44

by the plug which was found in the opening. This was evi-denced by the dulness of the base of the lung during life atthe first examination, and after death by the fact that theblood in this situation had undergone such changes as provedthat it must have existed there for some time. This view ofthe case is further borne out by the result of the second ex-amination two days after, when the whole of the left lung -wasfound to be dull on percussion, denoting that the entire organwas infiltrated with blood; and this is corroborated by the factthat the sanguineous effusion was found, after death, to have eundergone less change in the upper than in the lower part ofthe lung. Lastly, some sudden movement on the part of thepatient most probably di3placed, to a certain extent, the clotwhich had formed in the opening, and produced the suddengush of blood from the month and nostrils from which thepatient died. The main objection to this hypothesis is thefact that during life there was no haemoptysis, which, supposingthat the opening existed, ought to have been present. This,however, may be easily explained by supposing that the clotof fibrin which was found in the opening at the post-mortem,blocked up the bronchus during life in such a manner as toallow the passage of the blood downwards into the smallerbronchial tubes, but prevent its passage upwards through themouth. And the fact that during life no air could be heardentering the lung is sufficient ground for this supposition.Another objection which might be urged is the fact that therewere no definite symptoms indicating the time when the firstrupture took place ; but this also may be explained away bythe presence of the clot. The fibrinous plug, having formed be-fore the vessel gave way, filled up the weak part of the vessel,and thus, when ulceration did take place, prevented a suddengush of blood, which is the cause of the well-known symptomsof rupture of an aneurism.

KING’S COLLEGE HOSPITAL.ANEURISM OF THORACIC AORTA MAKING ITS WAY INTO

THE LOWER LOBE OF THE LEFT LUNG, WHICHTHUS FORMED THE SAC OF THE ANEURISM.

(Under the care of Dr. JOHNSON.)WITH the foregoing case the following, for notes of which.

we are indebted to Dr. Fenn, the house-physician, may beconveniently associated. It is an example of one of the leastcommon terminations of thoracic aneurism.

George M-, aged thirty-eight, a strong well-made man,was admitted on February 1st, 1866. He was of intemperatehabits ; and two years prior to his admission had rheumaticfever. About the middle of the summer of 1865 he sufferedfrom a dull aching pain in the left side, extending from themargin of the lower ribs up into the axilla; and the pain re-curred, with short intervals of relief, up to the time of hisadmission. During the winter he had a cough and shortnessof breath, and expectorated frothy white phlegm.On examining him, the chest-walls moved very slightly

during respiration, though equally on the two sides. Themeasurement of the two sides was equal-namely, nineteeninches. On the left side there was dulness on percussion overthe whole front and back of the chest; on the right side per-cussion was normal. No bulging of the intercostal spaces ofthe left side. There was complete absence of respiratory soundson this side, except at the extreme apex, where a slight expi-ratory murmur and an occasional friction-sonnd were heard.Puerile breathing on right side. Heart’s -apex beat one inchand a half below and to the outside of the left nipple; soundshealthy. Urine contained one-eighth albumen.During his stay in the hospital but little change took place

Iin his condition. He was very restless, sleeping but little, wing to the pain in the left side; and the physical signs re-mained much the same. He was discharged on March 15th. ’

The patient was lost sight of from this time until the eveningof December 2nd, when the house-physician was asked to goand see a man who was throwing up large quantities of blood,at his house in Clare-market. On arriving at the house hefound George M- dead, and a large quantity of bright fluid.blood on the floor. It appeared that he died a very fewminutes after the vomiting of blood began.The autopsy (conducted by Mr. R. T. Smith and Mr. Wilcox)

revealed the following condition :-Chest large, harrel-shaped;the right side more bulging and prominent than the left. Rightlung very large, extending over to the left side of chest ; leftlung far back in the chest, bound down tightly by old firmadhesions extending from the apex to the diaphragm. On re-

moving the lungs, the lower lobe of the left lung presented itsusual shape, concave below and convex posteriorly, and wascovered with a thick false membrane ; it had a semi-fluctuatingfeel on pressure. On cutting into it, it was found to form alarge cavity, filled with a semi-fluid mixture of pale and blackcoagula ; the wall of the cavity was about a quarter of an inchthick, formed by thickened pleura, indurated lung-tissue, andlayers of decolorised fibrin. On slitting up the aorta, a largeopening of an oval shape, about half an inch in diameter, wasfound leading into this cavity ; the edges of the opening werequite smooth, hard, and everted towards it. There was nodilatation of the aorta. The upper lobe of left lung was exca

vated into a number of small cavities, filled with grumous,gelatinous pulp, and lined with a thin yellow fibiinous mem-

brane. li,ight lung emphysematous. Spleen large, exhibitingseveral fibrinous deposits beneath the capsule, of a yellowish-white colour, surrounded by a red zone. Liver healthy.Kidneys granular. Stomach nearly full of blood.

Dr. Johnson, in a clinical lecture, remarked that when thisrnanwas in the hospital there were a11 the signs and symptomsof an ordinary case of chronic pleurisy. It was. however, re-marked that the heart was not displaced, but; its apex beatrather more to the left than normal. This, it was supposed,might be explained by adhesions of the external surface of thepericardium to the chest wall. Without doubt there was atthat time pleurisy with liquid effusion, but the actual cause ofthis-namely, the pressure of an aneurism in the interior ofthe lung-was not suspected. The changes which had occurred

since the man left the hospital were chiefly these : a gradualenlargement of the aneurism, absorption of the liquid from theleft side of the chest, great thickening of the pleura, and con-traction of the side. As the stomach contained a large quan-tity of blood, it is probable that the aneurism had opened intothe œsophagus, but this was not ascertained at the post-mortemexamination.

Provincial Hospital Reports.SHEFFIELD PUBLIC HOSPITAL AND DIS-

PENSARY.STRANGULATED HERNIA OCCURRING IN A PATIENT

SUFFERING FROM HEMIPLEGIA.

(Under the care of Dr. FRANK SMITH.)FOB. notes of the following case we are indebted to hlr.

Henry Brietzeke, house-surgeon :-S. C-, aged thirty-five, table-blade striker, admitted

June 13th, 1866. States that he had a sudden attack of

paralysis while at work on the 4th of April last, which de-prived him of the use of his left side. On admission he was

suffering from perfect loss of motion of the leg and arm, andslight affection of speech. There was a reducible hernia on

the left side. During his stay in the hospital he improvedconsiderably under treatment, so much so that he was able towalk about with the aid of a stick; no power, however, wasgained in the arm. He has been ruptured for thirteen years,but has never worn a truss, although the gut frequently de-scended into the scrotum.On Oct. 13th, at four P.M., while walking in the grounds,

he felt his rupture suddenly slip down in larger quantity thanhe had ever noticed before, and after trying for some time toreduce it sent for assistance.On examination a large nuantitv of intestine was detected

in the scrotum; the tumour was pyriform in shape, about thesize of a large cocoa-nut, and on coughing no impulse wastransmitted. He looked pale and nervous, and complained ofgreat pain in the groin; the bowels had acted once the daybefore. The taxis was applied without success ; subsequentlyforty drops of sedative liquor of opium were administered, anda warm bath ordered, but no relief was obtained ; he vomiteda bilious fluid, and the pain increased in severity. At ten P.M.an operation was decided upon. Mr. Arthur Jackson accord-ingly cut down and exposed the sac ; he then divided a con-striction at the internal ring, but the tumour could not bereturned; the sac was accordingly opened, some tight bands ofadhesion divided, and the rupture returned. The constricted

portion of intestine was of a dark port-wine colour. It wasdeemed advisable not to administer chloroform, but Dr.