its normal size; no pleuritic adhesion anywhere. Right lung rather full and upper part thoroughly melanotic (grey), lower part congested, not hypostatic; pleuritic adhesion above right nipple. Arch of aorta very prominent and thoroughly adherent to chest wall, as were all surrounding tissues, commencing opposite space. between second and third ribs. When exposed it was found one immense aneurismal mass, extending backward and downward, springing from left lateral and posterior walls of arch and descending aorta, and extending downward behind heart to diaphragm, involving in its upper portion the origin of left subclavian artery, left bronchus, œsophagus and all contiguous parts. On opening the aneurism it was found the anterior part was a large sack, and the posterior portion filled with layers of semi-sanguineous and fibrinous clots, estimated between a pint and quart in quantity. Where the mass rested on the left bronchus an eroding ulcer had opened into the bronchus which would easily admit of the index finger and did not seem recent. REMARKS. Of the many questions of interest which this case suggests I wish briefly to call attention to First-Its probable cause. Third-Symptoms and their interpretation ante and post-mortem. 1. Inflammation of contiguous parts would seem to have been the cause of the original weakening of the artery. Atheroma is the commonly assigned cause, but good authority sustains the claim of inflammatory origin. It is suggested by this case that pleuritic inflammation may be a more frequent cause of aneurism of the arch of the aorta than is usually regarded. It would seem strange that this peculiar site should be so frequently occupied by this form of disease, unless this be its explanation. The great frequency in England and its occurrence in the person of an Englishman also suggests nationality as a cause. It would be interesting to look up the history of American cases and test this idea. Fatty degeneration on account of his quiet life in later years may have played a part in weakening the vessel. 2. Difficulty of detection: Accompanied with an apparent inflammatory origin and symptoms pointing seemingly to inflammatory conditions rendered the case very misleading, and without the use of the laryngoscope it might have gone undetected till the autopsy, and brought discredit to our profession and sad reflections to friends. It would seem to indicate, when we consider how much can be learned of other diseased manifestations by it, that the laryngoscope should be brought constantly to our aid in persistent chest affections. In other words, physical diagnosis is not complete without it. 3. The symptoms and their interpretation: Cough, hoarseness and expectoration do not necessarily indicate laryngeal disease. As witnessed in this case, and many cases of laryngeal paralysis, the strained effort in phonation caused the laryngeal congestion and hoarseness, because of imperfect formation of glottis. Sounds in the chest also may not always originate in the lungs, as rales in this case originated in the larynx from want of tension of the vocal bands. Apparent congestion and engorgement of the lungs, as indicated by the suppressed respiratory sound and percussion resonance on the left side of the chest, together with dyspnoeahemoptysis, fixed pain in the side and running through to the back, were found to be the result of obstruction by the pressure of aneurism upon the left pneumogastric nerve and the bronchus and its attending vessels. In other words, mechanical in origin and not the result of the inflammatory processes; explaining how his left lung appeared to clear up after the first hemorrhage, and collapse, for the time, of aneurism. The occurrence, quantity and control of hemoptysis, even after the most positive diagnosis of aneurism, was very much calculated to disturb one's faith in it. The explanation offered in writing to his physician was correct, minus that relative to the relief of an engorged lung, since it was developed by sectioncadaveris that there had been no engorged lung. EXTIRPATION OF THE KIDNEY-REPORT OF A CASE, WITH REMARKS. BY L. N. DUNNING, M. D., SOUTH BEND. The patient, Mrs. H., aged forty-six, underwent the operation of nephroraphy October 30, 1884. The kidney was fixed at the time of the operation by eight sutures, three of which passed through and included the renal capsule. These latter untied and loosened within the first twenty-four hours after the operation, and on this account I think the kidney was not firmly anchored. However, three months after date of the operation, the kidney was movable only to the extent of one inch in a transverse direction. The symptoms for the relief of which nephroraphy was done, viz., pain and vomiting, were for a time relieved, but after a few months gradually returned, and at the end of one year were more severe than they were before any operative procedure was resorted to. During the last year the symptoms progressively increased until they had become so grave as to threaten the life of the patient. The pain is located upon the right side in the hypochondrium and right lumbar region, and sometimes extends downward into the right groin and hip. The pain is for the most part of a dragging, pulling character, though sharp lancinating pains sometimes shoot through the right side. Vomiting occurs three or four times after each meal. For the relief of the vomiting every known means at our command had been used, including diet, medicine and lavage, all to no avail. The patient had become much emaciated, though not bed-ridden. The abdominal walls were so much relaxed, the outlines of the lower border of the liver could be easily felt, and the left kidney, though entirely fixed and normal, could be unmistakably and distinctly palpated. To this fact numerous physicians of our city will bear testimony, as they were invited to examine the patient on account of this rare condition. Frequent examinations of the urine had revealed nothing abnormal except that at times it would be scanty and of high specific gravity, and at other times very abundant, and of low specific gravity. February 22, 1887, assisted by Drs. Hitchcock and Burchard, the kidney was extirpated by the writer. Two incisions were employed, one transverse, commencing two inches to right of the spinal column and extending four inches in a direction nearly parallel to the twelfth rib and about one-half inch below it; the other, a vertical one, beginning at the starting point of the first one and extending downward to the crest of the ileum. By means of these incisions the kidney was easily reached, though we experienced some difficulty in keeping the colon out of the way. The peri-renal adipose tissue was torn through, and the kidney, invested by its capsule, brought into the incision. It was carefully examined for calculi, both by touch and with the needle, but none were found. The pedicle was tied, first with a double ligature, i. e. one around the ureter and another around the vessels, then a stout ligature including both. The pedicle was then cut off next to the kidney and dropped. There being no hemorrhage, the wound was quickly closed by sutures. A drainage tube was left in the wound and an antiseptic dressing applied. The patient rallied well and went on to speedy recovery. For the first few days she was nourished almost entirely by enemas. After a few days time, water and milk were given in small quantities and retained; after a time beef extract was given, then boiled rice. The remaining kidney took the double work thrown upon it, and performed it without apparent disturbance. The wound healed speedily, with little suppuration. All circumstances combined to make the patient's recovery both safe and comfortable, so that at the end of four weeks she was able to leave her bed a part of the time. The kidney which was removed was carefully examined by Dr. Hitchcock, who reported to the writer that the kidney was normal in every respect, except that upon the posterior surface, near the external border, there was found cicatricial tissue, limited to an area of one inch in length, one-quarter of an inch in width. and one-quarter of an inch in depth. The weight of the kidney was five ounces. The accompanying table is an accurate record of the case for thirty days after the operation. It may be found to contain some points of interest, particularly those relating to the action of the left kidney. RECORD OF PULSE, TEMPERATURE, AND OTHER ITEMS, In a case of Nephrectomy for the first thirty days after the operation. Patient aged forty-six years. Operation February 22, 1887, 8:30 a. m. Date. Temperature. Pulse. MISCELLANEOUS. 62 Patient rallied somewhat; very drowsy; surface warm; considerable nausea. Urinated at 8 a. m., before operation. 99.0 90 78 8:30 p. m. Feb. 23. 7:30 a. m. 1:00 p. m. 8:30 p.m. Catherized and drew 1 oz. clear light straw-colored urine; complains of Comfortable night; catheter, oz. xii healthy looking urine; vomits 6 oz. urine; vomited once; rectal alimentation every four hours. Catheter, oz. v urine, sp. gr. 1020, normal color; no vomiting; looks well; drinks little water; continued enemas; ordered two or three teaspoonfuls milk and lime water; continued ox. cerium. 17 oz. urine, sp. gr. 1019, normal color; has taken three teaspoonfuls lime water and milk every two hours, and no vomiting; everything favorable. Catheter, 13 oz. urine; no vomiting; enema of one quart water, which caused light liquid movement; patient feels well; continued treatment. 17 oz. urine; normal; no vomiting. Rested well; 14 oz. of urine; dressed wound; dressing soiled with bloody serum, but not offensive; left in tube. 12 oz. urine passed voluntarily; some headache; she now takes four tablespoonfuls of milk every two hours without vomiting. 10 oz. urine; normal; nourishment same; ordered cathartic. 14 oz. urine; more cathartic given. 12 oz. urine, sp. gr. 1018, acid; no albumen or pus; bowels moved well; no vomiting. 12 oz. urine; bowels acted several times; wound dressed; little pus, 3ss; Removed tube, wound apparently healed, except tube track; no vomiting; ordered oz. iii of milk every three hours. 12 oz. urine; slight nausea; no vomiting. |