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YORK COUNTY HOSPITAL.
85 Ether having been administered a director was passed into the punctured wound and an incision about 6 in. in length was made in the direction of the fibres of the gluteus maximus, having its centre at the puncture. The wound was carefully deepened till the bone was reached, a considerable amount of blood-clot being turned out. H2morrhage was controlled by pressure forceps and the bleeding vessel was carefully sought for. It was then found that the internal pudic artery had been completely divided at the point where it crosses the spine of the ischium. The cut ends were ligatured with silk. This proved to be a matter of great difficulty owing to the depth of the wound. The
react to light, but there was a sluggish conjunctival reflex. He had vomited whilst he was being conveyed to the hospital. From the extreme collapse, associated with rigidity of the limbs, the diagnosis of cerebral haemorrhage was made. The patient was at once put to bed with plenty of hot bottles and under the influence of hypodermic injections of brandy and ether and the application of hot
Fic. 2.
carefully
wound was cleansed, the muscles were approximated with continuous silk suture, and the skin was brought into apposition by interrupted salmon gut sutures. The patient made a good recovery and was discharged from the hospital on June 17th with the wound quite healed. Rerna.rks by Mr. OOLLINs.-The case seems to be one of interest, firstly, on account of the rarity of such an accident, ,and, secondly, because of the difficulty of controlling the haemorrhage owing to the depth at which the wounded vessel In conclusion I have to thank Mr. Golding’was situated. Bird and Mr. Dunn for their kindness in permitting me to publish the case.
YORK COUNTY HOSPITAL. A CASE OF COMPLETE RUPTURE OF THE AORTA PRESENTING SOME EXTRAORDINARY FEATURES ; NECROPSY.
(Under the
care
of Dr. R.
PETCH.)
IN the very rare condition which is met with in the case reported below the length of time during which the patient survived is remarkable. Although there was a complete rupture of the aorta life was prolonged for more than five rhours ; this was only rendered possible by the attachment of the pericardium preventing the further effusion of blood. ’The explanation offered by Dr. Ashwin of the manner in which the vessel underwent such a curious invagination is ery ingenious. For the notes of the case we are indebted to Dr. R. H. Ashwin, assistant house surgeon. A man, aged fifty-six years, absolutely destitute and homeless, was observed to fall suddenly at 9 P.M. on April 20th while he was walking quietly on level ground. He imme,diately became unconscious and was taken to the York County Hospital, where he was admitted at 9.30 P.M. under the care of Dr. Petch. On admission he was in an extreme
A
represents the first rent.
flannels to the pnecordial region the pulse improved considerably for a time. He vomited again whilst he was in the hospital, but there was no smell of alcohol or anything characteristic in the vomit. Death took place at 2.30 A.M., about five and a half hours after he fell, without his ever regaining consciousness. Neoropsy.-At the post-mortem examination it was found that the pericardium contained 6 oz. of blood. The heart
FiG. 3.
FtG. 1.
A
A
represents the first rent with the first invagination passing through it.
The pulse was only just perceptible state of collapse. at the wrist, the skin was cold, clammy, and covered with perspiration, and the respirations were very infrequent and stertorous. There was also extreme rigidity of all the limbs with increased knee-jerks and an occasional spasm of the pectoral muscles drawing the upper arms m front of the chest. The pupils were dilated and did not,
represents the
same as
with the second
in
Fig. 1.
B
represents the second rent
invagiDation passing through it.
showed some hypertrophy of the left ventricle but all the. There was a complete valves were perfectly healthy. rupture of the aorta in a slightly oblique direction about fin. above the aortic valves. The pericardium covering the’ ascending aorta had been forced away from the outer coat of the vessel as far as the origin of the innominate artery and was distended with recent blood-clot forming the wall of a false aneurysm. The ascending pcrtion of the aorta was
86 it found. In these figures the iirst rent is market l which A way for the blood to pass from and the second rent
into the transverse portion as far as the comuf the descending portion. This, however, was not a simple iuvagination as the intima of the penetratingportion looked inwards, and not outwards, towards the intima of the receiving portion. At first sight it was not apparent how this had been brought about and not till the invagination had been reduced was it discovered that
invaginated mencement
FIG. 4.
A
A
and
B
represent the same
as
in
Fig. 3.
there was yet another invagination. It was then seen that the condition had been produced thus. The ruptured end of the aorta had been turned inwards and passed through a rent in the arterial coats just below the origin of the innominate artery, as shown in Fig. 1, thus occluding the passage for the blood into the transverse aorta. A second invagination had then taken place, the ruptured end again
FIG. b.
was
A
B.
the cavity of the false aneurysm into the aorta was thus; restored. These figures are very diagrammatic and it has not in them the fact that the different been attempted to coats of the vessel were not all torn through at exactly thesame place. In the case of the rent marked B the opening was markedly valvular, the intima being ruptured 2 in. further down the vessel than the adventitia. Fig. 5, which is re-produced from a photograph, gives a good idea of the appear-The transverse aorta is slit up to. ance of the invagination. the expose invaginated ascending portion and the left ventricle and the commencement of the aorta are also cut. open. There is a blow-pipe (1) passed through the lumen of the invaginated portion showing the course the blood took from the aneurysmal cavity into the descending aorta. A needle (2) is passed through the first rent (A) through which the primary invaginaticn took place and a needle (3) is passed through the second rent (B) through which thesecond invagination had taken place, a third needle (4 is passed from the cavity of the aneurysm into thecommencement of the innominate artery which was torn off’ from the aorta, and there is a needle (5) placed in the pericardial cavity lying in front of the parietal layer and partly concealed by the visceral layer of pericardium which had been forced away from the outer coat of the aorta. Remarks by Dr. ASHWIN.-The above case of rupture of’ the aorta is, I think, interesting, not only on account of the rarity of the accident but also because the distal portion was invaginated twice through two distinct rents in the coats of the artery in such a manner as to restore the lumen of the vessel so that the circulation was maintained and life pro-longed for five and a half hours after the occurrence of the rupture. As regards the cause of the rupture I fear I can. make no suggestion. The patient does not appear to havebeen making any violent exertion at the time of its occurrence and the aorta was remarkably healthy for a man of his; age, there being only two small patches of atheroma, one of which is marked 6 in Fig. 5. The brain was perfectly normal. I am indebted to Dr. Petch for permission to publish the case and to my senior colleague, Dr. G. W. Gostling, for his assistance and valuable suggestions at the.
represent
post-mortem I
examination.
Medical Societies. ROYAL ACADEMY OF MEDICINE IN IRELAND. SECTION
OF
ANATOMY AND PHYSIOLOGY.
P7zrenic Nerve.-Muscula.r fibres of the lessFibres of the Stomaeh.-Dislocation of Crystalline Lenses. A MEETING of this section was held on June 3rd, Dr. D. J. COFFEY, the President, being in the chair. Dr. J. BARTON read a short note on an Irregular Phrenic Nerve which came off from the fourth cervical and ran for one and a half inches in the trunk formed by the fifth and, sixth nerves, getting a branch from the fifth. It then passed downwards and inwards in contact with the posterior surface of the sterno-mastoid, crossed the subclavian vein oppositethe insertion of the scalenus anticus, and entered thethorax in front of the internal mammary artery and right. innominate vein and then passed down by the vena cava andpericardium as usual. He also referred to the frequency with which the phrenic nervepassed behind instead of in-
Iri-tltila,l,
pA,7,qli,s.--Ifitse?llar
_
_r’=._Showing the appearance of the invagination. ..
_
__
--
-
-
I",
---
turning in and passing through a second rent in the arterial walls into the lumen of the transverse aorta. Fig. 2 shows this second invagination just commencing, and in Fig. 3 it is fiecn at a further stage after passing through the second rent, yig. 4 showing it forced further through in the condition in
front of the internal mammary artery.-Professor BIRMING-HAM suggested that the phrenic had perhaps associatedt itself with the nerve to the subclavius for some distance in’ this specimen and exhibited a specimen illustrating the’ Course of the Left Phrenic Nerve in the Upper Part of the Thorax, which he thought showed the true position of the nerve at a part of its course which is generally neglected in the usual descriptions. Professor BIRMINGHAM read a paper on the Muscular Fibres of the (Esophagus in which he pointed out (supporting his views by several specimens) that the usual description. which made the longitudinal fibres of the oesophagus divide above into three bands, two of which were caic1 to be
react to light, but there was a sluggish conjunctival reflex. He had vomited whilst he was being conveyed to the hospital. From the extreme collapse, associated with rigidity of the limbs, the diagnosis of cerebral haemorrhage was made. The patient was at once put to bed with plenty of hot bottles and under the influence of hypodermic injections of brandy and ether and the application of hot
Fic. 2.
carefully
wound was cleansed, the muscles were approximated with continuous silk suture, and the skin was brought into apposition by interrupted salmon gut sutures. The patient made a good recovery and was discharged from the hospital on June 17th with the wound quite healed. Rerna.rks by Mr. OOLLINs.-The case seems to be one of interest, firstly, on account of the rarity of such an accident, ,and, secondly, because of the difficulty of controlling the haemorrhage owing to the depth at which the wounded vessel In conclusion I have to thank Mr. Golding’was situated. Bird and Mr. Dunn for their kindness in permitting me to publish the case.
YORK COUNTY HOSPITAL. A CASE OF COMPLETE RUPTURE OF THE AORTA PRESENTING SOME EXTRAORDINARY FEATURES ; NECROPSY.
(Under the
care
of Dr. R.
PETCH.)
IN the very rare condition which is met with in the case reported below the length of time during which the patient survived is remarkable. Although there was a complete rupture of the aorta life was prolonged for more than five rhours ; this was only rendered possible by the attachment of the pericardium preventing the further effusion of blood. ’The explanation offered by Dr. Ashwin of the manner in which the vessel underwent such a curious invagination is ery ingenious. For the notes of the case we are indebted to Dr. R. H. Ashwin, assistant house surgeon. A man, aged fifty-six years, absolutely destitute and homeless, was observed to fall suddenly at 9 P.M. on April 20th while he was walking quietly on level ground. He imme,diately became unconscious and was taken to the York County Hospital, where he was admitted at 9.30 P.M. under the care of Dr. Petch. On admission he was in an extreme
A
represents the first rent.
flannels to the pnecordial region the pulse improved considerably for a time. He vomited again whilst he was in the hospital, but there was no smell of alcohol or anything characteristic in the vomit. Death took place at 2.30 A.M., about five and a half hours after he fell, without his ever regaining consciousness. Neoropsy.-At the post-mortem examination it was found that the pericardium contained 6 oz. of blood. The heart
FiG. 3.
FtG. 1.
A
A
represents the first rent with the first invagination passing through it.
The pulse was only just perceptible state of collapse. at the wrist, the skin was cold, clammy, and covered with perspiration, and the respirations were very infrequent and stertorous. There was also extreme rigidity of all the limbs with increased knee-jerks and an occasional spasm of the pectoral muscles drawing the upper arms m front of the chest. The pupils were dilated and did not,
represents the
same as
with the second
in
Fig. 1.
B
represents the second rent
invagiDation passing through it.
showed some hypertrophy of the left ventricle but all the. There was a complete valves were perfectly healthy. rupture of the aorta in a slightly oblique direction about fin. above the aortic valves. The pericardium covering the’ ascending aorta had been forced away from the outer coat of the vessel as far as the origin of the innominate artery and was distended with recent blood-clot forming the wall of a false aneurysm. The ascending pcrtion of the aorta was
86 it found. In these figures the iirst rent is market l which A way for the blood to pass from and the second rent
into the transverse portion as far as the comuf the descending portion. This, however, was not a simple iuvagination as the intima of the penetratingportion looked inwards, and not outwards, towards the intima of the receiving portion. At first sight it was not apparent how this had been brought about and not till the invagination had been reduced was it discovered that
invaginated mencement
FIG. 4.
A
A
and
B
represent the same
as
in
Fig. 3.
there was yet another invagination. It was then seen that the condition had been produced thus. The ruptured end of the aorta had been turned inwards and passed through a rent in the arterial coats just below the origin of the innominate artery, as shown in Fig. 1, thus occluding the passage for the blood into the transverse aorta. A second invagination had then taken place, the ruptured end again
FIG. b.
was
A
B.
the cavity of the false aneurysm into the aorta was thus; restored. These figures are very diagrammatic and it has not in them the fact that the different been attempted to coats of the vessel were not all torn through at exactly thesame place. In the case of the rent marked B the opening was markedly valvular, the intima being ruptured 2 in. further down the vessel than the adventitia. Fig. 5, which is re-produced from a photograph, gives a good idea of the appear-The transverse aorta is slit up to. ance of the invagination. the expose invaginated ascending portion and the left ventricle and the commencement of the aorta are also cut. open. There is a blow-pipe (1) passed through the lumen of the invaginated portion showing the course the blood took from the aneurysmal cavity into the descending aorta. A needle (2) is passed through the first rent (A) through which the primary invaginaticn took place and a needle (3) is passed through the second rent (B) through which thesecond invagination had taken place, a third needle (4 is passed from the cavity of the aneurysm into thecommencement of the innominate artery which was torn off’ from the aorta, and there is a needle (5) placed in the pericardial cavity lying in front of the parietal layer and partly concealed by the visceral layer of pericardium which had been forced away from the outer coat of the aorta. Remarks by Dr. ASHWIN.-The above case of rupture of’ the aorta is, I think, interesting, not only on account of the rarity of the accident but also because the distal portion was invaginated twice through two distinct rents in the coats of the artery in such a manner as to restore the lumen of the vessel so that the circulation was maintained and life pro-longed for five and a half hours after the occurrence of the rupture. As regards the cause of the rupture I fear I can. make no suggestion. The patient does not appear to havebeen making any violent exertion at the time of its occurrence and the aorta was remarkably healthy for a man of his; age, there being only two small patches of atheroma, one of which is marked 6 in Fig. 5. The brain was perfectly normal. I am indebted to Dr. Petch for permission to publish the case and to my senior colleague, Dr. G. W. Gostling, for his assistance and valuable suggestions at the.
represent
post-mortem I
examination.
Medical Societies. ROYAL ACADEMY OF MEDICINE IN IRELAND. SECTION
OF
ANATOMY AND PHYSIOLOGY.
P7zrenic Nerve.-Muscula.r fibres of the lessFibres of the Stomaeh.-Dislocation of Crystalline Lenses. A MEETING of this section was held on June 3rd, Dr. D. J. COFFEY, the President, being in the chair. Dr. J. BARTON read a short note on an Irregular Phrenic Nerve which came off from the fourth cervical and ran for one and a half inches in the trunk formed by the fifth and, sixth nerves, getting a branch from the fifth. It then passed downwards and inwards in contact with the posterior surface of the sterno-mastoid, crossed the subclavian vein oppositethe insertion of the scalenus anticus, and entered thethorax in front of the internal mammary artery and right. innominate vein and then passed down by the vena cava andpericardium as usual. He also referred to the frequency with which the phrenic nervepassed behind instead of in-
Iri-tltila,l,
pA,7,qli,s.--Ifitse?llar
_
_r’=._Showing the appearance of the invagination. ..
_
__
--
-
-
I",
---
turning in and passing through a second rent in the arterial walls into the lumen of the transverse aorta. Fig. 2 shows this second invagination just commencing, and in Fig. 3 it is fiecn at a further stage after passing through the second rent, yig. 4 showing it forced further through in the condition in
front of the internal mammary artery.-Professor BIRMING-HAM suggested that the phrenic had perhaps associatedt itself with the nerve to the subclavius for some distance in’ this specimen and exhibited a specimen illustrating the’ Course of the Left Phrenic Nerve in the Upper Part of the Thorax, which he thought showed the true position of the nerve at a part of its course which is generally neglected in the usual descriptions. Professor BIRMINGHAM read a paper on the Muscular Fibres of the (Esophagus in which he pointed out (supporting his views by several specimens) that the usual description. which made the longitudinal fibres of the oesophagus divide above into three bands, two of which were caic1 to be