CHAPTER VIII.

ANEURISM.

Aneurism and atheroma of the aorta.-For many years the existence of this condition in infants and young children was totally denied; however, Roger,* in 1863, recorded a case of aneurism of the arch of the aorta in a girl of ten years of age, and Herveux remarks that out of the five hundred and fiftysix cases of aneurism reported by Crisp, five alone appeared in individuals of several days up to twenty years.

Again, of ninety-eight cases of aneurism, but one was found in a person under twenty years of age.

One case of abdominal aortic aneurism is recorded as occurring in a child aged fourteen years,† and Broca, in a treatise on aneurism, relates one case of aneurism of the aorta in an infant of one month.

A case is reported (Phaenomenow, Arch. für Gynæ., 1881) of a fœtus who presented an aneurism of the abdominal aorta ten centimetres wide and eleven centimetres long. It was situated between the origin of the renal arteries and the bifurcation of the iliacs. Microscopic examination showed its walls to be composed of the layers of the arterial coats.

Sanné (ibid.) made an autopsy in a child, aged thirteen: the arch of the aorta was increased in size and very atheromatous; on the convex superior portion (transverse arch) was to be seen

* Bull. de la Soc. Méd. des Hôp., Paris, 1863, p. 499.

† Bull. Thérap., 1835, p. 393, vol. ix.

Sanné, Rev. de Méd. L'Enfance, February, 1887; also Edinb. Med. Jour., August, 1887, p. 188; also Med. and Surg. Reporter, October 22, 1887, p. 549.

a sacculated aneurism whose orifice of communication with the aorta was partly closed by cretaceous deposits; the aortic valves were insufficient, stenotic, and atheromatous. The pericardium contained several ounces of serum, and the left ventricle was hypertrophied. The same author has seen two cases, aged respectively two and three years, with marked general atheroma. Moutard-Martin* contributes the clinical and post-mortem notes of a child, aged two, who presented chronic aortitis, with contraction and stenosis of the aortic valve, hypertrophy of the heart, chronic pericarditis, and loud murmur. The aorta was two or three centimetres higher in the chest than normal, and was very atheromatous. Norman Moore† exhibited to the London Pathological Society a specimen of aortic aneurism taken from the body of a child aged five years. Sex in early life does not bear such a direct relation to the production of aneurism as it does in adults, in whom the disease is more frequent in males than in females; this is to be accounted for in great part by the fact, as stated by Beneke, that the bloodpressure during childhood is about the same for both sexes, but from puberty onward it is greater in the male.‡

Sufficient cases have now been cited to show that aneurism and atheroma of the aorta may occur at any period from fœtal life upwards, nor does youth protect the cerebral circulation from atheromatous degeneration and aneurismal dilatation, as the case of aneurism of the middle cerebral artery in a boy, aged twelve, recorded by West, will show :

Boy had mitral insufficiency. At eight years of age had had scarlet fever and dropsy, afterwards some rheumatic joint-pains. For two years had dyspnoea. Four days after admission to hospital was suddenly seized with headache and vomiting; shortly afterwards became drowsy and had several fits, though none of them were severe. No paralysis was detected, but the drowsiness gradually deepened into coma, and the boy died about twenty-four hours after the commencement of head-symptoms.

Post-mortem.-All the loose tissue at the base of the brain

*Bull. Soc. Anat., 1875, p. 775.

Trans. Path. Soc., 1882, quoted by Shattuck, Boston Med. and Surg. Journal, Sept. 22, 1887, p. 280.

NOTE.-See Addenda, Nos. VIII. and IX.

was distended with blood, which tracked in all directions upward towards the surface of the brain, and downward along the medulla and cord, and on both surfaces of the cerebellum. All the ventricles, the fourth included, were filled with recent blood-clot. The source of the hemorrhage was an aneurism of the left middle cerebral, of the size of a small pea, about an inch from its origin. The walls of the vessel were very atheromatous and brittle, although elsewhere they were perfectly healthy. The aneurism had contracted dense adhesions all around, and had ruptured into the lip of the descending cornu of the left lateral ventricle. The blood had filled both the lateral ventricles, and had then spread by the transverse fissure to the exterior of the brain, chiefly along the base, around the crura cerebri, over the cerebellum, and round the crura cerebelli to the fourth ventricle. There was no evidence of embolism in the diseased artery.

The pericardium was universally adherent, and the mitral valve much thickened and covered with numerous recent vegetations. The other organs were healthy.

Osler* records an aneurism of a branch of the anterior cerebral in a boy six years of age, being one of the youngest cases on record. The boy was brought to hospital unconscious, with feeble pulse, pale face, eyes and head turned to the right, and left hemiplegia; death in six hours. He had fallen from a hay-loft three weeks before, but he recovered rapidly from the effects. There was meningeal hemorrhage at base and in the longitudinal fissure. An aneurismal sac was found imbedded in the calloso-marginal fissure just where it turns vertically upwards. The rupture was on the meningeal surface, but hemorrhage had extended into contiguous portions of the brain; the arteries were not atheromatous, presumably altogether normal, and the heart was healthy.

The symptoms, physical signs, modes of termination, and treatment of aneurism in the child are precisely similar to those in an adult, and it would be superfluous to recapitulate here, as the subject is so fully covered in the various standard text-books.

* Canada Med. and Surg. Journal, 1886. This case is referred to by Sachs, Journal of Mental and Nervous Diseases, Aug., 1887.

Care, however, must be exercised in the diagnosis of aneurism, as mistakes are by no means uncommon. Hare* has recently recorded an interesting case of spurious aneurism of the innominate artery in a young girl aged seventeen. In this case the most definite signs of true aneurism were present, yet the post-mortem proved the entire absence of any lesion of the blood-vessel. The physical signs were characteristic and supposed to be very diagnostic, as several expert physical diagnosticians saw the case, one of whom lectured upon it as a text of aneurism in the young. The vessel, when examined at the section, seemed to be a little relaxed, and somewhat more elastic than normal. The aortic valves were extensively diseased, all the others healthy; the girl was weak, anæmic, and hysterical. The thyroid gland, during the early developmental stages of exophthalmic goitre, presents some signs which simulate an aneurism. A further diagnosis must be made between the enlargement of a tubular peri-bronchitis and an aneurismal dilatation-a point fully elaborated by Roger (ibid.).

HYPERTROPHY AND DILATATION.

We are not at all apt to confound these conditions, but it is better to consider them together, as they so generally exist at one and the same time in a given case.

Between the ages of three and eight years the difference in the size of the heart is marked. Guersant states that the left heart is the larger, in the proportion of one to three. At this early period more work is required of the left side in order to send the blood actively to the periphery of the body; we also note the fact that the arteries are equal in size with the veins, whereas in an adult the veins are the larger.

Three forms of hypertrophy have been described, as simple hypertrophy, eccentric hypertrophy, and concentric hypertrophy; the former being a simple increase in the thickness of the muscular wall, the second an hypertrophy accompanied by dilatation, the former being in excess, however; the third is supposed to be a condition of hypertrophy in which the cavities are contracted.

Hypertrophy and dilatation is somewhat frequent in early

* Med. News, Oct. 1, 1887, p. 388.

life as a consequence of the various lesions of the valves or pericardium; in other words, the same disorders which bring about hypertrophy in an adult will also set the process on foot in a child.

Aortic and mitral regurgitation are peculiarly prone to give rise to a dilated hypertrophy, as the cavity or cavities are receiving two streams of blood under increased pressure. Dilatation is often established by the many pulmonary affections of early life. Rillet and Barthez say that under these circumstances we are much more apt to have dilatation than hypertrophy. Displacement of the heart from a pleuritic effusion and deformity of the thorax are potent causes of the condition in the young. Some authorities consider that permanent enlargement or a hypertrophy may supersede the condition of cardiac degeneration seen in systemic fevers, or the softening of a myocarditis, which was secondary to peri- or endocarditic inflammation. The latter is well illustrated by the case of a child eleven years old, reported by Guersant, who was attacked by acute rheumatism, accompanied by hyperpyrexia, soon developed extreme dyspnoea and marked palpitation; pulse irregular and intermittent; extremities cold and œdematous, bulging præcordia, excessive action of the heart; bruit at apex and in axilla.

The autopsy revealed a right pleural effusion with false membrane, an adherent pericardium, and an enormous cardiac hypertrophy. Bamberger also reports the case of a child aged eleven, with acute rheumatism and pericarditis, in which the hypertrophy was well marked, and arose with great rapidity. A definite cause of hypertrophy which all who treat the young must clearly recognize and guard against is repeated violent effort or exercise with the arms, as gymnastic exercises, rowing particularly. This change in the cardiac walls is brought about in two ways. An important factor is the excessive cardiac action suddenly produced; secondly, the constriction of the arteries and the obstruction to the circulation caused by the rigid muscles crossing the arteries and opposing the passage of blood.

The right cavities are very apt to be affected in swimming or running contests or in excessive diving. All these sports