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of the lips, and cheeks are blanched and pallid, The skin was of the same straw-yellow coland on them are visible a few ecchymoses of our noticed during life; the sclerotics of a minute size. The tongue is dry and fissured, pearly white. Rigor mortis was but little chiefly transversely, with some blood caked | marked, and there was an absence of cadaveric on it. The lips are dry, and similarly covered staining. The abdominal parietes were covwith dried blood. This seems to have come ered with half an inch of yellow fat, and there from the fissures in her tongue, as there has was but slight emaciation of the extremities. been an absence of all hæmoptysis or hæma- The lungs were pale, but free from morbid temesis. Thirst is a prominent symptom. changes. The stomach is irritable, and although actual vomiting is not present, it was stated to have been so before admission to hospital, and fiuids alone are tolerated, and that in small quantities at a time. She is, however, able to take beef-tea, milk, eggs, and wine. The bowels are costive, and the abdomen is tympanitic, though not hard and resistant. Pain and tenderness on pressure over the epigas-condition of the heart was not unnoticed by trium exist, but the most careful examination fails to detect any cancerous tumour of the stomach, or any enlargement of the liver or spleen.

Respiratory System.-There is a total absence or any abnormal breath-sound, or of any interference with the free expansion of the lungs. However, the breathing is short and hurried on any exertion, and she cannot breathe easily while lying on the right side-hence her attitude is either dorsal or on the left side.

The Circulatory System.-The pulse ranged from 92 to 102, and was small and compressible. Loud venous murmurs are audible in the neck. Faintness and panting breathing follow the effort to sit up or any sudden movement. The heart's impulse is in the normal position; the area of cardiac dulness is somewhat less than normal; there is no thrill on palpation; a soft systolic murmur, probably hæmic in nature, is audible at the apex and carried slightly into the axilla.

The urine when examined on the 22nd was acid, of sp. gr. 1,017, free from albumen and sugar and all deposit. The colour, which was darker than might have been expected, became deeper and more pronounced on the addition of nitric acid.

The heart was normal in size, with some yellow fat on its surface. Its muscular tissue was far advanced in interstitial fatty degeneration, and the internal surface of the left ventricle, and especially the musculi papillares, presented a typical example of the striated or zigzag appearance to which the name of "tabby mottling" has been applied by Dr. Quain. This

Addison, and is the most constant anatomical condition in idiopathic anæmia-so much so that some observers doubt the existence of the disease in the absence of this pathological change. The valves of the heart were healthy. A large, soft, pale clot occupied the right auricle; and some fluid, thin blood was removed from the vena cava for microscopical examination.

The liver was somewhat enlarged and dotted over with small, yellow-white bodies the size of hempseed, which were also found deep in its structure. They were unaccompanied by any surrounding change, and looked like a number of minute emboli or lymphatic growths. Their nature was, however, proved to be granular, and as if composed of the débris of a caseous degeneration. It is very probable that they were embolic in nature, and derived from the spleen. This organ was a little larger and firmer than normal, and otherwise healthy, except that at its upper end was found a nodule the size of a small marble, which, while firm on its outside, was undergoing caseous degeneration in its centre, and presented all the characters of a scrofulous tumour in a state of caseation.

The kidneys and suprarenal bodies were apHer temperature was subfebrile, viz.: parently healthy, and no structural change Feb. 21st.-Evening-Temp. 101'4°; pulse, could be discovered in the stomach or intestinal 92. 22nd.-Morning-Temp. 100'4°; pulse, 96. canal beyond a congested condition of the Evening Temp. 100'6°; pulse, 94. 23d. stomach near the pylorus. The duodenum was Morning-Temp. 97'8°; pulse, 92. Evening-free from all parasites. The pancreas appeared Temp. 100'4°; pulse, 112. 24th.—Morning— to be healthy. One ovary was slightly cystic, Temp. 99°; pulse, 104. Evening-Temp. 99'2°; but there was a total absence of any cancerous pulse, 120. 25th.-Morning-Temp. 100°; disease, or lymphatic hyperplasia in any of the parts of the body examined.

pulse, 112.

Treatment consisted in nutritious food and stimulating tonics; but the patient never really rallied, and died of asthenia on the 25th.

Post mortem examination was made nine hours after death. The thorax and abdomen were the only cavities opened.

The brain was not examined, nor were the long bones laid open, nor the fundus oculi exposed.

The blood removed from the right auricle was immediately placed under the microscope and found to present many of the characters

supposed to be peculiar to idiopathic anæmia. It contains fewer red corpuscles than normal -some few were large and tailed, and many small, with no increase of white cells.

Ecchymoses have been observed in the skin in some few cases, Dr. Pye-Smith tabulates but seven out of 102 cases, and, as occurred in my case, the bleeding is usually but slight and punctiform.

The diagnosis of idiopathic anæmia to which I inclined during her life became absolute when the post mortem revealed the complete absence of any organic disease which could be deemed adequate to produce such a profound state of bloodlessness and debility. The morbid anatomy of this variety of anæmia may be simply stated to be either of an entirely negative character, or else that consequent on the anæmia, since to this latter category belong the punctiform hæmorrhages on the skin, the mucous membrane of the mouth or stomach, and on the retina, the changes noticed in the marrow of the long bones, and the tabby mottling of the muscular structure of the heart.Dublin Four. Med. Sci, July.

ON A CASE OF PATENT DUCTUS AR-
TERIOSUS, WITH ANEURISM OF

exertion, and her dyspnoea was little, if anything better; also the noises in her head and chest distressed her very much. On placing the stethoscope over the base of the heart, to the left side of the sternum, in the region of the second intercostal space, two loud murmurs were heard. The first murmur, which was very loud and blowing with a decided thrill in it, accompanied the systole of the heart, and at the same time a strong heaving impulse was communicated to the stethoscope. Just before this murmur ceased a distinct "click" was heard, and then immediately a second murmur, but of a softer nature and of shorter duration than the first murmur, was heard. On moving the stethoscope to the aortic area, the murmurs were still very distinctly heard, but the click which, as I have said, joined the two murmurs together was heard much more clearly, and I believe indicated the quick and sudden closure of the aortic valve. How the murmurs themselves were produced I could not at this time venture to say. They were heard also at the apex of the heart, but not nearly so loud as at the spot already stated. The point of maximum intensity of both murmurs was to the left of the sternum between the second and third ribs.

I learned that about six years previously she had an attack of scarlet fever, but she could not say that her health in any way was worse after the attack. No history of rheumatic affection. I advised my patient to give up all unnecessary exertion, and to rest as much as possible, and to continue taking the iron and arsenic for another month. At the end of a month she was looking greatly better. Her face and lips showed that her anæmia had quite disappeared. She still had great breathlessness on exertion, and complained much of the noises in her head and chest.

On listening over the base of the heart to the left of the sternum, in the second intercostal space, a strong heaving impulse was communicated to the stethoscope with the systole of the heart, and both murmurs, as already described, were heard with extraordinary clearness

THE PULMONARY ARTERY. BY JAMES FOULIS, M.D., EDINBURGH. ONE morning, early in 1882, a young girl came to my consulting-room for advice for the following distressing symptoms: Great palpitation of the heart on slight exertion, breathlessness, and buzzing noises in her chest, in her head and ears. She was very nervous, and her face bore an extremely anxious expression. Nose and lips were pale, with a slightly bluish tinge, and the conjunctival mucous membranes were very anæmic and flabby. There was no cough. Concluding from her pale face and lips that her symptoms were in a great measure due to bloodlessness, I made a very superficial examination at this time; but on placing the stethoscope over the base of the heart, I heard a loud blowing murmur, and at the same time felt a strong heaving impulse accompany the I never heard anything like those murmurs heart's systole. Immediately following the systolic murmur, another softer murmur was heard. These extraordinary murmurs puzzled me very much, as they were not at all like the ordinary humming murmurs of anæmia. I at once prescribed iron and arsenic and rest, and in three weeks time her face and lips showed that she had gained much blood, and that her general health had greatly improved; but on examining her heart at its base, to my intense surprise, I heard the murmurs louder than they were before, and much more marked in every respect. Her pulse was fairly good and quite regular. She still complained of palpitation on

before or since. At the apex of the heart the murmurs were not so loud as at the spot indicated; and in the aortic area, while the click joining the two murmus was very distinct, the murmurs themselves were but slightly diminished in intensity.

Being very much puzzled as to the cause of these murmurs, which, be it borne in mind, were much louder and better marked since the girl's anæmia had disappeared, I thought it would be interesting to hear what Dr. George Balfour had to say; he came to the conclusion that the case was one of patent ductus arteriosus, but at the same time confessed that his

diagnosis was founded upon hypothetical amination a loud, continuous, rough friction rather than well-known scientific data.

At this time Dr. Wyliie kindly took me to see a case in the Infirmary which was of great interest. The case was believed to be one of patent ductus arteriosus. I had an opportunity of examining this girl immediately after seeing my own patient. On auscultation in the second left intercostal space two loud murmurs were heard very like those described as existing in my own case, but both murmurs seemed coarser and rougher, and the girl herself had a very healthy, even ruddy appearance. My patient went into the country and I did not see her for two or three months, but I heard from a friend that he had been called to treat her for hæmoptysis and bleeding at the nose. From this time her health began to fall off greatly; she suffered much from cough. Feet were occasionally swollen, and she became very anæmic. Patient suffered greatly from breathlessness and cough, and she often coughed up some blood, and had several attacks of bleeding at the nose, and was now extremely pale and weak. She was rapidly getting worse. Aug. 31 I saw her at 8.30 P.M. What struck me at once was the quickness of her breathing. Pulse 120, and resps. about 54. On examining the chest there were crackling, moist sounds on both sides in front and behind; there was constant cough, with some frothy and bloody expectoration. The veins in the neck were much distended. Could not lie down, but was kept in bed propped up with pillows. On placing the stethoscope over the base of the heart on the second intercostal space, a very strong heaving impulse was communicated to the instrument, but, to my great surprise, both loud murmurs had almost entirely disappeared. The heart was violently wobbling about and striking against a large area of the chest wall, and occasionally I heard two sounds which I can best describe by the words "filupp," "flupp," pronounced quickly. I came to the conclusion that all the cavities of the heart were extremely overgorged and in a state of tension.

sound was heard all over the cardiac area. Pericarditis had evidently set in. After her return from the country I did not again hear the remarkable murmurs. They had entirely disappeared; but it was often possible to hear the "filupp," "flupp" sounds during the violently wobbling action of the heart. She died Sept. 25, thoroughly worn out and exhausted, 22 years of age.

Post-mortem Sept. 27, 1882: The body was 5 ft. 14 inches in length. Circumference just below the level of the mammæ 2734 inches. Body was delicately formed, rather emaciated. Mammæ rather small. There were evidences of commencing putrefaction, abdomen being distended and tympanitic. Skin over the abdominal region being greenish blue in tint. The same tint of skin was seen on the throat. Rigor mortis still slightly present in the legs, but absent in neck and upper extremities. The legs below the knees were somewhat œdematous, pitting on pressure being best marked above the ankles. On proceeding to examine the chest, the skin over the costal parietes was first reflected before the thoracic or abdominal cavities were opened into. The chest wall was then transfixed with four long barbed crotchet needles at the following points:

Needle No. I was driven into the second left intercostal space, exactly at middle distance between the two cartilages, at a spot one inch to the left of the sternal margin. Needle No. 2 was inserted in the same intercostal space exactly between the two ribs, but at the distance of 1⁄2 inch from the left margin of the sternum. Needle No. 3 was inserted into the third left intercostal space, exactly at mid distance between the third and fourth ribs, at a spot 1⁄2 inch from the left margin of the sternum. Needle No. 4 was inserted in the second right intercostal space, mid way between the ribs, at a spot 1⁄2 inch from the right margin of the sternum. These needles, being thus fixed in position, were driven deeply inwards in a vertical direction, and the costal cartilages were divided in the usual way on each side, and the sternum with the attached cartilages and soft parts was removed. The needles, being fixed by their barbed points to the cardiac tissues, were left attached to the heart after the sternum had been removed.

The pallid face and bloodless and bluish lips showed that she was extremely anæmic and somewhat cyanotic. Day by day she lost more blood in the frothy expectoration. Her urine, which was very scanty, contained onefifth albumen. She was at times delirious. On thus removing the sternum the needles She was not allowed to take any food but milk which had been inserted to the left side of the and water with white of egg. For some time sternal bone were all found to enter directly she showed a decided improvement, but the into the anterior surface of the pericardial sac distressing cough, with bloody expectoration, without piercing the margin of the left lung, never left her. Some days better, some days which lay close, inch, to the outer side of worse, she lingered on until Sept. 20, when she needle No. I. On the other hand, the needle began to complain of sharp cutting pain in the No. 4, which was inserted half an inch to the region of her heart; and on stethoscopic ex-right of the sternum in the second intercostal

space, transfixed the margin of the right lung in its upper lobe 3/4 inch to the right of its free edge. Having thus transfixed the lung, this needle passed into the surface of the pericardium close to the right margin of the sac. The pericardium was next opened. The sac was found to contain about 1⁄2 pint of bloodstained serum, and the serous membrane, parietal and visceral, was found to be coated with a delicate villous layer of soft and recent lymph, which extended in patches over the whole surface of the heart and its containing sac. The following was now found to be the positions of the needles: Needle No. 1 pierced the anterior surface of the pulmonary artery about its middle, and at a spot about 4 inch above its valve. No. 2 transfixed the aorta immediately above its valve, passing immediately to the right of the pulmonary artery before piercing the aorta. No. 3 pierced the conus arteriosus I inch below the pulmonary valve, and at a spot 4 inch to the right of the middle line of the conus arteriosus, and then passed backwards through the interventricular septum, and transfixed the left ventricle about an inch below the aortic valve. No. 4 passed through the pericardial sac at its outer limit, and merely transfixed a portion of the right wall of the heart without entering its chambers.

The Heart as a whole was much enlarged, measuring in length from pulmonary valve to apex 434 inches; and when flattened out, it measured in breadth across its middle 41⁄2 inches. Its muscular substance was a good deal softened by putrefaction. There was evident hypertrophy of both ventricles, the left wall measuring inch in thickness, and the right wall measuring 3⁄4 inch in thickness. The ventricular cavities were both considerably dilated. The auricles were not pierced by any of the needles. The left auricle was only slightly dilated, and its appendix was empty and flaccid, being in position behind and to the left of the pulmonary artery, and quite overshadowed by the aneurism on the pulmonary artery to be presently described. The appendix of the left auricle as a whole was large enough to contain easily the point of the forefinger, but the cavities of its fringe-like margins were not large enough to permit the entrance of the little finger point. The right auricle was considerably dilated, except as regards its appendix, which was of natural size.

much congested and enlarged, and were softened by putrefaction; otherwise they were natural.

The heart, pericardium, and great vessels, were now removed and carefully dissected, without severing the connexion of the heart and its great vessels.

The following was found to be the condition of the great vessels: The Conus Arteriosus was very considerably dilated. When the pericardium was first opened its anterior surface was found bulging forward with unnatural prominence. The Pulmonary Artery measured from the base of its valvular cusps to its bifurcation, 25% inches. At the bifurcation the ductus arteriosus communication with the aorta was patent; the orifice of communication being large enough to admit freely a goose quill.

The Ductus Arteriosus was represented by a very short vascular trunk about inch in length. When viewed externally its narrowest diameter appeared to be about inch. At its aortic attachment there was a bulging of the aortic wall, which corresponded with the funnel shaped opening of the ductus arteriosus on the inner wall of the aorta.

The Pulmonary Artery, as a whole, was found to be dilated to at least twice its natural size, but this dilatation was not uniform in all directions, for whilst the posterior, right lateral, and anterior walls presented no special bulging or marked irregularity of outline, the left lateral wall from the ductus arteriosus close down to situation of the pulmonary valve was bulged in an outward direction towards the left, and at the lower limit, where the bulging was greatest, a regular aneurismal sac was formed about the size of a large walnut. This sac was contained within the pericardium, and, as already said, lay in front of the left auricular appendix, which it entirely hid from view.

The needle No. 1 transfixed the middle of the pulmonary artery, about 3/4 inch to the right of the aneurisma sac. The sac was filled internally with pretty firm coagulum, and from the sac this coagulum extended along the surface of the left anterior wall of the artery to near its bifurcation, being bound to this wall by pretty firm adhesion. A conical prolongation of this clot partially blocked the lumen of the ductus arteriosus. Externally, the part of Right lung, especially at its upper lobe, con- the sac which was contained within the peritained a number of old and indurated infarc- cardium was covered with abundant inflamtions of a grayish red colour. Both lungs matory lymph of older date than the lymph were greatly congested and oedematous, with effused on the pericardial surface generally. a feeling of partial consolidation, probably the This lymph was deeply stained with blood result of catarrhal pneumonia. Liver was colouring matter, and formed firm adhesions natural. Spleen was greatly enlarged, 8 inches between the aneurismal sac and the parietal in length by 4% in breadth. Kidneys were | layer of the pericardium.

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