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hypertrophy. Dr. Budd has contributed some valuable observations to this volume of the Society's Transactions. He is a young physician of energy and promise.
The only remaining paper that we can notice is one by Mr. Thurnam, formerly apothecary to the Westminster Hospital. Those who have the pleasure of his acquaintance are aware of his industry and intelligence, and the paper we are about to examine is characteristic of both.
X. ON ANEURYSMS of the HEART; WITH CASES. By JOHN THURNAM.
Partial dilatation, or aneurysm of the heart, attracted comparatively little attention till 1827, when the occurrence of several cases, nearly simultaneously, at Paris, gave rise to an important memoir from the pen of M. Breschet. That memoir contained the history of ten cases, and the inferences that appeared to be reasonably deduced from them. But other cases and more correct conclusions have, subsequently, been obtained, and the object of Mr. Thurnam is to present an account of what the existing amount of facts is capable of telling us.
"My attention," he says, "was first strongly directed to this disease, by the occurrence of a remarkable case of it in the Westminster Hospital, which will be the first narrated in this paper. I have since visited the different museums of this metropolis, and that at Fort Pitt, Chatham, and have thus had an opportunity of inspecting, at the least, twenty-five specimens of the lesion in a more or less advanced stage. Of these cases, I found that the greater proportion had not been published at all, and that many of the remainder had only been very imperfectly described in catalogues. Of the appearances of the disease in all these cases I have taken notes, and have endeavoured to obtain as much information respecting their history as possible; and in some instances, have succeeded in obtaining tolerably complete cases, which have been very obligingly confided to my disposal. The new cases with which I have in this way become acquainted are thirteen in number, and of these, eight I have detailed at length; of the others, the accounts are too defective for this purpose, but such particulars as I have been able to collect respecting them, as well as of others before described, I have availed myself of, and have arranged in an appendix to this paper, which contains every case of the affection with which I am acquainted. The materials thus collected are very considerable, amounting altogether to 84 cases, of which 58 are in the left ventricle. With such a number of facts before us, I cannot but conclude that a history of this disease may be formed, more complete than any we have hitherto possessed." 189.
Aneurysms of the heart, though most frequent in the left ventricle, have occurred in the left auricle, and, in a few rare instances, in the valves of the heart themselves. Mr. Thurnam treats of them in each of these three situations.
A. ANEURYSM of the Ventricles.
So far as is known, the right ventricle is totally exempt from aneurysm. Putting aside the hypothetical explanations of the facts that have been offered, and some remarks of Mr. Thurnam's on the right and left hearts, we must mention the sense in which he employs the term aneurysm, in order that no misconception may exist with regard to his meaning. He understands by it :
An abnormal dilatation of a portion of the vascular system of red blood, either dependent upon, or necessarily connected with a morbid change in the tissues forming the walls of the diluted part.
This definition will of course exclude not only all forms of dilatation of the right cavities of the heart and of the pulmonary artery, but also all general dilatations of the left cavities of the heart; different forms of which, either combined or uncombined with hypertrophy, have since the days of Baillie and Lancisi been generally known under the name of aneurysm. Mr. Thurnam points out the objections to the application of the term aneurysm to general dilatations of a cardiac cavity with or without hypertrophy-an application too generally made with the effect of producing inconvenience and confusion.
a. Aneurysm of the Left Ventricle. Mr. Thurnam relates, more or less circumstantially, the particulars of seven cases, and refers in an Appendix to fifty-one others. These details are too extensive for a Journal, and we must refer our readers to the Paper itself, if they are anxious to become acquainted with them. A summary of twenty-nine pages will enable us to obtain all the leading particulars, and the great generalizations. We shall condense, where condensation would be prudent, the analysis of Mr. Thurnam. numerical and statistical character renders compression almost impossible. Lateral aneurysm, he says, of the left ventricle is met with under two principal forms. Thus it may be either unattended by any external deformity of the heart, and confined altogether to the ventricular walls; or it may present itself in the form of a tunior growing from the exterior of the organ, and in size varying from that of a nut to that of the heart itself. In sixtyseven aneurysms occurring in the fifty-eight cases, thirty-five were attended by tumor; in nineteen there was no tumor; and in the remaining thirteen, it is doubtful whether tumor existed or not; although, from the small size of the sacs in these latter cases, it is probable that the disease scarcely extended beyond the surface of the ventricle. There can scarcely be a doubt that, in its earlier stages at least, this lesion is far from unfrequent; and it may be observed, that it is in these stages that anatomical examination will be likely to throw light upon the mode of its formation.
b. The size of the sac varied from that of a nut to that of almost the healthy heart itself. In one case it had nearly projected externally. When the disease has been of some standing, and the sac has attained a certain size, it usually opens into the ventricle by a mouth, the diameter of which is narrow, relatively to that of the sac itself; and the lips of which, like those of old arterial aneurysms, are generally projecting, well-defined, and formed of a dense fibrous tissue.
"With respect to the tissues of the heart engaged in the formation of the aneurysmal sac, a careful analysis of the cases would seem to shew, that in fifteen, the sacs were formed by the muscular fibres and pericardium; in four, by the endocardium and pericardium only; in twenty-five, by all of the structures entering into the composition of the walls of the heart; whilst in twenty-three cases, the disease was either too far advanced, or the data are insufficient to enable us to assign them to their proper places. The aneurysmal sacs had in some cases undergone changes and transformations of different kinds; thus in two cases, they are stated to have assumed a steatomatous structure; in three, a cartilaginous one; which latter change, in six others, was combined with a more or less advanced calcareous or osseous degeneration." 219
d. In twenty-one cases, and probably in a still greater number, the sac had become strengthened by adhesion to the loose or fibrous layer of the pericardium; and in all these instances, the disease had advanced to the extent of producing tumor on the external surface of the heart. A very small tumor would appear adequate to the production of such adhesion. In a few cases there were only opacity and thickening, or shaggy false membranes on the surface of the sac.
e. “In six cases, in none of which had adhesion taken place between the aneurysmal portion of the heart and the pericardium, and in which the aneurysm scarcely, if at all, projected beyond the surface of the ventricle, a rupture of the sac had occurred, which had led to a fatal extravasation of blood, into the pericardium. In one case only, related by Sir Astley Cooper, does rupture appear to have occurred when there was the adhesion alluded to, and in this instance the left pleura was the seat of the hæmorrhage. In another instance, the tendinous centre of the diaphragm was adherent to the greater part of the sac, which was very large, and had a small supplementary pouch, with very thin walls engrafted upon it; and had this become the seat of a rupture, it must have led to extravasation into the peritoneum." 220.
f. In twenty-three cases, the sacs, chiefly those with constricted mouths, and of considerable size, contained a greater or less quantity of laminated coagula; seventeen, either apparently of less standing, or situated more in the direct channel of the blood, contained simple amorphous coagula; whilst nineteen appear to have been found empty after death; one contained a hollow globular coagulum; two, simple but ancient fibrinous
g. No part of the ventricle is exempt from aneurysm, but the apex is its most frequent seat. Thus the sixty-seven aneurysms which occurred in the fifty-eight cases, omitting one case in which this is not mentioned, may, as regards situation, be thus distributed; at or near the apex of the ventricle, twenty-seven; in different points of the base, twenty-one; in intermediate portions of the lateral walls, fifteen; in the interventricular septum, three. In short, setting aside more minute considerations, the thinnest parts of the walls of the left ventricle, or the apex and the highest part of the base, are those which are much more frequently than any others the seat of the disease.
h. In general, or in fifty-two out of the fifty-eight cases, only one aneurysm existed in each; but in four cases two were met with in each; in one there were three; and in another four incipient aneurysms. In two instances, it is not improbable that two sacs which were originally distinct had coalesced, so as to form a single aneurysm; and in another case, three sacs appear to have united in this way.
i. " An important point in the history of lateral aneurysm of the heart, is that which relates to the other lesions of this organ, which are found to accompany it. To begin with the pericardium in addition to the twenty cases already alluded to, in which there was adhesion to the surface of the aneurysmal tumour, we find that, in seven cases, there was general adhesion of this membrane to the surface of the heart; that in one, there was recent hæmorrhagic pericarditis; and that in three, there was dropsy of this cavity. In twelve cases, the endocardium is stated to have undergone different changes of structure; so as to have become either white, opaque, or thickened in the immediate neighbourhood of the sacs, or even more extensively; and in one case, there was a minute deposit
of calcareous matter either in or beneath this membrane. The muscular substance of the ventricle was, in at the least nine cases, the seat of more or less extensive fibro-cellular degeneration, which was generally most marked around the sacs; in one case, there was a cartilaginous transformation; and in another, induration from a non-specified cause. In one instance, the walls of the ventricles are said to have been the seat of 'lardaceous tumours,' and in another, of extensively diffused suppuration. In numerous cases, there was a marked atrophy either of the fleshy columns which form the pillars of the mitral valve, or of the smaller ones, which constitute the net-work on the internal surface of the ventricle. The valves of the left cavities are stated to have been diseased in ten cases; in five of these the mitral valve was the seat of the lesion, and was constricted by cartilaginous or osseous deposit; in three, the aortic valves were diseased, and both these sets of valves were implicated in one example. In eight cases, the valves are reported to have been healthy; whilst, in the remainder, their condition is not mentioned." 224.
The majority of these changes are inflammatory, or allied to inflammation. From their variety, it appears that aneurysm of the heart cannot be regarded as exclusively dependent upon pathological changes in one only of the tissues entering into the composition of this organ.
k. In the fifty-seven cases of aneurysm, there are reported to have been general dilatation of the organ in three instances; dilatation with hypertrophy of all the cavities in three; dilatation with hypertrophy of the left ventricle in nine; simple dilatation of the left ventricle in four; and simple hypertrophy of the same cavity in two other cases.
The number of cases in which the heart is not stated to have been the subject of some lesion in addition to the aneurysm, does not exceed ten ; and in three only is it positively stated to have been otherwise healthy.
Causes of the Disease.
a. Sex. Of forty cases, in which this is recorded, thirty occurred in males and ten in females.
b. Age. The age of the patient is either stated or to be inferred with tolerable accuracy in thirty-five cases. The youngest patient appears to have been eighteen, and the oldest eighty-one years of age; and the whole of the cases may be arranged in decennial periods as follow:
years of age;
c. Occupation. As regards the occupation and mode of life, out of seventeen cases, all males, in which this is stated, it appears that there were one nobleman, one merchant, one tragedian, the celebrated Talma, two generals, one colonel, five private soldiers, one gondolier, one cabinet-maker, two tailors, and two victuallers. The inconsiderable number forbids positive inferences. But, as Mr. Thurnam remarks, it is singular that one half of the patients should have been soldiers.
d. Under the head of predisposing causes may be ranked intemperate habits in four cases, and rheumatic disease of the heart in two. Yet in other cases (some of six) the presence of universal adhesions of the pericardium renders it probable that rheumatism had existed. And this may explain the comparative frequency of the complaint in early life, a frequency not seen in other aneurysmal disorders.
The exciting cause of the disease would appear to have been external violence in the form of an injury of the chest in the case of the gondolier, a fit of violent anger in that of the nobleman, protracted mental anxiety in another instance, severe efforts on the stage in the character of Hamlet, in the case of Talma, and in a fifth instance, the retention of the breath during a military flogging.
"From an examination then, of the anatomical details, as well as of the apparent causes of the disease, in reference to the determining of its nature; I come to the conclusion, that in twenty-two cases out of the fifty-eight, the aneurysm originated in a dilatation of all the structures entering into the composition of the walls of the heart; and in six in a solution of continuity of the lining membrane and in a stratum of muscular fibres, either as a consequence of ulceration, or, what is more probable, of rupture; whilst in the remaining thirty cases the disease was either too far advanced or the data given are insufficient to enable us to form a satisfactory opinion on this question.
I therefore conclude that this lesion, in by far the greater proportion of cases, is of the nature of true aneurysm; or that it has its origin in the dilatation of a portion of the walls of the heart, which has become less able to resist the distending force of the blood, during the ventricular systole, in consequence of organic changes in the tissues composing it. These changes may be confined to one of these tissues, as the endocardium; or they may involve that membrane and the muscular structure simultaneously; or, lastly, they may, I believe, originate in the pericardium, and be propagated from without inwards. In a great majority of instances, these changes would appear to have been the result of a more or less active antecedent inflammation.
I have, on one or two occasions, noticed an appearance on the internal surface of the left ventricle, which appears to me to have been the earliest stage of those pathological changes which terminate in the formation of true aneurysm. This consists in a more or less decided enlargement of one of the natural interspaces or depressions between the smaller fleshy columns. In one case which I have had a recent opportunity of examining, I met with a small cavity in the centre of the interventricular septum, which was capable of containing a small horse-bean. This cavity was evidently an enlargement of one of the natural sulci, which have been alluded to; it was traversed by the lining membrane of the heart, which in this particular spot was white and opaque, and it was only separated from the cavity of the right ventricle by a very thin stratum of muscular fibres, of a whitish appearance and dense fibrous texture.
Granting that the condition which has been now described, would, under certain circumstances, have led to the production of an aneurysm of the heart; or, in other words, that it constituted an aneurysm in its earliest stage, the observation must be regarded as important, and as fully confirming the view which has been advocated of the more usual mode of formation of true cardiac aneurysm." 230.
a. But false aneurysm, that is, aneurysm originating not in a partial dilatation, but in a partial rupture of the heart's parietes may, undoubtedly, take place also. Mr. Thurnam observes that, the examination of some cases and preparations would lead us to conclude that rupture of the heart, even