ON A CASE OF EXCISION OF THE SCAPULA
889 mainly systolic, was felt all over the heart, but was most distinct at the apex. The hepatic dulness descended to the level of the umbilicus, but the liver did not pulsate. The jugular veins were distended and pulsated. Respiration was puerile, but otherwise normal. Temperature 96 -4'; urine 1031 sp. gr., and contained no albumen. The patient suffered from pain and paroxysms of dyspnoea, at intervals. By Feb. 7th, 1877, the dropsy had increased, and the urine contained a quantity of
... quantity of albumen. She had much pain and severe paroxysms of dyspnoea, and there was much bronchitic rhonehus in the chest. She died on Feb. 24th, and during the latter part of her life the cardiac murmur was heard most loudly at the apex. On post-mortem examination it was found that the heart was enormous. The right auricle and ventricle were greatly dilated and occupied almost the whole anterior aspect of the heart. The pulmonary artery was greatly dilated, but the valves healthy. The aortic and mitral valves were healthy, but the aortic orifice was very small, as was the whole thoracic portion of the vessel. In the auricular septum was a large orifice, which measured 3'4 inches in circumference. The foramen ovale and ductus arteriosus were closed. The probable history of this case is, I think, that during intra-uterine life the development of the aorta was owing to some cause or another arrested. This increased the bloodpressure abnormally behind the aortic orifice, so that the blood found a way of escape into the right auricle through the incomplete auricular septum, and kept open a permanent orifice in it. The right side of the heart being thus constantly over-filled, acted with greater energy ; and, by constantly propelling more than the normal amount of blood into the pulmonary circulation, it not only greatly increased in size itself, but also caused a simultaneous increase in the size of the pulmonary artery. The closure of the foramen ovale, notwithstanding the persistence of an aperture in the auricular septum, may probably be explained by the fact that the blood flowed from the left to the right auricle, and, as the valve of the foramen ovale projects on the left of the septum, the increased bloodpressure in the left auricle would tend to close rather than to keep it open. When we consider the physical signs during life-viz., great increase of cardiac dulness to the right of the sternum, and but slight increase to the left, a thrill most evident at the apex, and a murmur which, though heard everywhere, was at first loudest at the base and subsequently at the apex-we must confess that no one could have solved the problem and predicted the results of the post-mortem examination. CASE 2.—M. A. J-, aged thirty-four, was admitted under Dr. Ord on Oct. 29th, 1879. She had had measles, but no other severe illness ; had always suffered from palpitation, some shortness of breath, and tendency to blueness on exertion, but she had nevertheless worked hard. She had also suffered from occasional epileptic fits for the last twelve months before admission. When seventeen years of age she was blown up " in a cartridge factory, when her spine was injured and her right leg broken. Her illness, for which she was admitted into St. Thomas's Hospital, commenced three weeks previously with pain in the " stomach," unaccompanied by tenderness or vomiting. On Oct. 29th she had been walking quick to get to the hospital in time, when she vomited a large quantity of blood. On admission the patient was ill-nourished, anæmic, short of breath, and altogether very ill. There was evident pulsation in the jugular veins. The cardiac area was prominent, and pulsation could be seen from the second intercostal space on the left to a point two inches below and within the nipple. A thrill could also be felt all over the cardiac area, but was most marked over the origin of the pulmonary artery. Dulness on percussion extended upwards to the first intercostal space on the left, to the right as far as mid-sternum, and to the left just bevond the nipple. A loud, crashing, systolic murmur could be heard all over the heart, but was most intense at the base, being heard loudly up the sternum and towards the left clavicle, and much less so to the right of the sternum. The lungs were resonant. She died on Nov. 7th. Post-mortem examination.—The abdominal viscera were transposed. The pericardium measured seven inches and a half vertically, seven inches transversely in the line of the nipple. A number of old, white, thickened patches, from half an inch to an inch in diameter, were situated on the visceral layer of the pericardium on the anterior surface of the right ventricle, and on the front of the great vessels at the base, where in some places they projected in conical villous masses. The heart was very large, and the greater part of it was situated on the left of the median line. Its anterior surface was almost entirely formed by the right ventricle. The right auricle and ventricle were greatly dilated and hypertrophied. The left auricle was also very much enlarged. The left ventricle was comparatively small. The conus arteriosus and the pulmonary artery were enormous, and apparently gave rise to the great increase of dulness to the left of the sternum towards the clavicle, which was observed during life. Though the calibre of the pulmonary artery was so greatly increased, the vessel and its valves were healthy. The septum ventriculorum was complete, and the ductus arteriosus closed. The auricular septum was very thin, and the foramen ovale was altogether open and destitute of valve. But, besides this, the whole of the lower part of the septum was absent, so that a very free communication existed between the two auricles. The tricuspid valve was healthy, and on looking up from the right ventricle towards the auricles, one saw clearly into both of them, the defect in the auricular septum being in a direct line between the left auricle and right ventricle. The mitral valve was thick, and the orifice constricted, not admitting two fingers. The aortic valves and orifice were healthy, though the vessel was rather small. The probable history of this case is that the mitral orifice becoming diseased the flow of blood through it was obstructed, and the stream became diverted through the incomplete auricular septum, which consequently remained undeveloped. The blood arriving in the right auricle, as well as part of that in the left, was propelled through the tricuspid orifice into the right ventricle, and the latter became greatly hypertrophied owing to the abnormal amount of work thrown upon it. The great quantity of blood driven into the pulmonary artery by the hypertrophied right ventricle gave rise to an increase in the size of this vessel, while the small quantity of blood which passed through the aorta was accompanied by a diminution in its calibre. It is possible, however, that an abnoimally largely developed pulmonary artery was the original malformation, and that the incomplete septum, the diversion of the blood from its natural course, and consequent diminution in the size of the mitral orifice and aorta, were only secondary results. But whatever may have been the true intra-uterine history of the case, the only thing which could have been diagnosed during life was an abnormal condition of the pulmonary artery ; while neither the condition of the auricular septum nor the mitral valve could have been determined. Such a case brings forcibly before us how little skill we can pretend to in the diagnosis of congenital diseases of the heart, and justifies, I think, some of the remarks which I have made upon this subject.