF DISEASE OF THE AORTA, AND a coincidence depending on some other influence which escapes HYPERTROPHY OF THE LEFT VENTRICLE The prostatic portion of the urethra is widened our detection. OF THE HEART. in cases of this kind. The calculus often lies close on the neck WITH REMARKS. of the bladder; and if lithotrity be had recourse to, the fragments are very apt to become impacted in the vesical extremity of the BY JOHN TOPHAM, M.D. Lond.
urethra. The only pathological effects of vesical calculus which it remains for us to consider, are those produced on the ureters and kidneys. The ureters are seldom found in a completely healthy state when the bladder has been subject for any length of time to the irritation of a calculus; more or less dilatation of these tubes is the lesion ordinarily discovered, and its degree will depend on the obstacle offered to the free discharge of urine from the bladder, for I do not now include cases in which the ureters themselves may be the seat of calculi. I speak only of the effects of vesical calculus on these parts. The dilated ureter is often inflamed, though inflammation of the internal membrane may exist without any change in the calibre of the duct. The inflammatory action is usually propagated upwards from the bladder, which is itself in a state of subacute inflammation, and the latter often extends to the pelvis of the kidneys, and thence to the substance of these organs. For a more complete description of this complication, I would refer to a memoir on Pyelitis, which I published in the June number, this year, of the London Journal of Medicine. Inflammation of the mucous lining of the ureter or pelvis is almost always attended by a secretion of pus, which sometimes distends the pelvis to such a degree as to produce complete absorption of the substance of the kidney. The secreting urinary organs themselves often become implicated during the progress of calculous affections of the bladder, either directly by the upward extension of inflammation along the ureters, or by sympathy. These secondary diseases, gentle-
PHYSICIAN TO THE SOUTH STAFFORDSHIRE GENERAL
HOSPITAL,
WOLVERHAMPTON.
M. N-, thirty-one years of age, is employed as a labourer in the coal-mines, and from the nature of his occupation is continually exposed to mechanical injury, from the falling-in of portions of the roof of the subterranean galleries in which he works, and has from time to time received severe contusionf; about the thorax from this cause. He refers his present sensations to the consequences of a fall of coal upon his chest fifteen weeks previously to my first seeing him, as ever since that accident he has complained of difficulty of breathing, and has been sensible of a continual beating sensation in his chest, any act requiring great muscular exertion occasioning palpitation of the heart. During the last three weeks, violent cephalalgia and a slight cough have been added to the above symptoms. He is a married man, of temperate habits; has never had rheumatism; and the only severe illness he can recollect having undergone occurred three years ago, when he suffered from haemoptysis to a considerable extent, the blood expectorated being of a dark colour. Physical signs.-The thorax is well-formed generally but the there is an evident vaulting over the region occupied heart. A measurement of the chest made in the situation of the fifth and sixth ribs, demonstrates that the left exceeds the right side of the thorax in its dimensions by about three-fourths of an inch. (The patient is right-handed.) On the right side of the chest, in the region corresponding to the articulation of men, constitute a most important portion of our subject, for they the second and third ribs, there is a pulsation synchronous exercise more influence on the results of lithotrity than even with that of the heart; and a similar phenomenon is percepdirect lesions of the bladder itself; while, at the same time, they tible in front of the neck, between the sternal articulations of are of so obscure and. insidious a nature as to escape, in many the clavicles. There is dulness on percussion, extending from cases, the notice of experienced practitioners. In o!d cases of the left nipple downwards to the lower margin of the last true stone in the bladder, the kidneys are seldom found healthy; and rib, and laterally to the left margin of the sternum. Over all in other cases of shorter standing, they are very apt to become this space, the performance of the act of percussion occasions implicated by the disorder which already exists in the bladder. pain to the patient. The right side of the chest is naturally The lesions of the kidney thus connected with vesical calculus resonant, except over a portion of about an inch square, situated are numerous and of various degrees of intensity. The most over the sternal attachment of the second and third ribs. In ordinary are chronic degeneration or inflammation of the sub- this locality the fingers discover a pulsation coincident with stance of the organ. In the early stages the glandular structure that of the heart; the motion communicated is, however, becomes injected, more soft and vascular than is natural. As the double, the second impulse being longer in duration than the disease advances, we find the usual effects of inflammation; pus preceding one. A distinct frémissernent accompanies the is secreted at an early period, and often in a rapid manner; second of these pulsations. Upon placing the hand over thenumerous small abscesses are found under the peritonaeal coat, or cardiac region, a strong heaving impulse is felt. Auscultation disseminated throughout the substance of the kidney ; in rarer practised over the front of the thorax demonstrates tha cases, the pus is collected into one large abscess. respiratory sounds to be natural, save in the situations menThe kidney sometimes presents an appearance of hypertrophy. tioned as existing on either side; for in these places there is It is then uniformly enlarged, and is of firm consistence, but au absence of respiratory murmur. The first sound of the sometimes soft. In more rare cases we meet with atrophy of hearty unusually dull, and the second is accompanied bya
by
173 from its attachments, and thus two of its pouches were reduced to a single irregular one." When acting as house-surgeon to cular murmur observable in the back of the thorax, save a University College Hospital, London, an instance, occasioned slight bruit de 80ufftet to the left of the first dorsal vertebra. in a similar manner to the above, was shown to me by Mr. The murmur described as existing to the right of the sternum, Mercer, of Deal; and the precise nature of the disorder has is audible in both carotid arteries, and most so in that of the since been ascertained and described by my friend Dr.R.Quain, right side; it is also heard between the sterno-clavicular under whose care the man afterwards was placed. He lived articulations. for nearly two years (this was in 1843), and after his death, I had the patient admitted into the wards of the institutionI Dr. Quain had an opportunity of examining the organs conat which he had applied for relief (the Wolverhampton Dis- tained within the thorax, when it was found that " all the pensary) on the 26th of July, 1848; but he left at his own cavities of the heart were enlarged and filled with blood. The request at the expiration of three days. The diagnosis then arch of the aorta was somewhat dilated; the heart weighed made was aneurism of thoracic aorta, with hypertrophy of left twenty-two ounces. The chief disease was found at the ventricle. lIe came to see me at intervals until the 21st of entrance of the aorta; here it was noticed that the conjoined October, 1848, during which period there was little change attachments of two of the valves to the aorta had been observable in the physical signs, save that the inequality in separated from the wall of that vessel, and thus those valves the duration of the two cardiac sounds had to a great extent were allowed to drop below the level of the third, which redisappeared. He was enjoined to avoid all active pursuits as tained its connexions." When I saw the patient, the character far as possible, with all excesses in diet, and was ordered a of the lesion was plainly evident from the loud regurgitant mixture containing tincture of digitalis and sulphate of mag- aortic murmur which existed, and which was strongly audible, even along the course of the femoral arteries. This case, nesia. From October the 21st, 1848, until the time of his decease, with other similar ones, was submitted by Dr. Quain to the May 16th, 1851, he was entirely lost sight of, and the above Pathological Society of London, October 20th, 1846; and they history and observations are copied from notes made by me at are all recorded in the Itlont3cly Journal of 3fedical Science for December of that year. the time. The weight of the heart in the case now under consideration, .Pos< mor<6)M oppeafCtMCM.—An examination of the contents of the thorax was made on the night of the patient’s death. in place. of being eight ounces and a half, as is stated by Dr. The left ventricle of the heart was found to be greatly en- Clendinning to be the average in persons aged between thirty larged, the corresponding cavity on the opposite side remain- and fifty years, amounted to two pounds twelve ounces. It is ing of the natural dimensions. The wall of the dilated to be regretted that a microscopical examination of the ventricle was exactly one inch in thickness, measured near morbid deposit observed in the aorta was not made; but owing the septum ventriculornm; and the weight of the entire heart to some carelessness, the parts were mislaid before I had time amounted to two pounds twelve ounces. The division between to institute such an investigation. In respect to the physical signs observable during life, these two of the aortic sigmoid valves was destroyed, and the two fused, as it were, into one, so that an irregular, buttonhole- were such as to admit of no doubt as to the nature and seat looking orifice remained. Tite other valves of the heart were of the disease. The localization of these signs on the right of healthy. The aorta was greatly dilated from immediately the sternum, at the seat of articulation of the second and third above the situation of the semilunar valves to the giving off ribs, was sufficient to indicate that the ascending aorta was of the brachio-cephalic trunk. An inch above the aortic the part implicated. Besides the dulness on percussion and valves, on the posterior aspect of the vessel, there was an the impulse, the presence of two morbid sounds, neither of aneurismal pouch, about the size and shape of a chesnut. which existed prominently over the heart itself, (though there There was no rupture of any of the coats of the aorta, but its were most unequivocal signs of great disease of that organ,) inner surface was studded with cartilaginous-looking nodules. showed that the origin of these must be referred to something The pericardium was not adherent, but traces of former in- extraneous to the great organ of the circulation. The natural flammation of that membrane were shown by the presence of resonance on percussion of the right side of the thorax (save two white patches situated upon its visceral layer, upon the over the situation before indicated), went to prove that there left ventricle, the larger of these being two inches in length. was no tuberculization of the lung, since in that case the They were not raised above the surface of the heart. Each dulness would probably have extended up into the acromial of the lungs exhibited marks of extensive recent inflamma- angle, the- proper stethoscopic corner, as it is called by Dr. tion, the patient having succumbed to an attack of pneumonia C. J. B. Williams (" Library of Practical Medicine," vol. iii. after a short illness. p. 176). The necropsy demonstrated that there were no Remarks.-It must ever add to its interest upon our minds,, tubercles deposited in the lungs, and thus added another to when, after having lost sight of a case of disease for manyr the instances tending to show that pulmonary tuberculosis and months, or even for years, the subject of it is again unex- aneurism are not frequent concomitants. The haemoptysis pectedly presented to our observation, and the notes andt which had occurred three years previously, must be attributed remarks registered and made upon previous occasions are to some other cause than the disease now described; perhaps rendered capable of being compared, and the accuracy of the to that given by the patient-viz., unusual bodily toil, views then taken verified, as was enabled to be done in the3 occasioning rupture of some of the pulmonary tissues. instance under consideration. August, 1852. The complaint under which this patient laboured was probably referred to its true c <.use by the sufferer himself-that REMOVAL OF A CARIOUS OS CALCIS. of mechanical injury, coupled with a life passed in laborious exertion. A very parallel instance is thus related in the BY A. G. FIELD, M.R.C.S., L.S.A., graphic words of Dr. Latham:SURGEON TO THE ROYAL SEA-BATHING INFIRMARY. " A man passing through Spa-fields one night was unmercifully beaten and plundered; and thrown into a ditch, and left CASE.—Edward E-, aged seventeen, was admitted to the to die. Die, however, he did not, but lay there he knew not how long; for he was insensible. The next day he was found, Royal Sea-bathing Infirmary, with caries of the left os calcis. and taken home. He was disabled by the bruises he had re- There was an ulcer about an inch behind each malleolus as ceived, and by palpitation of the heart and dyspnoea, which he large as the top of the finger; through these a probe could be had never complained of before; and was never again able to passed directly on to so large an extent of diseased bone as return to his ordinary occupation. After some months he was to leave little doubt that the whole was affected; its removal admitted into St. Bartholomew’s Hospital, dropsical, and was therefore determined on. An abscess formed in the back bearing all the symptoms which denote hypertrophy and of the heel six days before the operation, but this was dilatation of the heart. He soon died, and his heart wasi opened immediately fluctuation could be detected, and the found of a size which was almost incredible. All its musculai. parts around it recovered sufficiently to form a flap. substance was enormously amplified, and all its cavities; Operation.-On the 26th of July, with the assistance of enormously dilated; its pericardium, and lining membrane , Messrs. Hoffman, Hunter, and Price, (consulting-surgeons to and valves free from disease." (" Lectures on Diseases oiF the Infirmary,) I proceeded with the operation in the followthe Heart,"vol. ii. p. 205.) ing manner :-The patient being placed well under the influIt has been proved, in various instances, that excessive ence of chloroform, the point of a scalpel was passed through muscular exertion is capable of occasioning immediate injur; the internal ulcer down to the bone, carried downwards and Thus in Dr. Latham’s forwards, across the sole, backwards and upwards to to the mechanism of the heart. admirable work, is a case communicated by Dr. Bence Jonef!, the ulcer described as situated behind the outer ankle; this n which one of the senta, of the aortic valves " was torn awa’I incision was behind the posterior tibial artery and nerve.
slight blowing murmur, so protracted, however, as to render this longer by one-half than the first sound. There is no vas-
.
.
.