William Bain
1912 The Lancet  
No tubercles were detected on it. The heart was very large, weighing 37 oz. on removal. It presented a most unusual appearance, the walls both of the auricles and ventricles being studded with nodular masses of the shape and size of small marbles. The organ was not opened at the time of the necropsy, but was preserved and brought to England entire. Both pleural sacs contained a great excess of clear straw-coloured fluid. On the right side many adhesions bound the lung to the chest wall, while
more » ... chest wall, while numerous miliary tubercles could be seen dotted over the pleural membrane on both sides. On section fairly advanced tubercular lesions, from miliary tubercles up to caseating masses of the size of hazel nuts, were found scattered through both lungs. The apices were both involved. The bases of the organs behind showed considerable oedema. Of the other viscera, the liver was hard, bile-stained, and typically nutmeg; it weighed 56 oz. The spleen was FiG. 2. The cavities of the heart have been more widely opened. The enormously thickened caseating wall of the left ventricle is well seen, and the very small ventricular cavity. normal. Both kidneys contained a few miliary tubercles, while large caseating areas were found in the mesenteric glands and miliary tubercles were scattered over the peritoneum. Many typical tubercular ulcers were found scattered throughout the small intestine. The brain was not examined. So far, then, the necropsy notes show that the case was one of tuberculosis of the lungs with a spreading general infection, the unique features being the extraordinary condition of the heart. Description of the heart. -The heart was brought home from Fiji preserved in formalin and was opened and studied soon after its arrival at the London School of Tropical Medicine. The accompanying illustrations give some idea of the extraordinary lesions found in its walls after section and render a minute written description unnecessary. The left ventricle, perhaps more so than the other chambers of the heart, was greatly diminished in size owing to an enormous, more or less concentric, hypertrophy of the ventricular wall. The myocardium showed an extraordinary appearance, being infiltrated, or rather replaced, by caseous, cheesy masses of different sizes, these having produced the nodular or marblelike lumps seen on the outside of the heart during the necropsy. Fig. 1 shows these well. The wall at the base of the ventricle measured no less than 1 3/4 in. in thickness, this gradually tapering to i in. at the apex. Practically no normal muscular tissue was left, the tubercular lesions having entirely replaced this. Fig. 2 illustrates these points. The right ventricle and both auricles were also affected, the cavity of the left auricle especially being surrounded and infiltrated by tubercular masses and thereby greatly obliterated. Remains of pericardium adherent and firmly bound to the auricles and great vessels at the base were easily found, but, as already mentioned, the pericardial membrane was, on the whole, quite free from tubercular changes. The case furnishes an excellent example of a tubercular myocarditis, and with such advanced caseous masses replacing almost entirely the whole muscular substance of the heart it is extraordinary how life could have been prolonged as long as it was. The caseation and. cheese-like masses were quite typical of tubercle, but to make absolutely certain of this sections were cut both of these and the lesions in other parts of the body. Histologically these showed typical tubercular lesions, and by Ziehl Neelsen's method tubercle bacilli were detected in large numbers in the material taken from the heart. In conclusion, we must state how greatly indebted we are to Dr. Smartt for his kindness in allowing us to publish this. case. FOR the past dozen years I have met patients who declined to continue massage on account of the pain it produced. This hyperaesthesia I thought then was purely neurotic. During the last few years I have had a number of these cases. On examination it was found that the hyperæsthesia was generally limited in extent and distributed in patches. The patches occur most frequently on the abdomen, next in order of frequency on the legs, arms, and back, and occasionally on the thorax. I will attempt to describe a patch. If you pick up the skin and subcutaneoustissue over it and roll them between the fingers they feel somewhat firmer and less elastic than the normal structures. The slight infiltration is either in the deepest layers of the corium, or in the subcutaneous tissue, or in both. Judging by tactile sensation my impression is that the inflammatory deposit is in the subcutaneous tissue. The sensitive areas are generally smooth, about 1 or 2 inches in diameter, and very tender on pressure. If the pressure is applied perpendicularly to the surface the tenderness is, slight, but if applied from the circumference of the sensitive area it is very marked. A patch is evidently an aggregation of smaller ones. When the patch is disappearing under massage it splits up into several smaller ones, and the thickening therefore becomes uneven. The contour of the smaller patches can be made out, and before they finally disappear they feel like small pin-heads. These sensitive deposits occur chiefly in neurotic patients. Most of the patients are females about the middle period of life, and are inclined to be stout. I will briefly mention the last two cases I saw during the autumn. Mrs. A, aged 46, gouty, had a hasmorrhage on the left side of the brain 12 years ago. The systolic blood pressure was 150, and the weight 12 st. She was somewhat neurotic. She had a single patch in each upper arm ; both were very painful when massaged. Mrs. B, aged 48, had appendicitis four years ago; no operation on account of the feeble condition of her heart. The heart was slightly dilated and the pulse was weak. The systolic blood pressure was 99, and the weight 14 st. 12 lb. The patient was not in the least neurotic. She had four patches on the abdomen which were very painful on pressure. It is difficult to give an accurate description of the condition, as there is so little to feel. In the case of Mrs. B the exudations would probably have escaped observation were it not for the pain produced on examining the abdomen.
doi:10.1016/s0140-6736(00)78344-9 fatcat:fe46pcldajblpiebf5jzs5kclm