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Quarantine. The national quarantine, 612. Statistics. The Massachusetts Board of Supervisors

of Statistics, 247.
Reed, A. F. Intestino-vesical fistula, 311. Stearns, U. P. Relations of insanity to civiliza-
Respiratory System. Case of pleurisy, Bow- tion, 638.

ditch, H. I., 15; on strapping the affected side in Stebbins, G. S. Obscure forms of liver disease,
cases of acute pleuritis, Gleason, J. C., 98 ; croup- 309, 450.
ous, fibrous, or pseudo-membranous bronchitis, Stevens, E. H. Cancer of liver, kidney, and
Lyman, G. II., 108; phthisis, ulceration of the spleen, 603.
larynx, Lyman, G. H., 108; recent progress in the Stlokney, H. G. Tuberculosis, 312.
treatment of thoracic diseases, Knight, F. I., 205, Storer, H. R. Upon the treatment of strumous
337; the relations of diphtheria and croup, Curtis, disease by what may be called the Solfatara method,
T. B., 331 ; pneumono-dynamics, Hunt, D., 339, 831.
croup; tracheotomy, Cheever, D. w., 390; pneu- Surgery. Recent progress in surgery, Warren, J.
monic conditions at work within the thorax, Gar- 0., 838.
land, G. M., 472; cancer of the trachea, Shattuck, Surgical Operations. Cases treated by bleeding,
G. o., 578; malignant disease of the lung, Bow Hayden, D. H., 17; excision of knee-joint, Richard-
ditch, H. 1., 607; pneumono-dynamics, Garland, G. son, A. K., 43; excision of the upper jaw, Cheever,
W., 670; pneumo-thorax with embolism of the pul. D. W., 130 ; lithotrity by a single operation, Bige-
monary artery, Lyon, I. W., 843.

low, H. J., 259, 291; cases of plastic surgery, Por-
Richardson, A. K. Excision of knee-joint, 43. ter,'c. B., 423; recent progress in orthopædic sur-
Richardson, W. L. Recent progress in obstet. gery, Bradford, E. H., 504; rapid lithotrity, Curtis,

rice, 10; case of induction of premature labor for T. B., 560, 704, surgery in Berlin, W. B. Platt, 682;
pelvic deforinity, 131.

fracture of the leg treated by a new method of ex-
Robertson, W. D. Fracture of the leg treated by tension, Robertson, W. D., 662.
a new method of extension, 662.

Swasey, E. P. Urethral hæmorrhage, 843.
Rollins, W. H. Treatment of deciduous teeth,

Tarbell, G. G. Colloid cancer of the intestino at
Root, R. B. The tourniquet in treatment of fract- the ileo-cæcal valve, 111.
ure of the patella, 851.

Thomas, T. G. Laceration of cervix uteri, 519.

Tumor. Malignant tumor of the mouth, Cheever,
Sargent, B. W. Medical ethics, 45.

D. W., 128; malignant tumor, Marcy, H. O., 536 ;
Sayre, L. A. Letter from Dr. Sayre, 93.

malignant tumor of breast, Cheever, D. W., 195.
Seaverns, J. Mineral waters of New England,
141.

Urinary System. Pathological specimen from
Shattuck, F. C. Severe neuralgio pain following the urethra, Cutler, E. G., 17; case of disease of fe-
herpes zoster, 379.

male urethra, Marion, H. E., 18; anatomy and
Shattuck, G. C. Cancer of the trachea, 578; physiology of the kidney, Edes, R. T., 140; lithot-
thrombosis of the inferior cava, 579.

rity by a single operation, Bigelow, H. J., 259, 291;
Shaw, B. S. Chronic ulcers of the stomach and Intestino-vesical fistula, Reed, A. F., 311, multiple
duodenum; old pyelonephritis, 374.

urinary calculi; sacculated bladder, Warren, J.C.,
Societies. Boston Society for Medical Observation, 878 ; recent progress in urinary surgery, Curtis, T.

14, 411, 598, 698; Connecticut River Valley Med B., 438; sections of rabbit's kidney, showing action
ical Association, 43; Strafford District (N. H.) Med of secreting epithelium, Edes, R. T., 474 ; inconti-
ical Society, 44; Medical Society of the District of pence of urine in children, Kemble, A., 526; rapid
Columbia, 46; Springfield Society for Medical Im lithotrity, Curtis, T. B., 660, 704; uramic convul-
provement, 79, 243; Boston Society for Medical Im sions, Morrill, F. G., 591: catheterism versus
provement, 106, 374, 572; Norfolk District Medical urethrotomy, Gouley, J. W. s., 651; the rational
Society, 140, 509; annual meeting of the New York treatment of stricture of the urethra, Gross, S. W.,
State Medical Society, 146; second annual report 783; urethral hæmorrhage, Swasey, E. P., 843.
of the Boston Medical Library Association, 173;
Cambridge Society for Medical Improvement, 175; Wadsworth, 0. F. Recent progress in ophthal-
Androscoggin County Medical Society, 178; New mology, 467.'
England Paychological Society, 178, 636 ; New York Wainwright, w. A. M. Perforation of vermi-
Pathological Society, 212; Dorchester Medical Club, form appendix, 843.
278; Canada Medical Association, 282; Hampden Warren, J. Ó. Surgical cases at Massachusetts
District Medical Society, 309; Providence Medical General Hospital, 25, 319; multiple urinary calculi,
Association, 313; American Neurological Associa-
can Neurological Associa- sacoulated bladd

rocent progress in surgery,
tion, 313; Suffolk District Medical Society, 337, 670, 838.
700 : Masgachusetts Medico-Legal Society, 443, 803; Webb. M. E. Disease of knee, 339.
Boston Society of Medical Sciences, 472 ; Middlesex Webber, S. G. Cerebral tumors, 110; tumor of the
South District Medical Society, 536; Worcester As- cerebellum, 411; nerve cell from spinal cord having
sociation for Medical Improvement, 539; American two nuclei, 477 ; amyloid degeneration, 698; cere-
Medical Association, 642; what is the object of the bral hæmorrhage, 698.
Massachusetts Medical Society, and how can it best Wells, D. E. Vicarious menstruation, 617.
be fulfilled ? Edes, R. T., 724 ; Medical Journal As White, J. C. Ringworm, tinea trichophytina,
sociation of the City of New York, 783; Connecticut 191 ; melanoderma

derma, 619; recent progress in derma-
Medical Society, eighty-seventh annual meeting, 741; tology, 769, 796.
Gynecological Society of Boston, 746; the obliga- Whitney. J. 0. Gun-shot fracture of skull, 667.
tion of the Massachusetts Medical Society to female Wigglesworth, E. Recent progress in syphilol-
physicians, 747 ; hints in ethics and hygiene, an ogy, 271; auto-inoculation, 412; faulty innervation
abstract of the annual address before the Massa- as a factor in skin disease, 702; the metric system
chusetts Medical Society, Minot, F., 755; the Asso- in a nutshell, 766.
ciation of American Medical Colleges, 774; the As- Wilcox, L. S. Germ theory, 844.
sociation of Medical Editors, 776 ; 'the National Williams. H. W. Eserine and pilocarpine in the

yngological Association, 776; American Medical treatment of eye disease, 327; eserine and pilocar-
Association, twenty-ninth annual meeting, 776, 810; pine in ulceration of the cornes, 671.
American Medical Association, Bowditch, H. I., 788; Wing. C. E. Intestinal cast, 839.
Massachusetts Medical Society, annual meetingWood, E. S. Recent progress in medical chemis-
803; Hartford County Medical Society, annual try, 170; argenical poisoning, 412.
meeting, 842; the attitude of the Massachusetts Wood, H. C., Jr. The heroio treatment of idi

Medical Society toward the “ 'pathies," 847.
Spafford, G. Plants in rooms, 43.

Wright, J. H. Diphtheria, 538.
Spaulding, M. A case of scirrhous testis cured by
electricity, 267.

Yale, J. Gum cutting again, 861.

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THE BOSTON MEDICAL AND SURGICAL JOURNAL. VOL. XCVIII. – THURSDAY, JANUARY 3, 1878. NO!

LECTURES. ( 17 ) ANEURISM OF THE THORACIC AORTA.

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BEING A CLINICAL LECTURE.

BY WM. PEPPER, M. D., Professor of Clinical Medicine in the University of Pennsylvania. CASE I. The patient is a sailor, of middle age, and born in Germany. His health was unimpaired until about ten months ago, when he felt slight pains in the upper part of the right side of the chest, and complained of some shortness of breath upon exertion. He has a venereal history, and of late years has been frequently exposed to rough weather. Within the past ten months his symptoms have been gradually increasing, and he has been obliged for the last five months to give up all work and confine himself to bed. He has never had any cough, and there have been no sputa since he has been sick.

An examination of the heart shows that its action is much excited, that the area of impulse is enlarged, and that the maximum impulse is felt in the sixth interspace, one inch to the left of the left nipple. The area of cardiac dullness upon percussion is increased. The heart extends up to the third rib, down to the level of the stomach, and from the left border of the sternum to one inch beyond the left nipple. This proves that the size of the heart has increased. The first sound of the heart is roughened. There is no valvular murmur heard at the apex, but I find a slight murmur at the base. This murmur is heard high up and at the anterior border of the axilla, and is also feebly transmitted to the inferior angle of the left scapula behind. There may be some slight mitral regurgitation, therefore, in addition to the functional disturbance of the heart. The murmurs are strongest in the second interspace, two inches to the right of the sternum. They, however, are very much weaker at the aortic cartilage, and do not follow at all the laws of the transmission of mitral or aortic murmurs.

The lungs are entirely healthy. The right upper chest is slightly fuller than the left. Upon examination of the right upper chest, where the pain is located, I discover a strong pulsation and thrill. These signs are situated at the exact point mentioned above as that where the murmurs are loudest. This spot is two inches to the right of the sternum and four inches upwards and to the right of the heart's impulse. On percussing the chest I get resonance over the upper part of the left chest, but on the right side there is flatness, extending from the lower margin of the third rib up to the clavicle, inwards beyond the middle of the sternum, and outwards to the junction of the middle and outer third of the clavicle. There is evidently a pulsating tumor exactly over the site of the arch of the aorta.

This tumor certainly is not the heart. It must be either some body with pulsation of its own, or some solid body which the heart hits at each stroke and to which it transmits its impulse. Can this be a tumor which receives and transmits the impulse of the heart ? We rarely find a tumor in this part of the chest, for the simple reason that there are no glands here which could become the site of a tumor. On auscultation over the site of pulsation and thrill I hear a hoarse, strong, blowing murmur. This murmur cannot be heard over the heart. Putting those facts together we are able to diagnosticate the existence of an aneurism. No such enlargement is possible in the course of a vein. From the position of the aneurism it must be one involving the outer wall of the arch of the aorta and possibly the mouth of the innominate artery. This aneurism is as large as the head of a child at term. It is the result, probably, of atheroma of the coats of the innominate artery and aorta, brought on by syphilitic arteritis.

The patient is unusually free from the complications which commonly attend an aneurism of the aorta and innominate. Such an aneurism may press upon the trachea, causing cough, dyspnea, and in some cases aphonia ; or upon the pneumogastric nerve, producing paralysis of its branches, with hiccough, belching, etc. Again, by pressure on the csophagus, the reception of food might be seriously impeded, if not entirely prevented. This man presents none of these symptoms. In some cases of aneurism of the aorta, there is a difference in the two radial pulses, owing to interference with the passage of the blood on one side or the other of the aorta. In this case the two pulses are pretty nearly alike; the right is perhaps a shade smaller than the left. Sometimes there will be pressure on the neighboring sympathetic ganglia, which regulate the vasa vasorum. At times there is an inequality in the circulation on the two sides of the head, as shown in the size of the pupils, one being larger than the other. There is no difference in the size of this man's pupils. The aneurism in this case, fortunately, does not interfere with any important structures. It is gradually, however, leading to absorption of the ribs above its site.

As there is great danger of the sac bursting, treatment must be directed (1) to the stoppage of the progress of the atheroma, and (2) to the diminution of blood pressure. The only drug which can

favorably affect the atheroma is iodide of potassium. This should be given in doses beginning with fifteen grains three times a day. The patient must be rigorously confined to bed. To reduce the blood pressure, from three to five drops of the tincture of the i'oot of aconite should be given thrice daily. Under this treatment in the present instance the pulse has been reduced from 96 to 70 in the minute, the pain and palpitation are all gone, the impulse is less strong, and the aneurismal murmur is much softer and weaker. All these signs point to a gradual solidification of the contents of the sac.

To diminish the mass of the blood, thus reducing the amount of red corpuscles and of albumen, and to increase the amount of fibrin, and so favor the coagulation of the blood in the sac, the patient should be placed upon a reduced diet, — about one half as much as would amount to full rations. I am allowing this man at breakfast two ounces of bread and a little coffee, at dinner two ounces of meat and a little bread, and at supper two ounces of bread. This diet has reduced his weight from one hundred and sixty-nine to one hundred and forty-five pounds, and has greatly increased his comfort, rendering sleep easier. I hope thus to bring about coagulation without surgical interference.

[Three weeks ago the man spat blood, and I was afraid the sac had burst. The patient was kept perfectly quiet; gallic acid was administered internally, and ice applied to the chest. Under this treatment the hæmoptysis stopped immediately. It was probably only the result of a local congestion.]

Case II. Also a sailor. The patient came to port about one month ago. For the past three weeks he had been suffering from cough, general weakness, dyspnea, and excited action of the heart. There had not been, during his sickness, any expectoration. His temperature had ranged as high as 1011° F., and he had complained of considerable pain in the left side of his chest. He could not breathe easily if he lay down, and so he sat up all through his illness. Percussion of the right chest revealed healthy resonance. There were no râles, and the respiratory murmur was good. Percussion over the upper lobe of the left lung elicited perfectly solid dullness extending all the way down to the fourth rib. The resonance was good, however, in the left axilla. The apex beat of the heart was outside the line of the left nipple. The heart was very much enlarged, and its sounds were feeble. No heart murmur at all could be heard upon auscultation of the back of the chest. Auscultation over the apex of the left lung in front showed entire absence of respiratory sounds, as if it were completely solidified or the sounds were muffled by an intervening pleural effusion. Behind there was a blowing murmur heard above and some slight bronchial breathing below. The train of symptoms and physical signs, together with the entire absence of any satisfactory history of the case, rendered

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