Cases from Private Practice
BMJ (Clinical Research Edition)
Late President of the Royal Physical and Hunterian Medical Societies, Assistant Pathologist in the Royal Infirmary, Edinburgh, &c. &c. CASE VIII. SUBCLAVIAN ANEURISM. On the morning of January 19th, 1846, when visiting a patient in the neiglhbourhood, I was requested to see John Armstrong, who was reported to be suffering from an acute rheutatic pain in the right shoulder. In the 65th year of age, and for his timne of life, a freshlooki Eg man; complexion ruddy ; volume, of flesh good appetite
... lesh good appetite not in any degree impaired; regularly puirsued his occupation, (being a repairer of the roads,) and with the exception of the previously-mentioned pain in the shoulder, to which he attributed but little importance, was in the enjoyment of wonted lhealth. Upon interrogation, this paini in the shoulder had been experienced for many weeks, and he had appli[6d to' one or two irregular practitioners, by wvhom be had been bled, blistered, and plastered, but withouit deriving any benefit. The right hand was slightly swollen; he comnplained of a sensation of numibness, arnd thought it was not so strong as the otber. He also said thiat near to the collar bone was " a small lunmp which fluttered and beat," after wlhich statement I immediately introduced mylhand beneath his shirt, and at once discovered an aneuri §mal tumtilour, the natuire of whiclh enlargemilent from the distinct pulsation, was readily recognized. It was about the size of the section of a stmall orange, and situated below the middle third of the clavicle. On a more careful exanmination, the anormal degree of pulsation extended further than was at first anticipated, as the vessel could be felt beating powerfully until lost behind the sterno-clavicular articulation ; fremiiissement very perceptible; the right carotid artery beat with far greater force than the left, and on applying the stetlhoscope to the turmour, a distinct bruit could be lieard isochronous with the second sound. By precise admeasuremiient its size was as follows :-From superior margin of pulsatory motion passing dowvnwards and over its contour, 4' inchles; horizontally, and as before exactly following its configuratlon, 35 iniches; between the pulsatinig margin on the mlesial side, and the sternoclavicular articulation, was an indented-looking space measuring 1' inch. The clavicle could now be distinctly traced along the whole of its course; slight pulsating enlargement could be felt protruding upwards behind its superior edge. In the morning, the pains in the shoiulder and armns were said to be less urgent than at night, and he confidently asserted that on rising in the morning the enlargement was of decidedly less dimensions. le was now warned of the very serious nature of the disease, whilst rest and a complete cessation from all employment were strictly enjoined. The bowels were to be kept open bv gentle laxatives, all stimulating liquors to be avoided, and a spare farinaceous diet to be taken. The following mixture was then prescribed:-IR. Tinct. Digitalis, dr. iss.; Aqum, oz. Vj. Sit Mb,s,.