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RUPTURE OF AN AORTIC ANEURYSM INTO THE LEFT INNOMINATE VEIN.
337
language which
has
been
more
quoted, more
discussed, and more misunderstood thanSunt lacrymae rerum et mentem mortalia tangunt." and all kinds of meanings and undercurrents of "
feeling have been read into this line, varying according to the taste and fancies of the readers. But, as shown by a writer in the Classical Review (February-March, 1919), all the presumed difficulty has arisen from the line being divorced from its context, and if taken in connexion with the
accom-
1. The local authority should appoint a small emergency committee to whom, with the medical officer
of health, would be delegated full powers to act and incur necessary expenditure. 2. Medical practitioners and voluntary health workers should be consulted and their cooperation invited. The cooperation of the local employment exchanges of the Ministry of Labour should be invited also. in order that the opportunities for service may be brought under the notice of suitable persons. 3. A scheme should be drawn up for the provision of medical nursing and other assistance to the sick, and for the employment of women as home helps in cooking, care of children, and domestic work. 4. Arrangements should be made by which health visitors and other members of the staff of the local authority and of its institutions may be used to the best advantage and temporary creches and special kitchens promoted. The prophylactic inoculation of the staff of the health department and of nurses, home helps, and other workers under the scheme may be taken into
lines its meaning stands out perfectly Here the guesses of readers have led them clearly. into a morass, but if Virgil had written a baldly clear statement much of the charm of the passage would have been lost. If we pass to the question of too much clearness in other departments of life we are met by the problem, "How far is it desirable to tell the whole truth ?"-and this is a problem the solution of which very often affects consideration. 5. Wards of the infectious diseases hospitals of the the medical profession. Dr. Batty Shaw, in a paper which appeared in our issue of Jan. 24th, laid stress local authority and of general hospitals should be set for the treatment of cases of influenza judged to upon the fact that "probably all children ...... living require hospital treatment and the provision of emergency under the conditions of civilisation are infected accommodation should be arranged for in case " hospital by B. tuberculosis." Further on he said, I think of need. that the subject of tuberculosis has becomepopu6. Steps should be taken by the local authority to larised too much, or should I say has been only prevent overcrowding and to secure adequate ventilapartially popularised. It is more palatable to a lay tion in public buildings and public conveyances. 7. Notices and leaflets should be prepared for issue to audience to listen to the accounts of the marvellous people having reference to the importance of free cures which have come as a result of this, that, or the avoidance of needless exposure to the other treatment. It is not at all palatable, and the necessity to keep away from places of infection ; lay men and women would not be tempted to join public resort; and similar points; and furnishing for associations for the study of this disease if they public information suitable details of the local authority’s were told the whole truth." Here, then, is one scheme. instance where the problem above mentioned The Board is prepared to supply gratis to medical If the average lay- officers of health, for distribution to comes forward for solution. practitioners man knew the whole truth, would it make him and hospitals in their areas, supplies of recently throw up the sponge in the contest against tubercu- produced vaccines against secondary infections. losis or would it stimulate him to further exertions ? These are not intended to replace any other In this case the knowledge or reverse of the truth vaccine, prepared from a local strain, which may affects the community as a whole, but the same be in use in different localities. problem arises as affecting individuals in those many cases which arise in medical practice where RUPTURE OF AN AORTIC ANEURYSM INTO THE it becomes the medical man’s duty to decide whether LEFT INNOMINATE VEIN. or no he should tell his patient, or those responsible RUPTURE of an aortic aneurysm into the superior for the patient, the whole truth as to the disease is so rare as to be among the curiosities from which that patient may be suffering. Hope, as vena cava literature. Dr. J. B. Herrick has recently of medical everyone knows, is a large factor in recovery, and a case of rupture into the left innominate reported to dash such hope to the ground may be the last vein within less than a third of an inch from its impulse which sends the sufferer into the abyss. debouch into the cava, which can therefore be But, on the other hand, there are cases in which, classed under same head. the so far as human knowledge can tell, the patient is The patient, a medical practitioner, aged 33 years, absolutely doomed; what should be the medical had suffered for 6 months from pains in the chest which man’s action then ? In our opinion there can be no at times extended to the right arm. He denied syphilis, hard-and-fast rules for action laid down, for so but the Wassermann reaction was strongly positive. much depends upon the individual circumstances One evening while ascending stairs he had a feeling of each case. May there not be too much clearness ? of something giving way in his chest, and his Sometimes, surely, to paraphrase Mr. Montague’s face and neck felt flushed and full. The sense words, "It is more blessed for a patient to guess of choking and pressure was so urgent that he tore open his collar and the neckband of his shirt. right than to be told."
panying
aside
the
ventilation;
°
INFLUENZA:
PREPARATIONS IN
SCOTLAND.
CORRESPONDING to the advice given by the of Health to medical officers and local authorities in England and Wales, a circular on the risk of a general outbreak of influenza has been issued by the Scottish Board of Health to authorities and officers in Scotland. The circular emphasises the importance of having in readiness a preconcerted scheme to meet the outbreak if it should come. The scheme recommended by the Board, subject to modification to meet local conditions, is as follows.
Ministry
While trying to turn on the electric light he lost consciousness. How long he lay on the floor in a swoon was not known—he thought about 20 minutes. On recovering he turned on the light and looked in the mirror, and saw that his neck and face were swollen and ’"almost black." Breathing was difficult and he summoned aid by telephone. During the next five weeks he suffered from dyspnoea, at times amounting to orthopncea. Attacks of coughing, with choking sensations and cyanosis, seemed to threaten death. He became weak and irritable, and at times was somewhat delirious. At the end of this period he came under Dr. Herrick’s observation. The picture was such as he had The face and neck, as well as never seen before. 1 American Journal of the Medical Science. December, 1919.
338 the chest of chronic
wall,
were
swollen,
as
in
the
anasarca
parenchymatous nephritis. The injected eyeballs bulged through the narrow slits between the swollen lids. But instead of the pasty nephritic pallor, the patient’s colour was almost black, a tint observed only in extreme cyanosis. The visible veins distended and tortuous. The contrast between upper half of the body and the pale, emaciated lower portion was remarkable. The patient had the spindle legs of the last stage of wasting disease without oedema. The abdominal wall was slightly oedematous above the umbilicus. The line of separation between the pale, tlaecid abdominal wall and the swollen, purplish chest wall, which was hard and brawny, pitting only on firm pressure, was almost as clear cut as the line of demarcation in a case of gangrene. The cardiac outline was difficult to determine because of the thick, oedematous chest wall. At the base of the heart and over the manubrium was an increased area of dullness. A systolic murmur, which lasted into the diastole, was heard over the precordium and in the interscapular region. At the aortic cartilage were
the
bloated, dark
On comparing the clinical and pathological aspects it was found that one patient who was known to have had a stone for six years had a negative urine and a normal kidney. Another patient who had passed stones for at least seven years had a negative urine and a kidney which was normal apart from a very slight dilatation. Of the four cases without symptoms and with a negative urine only one showed an entirely normal kidney; it contained many small stones in the calices and the pelvis. The other three were, however, essentially normal, some interstitial changes and atrophy of renal elements being the only lesions noted. MULTILOCULAR
HYDATID
DISEASE.
called Multilocular (also alveolar) hydatid was first disease recognised and described in Germany by Virchow in 1855. Previous to his the cases when met with appear to it was most intense, continuous, soft, blowing, and description, have been regarded as alveolar colloid cancer. somewhat humming. Numerous rales, moist and dry, The for a long time the only organ liver was At the were heard over the lungs, particularly behind. bases there was some dullness, with obscuring of breath known to be affected, and the few recorded cases sounds, as from pleural effusion. Breathing grew more have come principally from Russia, South Germany, and more difficult, dysphagia developed, and sleep was and Switzerland. Writers have been much exercised possible only by the aid of drugs. A radiogram showed as to the way the formation arises. It is known He that a shadow as from an aneurysm of the aortic arch. exogenous budding, with the production of gradually lost strength, and died eight days after he external daughter-cysts, is a phenomenon exhibited The necropsy showed old came under observation. and active aortitis, typically syphilitic. The aneurysm by some hydatid cysts, just as internal daughteroriginated 4 cm. above the aortic valves. The sac cysts occur from endogenous growth. It is stated projected so as to press on the superior cava, especially by Neumann that the two kinds of buddingnear the heart. The opening into the vena cava was exogenous -and endogenous-are not generally 1’5 cm. in diameter. The innominate and azygos veins found in the same echinococcus, nor in the same were much distended. host. If this is true, it would seem as if there The case narrated conforms to the description existed either an influence derived from the tissues given by Pepper and Griffithin their classical of the host or a special propensity implanted in paper on Rupture of Aortic Aneurysm into the some races of the parasite. After the typical picture of multilocular hydatid Superior Vena Cava. They found records of 29 cases. With the present case the number now reaches 43. had been established from examination of liver While the typical case permits of diagnosis, varia- specimens a new series of echinococcus tumours tions in the size of the aneurysm, in the point of began to be observed. These appeared to have their pressure, and in the degree of obstruction may primary seat in bone. Virchow stated in 1883 that cause difficulty. Treatment can be only palliative. multilocular hydatid of the liver and hydatid of Bleeding has been of only temporary benefit. bone were the same disease. Moreover, he regarded Death may occur soonafter the accident, or be the echinococcus of the multilocular form and that of the cystic type as the same parasite under postponed many weeks or even months. different conditions of life, and especially of pressure in dense tissues. This theory would hardly suffice SILENT RENAL CALCULI. to explain why the cysts continued to be small in Dr. Edmund L. Young, jun.,1 of Boston, states that collections situated in the soft tissues of the in 3960 autopsies performed at the Massachusetts interesting case described by Dr. C. E. Corlette, General Hospital since 1896 stones were found in of Sydney, in our present issue ; for instance, the kidney or ureter or both in 45 cases. In 7 cases those in the left thigh, in the right retrooperations had been performed for stone, and one peritoneal region, or above the spleen. Compressmall stone out of many, or a fragment from a large sion could not there be the cause of their small stone, had been lost in a pyonephrotic cavity. In a size, and it is probably partly a question of bilateral case one side had been operated on and nutrition and partly of the mechanical conditions, the other was to have been done later. One case since the cysts were naked and quite free, like with calculous pyonephrosis died without opera- marbles in a bag, and the large ones probably got tion. In the remaining 37 cases the patients ruptured. were in hospital for some other condition than Dr. J. B. Cleland, principal microbiologist of stone in the kidney. Stones were known to be New South Wales, has compiled a bibliography present in three of these, but had nothing to do and short abstract of those cases of hydatid disease with the condition from which the patient suffered of bone recorded in Australian periodical literature. and ultimately died. There was only one case with About 18 separate cases have been recorded, of a completely negative history and urinary findings which 5 are in the femur, 3 in the sacrum or coccyx, and a normal kidney on naked-eye and microscopic 2 in the tibia and the ilium, and 1 in each of the examination, but there were four cases without following bones : vertebra, skull, superior maxilla, symptoms and with a negative urine, six cases humerus, a rib, terminal phalanx of a finger. without any damage to be demonstrated at the The records show that when the bones of the limbs autopsy, and 15 cases in which the damage was too have been attacked there has been a marked proslight to compromise the integrity of the kidney. pensity to fracture, and that the nidus has practically always been in cancellous bone. The question 2 Trans. Assoc, of American Physicians, 1890. how the hydatid embryo gains its entry to the bone, 1 Boston Medical and Surgical Journal, Nov. 13th, 1919. ,
language which
has
been
more
quoted, more
discussed, and more misunderstood thanSunt lacrymae rerum et mentem mortalia tangunt." and all kinds of meanings and undercurrents of "
feeling have been read into this line, varying according to the taste and fancies of the readers. But, as shown by a writer in the Classical Review (February-March, 1919), all the presumed difficulty has arisen from the line being divorced from its context, and if taken in connexion with the
accom-
1. The local authority should appoint a small emergency committee to whom, with the medical officer
of health, would be delegated full powers to act and incur necessary expenditure. 2. Medical practitioners and voluntary health workers should be consulted and their cooperation invited. The cooperation of the local employment exchanges of the Ministry of Labour should be invited also. in order that the opportunities for service may be brought under the notice of suitable persons. 3. A scheme should be drawn up for the provision of medical nursing and other assistance to the sick, and for the employment of women as home helps in cooking, care of children, and domestic work. 4. Arrangements should be made by which health visitors and other members of the staff of the local authority and of its institutions may be used to the best advantage and temporary creches and special kitchens promoted. The prophylactic inoculation of the staff of the health department and of nurses, home helps, and other workers under the scheme may be taken into
lines its meaning stands out perfectly Here the guesses of readers have led them clearly. into a morass, but if Virgil had written a baldly clear statement much of the charm of the passage would have been lost. If we pass to the question of too much clearness in other departments of life we are met by the problem, "How far is it desirable to tell the whole truth ?"-and this is a problem the solution of which very often affects consideration. 5. Wards of the infectious diseases hospitals of the the medical profession. Dr. Batty Shaw, in a paper which appeared in our issue of Jan. 24th, laid stress local authority and of general hospitals should be set for the treatment of cases of influenza judged to upon the fact that "probably all children ...... living require hospital treatment and the provision of emergency under the conditions of civilisation are infected accommodation should be arranged for in case " hospital by B. tuberculosis." Further on he said, I think of need. that the subject of tuberculosis has becomepopu6. Steps should be taken by the local authority to larised too much, or should I say has been only prevent overcrowding and to secure adequate ventilapartially popularised. It is more palatable to a lay tion in public buildings and public conveyances. 7. Notices and leaflets should be prepared for issue to audience to listen to the accounts of the marvellous people having reference to the importance of free cures which have come as a result of this, that, or the avoidance of needless exposure to the other treatment. It is not at all palatable, and the necessity to keep away from places of infection ; lay men and women would not be tempted to join public resort; and similar points; and furnishing for associations for the study of this disease if they public information suitable details of the local authority’s were told the whole truth." Here, then, is one scheme. instance where the problem above mentioned The Board is prepared to supply gratis to medical If the average lay- officers of health, for distribution to comes forward for solution. practitioners man knew the whole truth, would it make him and hospitals in their areas, supplies of recently throw up the sponge in the contest against tubercu- produced vaccines against secondary infections. losis or would it stimulate him to further exertions ? These are not intended to replace any other In this case the knowledge or reverse of the truth vaccine, prepared from a local strain, which may affects the community as a whole, but the same be in use in different localities. problem arises as affecting individuals in those many cases which arise in medical practice where RUPTURE OF AN AORTIC ANEURYSM INTO THE it becomes the medical man’s duty to decide whether LEFT INNOMINATE VEIN. or no he should tell his patient, or those responsible RUPTURE of an aortic aneurysm into the superior for the patient, the whole truth as to the disease is so rare as to be among the curiosities from which that patient may be suffering. Hope, as vena cava literature. Dr. J. B. Herrick has recently of medical everyone knows, is a large factor in recovery, and a case of rupture into the left innominate reported to dash such hope to the ground may be the last vein within less than a third of an inch from its impulse which sends the sufferer into the abyss. debouch into the cava, which can therefore be But, on the other hand, there are cases in which, classed under same head. the so far as human knowledge can tell, the patient is The patient, a medical practitioner, aged 33 years, absolutely doomed; what should be the medical had suffered for 6 months from pains in the chest which man’s action then ? In our opinion there can be no at times extended to the right arm. He denied syphilis, hard-and-fast rules for action laid down, for so but the Wassermann reaction was strongly positive. much depends upon the individual circumstances One evening while ascending stairs he had a feeling of each case. May there not be too much clearness ? of something giving way in his chest, and his Sometimes, surely, to paraphrase Mr. Montague’s face and neck felt flushed and full. The sense words, "It is more blessed for a patient to guess of choking and pressure was so urgent that he tore open his collar and the neckband of his shirt. right than to be told."
panying
aside
the
ventilation;
°
INFLUENZA:
PREPARATIONS IN
SCOTLAND.
CORRESPONDING to the advice given by the of Health to medical officers and local authorities in England and Wales, a circular on the risk of a general outbreak of influenza has been issued by the Scottish Board of Health to authorities and officers in Scotland. The circular emphasises the importance of having in readiness a preconcerted scheme to meet the outbreak if it should come. The scheme recommended by the Board, subject to modification to meet local conditions, is as follows.
Ministry
While trying to turn on the electric light he lost consciousness. How long he lay on the floor in a swoon was not known—he thought about 20 minutes. On recovering he turned on the light and looked in the mirror, and saw that his neck and face were swollen and ’"almost black." Breathing was difficult and he summoned aid by telephone. During the next five weeks he suffered from dyspnoea, at times amounting to orthopncea. Attacks of coughing, with choking sensations and cyanosis, seemed to threaten death. He became weak and irritable, and at times was somewhat delirious. At the end of this period he came under Dr. Herrick’s observation. The picture was such as he had The face and neck, as well as never seen before. 1 American Journal of the Medical Science. December, 1919.
338 the chest of chronic
wall,
were
swollen,
as
in
the
anasarca
parenchymatous nephritis. The injected eyeballs bulged through the narrow slits between the swollen lids. But instead of the pasty nephritic pallor, the patient’s colour was almost black, a tint observed only in extreme cyanosis. The visible veins distended and tortuous. The contrast between upper half of the body and the pale, emaciated lower portion was remarkable. The patient had the spindle legs of the last stage of wasting disease without oedema. The abdominal wall was slightly oedematous above the umbilicus. The line of separation between the pale, tlaecid abdominal wall and the swollen, purplish chest wall, which was hard and brawny, pitting only on firm pressure, was almost as clear cut as the line of demarcation in a case of gangrene. The cardiac outline was difficult to determine because of the thick, oedematous chest wall. At the base of the heart and over the manubrium was an increased area of dullness. A systolic murmur, which lasted into the diastole, was heard over the precordium and in the interscapular region. At the aortic cartilage were
the
bloated, dark
On comparing the clinical and pathological aspects it was found that one patient who was known to have had a stone for six years had a negative urine and a normal kidney. Another patient who had passed stones for at least seven years had a negative urine and a kidney which was normal apart from a very slight dilatation. Of the four cases without symptoms and with a negative urine only one showed an entirely normal kidney; it contained many small stones in the calices and the pelvis. The other three were, however, essentially normal, some interstitial changes and atrophy of renal elements being the only lesions noted. MULTILOCULAR
HYDATID
DISEASE.
called Multilocular (also alveolar) hydatid was first disease recognised and described in Germany by Virchow in 1855. Previous to his the cases when met with appear to it was most intense, continuous, soft, blowing, and description, have been regarded as alveolar colloid cancer. somewhat humming. Numerous rales, moist and dry, The for a long time the only organ liver was At the were heard over the lungs, particularly behind. bases there was some dullness, with obscuring of breath known to be affected, and the few recorded cases sounds, as from pleural effusion. Breathing grew more have come principally from Russia, South Germany, and more difficult, dysphagia developed, and sleep was and Switzerland. Writers have been much exercised possible only by the aid of drugs. A radiogram showed as to the way the formation arises. It is known He that a shadow as from an aneurysm of the aortic arch. exogenous budding, with the production of gradually lost strength, and died eight days after he external daughter-cysts, is a phenomenon exhibited The necropsy showed old came under observation. and active aortitis, typically syphilitic. The aneurysm by some hydatid cysts, just as internal daughteroriginated 4 cm. above the aortic valves. The sac cysts occur from endogenous growth. It is stated projected so as to press on the superior cava, especially by Neumann that the two kinds of buddingnear the heart. The opening into the vena cava was exogenous -and endogenous-are not generally 1’5 cm. in diameter. The innominate and azygos veins found in the same echinococcus, nor in the same were much distended. host. If this is true, it would seem as if there The case narrated conforms to the description existed either an influence derived from the tissues given by Pepper and Griffithin their classical of the host or a special propensity implanted in paper on Rupture of Aortic Aneurysm into the some races of the parasite. After the typical picture of multilocular hydatid Superior Vena Cava. They found records of 29 cases. With the present case the number now reaches 43. had been established from examination of liver While the typical case permits of diagnosis, varia- specimens a new series of echinococcus tumours tions in the size of the aneurysm, in the point of began to be observed. These appeared to have their pressure, and in the degree of obstruction may primary seat in bone. Virchow stated in 1883 that cause difficulty. Treatment can be only palliative. multilocular hydatid of the liver and hydatid of Bleeding has been of only temporary benefit. bone were the same disease. Moreover, he regarded Death may occur soonafter the accident, or be the echinococcus of the multilocular form and that of the cystic type as the same parasite under postponed many weeks or even months. different conditions of life, and especially of pressure in dense tissues. This theory would hardly suffice SILENT RENAL CALCULI. to explain why the cysts continued to be small in Dr. Edmund L. Young, jun.,1 of Boston, states that collections situated in the soft tissues of the in 3960 autopsies performed at the Massachusetts interesting case described by Dr. C. E. Corlette, General Hospital since 1896 stones were found in of Sydney, in our present issue ; for instance, the kidney or ureter or both in 45 cases. In 7 cases those in the left thigh, in the right retrooperations had been performed for stone, and one peritoneal region, or above the spleen. Compressmall stone out of many, or a fragment from a large sion could not there be the cause of their small stone, had been lost in a pyonephrotic cavity. In a size, and it is probably partly a question of bilateral case one side had been operated on and nutrition and partly of the mechanical conditions, the other was to have been done later. One case since the cysts were naked and quite free, like with calculous pyonephrosis died without opera- marbles in a bag, and the large ones probably got tion. In the remaining 37 cases the patients ruptured. were in hospital for some other condition than Dr. J. B. Cleland, principal microbiologist of stone in the kidney. Stones were known to be New South Wales, has compiled a bibliography present in three of these, but had nothing to do and short abstract of those cases of hydatid disease with the condition from which the patient suffered of bone recorded in Australian periodical literature. and ultimately died. There was only one case with About 18 separate cases have been recorded, of a completely negative history and urinary findings which 5 are in the femur, 3 in the sacrum or coccyx, and a normal kidney on naked-eye and microscopic 2 in the tibia and the ilium, and 1 in each of the examination, but there were four cases without following bones : vertebra, skull, superior maxilla, symptoms and with a negative urine, six cases humerus, a rib, terminal phalanx of a finger. without any damage to be demonstrated at the The records show that when the bones of the limbs autopsy, and 15 cases in which the damage was too have been attacked there has been a marked proslight to compromise the integrity of the kidney. pensity to fracture, and that the nidus has practically always been in cancellous bone. The question 2 Trans. Assoc, of American Physicians, 1890. how the hydatid embryo gains its entry to the bone, 1 Boston Medical and Surgical Journal, Nov. 13th, 1919. ,