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consolidation, by successive deposits of fibrin. The previous history of the case is short. In July last, the gentleman, who was leaving Ireland, came to thank me for my long attendance upon him, two years before, for a stomach affection. I had not seen him for these two years, and he told me that, during that time he had suffered from intense neuralgia in the back and shoulder, along the back of the neck, and in the back of the head. For this he had been treated in various ways, and he had used large hypodermic injections of morphia, which gave him a good deal of relief; but, after some time he was obliged to give them up, from the intense itchiness of skin which they caused. He then appeared to be well, and had not suffered much from neuralgia for some time. He was a Presbyterian chaplain in the army, and was going over to take charge of troops at Shorncliffe, in England. He mentioned to me that he had little mark on his chest, beneath the right collar bone-a dusky spot, about the size of a five-shilling piece, as if he had got a bruise, and asked me to look at it. Upon examining it, I
, detected a distinct pulsation underneath, and came to the conclusion that he had a thoracic aneurism. But for the pulsation, however, it would have been impossible to detect an aneurism. There was no sign of pressure—no murmur, no difficulty of deglutition, no dilatation or irregularity of any vessel. There was no sign of interference with either recurrent nerve, and his voice was natural. The impulse of the aneurism was, if
anything slightly in advance of the heart's impulse, as if the commencement of the contraction of the heart acted
the aneurism before the apex of the heart struck the walls. This I have observed in two instances of aneurism of the aorta. There was no double impulse, and no murmur or bruit. He complained of little or no pain, except a burning sensation. I told him that I thought he was not fit for duty, and explained to him, to a certain extent, the nature of his illness—that an effort should be made to cure him ; and I suggested a consultation with Mr. Tufnell, who concurred in my diagnosis that it was an aneurism, and most probably of the arteria innominata. As I considered that this gentleman was likely to be benefited by the treatment which Mr. Tufnell has so ably advocated, we explained to him the nature of the treatment. He said that he would be glad to adopt it. He assumed the recumbent position the last week in July, and continued it until the middle of October. I had to leave town myself at the beginning of August, and Mr. Tufnell was then kind enough to take charge of the case. The patient took little or no medicine, and we did not give him any iodide of potassium ; but when he was under my sole care, and occasionally when his heart beat a little fast, he got small doses of aconite, which reduced the frequency of the pulse a good deal. The principal treatment consisted simply of the horizontal posture, absolute rest, and a minimum of liquids, his food consisting as much as possible of solids, so as to diminish the quantity of blood, and at the same time keep up its bealthy condition. He bore his confinement very well; but, in the beginning of October, he began to show signs of great restlessness, and I thought it better not to confine him any longer. He began to get up,
and gradually to go out; but became sleepless, and got into a state of great mental depression, fearing that he would be put on half pay,
and that he would be arrested for debts which really he did not owe. Mr. Tufnell and I now advised him to apply for additional leave of absence, thinking that the aneurism being now very much consolidated, a little more rest might enable him to go back to his duty. He applied for additional leave, and on the very day before the occurrence of the unfortunate act which terminated his life, went before a medical board; the leave of absence recommended was granted, but of this he could not be made aware, as the proceedings are private. He was now advised to go to the country for change of scene, and his friends were taking him there, when, at the Railway Station at Kingsbridge, he became suddenly excited, ran away from them, and threw himself over the wall, which is twenty-four feet in depth, into the Liffey. He was not killed by the fall, but the water in the river was shallow at the time, and he was immersed in the mud. From this he was extricated as speedily as possible, and taken to Dr. Steevens' Hospital, and after lying there for about two hours, he died. I did not see him myself, but was informed that no impulse could be detected over the aorta, but he got a violent cough, which was characteristic of pressure. The Coroner directed a limited post mortem examination to be made, which gave the opportunity of ascertaining exactly the site of the aneurism and the result. While undergoing treatment Mr. Tufnell and I came to the conclusion that the aneurism had undergone a great deal of consolidation, although to what extent exactly we could not tell, because there was still a strong impulse, It, however, gave the impression of a solid tumour striking against the sternum, and we could not feel any signs of lateral dilatation whatever. The centre of the impulse was about the edge of the sternum, between the cartilages of the first and second ribs, extending about an inch and a half in each direction; and there was also marked dulness on percussion. The heart was slightly displaced and pushed downwards, the
apex beating between the sixth and seventh ribs, a good deal to the left of the nipple and over a considerable surface ; and there was also some amount of dulness on percussion over the region of the heart. We came to the conclusion that the heart was slightly enlarged. Upon inspection by sectio cadeveris, a solid tumour was found, occupying the entire mediastinum, and firmly attached to the under-surface of the sternum and the cartilages of the first and second ribs. A portion of the sac of the aneurism being adherent to the under-surface of the bones, it was supposed at first that the shock of falling twenty-four feet had burst the sac of the aneurism, but it was found that there had been no rupture whatever, nor were there any signs of extravasation of blood. The heart itself was covered with fat, and to some degree enlarged, flat, and flabby. On opening the left side of the heart the wall was found to be
thin and the cavity a good deal dilated ; but the valves were perfect,when we opened the aorta, we found it very much dilated and altered by atheroma in a marked degree, with dilatation almost amounting to true aneurism. Upon slitting up the aorta, we found that the original aneurism occupied almost the entire of the arteria innominata. At the back of it the vessels were pervious—namely, the subclavian and the carotid on the right. Those on the left were also perfect; but the descending aorta was very atheromatous; and at a distance of between three or four inches, there was another small aneurism, the size of a walnut. This we could not diagnose during life ; but it, too, was all but filled up with fibrin. The principal interest in the case lies in the manner in which the aneurism was cured. The layers of fibrin were very firm, and closely laminated, the layers of it being almost as thin as sheets of paper spread one over the other. It is a most interesting example of what may be done by the absolute rest and other items of treatment advocated by Mr. Tufnell – in fact, this aneurism was cured. This case ought almost to have been Mr. Tufnell's, for he had more to say to the treatment; but as the patient was mine at the first and the last, I have laid the case before the society. The age of the patient was fifty-six.
DR. BOOKEY said that the lungs were congested, and had a good deal of frothy fluid in them, such as is met with in the lungs of a person who has been drowned. The patient, who was a heavy man, sixteen stone weight, had fallen twenty-four feet, and was found lying on his face. He died within two hours after he was received into the hospital, and breathed, it was stated, all the time he was there.
MEDICAL AND SURGICAL Cases OCCURRING IN THE PRACTICE OF THE
MONTREAL GENERAL HOSPITAL.
Gunshot Injury of Femoral Artery-Ligature. Under the
care of Dr. WILKINS.
(From Notes taken by Dr. BURLAND, Assistant House Surgeon.) J. McC., æt. 22, was admitted into the Montreal General Hospital 9th August, 1877, under the care of Dr. Wilkins, suffering from the effects of a bullet wound in the right thigh. The accident occurred in this way: Patient had a revolver at full cock in his hand, which he was about to place in his coat pocket, but before doing so forgot to let down the cock, and the trigger caught in the side of the pocket, causing the charge to
explode, the ball entering the right thigh about 24 inches below the anterior superior spinous process, taking a course downwards and inwards, becoming superficial in the inner aspect of the thigh about five inches below the crutch, where it was easily extracted by a small incision.
Patient is one of a family of six, all of whom are healthy except one sister, who is subject to rheumatism. Father and mother both living. Has followed the trade of tinsmith for several years ; has never been intemperate, and has enjoyed good health. Height 5 ft. 7 in,; weight about 133 lbs. On examining heart, a systolic basic murmur can be heard. The copious hæmorrhage which took place immediately after the accident had stopped before his arrival in hospital, and as there was almost no bleeding then, nothing further was done than to apply ice over the track of the wound. The case seemed to do well until a couple of days after (11th Aug.), when swelling was perceived over the femoral artery as well as to its inner side. Upon palpation pulsation was distinctly felt, accompanied by a thrill. Auscultation revealed a moderately loud bruit. No pulsatiou could be felt in popliteal artery, but there was pulsation in a small artery lying somewhat posterior to the usual situation of the posterior tibial. The leg retained its normal temperature.
These conditions revealed what we were before doubtful ofthat is, that an artery was injured and that a traumatic aneurism was forming
The next two days (Aug. 12 and 13) the swelling continued to increase and the temperature commenced to rise, reaching on the evening of August 13, 1020.2. The injured leg over affected part was three inches more in circumference than the left leg.
As it was decided (Aug. 14) to cut down upon the injured vessel and tie, the patient was etherized, and after completely emptying the leg of blood by elevating it and applying a roller, Esmarch's elastic ligature was firmly applied to the highest point of the leg, part of the ligature encircling the pelvis. Dr. Wilkins now made a free incision, about four inches in length