A MIRROR OF HOSPITAL PRACTICE. HOSPITAL 1st BATTALION 11th REGIMENT. NOTES OP CASES OP ANEURISM.

By Surgeon-Major

J. Tulloch,

M.D.,

In Medical

Charge.

Since the arrival of this Battalion in India, in November These, are 1864, ten fatal cases of anenrism have occurred. shown in the following table :?

Admitted.

Yrs. Yrs. Yrs 31

Died.

39

35

37

38

2J 11

15

15

19

19th Dec. 1S6G.

27th Dec. 1866.

9

31st March 1869.

Cth April 1869.

5i 11th

14

9

34

C

11

10th

March 1872.

20th

1st 1873.

4th

18.

19th

1873.

Jan.

8ept. July

External iliac ar-

tery. Superior

mesenteric

artery. Abdominal aorta.

April

1870.

1873. 39

Dec.

1869.

7&

29

33

Nov. 17th

1869.

of

Aorta.

2

18

fected.

23th March Arch

9

1865.

21

Vessels af-

Arch aorta.

of

Remakes.

Died suddenly out of hospital from rupture of sac. Case detailed. Death from rupture of sac. Case detailed. Death from rupture of sac. Case detailed. Died suddenly out of hosfrom pital of rupture sac.

27th

Dec.

1872.

Arch of aorta.

1st Jan. 1873. ?

Abdominal aorta.

dys-

Case

related. Died suddenly from rupture

of sac. of Died suddenly out of hos-

30th Sept. 1863.

Arch aorta.

30th Dec. 1873.

of Arch aorta.

1st March 1874.

of Died pncea.

pital. Case detailed. Died of pnoea

dysand

exhaustion. Case detailed. Left ante- Case detailed. rior bral

tery.

cerear-

THE INDIAN MEDICAL GAZETTE.

124

In practice it has been found that aneurism, when it occurs in vessels within the thoracic and abdominal cavities, reveals itself in many instances by unmistakable signs and symptoms ; yet, cases arise where it is most difficult to arrive at a certain diagnosis Even among soldiers, in whom the disease is known to be much more common than in civil life, and where consequently it is more likely to be looked for, it is often unsuspected. Not unfrequently, it causes so little inconvenience to the sufferer, that he is seen by the medical officer for the first time when dying ; or is brought to the hospital dead. Aneurism of vessels within the cranium is most obscure. The following cases are illustrative and otherwise interesting. CASE I.-FALSE ANEURISM OF INTERNAL ILIAC ARTERY. Private J. R-, aged 21 years, upwards of two years' service, temperate habits, and two years service in India; had been in Hospital for 128 days, from June to October, with phagedaenic sore on the glans penis by which the organ was almost entirely destroyed. He was discharged cured from this disease on 31st October, and re-admitted on 16th November on account of pain, oedema or fulness in perineum and rheumatic pains in left hip and thigh. November 20>th.?Rheumatism better and swelling in perineum subsiding. The prepuce has become infiltrated with serum, and there is a nodulated feeling in substance of penis, as if All corpora cavernosa contained exudation of some nature. these conditions subsided after a time, and he was discharged on the convalescent 3rd December. December 19th.?Re-admitted, with return of pain in left hip and thigh, and sciatica from inflammation of sheath of sciatic " nerve was diagnosed, great pain in hip and thigh in position of that nerve and slight pain in abdomen above the pubis, not much increased on pressure" are noted. 22nd.?Yesterday and to-day has mentioned inability to pass anything from his bowels, and has had sickness of stomach and flatus; opening retching. The colon seems distended with medicine ordered last night has not acted. " Tongue has slight black coating towards base, but it is moist and natural otherwise; pulse 90." 23rd.?Complains very much of pain in his hip and thigh, with numbness and weakness of entire limb. Bowels have not been moved, and he has vomited the contents of his stomach twice. Abdomen tympanitic. lith.?Says he i3 getting worse, the pain and loss of power in his limb are increasing, and he " cannot pass anything through him, nor can he eat anything." Examination of abdomen shows continued tympanitis, but no great tenderness or other sign of peritonitis. He again refers to " pain extending across a line from crest of ilium on left side to beyond pubis on right side, and there is some slight comparative dulness in this region, but nothing definite can be determined." 25th.?Great pain in hip and thigh all night, and has tremor of the limb from this cause. No passage from the bowels and he has vomited twice. There is rather profuse discharge of glairy The finger introduced into the mucus from the rectum. gut detects some thickening towards left side ; but the examination that the no other fact, except elicits rectum, so far as the finger can reach, is perfectly free from faeces and even faecal odour. and in 26th.?Great pain leg thigh continues unabated, and whole limb tremulous, twitching and partially paralysed. Bowels not been moved and has again been sick. There is more tenderness on pressure in left iliac region. Pulse 100. Skin cool. Expression somewhat anxious and worn, but patient in good

strength.

2,7th.?Died suddenly and unexpectedly at 4

a m.

Post-mortem appearances, seven hours after death. Body emaciated, but not very much. Rigor mortis incomplete. Abdomen distended, giving tympanitic sound on percussion. Head not examined Chest.?Lungs healthy and free from deposit. Pericardium contained a large quantity of fluid. Heart structure healthy. Abdomen.?On laying open this cavity, the exposed surfaces of contained viscera were found almost covered with thick clots of dark colored blood, while behind was large quantity of

and clots. The large intestine was highly distended bloody with flatus, and its descending portion showed signs of recent inflammation. This portion of the intestinal tube contained a quantity of thick fluid of dark green colour with- very slight odour of faeces. The small intestines were contracted, as wa3 also the stomach, but their structure wa3 quite healthy, and they were free from any cause of obstruction. The abdominal viscera, serum

[Mat 1,

1874.

in such condition as that they could have perfunctions during life. On searching for the source of extravasated blood, an opening, admitting forefinger easily, was found a little to the left of middle line, between bladder and rectum, the finger introduced, passed backwards, outwards and downwards towards the ischium, and inwards, slightly behind the rectum. Around this sac, the tissues were thickened, and above but close to the great ischiatic foramen, was a hard mass 1 inch in thickness' consisting of fibroid tissue interspersed with fat. After prolonged dissection, facilitated by sawing through the ramus and body of the pubis, the sac was removed, and found to be a false aneurism, from rupture of tlie anterior branch of the internal iliac artery, at its bifurcation into internal pudic and ischiatic ; and which, from the appearance of the sac, must have existed for some considerable time. The vessel where it had given way, and for some distance above, was of dirty brown colour, the coats in a condition which the word " rotten" may best express. The internal coat of aorta from its origin to bifurcation was found of a bronze colour, interspersed with patches of brighter tinge, and peeling off readily with the fingers. This condition obtained in the pelvic arteries generally, but ceased at the femorals.*

generally, were healthy

formed

CASE II.?ANEURISM OF SUPERIOR MESENTERIC ARTERY. Private. J. D., aged 39 years, of intemperate habits, 11 years' service, nine of which had been passed in India, was admitted on 31st March 18G9, suffering from dyspepsia, the effects of a debauch. On the night of 6th April, he suddenly died with symptoms

of internal hasmorrhage. Examination of the body showed the cause of death to have been aneurism of the superior mesenteric artery, which had burst and allowed escape of blood between the folds of the mesentery, where it was confined, and to which extravasation was limited. The puckered appearance of the mesentery thus distended with coagulum was peculiar, resembling a lady'a old-fashioned work-bag, when well filled, and the strings tightly drawn. CASE III.?ANEURISM OP ABDOMINAL AORTA. Drummer T. D., aged 35 years, married, no history of syphilis, was admitted on the line of march on November 11th 1869, suffering with cramps in abdomen, which were usually relieved by anodynes and carminatives. A few days after admission, pulsation above the umbilicus was observed; but no bruit, thrill, or other anormal sign could

be detected. His bowels were confined, requiring frequent use of medicine. December 2nd.?Is still suffering as when admitted, has severe

spasmodic pains extending from umbilicus, to both hypochondria. 1th.?Appearance is anaemic, and he is evidently suffering from serious organic disease ; there is copious perspiration on his forehead, his expression is anxious, pulse feeble but quite regular, both in radials and femorals. The pulsation continues in abdomen, and there is some dulness on percussion over epigastrium and tenderness on pressure over the liver. Stethoscope does not detect anything abnormal; no sound whatever of aortic pulsation can be made out, either in front or behind. 9th.? No remarkable change since last report ; suffers occasionally from the abdominal spasm. Pulsation continues. Patient looks very ill, forehead bedewed with perspiration. llth.?Less pain last three days, but otherwise no change. Vespere.?Been very low ail day, countenance blanched, pulse feeble, surface cold.

13th.?To-day a new feature has presented itself, he is passing large quantity of pure blood per anum. It is surmised

that an aneurism has burst into the bowels. No abnormal sound can be detected by the stethoscope. 14 th.?Has not passed any blood since yesterday morning. 15th.?Passed large quantity of coagulated blood. The coagulum is moulded to shape of small intestine, the valvuloe conniventes being so perfectly represented, that the clot, which wa3 *

A certain diagnosis in this case would have been difficult, if, indeed if the symptoms which are recorded, and the anatomical arrangement of the parts are considered, there is much in the case?? "after the event"?that is instructive. It was, indeed, surmised that a tumour of some nature was present, but the youth of this patient, and absence of pulsation, misled suspicion of its being aneurismal. I did not see the sore on the man's penis until it had almost healed, but the question arose to my mind afterwards?was the slough which occurred

possible; yet,

was gangrene from imperfect nutrition of the organ, or, if syphilis, this disease communicated to the blood vessel which had ruptured in this

extraordinary

manner

?

Mat 1,

A MIRROR OF HOSPITAL PRACTICE.

1874.]

the blood escaping downwards and forwards, forcing the rpleura in front, near base of lobe. The aneurism about size of small orange, was not only embedded in the lung, but firmly adherent to it ; as if one-half of the sac had been formed of condensed tissue.

firm and tenacious that it could be handled, was mistaken for bowel. On applying the stethoscope to-day, a low, splashing sound can be heard. On the 16th he lost more blood from the bowels, and again on the 17th, when he died. so

lung

Post-mortem Examination.

Abdomen.?On laving open this cavity the following were the appearances :?Small intestines and mesentery of dirty pale color, stomach nearly empty and projecting forwards ; behind its walls and below its lower border, a large clot of blood, 'he transverse colon passed obliquely from right hypochondrium to left hypogastrium. The pancreas projected convexly, embracing a tumour to which it was firmly adherent. This tumour was adherent also, below, to first portion of jejunum. On dissection it was found to be an aneurism from front of

Sosterior

aorta,

just

above

origin

of renal arteries, which had burst into

abdominal cavity, and, allowed escape of blood, as described. It has also opened into upper part of jejunum by aperture, size of three penny piece. CASE

IV.?ANEURISM OF

THORACIC AORTA.

(The

nature of this case will be sufficiently clear from the detailed medical historv for invaliding laid before the Annual ?Medical Board on 12th December 1872.) "Private P. H., aged 30 years, of 19 years' service, eight of ?which in India, has a syphilitic history, been in hospital since 18th March, laboring under symptoms indicative of derangement of the respiratory and circulatory systems, pain in chest in b )th Mammary regions, cough and dyspnoea. Expectoration for months has been irregular and very scanty, and is not now a constant symptom. The sputa has been frothy and mucous, or muco-purulent. and on several occasions has contained blood. At times there has been severe bronchial spasm, lasting for days. From the first, there has been aphonia and dysphagia; the latter only wnen liquids are swallowed. The pulse has been equable, sometimes irritable, but usually natural and the same in both arms. Pupils natural. On percussion there is some flatness of sound on right side in front, and the respiratory Murmur is imperfect, as it is all over the chest There appears to be dulness on percussion above, and to the right of left nipple ; ^''S '3 no'; decided In front no bruit can be heard, but behind, between spine and posterior border of left scapula, there is a low prolonged murmur, which however is limited to about three inches. The man's complexion is often sallow or

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