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CHESTER GENERAL INFIRMARY.
245
published in the " Guy’s Hoshe pointed out that the stertor the sudden attack of coma is very peculiar, and accompanying in a great measure characteristic of this form of cerebral affection connected with renal disease. It has not by any means, he observes, in general the deep, rough, guttural or nasal sound of ordinary apoplexy. It is sometimes slightly of this kind, but much more commonly the stertor presents more of a hissing character, as if produced by the air; but, in inspiration and in expectoration, striking against the hard palate, or even against the lips of the patient, rather than against the velum and throat, as in ordinary apoplectic stertor.
nected with Diseased Kidneys,"
pital Reports" for April, 1839,
Provincial
II
Hospital Reports.
CHESTER GENERAL INFIRMARY. CASE OF DIFFUSED FALSE ANEURISM, SPRINGING FROM A DILATATION OF THE DESCENDING AORTA ; DEATH FROM DYSPNŒA ; AUTOPSY.
(Under THE notes of the
the
of Dr. POWELL.) case were furnished
care
following
by Dr. Lewis
Brittain, house-surgeon :D. S-, aged thirty-seven, brickmaker, admitted Oct. 6th, 1863. He was an out-patient in March last, complaining of
cough, and pain in the left side shooting into the shoulder. He only attended two or three times, and was lost sight of until admission. He then stated that about eight weeks previously he noticed a small tumour over the left shoulder-blade, which grew to the size of an egg in a fortnight, and became painful and throbbed. It went on growing rapidly, extending downwards. His breathing became very short and laboured, and he On admission, a tumour, was troubled with a tickling cough.
the size of a half cricket-ball, but more oval, was situated between the posterior margin of the scapula and the spinous processes of the vertebrae. The scapula seemed raised and pushed outwards. There was distinct impulse all over the tumour, but no bruit or thrill to be heard or felt. Heart-sounds and area of dulness normal; to the left of the sternum dulness over the second and third ribs; tubular breathing; feeble respiration inferiorly and laterally on the left side, louder than normal over right lung. Has a peculiar barking cough ; no expectoration. No pain in the tumour except after it has been handled; no pain or tenderness in the back, except on one occasion for a few hours. In sleeping he can lie flat down, and on the tumour. Pulse small and frequent, equal in both wrists. Oct. 28th.-The tumour has grown very much during the last fortnight, and is now about the size of half a melon. Cough very troublesome. Nov. 6th.-Has been walking about up to the last two or three days. Great pain in the tumour, and he passes very bad
(inclusive) dorsal vertebrae were found absorbed for one-third of thickness, and about as much on the right side of the second, third, and fourth. The fifth and sixth ribs on the left side, with the lower border of the fourth, and upper of the seventh, were entirely absorbed between their attachments to the vertebrae and their angles, and thus a perforation was formed in the posterior wall of the thorax, four inches and a half in transverse, and four inches in vertical diameter. Through this aperture the contents of the sac had passed backwards; the effused blood was extravasated behind the ribs, extending up-
their
wards about three inches from the lower border of the fourth rib, and downwards about two inches below the seventh. The lungs were emphysematous at the borders, but generally crepitant ; right lung highly congested; lower lobe of left condensed. The liver was considerably enlarged and congested; granular on section. Spleen three times its normal size. The kidneys congested ; due proportion between cortical and tubular portions. Thin sections taken from the inner lining of the dilated aorta exhibited under the microscope osseous fibres and fatty granules. The treatment was merely palliative ; at first digitalis and cannabis indica, then chloric ether and digitalis, and latterly compound spirit of sulphuric ether. Dr. Powell called attention to the absence of bruit or tremor in the tumour, and to the freedom from neuralgic pain, notwithstanding the formidable erosion of the vertebrae and ribs. The cough was characteristic, although the voice was never affected. There was no dysphagia complained of, and no special physical signs, except slight dulness on percussion, and the bronchial respiration over the left lung. The diagnosis was mainly arrived at from the evidence of mechanical obstruction within the thoracic cavity, taken in connexion with the pulsating tumour behind, the impulse of which coincided with the heart’s systole. The radial pulses were of equal force, and gave no clue save from their feebleness contrasted with the heart’s forcible impulse. Dr. Powell ascribed the absence of bruit to the distension of the aneurismal pouch with coagula, of which there were twenty-seven ounces. The case was probably one of rheumatic inflammation, with subsequent degeneration and rupture of the arterial tissues.
NORFOLK AND NORWICH HOSPITAL. ANEURISM OF BOTH POPLITEAL
ARTERIES, TREATED BY COMPRESSION; CURED. (Under the care of Mr. FIRTH.)
FOR the following Williams :-
report
we are
indebted to Mr. Charles
George C-,aged twenty-seven, a well-formed, muscular, healthy-looking farm-labourer, was admitted in January, 1861, on account of stiffness and pain in the right knee. On examination, the joint was found to be swollen, and in the popliteal region there existed a globular pulsatile tumour, the size of a large orange. It expanded equally in every direction;9 a bruit de soufflet was well marked; and the pulsations were nights. strong over the whole swelling, and 84 a minute. Pressure on the 8th.-A sudden attack of dyspncea came on early this morn- vessel above diminished the volume of the swelling, and extining, and returned in paroxysms during the day. At these guished the sounds and impulse. The arterial system was in periods respiration was very noisy and prolonged, resembling a other respects in an apparently healthy condition, the heart’s "bray;" in the intervals much frothy phlegm was expectorated. murmur being normal, and the pulse exceedingly regular. The Sinapisms and dry cupping were employed to relieve the patient complained of a dull aching pain in the neighbourhood dyspncea and pain in the chest, and he took a little gin and of the knee-joint, which much interfered with sleep, and was beef-tea. becoming constant. The history of the case is, that seven weeks prior to admis. 9th.-A very bad attack about four r.M.; face livid, and all the extraordinary respiratory muscles at work. He died about sion the man noticed that his right knee was somewhat rigid and painful, and that it; became more so every day, and ultieight o’clock next morning. A utopsy, twenty six hours after death.-The tumour appeared mately compelled him to cease from working, which he did smaller than it was during life. The following were the dimen- about a fortnight before he presented himself at this hospital. sions :-Round the base, twenty-four inches ; from above down- He attributed his disease, not to injury, but to arduous work on wards, ten inches ; transversely, nine inches. On opening the which he was engaged-pulling up beet-root from land which thorax, the lungs and heart were found in normal position. On was particularly hard and dry. Ten years ago he had syphilis, displacing the lungs an immense tumour presented itself, and since then has suffered from several attacks of muscular occupying the whole posterior part of the left thorax, to which rheumatism. it adhered, and projecting to the size of an orange on the right Compression of the femoral artery by means of Dr. Carte’s of the spinal column. The pericardium contained about two apparatus was at once commenced with, and steadily persevered ounces of serous fluid. Heart and valves perfectly healthy. in up to the evening of the thirteenth day, at which time, after The arch of the aorta was dilated up to an inch beyond the a few hours of great agony, the aneurism ceased to pulsate. origin of the left subclavian, and at this point an aneurismal From this time he progressed favourably, and took his leave of pouch commenced, the size of a mature foetal head. The in- the hospital a month later, in excellent health, the tumour ternal coat of the aneurism was roughened from osseous plates being small and soft, and entirely free from anything like pul. and yellowish patches, and there was a small piece of rib-bone, sation or bruit. about an inch and a quarter long, found loose in the sac. On On the 25th of May of the same year he was re-admitted with removing the tumour, the left sides of the second to seventh vibrating swelling in the left popliteal space, not so large as and
a
2 i2
published in the " Guy’s Hoshe pointed out that the stertor the sudden attack of coma is very peculiar, and accompanying in a great measure characteristic of this form of cerebral affection connected with renal disease. It has not by any means, he observes, in general the deep, rough, guttural or nasal sound of ordinary apoplexy. It is sometimes slightly of this kind, but much more commonly the stertor presents more of a hissing character, as if produced by the air; but, in inspiration and in expectoration, striking against the hard palate, or even against the lips of the patient, rather than against the velum and throat, as in ordinary apoplectic stertor.
nected with Diseased Kidneys,"
pital Reports" for April, 1839,
Provincial
II
Hospital Reports.
CHESTER GENERAL INFIRMARY. CASE OF DIFFUSED FALSE ANEURISM, SPRINGING FROM A DILATATION OF THE DESCENDING AORTA ; DEATH FROM DYSPNŒA ; AUTOPSY.
(Under THE notes of the
the
of Dr. POWELL.) case were furnished
care
following
by Dr. Lewis
Brittain, house-surgeon :D. S-, aged thirty-seven, brickmaker, admitted Oct. 6th, 1863. He was an out-patient in March last, complaining of
cough, and pain in the left side shooting into the shoulder. He only attended two or three times, and was lost sight of until admission. He then stated that about eight weeks previously he noticed a small tumour over the left shoulder-blade, which grew to the size of an egg in a fortnight, and became painful and throbbed. It went on growing rapidly, extending downwards. His breathing became very short and laboured, and he On admission, a tumour, was troubled with a tickling cough.
the size of a half cricket-ball, but more oval, was situated between the posterior margin of the scapula and the spinous processes of the vertebrae. The scapula seemed raised and pushed outwards. There was distinct impulse all over the tumour, but no bruit or thrill to be heard or felt. Heart-sounds and area of dulness normal; to the left of the sternum dulness over the second and third ribs; tubular breathing; feeble respiration inferiorly and laterally on the left side, louder than normal over right lung. Has a peculiar barking cough ; no expectoration. No pain in the tumour except after it has been handled; no pain or tenderness in the back, except on one occasion for a few hours. In sleeping he can lie flat down, and on the tumour. Pulse small and frequent, equal in both wrists. Oct. 28th.-The tumour has grown very much during the last fortnight, and is now about the size of half a melon. Cough very troublesome. Nov. 6th.-Has been walking about up to the last two or three days. Great pain in the tumour, and he passes very bad
(inclusive) dorsal vertebrae were found absorbed for one-third of thickness, and about as much on the right side of the second, third, and fourth. The fifth and sixth ribs on the left side, with the lower border of the fourth, and upper of the seventh, were entirely absorbed between their attachments to the vertebrae and their angles, and thus a perforation was formed in the posterior wall of the thorax, four inches and a half in transverse, and four inches in vertical diameter. Through this aperture the contents of the sac had passed backwards; the effused blood was extravasated behind the ribs, extending up-
their
wards about three inches from the lower border of the fourth rib, and downwards about two inches below the seventh. The lungs were emphysematous at the borders, but generally crepitant ; right lung highly congested; lower lobe of left condensed. The liver was considerably enlarged and congested; granular on section. Spleen three times its normal size. The kidneys congested ; due proportion between cortical and tubular portions. Thin sections taken from the inner lining of the dilated aorta exhibited under the microscope osseous fibres and fatty granules. The treatment was merely palliative ; at first digitalis and cannabis indica, then chloric ether and digitalis, and latterly compound spirit of sulphuric ether. Dr. Powell called attention to the absence of bruit or tremor in the tumour, and to the freedom from neuralgic pain, notwithstanding the formidable erosion of the vertebrae and ribs. The cough was characteristic, although the voice was never affected. There was no dysphagia complained of, and no special physical signs, except slight dulness on percussion, and the bronchial respiration over the left lung. The diagnosis was mainly arrived at from the evidence of mechanical obstruction within the thoracic cavity, taken in connexion with the pulsating tumour behind, the impulse of which coincided with the heart’s systole. The radial pulses were of equal force, and gave no clue save from their feebleness contrasted with the heart’s forcible impulse. Dr. Powell ascribed the absence of bruit to the distension of the aneurismal pouch with coagula, of which there were twenty-seven ounces. The case was probably one of rheumatic inflammation, with subsequent degeneration and rupture of the arterial tissues.
NORFOLK AND NORWICH HOSPITAL. ANEURISM OF BOTH POPLITEAL
ARTERIES, TREATED BY COMPRESSION; CURED. (Under the care of Mr. FIRTH.)
FOR the following Williams :-
report
we are
indebted to Mr. Charles
George C-,aged twenty-seven, a well-formed, muscular, healthy-looking farm-labourer, was admitted in January, 1861, on account of stiffness and pain in the right knee. On examination, the joint was found to be swollen, and in the popliteal region there existed a globular pulsatile tumour, the size of a large orange. It expanded equally in every direction;9 a bruit de soufflet was well marked; and the pulsations were nights. strong over the whole swelling, and 84 a minute. Pressure on the 8th.-A sudden attack of dyspncea came on early this morn- vessel above diminished the volume of the swelling, and extining, and returned in paroxysms during the day. At these guished the sounds and impulse. The arterial system was in periods respiration was very noisy and prolonged, resembling a other respects in an apparently healthy condition, the heart’s "bray;" in the intervals much frothy phlegm was expectorated. murmur being normal, and the pulse exceedingly regular. The Sinapisms and dry cupping were employed to relieve the patient complained of a dull aching pain in the neighbourhood dyspncea and pain in the chest, and he took a little gin and of the knee-joint, which much interfered with sleep, and was beef-tea. becoming constant. The history of the case is, that seven weeks prior to admis. 9th.-A very bad attack about four r.M.; face livid, and all the extraordinary respiratory muscles at work. He died about sion the man noticed that his right knee was somewhat rigid and painful, and that it; became more so every day, and ultieight o’clock next morning. A utopsy, twenty six hours after death.-The tumour appeared mately compelled him to cease from working, which he did smaller than it was during life. The following were the dimen- about a fortnight before he presented himself at this hospital. sions :-Round the base, twenty-four inches ; from above down- He attributed his disease, not to injury, but to arduous work on wards, ten inches ; transversely, nine inches. On opening the which he was engaged-pulling up beet-root from land which thorax, the lungs and heart were found in normal position. On was particularly hard and dry. Ten years ago he had syphilis, displacing the lungs an immense tumour presented itself, and since then has suffered from several attacks of muscular occupying the whole posterior part of the left thorax, to which rheumatism. it adhered, and projecting to the size of an orange on the right Compression of the femoral artery by means of Dr. Carte’s of the spinal column. The pericardium contained about two apparatus was at once commenced with, and steadily persevered ounces of serous fluid. Heart and valves perfectly healthy. in up to the evening of the thirteenth day, at which time, after The arch of the aorta was dilated up to an inch beyond the a few hours of great agony, the aneurism ceased to pulsate. origin of the left subclavian, and at this point an aneurismal From this time he progressed favourably, and took his leave of pouch commenced, the size of a mature foetal head. The in- the hospital a month later, in excellent health, the tumour ternal coat of the aneurism was roughened from osseous plates being small and soft, and entirely free from anything like pul. and yellowish patches, and there was a small piece of rib-bone, sation or bruit. about an inch and a quarter long, found loose in the sac. On On the 25th of May of the same year he was re-admitted with removing the tumour, the left sides of the second to seventh vibrating swelling in the left popliteal space, not so large as and
a
2 i2