NOTES ON SOME CASES OF ANEURISM. By Surgeon G. F. A.

Second Resident I

permitted

am

to

few

a

cases

Harris, Calcutta

Hospital,

evening,

forward this

bring

*

of the members of the Socie-

for the consideration

ty,

General

Surgeon,

of thoracic aneuris

m

and

case

one

aneurism, which have come under notice lately at the General Hospital,?all, with exception, having been in my own ward.

of abdominal my one

Cases of thoracic aneurism are sufficiently uncomin this country to warrant my bringing forward this series ; at least, during the past two years I have not seen or heard of more than a dozen cases mon

been under treatment in the two medical wards in the General Hospital. I have only once

having

pulsating and bulging tumour of the chest, diagnosed as an aneurism; in a native India, and that in the person of a Bengali prisonwho was a short time in the Presidency Jail

seen

a

and

which I

of

er, in 1882.1 These cases will also serve to illustrate some of the difficulties in definitely diagnosing

thoracic aneurism in

the absence of some special symptoms. As often happens in medical practice, a number of similar cases come into hospital, in a batch as it were, and then perhaps one may not meet with like cases for months, the majority of these cases came into hospital very much about the same time. I regret extremely that I cannot show

sphygmographic tracings of the pulses patients: but few were nude, and as sphygmographic tracings of aortic aneurism

you of all these the

more

are

collected

should be

to

the obscurer

and

derive

cases

as

from

I

briefly

will

possible,

we

better able

I the

them,

remarks, as

the

useful aid in

possibly

cases

the omission. With these few

the

compared,

diagnosing more

to

proceed and have

the table the diseased organs obtained mortem examinations in the fatal cases.

regret relate

placed

at the

on

post-

Case.

First

month in India, age seaman, on the 13th October into admitted hospital 33, 1882 for " rheumatic pains" in the left hip along

James Scott,

the

one

of the sciatic nerve, also in left leg, of a few '? duration; and a history of previous rheu-

course

days'

matic" attacks of

a

similar nature

and knees.

ders, hips ago in America, of

one

affecting

He also stated that

he had had

an

attack

of

the shoul-

some "

years

paralysis'

body (I think right side), which quite suddenly, did not tender him perfectly

side of the

came on

unconscious, and from the effects of w hich he had quite recovered in three or four months. Had been a hard drinker at one time. No definite history of Read before the Calcutta Medical Society. + After this roan's release, I lost sight of him.

NOTES ON SOME CASES OF ANEURISM.

November, ?884.]

j.?

the sciatic nerve. Various sedative liniments and In appearance he was a tall well-made man, lotions, and also counter-irritants, as mustard plashut with a sallow anaemic complexion ; mentally and ters, croton liniment, etc. Bromide and chloral mixphysically sluggish. He was treated 011 the supposi- tures to put him to sleep. Salicylates, quinine and tion of the of a rheumatic nature. There cinchona for the fever. pains

syphilis,

being

was no

febrifuge

Morphia injections

cardiac bruit detected on auscultation. From to soothe pain and promote sleep. The ear-ache was the 13th to the 31st his general condition remained treated with hot water frequently dropped into the the same, the pains merely shifting to vsrious narts ear, and a strong solution of morphia subsequently of the body, but particularly affecting the right shoul- dropped in; at first this gave decided benefit. der. On the 1st November he had a sharp attack of Croton-chloral in io-grain doses, appeared to be of fever, and his temperature ran up to ioo'2'F. On some service in lessening the pain in the face, head the 2nd November a prolonged careful examination and ear ; but I believe now, that any and all these of all his organs was made, and a soft sjstolic murmur various narcotics simply gave relief by a general detected, which was heard loudest at the second right deadening of sensation, and in the stupor so induced mtercdstal space. There was no expansile pulsation the pain appeared less. to be felt on palpation, and no thrill; apex beat nor- Remarks.?The symptoms pointing to aneurism

mal, no

His

of good strength^ and regular, irregularity of heart's action. chief complaint was a pain on the right shoulder no

murmur;

intermittency

pulse or

and side of the neck ; none in the thorax. On the 4th of November he had a severe pain in the right ear, and on the 9th the right arm was stiff and painful. About this time the symptoms appeared to point towards there being an aneurism of the arch of the aorta, which by its gradual ascending was causing symptoms of pressure on the adstructures ; but the only definite signs were, a soft systolic bruit at the base of the heart and slight fulness at the right side of the chest, in the region of

growth,

jacent

the second and third costal cartilages. Subsequently the first attack, irregular attacks of pyrexia continued throughout the disease, and these were quite unchecked by quinine and such remedies, thetemPerature rarely going above ioi?F. On the 16th* November he complained of giddiness when he stood up, and a constant dull headache. The pain in the ear and neck continued unceasingly. He became very much depressed and took very little

were

at first

very

During

slight diarrhoea. be high-colored

albumen.

the

early

Urine and

part of December he had examined and found to

was

acid; specific gravity

10

o-6?;

no

but

as

the aneurismal

more marked. enlarged, The paralytic attack from which he suffered in America was probably of embolic origin. Latterly, the cyanosis and oedema of the face and neck were The caused by pressure on the superior vena cava. causation of the aneurism appeared to be softening and dilatation of the arterial coats from long standing atheromatous disease; this latter, brought on by a life of intemperance, causing increased arterial tension and atheroma. The persistent rise of temperature every evening* is curious, and to me inexplicable. more

and

Second Case.

to

food.

obscure, became

tumour

The next

case

is that of

Henry Mann, aged

37,

admitted into hospital on 23rd Novemjber 1882 with symptoms of valvular heart disease, which was suspected to be constriction of the aortic orifice also allowing of regurgitation; the murmur audible was double, harsh in sound, and heard loudest about the centre of the sternum, and propagated along the large arteries of the neck.

engine-driver,

The notes of the

very imperfect, and the valves of the heart is not

case are

exact nature of the other

He had also ascites and oedema very clearly stated. He was found on the 19th of the l:nver extremities. December lying dead in the water closet; and at the

On the 15th December evidences of right pleuro. pneumonia detected, and he became gradually weaker. examination there was found an intrahere was no dyspnoea, but progressive cyanosis of post-mortem of the left ventricular wall,f with a aneurism cardiac the head and neck, these parts also becoming much into the aorta at its comfew openings irrregular swelled and cedematous. He gradually grew weaker The specimen is 011 the table for your mencement. and died on the 19th of December. You will observe that its situation is During the last week of his illness, Doctors Birch inspection. and 1 think it would have been remarkable, and Murray also saw the case frequently with me, and very to impossible diagnose it during life. quite we agreed in suspecting an aneurism of the ascending notes in this case give us, I regret, little inThe aneurismal arch. we found a At the post-mortem

dilatation

of the

ascending

large

arch and innominate

ar-

tery, with extensive atheromatous and calcareous degeneration of the lining membrane of the aorta. 1 he sac was full of old blood-clot and layers of fibrin. Treatment.?Iodide of potassium internally. Acuand blisters applied along the course of

puncture

*

3, where there was also daily pyrexia, perhaps of the auriculo-ventricular septum. Compare a case brought before the Pathological Society in January 1876, by Dr. Wick ham Legg. Dr. Thurnam, to whom we owe much of our knowledge of cardiac aneurism, had forc? told an aneurism of the "undefended space."

Compare

t Or

ease

rather

Si8

THE INDIAN MEDICAL GAZETTE.

formation regarding special symptoms. The cause of death was probably cardiac failure and syncope. Treatment.--A mixture of nitrous ether, buchu and digitalis. Purgatives at various times, and latter-

ly powders

of

digitalis, squills

of

had "jaundice" six months previously, subsequently repeated attacks of "ague and fever," more especially during the last two months.

are

of drink

ence

command the

means

of

diagnosing

as

doubt-

the exist-

of cardiac aneurism."!

Cardiac aneurism

was

formerly said

to occur in

two forms:? 1.

Passive aneurism

Corvisart,

which

(improperly so called) was a simple dilatation

of of

pouch-like swelling arising abruptly from the ventricular surface; this second variety is properly called a cardiac aneurism. According to Rokitansky, there are two distinct

hesitating speech,

in

one

of the minute

the

sternum

and

gradually getting

fainter

the apex, which was beating a little below its normal position. On palpitation there was a vague thrill?the frcmissement cataire of Laennec?felt at

in the cardiac

area difficult to exactly localise. temperature chart shows the pyrexia which He complained of obtained throughout the case. no cardiac symptoms, and was very much surprised affected. He said to hear his heart valves were he never experienced any difficulty or shortness of

The

a pouch. form, which is the result of some inflammatory condition of the muscular fibres, or of the investing or lining membrane of the heart; the walls of the sac breath, or trouble in going up or down stairs, and consist of the endocardial and pericardial in the chest or region of the never had any pain membrane unbroken, whilst the muscular Until quite lately had been athletic inhabits. heart. fibre is replaced by a fibrous tissue. Either No history of dysentery to account for the liver comkind causes obscure and uncertain sympplication. The case was diagnosed as one of aortic

chronic

toms.

Death may

of heart's

action,

occur

from

sudden

impairment

obstruction with enlarged liver due to chronic febrile attacks, possibly of malarial origin. He was treated for the fever with various antiperiodic remeJohn Hunter, dies, but with little or no benefit.

failure,

ture.

or

rup-

Cardiac aneurisms were noticed by Galeati and Walter of Berlin, almost simultaneously. They occur more often in men than in women, in the proportion nearly of 4? i.J

On over

Booth, preventive officer, age hospital on the 19th February 1883

the the

of his left

Third Case.

D.

syphilis.

were

subsequently impacted

along

forming

J.

of the

On auscultation there was a soft but distinct systolic bruit heard loudest at the right second inter-costal space, and traceable along the larger arteries, also

forms of cardiac aneurism:? (a.)?An acute variety in which we have laceration or ulceration of the endocardium through which the blood passes, displacing and destroying the muscular fibres and gradually

into

enlargement

was no

would have

vessels of the brain.

A

(b.)?A

thick

came

the ventricular walls ; 2.

or

one

distinct sypmtoms of left aphasia, such tongue protruded to left side when asked to put it out, left angle of mouth drawn down ; saliva dribbled frequently out of the left corner of the mouth, and food accumulated in the left cheek. These slight aphasic symptoms did not inconvenience him much, and he had not noticed himself to be ill, but had heard people remark on the thickness of his speech. The aphasia was diagnosed to be of embolic nature, possibly a bead of fibrin had got detached from one of the cardiac valves, and beThere

ful, except in the presence of some special circumstances indicative of this condition, whether we have at our

which

expected from recurring attacks of ague, and only slight downward enlargement of the liver. He said his health previous to the attack of " jaundice " had been generally good ; on admission he looked anaemic and earthy. No history

"The symptoms of aneurism of such as may exist in common with

extremely

examination there

spleen

pil. hydrarg. apchief medicines used, with a

other lesions of the heart, and it is

having

On

and

temperate.

the heart

1884.

and

pear to have been the certain but varying amount of benefit. This was the only case not immediately under my own care.* Nothing is known regarding the man's habits, but I think we may infer from the hepatic cirrhosis and consecutive ascites, that he was not

strictly

[November,

,

2nd

of

March,

xiphoid cartilage hand,

sole of the foot.

he and

complained of pain pain in the fingers

also in the calf of the left

leg

and

I will not weary you by detailing of the case, but will shortly state

33, admitted the daily course with a history that he continued to have

daily

an

evening rigor

with

rise of temperature followed by profuse sweating, The patient was admitted into hospital under Surgeon " " pains in his Major Flood Murray, then Officiating First Resident Surgeon. and complained of vague neuralgic Dr. Murray kindly allowed me to keep the specimen. other the and of forehead body.* On the parts t R. Quain, M.D., in Dictionary of Medicine, p. 583. * J The Bradshaw Lecture for 1S83, by Dr. Wickham Legg, Compare the case of Robert Scott, ante, who also comis devoted to the subject of cardiac aneurisms, and contains plained of vague pains all over his body. references to the literature cf the subject. *

-

a

NOTES ON SOME CASES OF ANEURISM.

November, 1884.] 20th March there

noticeable distinct downward enlargement with percussion, dulness of the left lobe of the liver two inches below the costal arch, and an apparent bulging at this situation with pain on was

Looking at the course of the temperature, the enlarged liver with the bulging, and adding to this the previous history of jaundice and hepatic disease, I think I was justified in thinking tha#t the pressure.

.

chief mischief was in connection with the liver, and that if suppuration had not taken place it shortly

would. On the 22nd March he stated that when he lay on the right side he experienced a sense of great oppression in the chest, and on the 23rd of pain in the right shoulder and left arm. On the 29th morning, a

long and careful examination of his organs was made, and he seemed in excellent spirits and made no complaint of pain in the chest. The

stethoscopic signs

were

precisely

as

first

cardiac area of dulness detected, was not increased. On feeling his pulse it felt to Hie cord-like and rolled under the fingers, and I expressed to the Assistant Surgeon my belief that he had a general commencing atheromatous condition ?f his arteries, and hazarded the conjecture that the and

the normal

Vague pains all over his body were possibly of reflex due to latent thoracic aneurism. I left the ward, and within ten minutes of my leaving I received an urgent message saying the man had been taken suddenly very ill. On my return I found him lying with his face on the bed quite unconscious. He gave only one gasp and died. His face and neck were much cyanosed.

0r?gin,

Aget

companion patient said something, suddenly put

complaining

of intense

At

pain,

that Booth got up to his hand to his heart

and fell

on

the bed.

the post-mortem examination, made about two hours after death, the following condition of parts was found

Pericardium much thickened, and its cavity occupied by a mass of warm recently coagulated blood, calculated about eight or ten ounces in quantity. J his clot completely enveloped the heart. The heart itself

?f tonic was

was

contraction.

of normal size and in A small

a

irregular ragged

state rent

found in thfe right inferior lateral aspect of the ascending portion of the aorta, about an inch from its origin from the ventricle. This was found to be the mferior opening of a dissecting aneurism which involved' the aortic walls in the flexure of the ascending and transverse portions of the arch of the aorta. -The aneurism itself was a mulii-locular one, the locult communicating with each other, and with the cavity ?f the aorta by an irregular opening. Each lotulus was about the size of a walnut. The walls of the aneurismal cavity were pattly formed by the tissues of the aorta and partly by the muscular substance of the

heart;

319

the outer wall

by the external tissue of the aorta layer of the pericardium, where it surrounds the large blood vessels. The lining membrane of the transverse and descending arch of the aorta and the fibrous

shewed extensive atheromatous disease in its various Heart cavities empty and contracted. Left stages. ventricular walls thicker than usual. Aortic valves much thickened and leathery, and distinct evidence of aortic constriction, all the cusps being adherent. Mitral valves thickened and opaque, with fibrinous deposit on

the free

edges.

Liver weighed 4 lbs. 2 ozs., and was much enlarged. Lower margin extended fully two inches below the costal arches; liver tissue of dark reddish brown color, and dark blood flowed freely on section. No sign of suppurative disease. Spleen slightly enlarged. Nothing special about the other organs noticed. Remarks?There are a few points of interest about this case, which I will shortly state. The symptoms pointing to disease of the heart and large blood vessels were ill-marked and caused little or no inconvenience to the patient. The thrill felt on palpation, and which is stated by most authors to be often present in aortic aneurism, was very faint and sometimes imperceptible. The cardiac pain also said present in these cases was absent almost entirely. This may be attributable to the fact that the aneurism was not large enough to cause pain from There was an absence pressure on adjacent nerves. of systolic expansile pulsation throughout, which might be due to the sac having been a small one. There was a soft bruit present, systolic in rhythm, to

be

and heard

most

distinctly

at the

right

second costal

This was diagnosed space and over the mid-sternum. and this condition was as due to aortic obstruction, death. after found I submit, that it was difficult to correctly apportion the relative shares taken by the aortic obstruction and aneurismal dilatation in the production of the murThe uphasic symptoms I attribute, as mur heard. before stated, to a minute embolon detached from the heart

ed in

valves, carried by the blood stream and impactone of the minuter blood vessels of Broca's con-

volution,

or

possibly (according to Meynart and others)

due to a similar lesion of the island same side.

of Reil

on

the

The nightly rise of temperature, with an initial rigor and followed by profuse sweating, and the distinct enlargement of the liver, seemed to me to be very susof hepatic suppuration, and I am still not

picious

quite

satisfied

as

to the cause of

solely malarial, as quinine had no effect in checking it.

not

this

pyrexia.

and other

It

was

antiperiodics

doubt the correctness of the I place before you; I frewhich temperature chart, " an ague fit. in him saw Any portion of the quently I have

no

reason to

THE INDIAN MEDICAL GAZETTE

j2a

arch of the aorta may be the seat of dissecting aneurism. The ascending part is most frequently affected. And next in order comes the abdominal aorta. The outer

or

frequent

the anterior wall of the vessel The disease

site.

is its

most

usually terminates by

rupture of the external coat into the pericardium."* The causation here appeared to be excessive strain of the arterial walls in

of athletic

a man

tunics from the external

authoiity given above, there ing aneurism,! one in which

are

to

According

coat.

two forms of

there is

a

single

the

dissect-

aperture

to allow of the entry and exit of the blood to and from the aneurismal pouch, and the other in which there is one opening for the entry of the blood and

The former is the

the other for its exit.

more

grave

and the more common form. It would appear that life is sometimes prolonged for a considerable period after the rupture of the sac into the pericardium, for in specimens presented by the Societe de la Faculte de Medicine by M. Mai jolin, the margins of the aperture were

ii" of

long standing, and as it polished Morgagni? and Scarpa|| have colas

fistulous. {

were

lected

a

into the

considerable number of

cases

of rupture

pericardium.

age 42, chief officer of a ship, 13 days in India, admitted into hospital on the 22nd February 1883, complaining of cough and pain in

Eissing,

the chest, from which he had suffered four days. " all right," and had On admission he said he was not suffered from fever or cough previously; but subsequently it was elicited that five weeks ago he " asthmatic attack" which lasted three hud had an

days.

Present condition? On auscultation no bruit detected in the cardiac area ; the heart's action

quick but regular. loud

sonorous

There

rhonchi

was

were

and back of the chest.

manifest

audible all

dyspnoea, over

was

with

it

was

surmised that there might be an intra-thoracic on the bronchi and causing symptoms

growth pressing of pressure.

24th.?Orthopnoea continuing. There was much mucus in the throat, and he was

accumulation of

27///?Died

Autopsy?Fourteen ritic adhesions five

T. Hayden, in Quain's Dic ionary of Medicine. t Nichols in The Philosophical Transactions, Vol. 52, p. 269, says a dissecting aneurism was found at the post-mortem examinationof George II. According to Hope ( Cycloparfia of Practical Medicine, p. 108 et set/.) rupture into the pericardium is rare. Laennec never met with an instance. X Laennec de l'Auscuz. torn. ii. p. 715. ? Epist. Kxvi. Nos. 7, 17. and 21. [I On Aneurism, p. 103 et seq.

on

of both

extent

of

ounces

symptoms

hours

the whole

binding

to the thoracic vails.

reddish

fluid in

serous

the

Old pleu-

after death.

both sides found

lungs

continuing

Four

or

pericardial

cavity. but

Right lung deeply congested

crepitant through-

Emphysematous at lower margins, from the cut surface a frothy fluid exuded on squeezing. Small bronchi filled with inuco-purulent fluid. The whole of the lower lobe of the left lung cainified and granular on section, and small portions sank in water. Heart hypertroph ed, and columnse carnae and musculi pappilares much enlarged. The left cavity conout.

tained

decolorised clot which

a

chordae tendineae.

firmly

adhered to the

valves

opaque and fre e beaded with fibrinous nodules. Aortic semi-

edges

Mitral

There

lunars much thickened.

of the transverse

aneurism

was

portion

large

a

tubular

of the arch of the

completely filled with laminated fibrinous clot and recently formed coagula. On clearing these away, large atheromatous patches almost

cavity

in various stages seen on aortic lining membrane. Liver weighed 5 lbs. On section presented a markedly nutmeg appearance. Remarks.?In this case there was almost complete absence of definite diagnostic signs of the large aneurism

the

pressed noea during life. but

no

had

probably

large bronchi and caused the orthopThe chest

bruit heard. no

which

death,

after

found on

stay in

The

at 7-30 p.m.,

!md unrelieved.

same

tion and

some

freely.

unable to expectorate

was

Orthopnoea present to a marked extent. He could only breathe in a bent posture ; was perspiring profusely ; face pale ; pulse weak and soft. In the evening *

observed that his face had become

and

the front

Temperature 99"4?F.

asthma

was

bronchitis. diagnosis On the next day wheezing sounds were very markedly audible in front, but nothing like a cardiac bruit Heart sounds very faint and indistinct. was heard. made

was

aorta, its

Case,

Fourth

Christian

cyanosed, and

it

habits, causing

atheroma of the arteries. A breach or splitting of the internal and middle coats occurred and allowed of the entry of the blood, which forcibly detached these

[November, 1884:

;

thrill,

There

and

did

never

was

often

auscultated, expansile pulsaany period of his

was no

at

hear "the characteristic

hospital ing cough symptomatic of pressure on laryngeal nerves." The respiration at we

ring-

the recurrent no time could

be called stridulous.

Nothing special noted in the record about the conpupils. Fr mi the absence of metallic cough, persistent stridor and aphonia, we may condition of the

clude that the

recurrent nerve was not

pressed upon

Fifth Case. case the diagnosis was an aneurism of the portion of the arch at the junction with the descending aorta. The patient did not die, so that the- diagnosis was not confirmed.

In

this

transverse

Thomas Walsh, aged 40, seaman, admitted into hospital in the 2nd Resident's ward on the 30th of

June 1883.

;

.

/

NOTES ON SOME CASES OF ANEURISM.

November, 1884.]

Previous history.?Had a fall from a height thirty feet some years ago, but cannot remember whether he specially injured his chest at that time. Habits Is of and mode of life irregular, often drinks hard. moderate height, well built and slightly anaemic. No history of rheumatism or syphilis. His present illness commenced about six months ago with a "cold in the chest," as he himself describes it. He did not leave off work until a few days before admission to

hospital.

No

previous

treatment.

Present condition.?Complains of lancinating pain in the left mammary region and shoulder. Since the last four days the pain has assumed a boring character. Pain also extends upwards to the neck and shoots down the left arm, and at times the arm gets quite benumbed. Pain much easier some days than others. Suffers from palpitation and shortness of breath on the slightest exertion. No dysphagia, ?

oedema,

nor

feature.

Constipation

dyspnoea.

a

very marked

Occasional rise in evening temperature. No Vague pains in other parts of body. Voice normal.

Physical examination.?Area

of normal cardiac dui-

increased downwards and to the left. The impulse and heaving, and the apex can be fAlt the left sixth space. Percussion note in left mam-

?ess ts m

forcible

regions markedly

mary and infra clavicular

dull.

At

this spot there is also a distinct expansile pulsation. No visible bulging of thoracic walls. Some increased pulsation in large arteries of the neck. A loud double Murmur audible all over cardiac area and in the large arteries, the point of maximum intensity of One inch murmurs being at the base of the heart. below the centre of the left clavicle there is a distinct loud bellows murmur, systolic in rhythm. At the apex a systolic bruit is audible, which i$ conveyed through the left axillary spa:e to the inferior angle of the scapula. Cardiac action at times, irregularly intermittent. Pulse very markedly "water-hammer" type

(Corrigan's pulse.)

Respiratory

sounds

normal.

Other viscera healthy. A sphygmographic tracing shown of both riafht and left radial arteries.

is

m Fig.

i.?Sphygmographic

tracing of right radial.*

Remarks.?He

was treated throughout potassium, and his general health improved. Unfortunately he could not

of

he

suffering

was

wished several

to

*

radial.

radial.

The engraver has made the ascending stroke to end somewhat more abruptly and sharply than in the original tracing.

much

was

realize that

from

resume

a very serious disease, and his seaman's occupation. He his discharge altogether from

from the hospital for a few ou;, he in the small hours of the morning almost back came speechless from drink. His diet was not restricted in any way during his stay in hospital, and I doubt whether he would have submitted to low diet.* I had hoped to send him to England as a distressed him

leave

but

seaman,

rest

too irksome for

and confinement to

him,

and he left

one

hospital proved

day

of his

own

sight of him. Intermittent periods of powerful exertion, alternating with irregular periods of rest, during which he doubtless partook liberally of stimulants, coupled with privation, were doubtless powerful factors in the will and I lost

causation of this aneurism.

The symptoms of prescase, also it was re-

In this very slight.f marked that the temperature

sure were

would be without normal, apparently cause, for and then as suddenly subside.

frequently

than

higher few days

a

Sixth Case.

Carl Lusko, age 36, German, of

ship,

a

into

seven

the General

months

Hospital

a

fireman

on

board

India, was admitted the 3rd May 1883.

in on

He said that for the past four months he had been suffering from a very severe pain in the right side of the chnst. Attributed it to bonnet

sleeping

history,

on a

etc.

?

flagged pavement

in

one

of the Calcutta

" cold," and has suffered streets; he contracted a in the chest ever since. Had and from "fever" pain been four months in the Medical College Hospital

under Dr. Coates.... .On admission.?A bellows sound audible over the whole of cardiac area, which was loudest at the root of the aorta, and most distinct under the right clavicle. Pain steady and constant, and extending from right .mammary region right round the back. The right mammary and infra-clavicular regions are dull on percussion and tender. No bulging of ribs, no expansile pulsation or thrill to be detected on palpation.. Posteriorly the loud bellows murmur Over is very distinct in the inter-scapular region. ?

of left II.?Sphygmfgraphic II.?Sphygmrgraphic tracing tracing of left

with iodide

times took hospital, and came back after a few days very much On two occasions that I the worse for drink. gave

paper in a late number of the Lanctt, by Dr. Dyce on the treatment of internal aneurism by Tuffnell's He remarks on the great danger of the patient's method. rebelling ot being starved, and leaving the hospital after a few days' treatment ; and on the additional danger when (as in the case narrated in the text,), there is aortic regurgitation, in addition to the aneurismal dilatation. t For a complete discussion on the subject of thoracic aneurism, its symptoms and treatment, see a series of lectures in The Lan'et for June and July 1S72, by T, Holmes; also Bar well On Aneurism, iS8o. See

a

Duckworth,

Fig. Fig.

321

THE INDIAN MEDICAL GAZETTE.

3*2 the

right apex there was increased vocal resonance, blowing, breathing and some humid cracklings aud-

ible. Radials equal and synchronous. He was weak, anajmic and emaciated, and suffered occasionally from dyspnoea and cough. Sputum occasionally with blood.

Had an attack of syphilis seven He was put on io-grain doses of iodide years ago. of potassium and citrate of iron and quinine, three

tinged

times a day, and his general health seemed to improve. The diagnosis made being aneurism of the ascending portion of the arch of the aorta. On the 29th of May he said that after the heavy rain of the previous day he felt severe pain at the seat of the suspected aneurism and in the right side of face, head, and right arm, and said he always felt those pains worse in rainy and damp weather.* Gradually the quantity of iodide of potassium was increased, and on the 27th June he was taking 25 grains three times a day, or 75 grains a day, and a few days later the quantity was increased to 30 grains three

day, but caused much gastric irritation and inconvenience, and the extra 5 grains was stopped on the 1st July. On the 10th July a note is recorded that times

"

a

is much less distinctly audible in the mammary region, but is musical in character in the inter-scapular region." The dose of iodide later on was again increased to 30 grains three times a day without ill effect. The sphygmographic tracings of the right and left radials are given below :? the

murmur

questionably did good. His diet was not restricted, although very many authorities agree in recommending a very restricted diet in connection with rigid avoidance of all stimulants.* Dr. Tuffis notably associated with this form of treatment.! It must be borne in mind that the temperament of the patient is a main element in the treatment of aneurism by rest and restricted diet,

rest and the

nell's

name

and also that it

requires

class of

patients

whom

we

shall be

in to

judge

years ago. but had

On the 6th of August he was sent to England as distressed seaman, with a view to his being ultimately sent to his own country. I was away on leave at the time. Remarks?In this case I have no doubt of the fact of there having been an aortic aneurism affecting the commencement of the arch. The cause was

obscure, and the symptoms of eccentric pressure slight and ill-markecl. He was mainly treated with large doses of iodide of potassium, and these un*

This increase of pain in rainy and cases of this series.

noticed in the eight

damp

weather was also

most

in

commonly

of their value in

four

Had

the

meets

similar

been to and from India fre-

remained in it time. Had been

never

months at

a

beyond losing

three flesh

lately. for

his

a

man

of medium stature, of eyelids

Slight puffiness

age. and looks

worn ; marked arcus inch below and to inner side of nipple, action excited, sounds muffled. A distinct pulsation with a thrill was felt about three inches below xiphoid cartilage. On auscultation here, a loud blowing double bruit was audible, which diminished in intensity proceeding upwards; was barely audible at xiphoid cartilage, and above it was not audible. Posteriorly on the left side of the spinal column a distinct to and fro murmur was audible, also faintly heard on the right side of the spinal

pallor of skin, senilis. Apex beat

a

Unfortunately,

Seventh Case. Charles Evans, age 49, sail-maker, admitted into the General Hospital on the 7th October 1883, complaining of pain across the back extending on either side to middle of hypochondriac region, which was of a burning character, and attributed to exposure to rain and cold. He had been suffering from the paii for about a month. No evidence of syphilis or gonorrhoea, but he had been a hard drinker. Usual No previous ailments, with state of health good. the exception of a few days' fever in Bombay, about

and

of left radial.

the

cases.

Present condition.?Is

IV.?Sphygmographic tracing

on

Although the precise diagnostic value of sphygmographic tracings in cases of suspected thoracic aneurism is, I think, not yet definitely settled, still the more examples are collected the better position

muscular

Fig.

one

self-control

and I think seclu-

with aortic aneurism the requisite self-restraint is its absence. In some of Mr. Tuffnell's cases the cure was verified by dissection.

or

radial. radial.

in

on,

generally conspicuous by

thirty III.?Sphygmographic tracing'of right right

immense

part of the patient operated sion would be advisable.

quently, Fig.

[November, 1884-

column.

felt

Percussion

note was

abnormally

dull

right hypochondriac, epigastric hypochondriac regions. .Marked evidence of inner half of

over

and left athero-

* See remarks made,further on in connection with this mode of treatment. The introducer of this plan was Belliiigham. t The Successful Treatment of Internal Aneurism, 2nd edit., 1S75, hy T. J"lifFc Tuffnell, F.u.C.s.i., ctc.

NOTES ON SOME CASES OF ANEURISM.

November, 1884.]

The radials rolled disease of the arteries. the giving the idea of a whip-chord,

niatous

under

and the

fingers pulse was hard.

of the abdominal

Diagnosis.?Aneurism

of

one

splenic

of the smaller arteries, the

aorta or

or mesen-

teric.

(b.)?A growth arising or

liver,

or

mesentery and

from the

pressing

stomach, spleen on

the abdominal

aorta, the pulsation being communicated. (c.)?Enlargement of spleen, or left lobe of liver, or

both, pressing

due

on

to same cause as

and

was

loud,

not so

Pulsation

heaving;

and the thrill

Had pressure. 11 th January

(b).

pulsation

in the back was localized was softer and not

1883.?The pain

26th Derember

less and he felt easier. so

abdominal aorta, the

was

was more

murmur

only

felt

on

applying slight

gained 4 lbs in weight. 1884.?Impulse was not

so

heaving ;

thrill only distinctly felt when slight pressure was applied; murmur softer. He felt better and had

gained 2 lbs more in weight. 15th February.?Bruit louder, thrill very distinct, pulsation more heaving. Felt the pain in the back getting worse. Had gained 7 lbs more in weight. 23/7/ April.?Has been losing flesh gradually since last entry, and the pain in the back has steadily in-

examined and was found to His appetite contain a large quantity of albumen. failed and he had had occasional attacks of vomitjug. The bruit and thrill and heaving impulse had become as marked as when he .was first examined. He was recommended to be sent Home as a distressed seaman, and left India on the 24th April. Remarks.?He was treated throughout with small creased.

Urine

was

potassium. He came into hospital much emaciated, but gained nearly a stone in weight before he left for England. Causation obscure. The diagnosis in this case presented no diffidoses of iodide of

but many cases of suspected abdominal aneurism are unquestionably cases of simple hysterical or dyspeptic pulsation of the abdominal aorta. The are usually nervous antemic men, and

culties,

subjects

hysterical

women.* Eighth Case. married and

has healthy Day, aged 32 years; children living; East Indian, employed as a gunner in the Port Commissioners' jetties ; was admitted into the centre war i of the General Hospital on the 21st of December, suffering from "cough and heart

J.

A.

disease." History.? Stated that on the 22nd of May last, he was standing on the top of an engine whilst it was being lifted by a crane, when suddenly the hook The moral effect of semi-starvation and strict confinement bed possibly "cures" some of these latter classes of patients, although it may have the contrary effect of unduly exalting their nervous symptoms. *

to

of the

323

(which was attached to the engine) engine dropped down about three feet, and he jumped off it on to the ground, a distance of seven feet, thinking that the crane would fall on him. As soon as he reached the ground he crane

broke and the

felt acute

if it as

pain and a sensation about the chest 11 as lightning inside." (I presume he meant being galvanised ?). This lasted about three

was

of

when the

days,

pain and sensation abated. About June, he was caught in a heavy shower whilst crossing the Hooghly bridge, and

the end of of rain without

felt

chest,

with

also

warning he accompanied

extending and in

face

had

a

in his

constricting pain,

severe

right side

of neck, head and After the shower had had much abated, and before he had the

to

the

ceased the pain walked half

similar sensation

a

right

mile it

enjoyed good

ear.

entirely

left

him.

Previously

health and had been

active

an

In his younger days was a sailor, and accus work Had syphilis, twelve or tomed to hard in fourteen years ago, Calcutta; had a sore on the man.

and

penis,

secondary coholism.

treated with internal medicine;

symptoms followed. Of late years, the

exceptionally

been

Medical

at the

of

was

history patient said

Suffered

from

he

Had been

College Hospital

aorta."

the

temperate.

no

of

No

alhas

treated

for "aneurism

confluent

small-pox

twenty years ago in Calcutta, and is much marked. of both eyes and incipient cataract. Present condition.?On auscultation there is a loud diastolic murmur audible all over prascordia, but most

Coryza

distinct

at

second

right

costal

cartilage

and

over

centre of sternum ; very loud also below the sternal of right clavicle, at sternal notch and in

extremity

the vessels of the neck (carotid and sub-clavian, no thrill communicated to of side;) right chiefly hand on palpation over cardiac area, but a distinct

murmur indistinct at apex; over sternum the murmur is double. the of the centre Pulse synchronous on both sides, and of the waterPosteriorly the diastolic murmur is hammer type.

thrill felt in neck ;

very audible in

inter-scapular

scapular angles.

Has had

blood

expectorated

space,

hcemoptysis

is in dark clots.

also

at

for five

the

days

Has had

; a

cough for some months; generally expectorates thick yellow phlegm. Percussion note of left infra-claviThe breath cular region flatter than on right side. sounds are harsh below the clavicles and accompanied with wheezing rhonchi; expiration prolonged ; area of cardiac dulness not increased. Weight 120 lbs. He suffers much from headache after exertion and when he lies on his right side. No bulging notice-

superficial thoracic structures. His fingers markedly clubbed, and have been so since last June. No difficulty in breathing or swallowing, sometimes has a cough and finds it very hard to expectorate. Temperature 97'6CF. He was ordered able of

are

THE INDIAN MEDICAL GAZETTE

324

mixture of

grains 10 of iodide of potassium with drops of ext. ergot? liq. Had no pyrexia to speak of whilst in hospital up to 14th January, the temperature only on two occasions reaching 99'2?F. in the axilla. On the 23rd December I stopped the ergot, and only continued the iodide in 20 grain doses with His appetite was good, 20 drops of spt. chloroform. As the constant cough and he asked for full diet. prevented him sleeping, I ordered him one-sixth grain morphia subcutaneouslv. On the 27th December he began to spit blood after dinner, and I ordered liq. ext. ergotse, 20 drops Complained of much thoracic every four hours. the 6th On January 1884 his weight had pain. increased to 122 lbs. On the 14th January he left hospital, and I lost sight of him until the following May 14th, when he presented himself at the hospital, a

15

and I induced him to allow me to examine him. He had become more emaciated than when 1 last saw him. He had been continuously at home, and taken medicine

from the Medical College Hospital as an out-patient. (I found chiefly iodide of potassium and purgative

pills had a pain in

been

prescribed.) His chief complaint was the right shoulder, right side of neck, and right ear, and the pains are increased when

inside there is

When he attempts to speak much or to stoop forward his voice becomes husky and he feels choked. When he attempts to swallow there is breeze.

a

a sense of constriction in the oesophagus, sometimes has a harsh metallic cough ; very often suffers from pyrosis. Fingers much clubbed, and of a bluish

purple

color.

There is

no

apparent

dyspnoea ;

voice

natural. On

inspection.?There is a smooth round bulging right side of the thorax at the situation of the right sterno-clavicular articulation, about the size of half an orange. It is semi-solid, and conveys a sensation of elasticity and resistance. There is both heaving and expansile pulsation felt on palpation with a distinct thrill, which latter can also plainly on

the

be

felt

in

right side.

and sub-clavian arteries of arteries of the neck markedly and

the carotid The

visibly pulsate. epigastric pulsation. The radial arteries are synchronous in rhythm, markedly atheromatous and roll under the There

is

also

; the character of the pulse is markedly that of aortic regurgitation (Corrigan's.) The right pulse is distinctly weaker and more compressible than the

Eyes suffused and watery, superficial structures of eye ball dulled, conjunctivas injected. On auscultation, over the bulging there is a double to and fro murmur, somewhat metallic in character, one.

also audible in vessels of the neck and in sub-clavian arteries, but here chiefly systolic. At the apex, the

first sound is muffled, and there is a distinct murmur after the second sound. At second inter-costal space and all over the sternum is a double murmur. Pulse

heaving.

Diastolic bruit at

tric notch and along abdominal aorta. the man to come into hospital again. Remarks?When the man first came my

was, that he had

opinion

innominate artery also

probably

I

the

epigas-

I induced

hospital,

to

aneurism

an

involving

due to atheroma.

of the

ascending

think that

arch?

it is posof caused rupture

sible that the accident he spoke of the aortic lining membrane, to some extent previously softened-and diseased by atheroma, and the Sensation was possibly in part due to stretching of the thinned aorta and in part to the tearing of the

lining

membrane.

On the second

admission,

remains but that there is

I think very little doubt an

aneurismal dilatation,

the innominate artery, and possibly the commencement of the right carotid and sub-

chiefly involving clavian

ascending arch. matting of thickening

I also think that

arteries and

there is

allowing

and

of

regurgitation,

the aortic valves

and also

causing

obstruc-

tion to the free flow of blood from the ventricle to the aorta, and that the mitral valves affected.

are

secondarily

This is the only case in which the signs of aortic There is no aneurism are unmistakably obvious. irregularity of the pupils, and never has been. The

subject, I think, for operation, else ligature of the vessels of the neck, undoubtedly according to the method of Brasdor, might be attempted with some faint hope of temporary benefit, Mr. I saw Mr. Holmes perform the operation once. Christopher Heath, in November 1865, operated on a woman, who lived four years after the operation, man

is

bad

a

distal

and would

probably

have lived

longer

if she had

exceedingly intemperate.* The disease was stationary for two years. I had never proposed any operation to this patient, and as I think the arch itself is extensively involved, and also that there is free regurgitation through the aortic orifice, I would very much hesitate to recomnot

been

mend the

operation.!

marked

fingers

left

118. Heart's action

[November, 1884.

General Remarks.

Diagnosis.?In four out of my eight diagnosis was beset with difficulties. In

cases, the the cases

of Mann and Booth, I do not see how one could have definitely arrived at a conclusion of aneurism. Eminent authorities agree that thoracic aneurism is often latent. Numerous cases are on record of persons

seemingly

in the best

of

health,

who have

in this case, before the operation the aneurism to be chiefly, if not wholly, of the innominate artery, at the post-mortem it was found to be purely aortic. The carotid and sub-clavian arteries were simultaneously *

was

Although suspected

ligatured.

t For full discussions on the subject of distal ligature in these cases, I must refer the reader to the numerous papers by Messrs. Holmes, Erichsen, Harwell, etc.

NOTES ON SOME CASES OF ANEURISM.

November, 1884.]

If so, the transition to aneurism is natural, if not inevitable"* ; and again, " chronic alcoholism tends to impair the nutrition of all the tissues including the arteries, and is accompanied by a constantly irritable condition of the circulation."! Intemperate habits also load the blood with impure and imperfectly oxidized nitrogenous products, and thus its passage through the capillaries is rendered difficult, and as a result increased arterial tension is produced. The number of deaths from aneurism,

died suddenly from rupture of an aneurism into one ?f the important visceral cavities.* Any or all of the symptoms usually described in text books as

characteristic of thoracic aneurism given case.

may be absent

in a

-Age.?In

these

eight

the age of the youngest were 33 years old; 40, and one 42' years olu.

cases

was

32; the oldest 49;

?ne

36;

one

37 ;

one

two

This accords with the general experience that aortic aneurism is most common between the ages of 30 and 50. cases

Dr.

Hayden

observed

or

says,

that out of

analysed by him, sixty,

according Registrar-General's Returns, appear to be steadily increasing, the proportion in 1870 being 28 to 1,000,000 living against 17 in 1854. How much of this is due .to improved diagnosis and how

to the

ninety-two or

nearly

occurred between the ages of 30 and 50, twelve over 50, and five under 30 years of age. " Thus whilst atheroma is more common after 60, one of its most common results?aneurism?belongs

two-thirds,

to

an

period 01 life. The apparent discreexplained by the more frequent em-

earlier

pancy may be

ployment

of

men

under

fifty

in

severe

labour,

and

their greater capacity for extreme muscular effort, the condition of the arterial wall which favours aneurism

been

having

consensus men suffer

already established."

opinion is noted of the more frequently than women, in of

A

general

much to actual increase of the disease from greater exposure to arterial strain in the same classes of

way across the ward before my eyes. In all of my cases in which a fatal result took place, at the post-mortem examination more or less atheromatus disease of the vessels was found, and I think it probably the most generally frequent arterial lesion found. Wilks and Moxon, however, look uPon simple inflammatory softening without atheromatous deposit as a common cause of aneurism.

Rheumatism or gout may cause such a low inflammatory condition and predispose to aneurism. Violent

strain or mechanical violence are other causes of aneurism. The influence of syphilis and of intemperance, as powerful factors in the causation of aneurism, is also

definitely proven. theory that syphilis

neither fact is as yet in the

Little disbelieves

may cause atheroma and hence " that syphilis aneursim, but I think with Holmes, the vessels, of fibroid a cause may degeneration

must be allowed to be at least possible, and that it does so, is the opinion of many eminent pathologists. *

Three such cases Journal for June, 1S82,

firmary,

are

by

newly developed industries,

say.

carefully taught hand,

accurate

diagnosticians;

and

on

for existence" increases year by year. In England the average annual mortality from aneurism for the

of one of the carotid aneurisms gave way, and a stream of arterial blood jetted more than half

Dr.

in

accurately

to

In

recotded in the British Medical Mr. Lunn of the Maryleboue In-

my

subjects Five out two gave

we

cannot

forget

that the

"

has been 402. cases, with one exception,

struggle

1857-1866

ten years

own

all the

following laborious occupations. of the total gave a history of intemperance; a distinct history of syphilis. In the last were

men

case, I think that the direct cause which the man referred to.

was

the accident

Treatment,? On this head I have little or nothing which all of you do not know as well if not bettee

broad

belief, though

cannot

the pro-

extensively involved, I was accidentally present when slight exertion turning in bed, the thinned sac

common

or

I should feel inclined say that both causes have operated in causing the increase. On the one hand our appliances for correct diagnosis have been improved and multiplied, and also every year adds to the number of we

the other

from

very

population,

the

fact that

Portion of about 8 to r. This is doubtless due to the fact that the male sex is more actively engaged in laborious pursuits. I have only seen two cases of thoracic aneurism amongst females, both, years ag?> at St. George's Hospital. In the one case in which the carotid and innominate arteries were also

a

3*5

to say

Our best hope seems to me can tell you. of iodide of potassium and doses in to be large with a regulated strict rest, coupled diet; and of these three, the greatest is absolute rest in my judgment, and the avoidance of all strain on the already stretched and thin walls of the aneurism. I need only refer to the well known case of Mr. Stanleys, which was spontaneously cured by rest. At best, than I

however, these only serve as palliatives in most Numerous surgical methods have been attempted as curatives, as Brasdor's distal ligature of the vessels of the neck, exemplified in cases recorded by Dr. Cockle and Messrs. Holmes, Heath I would like to be favored with the and Barwell. opinion of those present on the distal operation. Then we have the introduction of horse hair and iron wire into the sac with disastrous, and I think I am correct in saying, universally fatal result; cases.

?

Holmes in Dictionary of Medicine, article

page 47. t Op. Cit. Ante.

"Aneurism,"

326

acu

THE INDIAN MEDICAL GAZETTE.

and galvano-puncture.*

latter I would refer to

an

With regard to this article by Dr. Duncan

Edinburgh, in the British Medical Journal for 1876, on the benefits of treating aortic aneurism by the method of electrolysis. I must confess myself sceptical as to the result obtained by following the method of Valsalva and Albertini, i. e., constant depletion and low diet and limited fluid, f

of

*

In Dr. Green has tried galvano-puncture in two cases. it did no good, but in the other some benefit resulted. Dr. Cameron of Valparaiso, in New York Medical Record, November 26th, 1881, reports a case of cure by this method. The patient was a man aged forty, and had an aneurism of the ascending arch- Two fine steel gilt needles were passed into the aneuIn two weeks the tumour rism and kept there twenty minutes. began to flatten, and all bad symptoms disappeared gradually. In this case, however, the effect could not be clearly charged to galvano-puncture, as, owing to a defect in the battery, almost no current had been passing. t See Dr. Copland's remarks on the subject. The patients of Valsalva were reduced to such an extreme pitch of debility that they could not raise their hands above their heads, their diet consisting of l/z lt>. of pudding in the morning and % lb. in the evening, with water in very limited quantities in the In conjunction with the spare diet, we find it strongly interval. recommended to take as much as 10 oz. of blood a day ior a fortnight consecutively. (Cyclopccdia Pract. Med., article "Aneurism," by Dr. Hope.) Foreseeing the difficulties in thoroughly carrying out the treatment and anticipating rebellion on the part of the patient, the practitioner is strongly urged " to insist on the treatment, and when once adopted to pursue it with uncompromising rigour(The italics are mine ) one

[November, 1884.