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A shows the subclavian; B the common carotid; C the internal carotid, through which a bit of whalebone is passed; D the external carotid, with whalebone; E the ruptured part; FFF the edges of the sac, which is cut off.
Upon the occurrence of the preceding case, it will be seen that I was not aware of the operation for carotid aneurism ever having been performed. We are now indebted to the abilities, skill, and judgment of Mr Astley Cooper and Mr Abernethy, for proofs that it is not only practicable, but that it may safely be undertaken by a dexterous surgeon. It is at the same time evident, that where so little can be left to nature, the operation should be no longer deferred than is necessary to ascertain the disease. Delay admits that increase and distension which perplexes the operator, and may be fatal to the result. With Ben, at least two months before he died, there was no possibility of doing any thing. The whole side of the neck being occupied by the sac, and merely covered by a thin integument, the first incision must have inevitably cut into it; and although about this time I became acquainted with the two cases related by the first of these gentlemen, I had not courage to make the attempt, seeing no prospect of success.
Case of singular Malformation of the Heart, with Remarks on deranged Circulation. By JAMES THOMSON, M. D. Edinburgh.
J. R. ætat. 46. The account this patient gave of her complaints was, that till the last summer she had enjoyed tolerably good health, when she remarked her lips and mouth to turn of a dark colour: her health was not materially altered. She remained much in the same state till three months ago. She then began to complain of her breathing, and the blueness became much more general; but it is only during the last three weeks that she has been forced to keep her bed. During the time I saw her, which was only three days before her death, she had all the appearance of a person labouring under the severest symptoms of hydrothorax. The pulse was not very much altered, rather feeble; she could only endure the half erect posture,
and breathed with very great difficulty. let blood, and lost nearly eight ounces. in sixteen hours after.
She was ordered to be Felt no relief, and died
External appearances.-Not much emaciation; blue colour more faint than during life; the chest sounded ill when struck, especially the left side; and there was a peculiar form of the thorax, very frequent in cases of diseased heart.
Thorax-Pericardium contained six ounces of a clear fluid; the right cavities of the heart enormously distended with black blood; the right auricle thickened and enlarged in a small degree. In the seat of the foramen ovale, there was a circular aperture sufficient to admit the points of the four fingers to a considerable extent; the pillars of the foramen ovale were not distinct. The direction of the aperture was not such as could warrant one in saying, that it was more particularly directed from one side or another. The right ventricle was considerably enlarged and thickened; left auricle rather small; left ventricle natural, but, as usual, contracted; great quantity of blood at the commencement of the aorta; the ductus arteriosus was quite impervious. The lungs were adhering in most places, and their substance was dark-coloured, and full of blood and air; the left lobe at the inferior part contained some extravasated blood. The veins were much distended with blood, particularly those of the liver. The trachea at the bifurcation was much reddened; the stomach internally had a red spotted appearance; the inner surface of the intestines was of a very dark colour through
The case which I have now detailed is interesting, both from the unusual appearance presented on dissection, and also from the speculations it gives rise to, as tending to illustrate some obscure parts of the circulation.
The first question that naturally suggests itself is, whether this was an original malformation, or a change of structure arising at an after period of life? If it proves to be a malformation, we must show how so singular a deviation could have existed for so long a period without inducing more serious derangement in the system of circulation.
If we view it as an alteration in structure occurring after birth, we must point out the causes and the time of its formation. After considering the subject attentively, the following circumstances have induced me to refer it to an original malfor mation.
1st, The appearance of the aperture, the edges of which were
rounded and thickened, indicated that it was not of recent formation; as also, that it was not the foramen ovale merely remaining open; for, in that case, there should have been the two pillars as they are called, and the aperture should have been of an elliptical form, an appearance which it acquires as the child advances nearer to maturity.
2dly, At birth, and for some time after, a passage must remain in the seat of the foramen ovale, and ductus arteriosus; yet no unusual appearance takes place, unless some cause deranging the circulation occurs, and then, as we shall afterwards endeavour to show, the foetal circulation is often again in part renewed.
The instances in which the foramen ovale remains open are so common, that few apply them to explain the cause of any symptom during life; for at all ages the aperture occurs of various sizes; and its being always unlooked for, sufficiently shows the importance we should attach to it.
Sdly, Bichât injected two different kinds of fluids into the auricles at the same time, and found that they did not intermix, though the foramen ovale was open. This celebrated anatomist seems to think that it is impossible for any fluid to pass from the one auricle into the other, however large the aperture may be.
4thly, In cases where a communication is found between the ventricles, a striking analogy is observed with the one I have just related. Little derangement happens, as long as both veniricles continue to send out the same quantity of blood; but the moment this relation is lost, the dreadful effects are easily distinguished.
5thly, Cases of an opening in the septum of the auricles are extremely rare. I find one, however, mentioned by Corvisart. It is particularly detailed in Observation 44, page 279, of that elegant work. The patient was 57 years of age before he complained, and that was seemingly induced by repeated accidents. The right auricle was extremely dilated, and an opening of more than an inch in diameter was found in the septum of the auricles.
These facts may persuade most of the accuracy of the opinion which considers the aperture as an original malformation. It is certainly more consistent with our present knowledge to view it as such, than to refer it to ulceration or rupture, induced by a violent fit of coughing.
We must, however, prove how this patient enjoyed her health for so long a period, before admitting implicitly the above statement as a correct view of the subject. We shall therefore en