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and it contained only post-niortem clots.^ It was in every
way a most instructive and satisfactory case ; but we had
much yet to learn.

]\Iy next case, though more obscure in its diagnosis, was
even more immediately .satisfactory in its results.

Case XLII. John Kerr, a seaman, aged twenty-six, ad-
mitted into "Ward YII. on 22nd October 1867. He said he
had been ill for eighteen months, dating his illness from the
time of an arctic voyage, when he had been exposed to much
privation and had to make strenuous exertion in hauling
boats over ice and snow while in a feeble state of health.
In America he had been supposed to suffer from an aneurysm
of the abdominal aorta, and he presented himself at the
surgical wards of the Edinburgh Eoyal Infirmary to be re-
lieved of this, thence he was transferred to my care. Kerr
complained of intense pain in the scrdbiculus cordis extending
through to the back and passing round both sides. On ex-

1 The preparation is in the iluseum of the Royal College of Surgeons,
Edinburgh.



DISEASES OF THE HEAET 451

amination a tumour could be obscurely felt a little below the
sternum, and just under the edge of the right false ribs. On
turning the patient over toward the left the tumour was
more readily felt ; it dropped, as it were, into the hand. Over
the tumour referred to, or at least as near as could be got, a
loud murmur was to be heard through the stethoscope. Xot-
withstanding the obscurity of the diagnosis, it was thought
desirable to give this patient potassium iodide, as likely to
be useful whether the tumour was solid or truly aneurysmal.
Accordingly he got tliirty grains of potassium iodide twice
a day ; he was put upon fish diet, a restricted amount of
fluids, and confined to bed. The result was remarkable ; he
got almost immediate relief from the agonising pain, the
uneasy pulsation felt by the man himself was at once con-
siderably lessened, and the force and volume of the radial
pulsations appeared to be also greatly diminished. He im-
proved steadily ; in a few months tumour and murmur had
quite disappeared, and on 22nd January he was discharged
at his own request, and engaged himself for a short voyage
to test his reacquired health before going to sea for a longer
term. The obscurity of this case is patent to all, yet the
signs and symptoms pointed strongly to aneurysm, and the
success of the treatment, coupled with the rapid manner in
which relief was obtained, seemed to confirm the diagnosis.

A year afterwards I reported as follows: — ■•John Kerr
left for a trial voyage, but never returned. In January 1869,
a year after his discharge, the ward nurse got a letter from
him dated Australia and saying he was now so well that he
was off to the g-old digcpings." -^ I have heard nothing more
of this patient.

The diagnosis in the nest case was more unequivocal, and
as the liistory includes the jjost-mortem appearances, we know
exactly what ailed him and to what extent it was remedied.

Case XLIII. James Wilson, a mason from Xewcastle,
aged forty-four, admitted into Ward YII. on 31st August

1 Edinhurgh Medical Journal (July 1869;, p. 48.



452 CLINICAL LECTURES ON

1867. About nine mouths before admission this patieut
begau to have occasional attacks of lightness in the head with
a flashing of light before his eyes. These attacks came on
while he was at work, and obliged him to sit down for a
little to recover himself At first the seizures came only
once or twice a day, but they soon became more frequent,
and he always felt much weaker after them. During these
attacks he perspii'ed profusely. About the same time the
patient began to suffer from " beatings " in his abdomen, in
the left side of the chest, and on the right side of his neck.
A swelling also appeared at the right side of his neck w^hich
gave him great uneasiness, and produced a feehng of choking.
Getting no relief from those w^hom he consulted he came to
Edinburgh. On admission to the Infirmary it was found
that he had no pulse in the left radial artery, but for this
there was no apparent cause, the " beatings " on the left side
being evidently only cardiac palpitation ; on the other hand,
those in the abdomen, and on the right side of the neck, had
each an abnormal and e\ddent cause. In the lower part of
the epigastric region, towards the left side, and lying close
above the aorta, the course of which could be distinctly
traced, a tumour the size of a small orange could be distinctly
felt pulsating — expanding in all directions — and not merely
moved by the artery beneath it. Over this tumour a loud
systolic murmur was heard. On the right side of the neck
there was also a pulsating tumour extending up the neck
from the sterno-clavicular articulation towards the mesian
line. This tumour was somewhat larger and longer than that
in the abdomen ; it resembled in shape a large kidney potato,
and upon any excitement, especially when the man was up
and walking about, it increased considerably in size. No
distinct murmur could be heard over it, nevertheless it was
evidently an aneurysm implicating the innominate, subclavian,
and carotid arteries. Wilson was at once given thirty grains
of potassium iodide twice a day, and a diet and regimen
similar to that already described were prescribed for him.



DISEASES OF THE HEAKT 453

but as his symptoms were not so urgent strict recumbence
was not insisted upon, and he was allowed to go to chapel
every night. The iodide was not so well borne by this
patient as by the two already commented on ; every now and
then pain in the stomach, or severe headache gave warning
that it was time to omit it. These symptoms always abated
after leaving off the medicine for a day or two. His appetite
always remained good, but his bowels required to be regulated
by medicine. No immediate effects were observed from the
iodide, but after some months the abdominal aneurysm was
found to be quite firm and apparently solid ; the murmur had
also disappeared, and could only be reproduced by pressing
somewhat strongly with the stethoscope. After a time the
aneurysm in the neck also ceased to swell out when he
walked about ; it gradually became firmer and ceased to give
him any inconvenience. His general health was much im-
proved ; he no longer had any disturbing pulsations, and
though he occasionally suffered from lightness in the head,
and from dazzling flashes of light, his condition was much
better than it had been, and, considering his inveterate
aneurysmal diathesis, he had probably reaped as much benefit
from the treatment as was possible.

A year subsequently I reported of him as foUows : —
"James Wilson, labouring under an aneurysm of the in-
nominate, implicating the subclavian and carotid arteries,
also an aneurysm of the abdominal aorta, and a general
diseased state of the vessels. This man worked for many
months comfortably and without inconvenience at his trade
of mason, avoiding, as desired, any heavy lifts ; he has now,
however, got an easier berth in connection with the Cale-
donian Eailway. His abdominal aneurysm is still to be felt
as a hard, firm knot, much diminished in size from what it
was. His innominate aneurysm never troubles hun, and
gives rise to no symptoms, but it is not consolidated, neither
is it any longer an aneurysm. To all intents it is nothing
now but an elastic artery, fusiformly dilated no doubt, but



454 CLINICAL LECTUKES ON

no longer bulging as a globular pulsating tumour across the
trachea." ^

This poor man presented himself every now and again for
inspection, and occasionally came into hospital for a week or
two for relief of catarrhal symptoms. On 27th June 1870
he re-entered hospital because of a recurrence of the symptoms
of abdominal aneurysm. The original abdominal aneurysm
was to be felt as a small hard nodule resting upon the aorta
just beneath a large, soft, pulsating swelling passing up
beneath the ribs on tlie left side. Over this tumour a
systolic murmur was to be heard ; the subjective symptoms
were confined to flatulence and occasional pain of a dyspeptic
character in the stomach. He was treated as formerly with
potassium iodide and with a similar result. By the beginning
of December 1870 he was about to be discharged when he
showed symptoms of typhus, caught through unauthorised
contact with fever convalescents in the infirmary chapel.
He was removed to the fever wards, passed through the
regular course of typhus, and after disinfection was received
back into a side-room seven weeks subsequent to his trans-
ference. On 24th January 1871 his abdominal tumour
measured six inches, from the lower edge of the hard nodule
of the first tumour to the point where it disappeared beneath
the ribs. The tumour lay along the aorta; it was three
inches in breadth, and could Ije readily grasped through the
thin abdominal parieties ; it was firm and devoid of lateral
pulsation ; and, unless firmly pressed upon by the stethoscope,
no murmur was audible, merely a dull thud. At its upper
extremity, however, just where it dipped beneath the ribs, a
slight systolic murmur was still to be heard, and this part of
the tumour seemed to have grown somewhat larger during his
illness. Wilson made a good recovery, was discharged, and
continued to maintain himself by manual labour till Septem-
ber 1873, when he was readmitted to the Infirmary for a
recurrence of symptoms of aneurysm, and he died there on
1 Edinburgh Medical Journal (July 1869), p. 48.



DISEASES OF THE HEAET 455

1-itli October, over ^ix years after his first admission. The
large, recent abdominal aneurysm occupied the \Yhole of the
left h}^ochondriac region : at -fii-st its pulsations were c^uite
fluid, but under treatment the walls of the sac became firmer
and the pulsations less distinct, but it never diminished in
size ; indeed for this there was scarcely time before the patient
died exhausted. After death the whole of the aortic arterial
system was found to be greatly atheromatous ; the innominate,
subclavian, and right carotid arteries had thicker walls than
usual, and seemed altogether larger. The left subclavian
was plugged by a firm fibrinous clot just where it passed out
of the chest, the coats of the artery being contracted round
this plug. The descending aorta gradually dilated till, after
passing through the diaphragm, it developed into an aneu-
rysm the size of a large cocoa-nut, and below this there lay
the hard, firm nodule of the origmal aneurysm ; this contained
ovlj post-mortem clots, but its walls were made almost as dense
and hard as bone by atheromatous deposit.

Case XLIV. Peter Eeid, hotel porter, aged forty-six,
admitted into Ward A^I. 18th June 1868. This man was
drunk on admission, having avowedly taken spirits to nerve
himself for his apparently rapidly approaching dissolution.
He had intense dyspnoea, amounting to complete orthopnoea,
violent, harassing, but dry cough, and felt and looked as if on
the point of suffocation, while a large, soft, projecting and
pulsating tumour seemed to threaten death in another form.
He was ordered at once fifteen minims of chlorodyne to be
repeated every half-hour till the cough was quieted, and also
twenty grains of potassium iodide three times a day. He was
confined to bed, in which he was supported in a semi-erect
posture, and his food and drmk were somewhat restricted.
Within twenty-four hours this man expressed himself as much
relieved, and in a few more hours he breathed more freely.
Eeid was an old solcher, and about five and twenty years pre-
viously he had been cupped in a military hospital for palpita-
tions which continued more or less after his discharge. About



456 CLINICAL LECTURES ON

ten years ago, in the end of February 1858, he was admitted
into this hospital on account of excruciating pain in the right
side and down the right arm, which had troubled him for
some months previously. There was also at that time a
slight swelling, accompanied by pulsation, to the right of the
sternum. The pain complained of was most excruciating in
winter, when he caught cold, or made any unusual exertion.
In about eighteen months the tumour protruded externally,
and then the pain ceased to be so agonising. During the past
eighteen months the tumour has grown more rapidly than it
has done for years ; this he attributes to the extreme violence
of his cough.

To the right of the sternum there was a large pulsating
tumour, extending from the third to the seventh rib, and
projecting fully half an inch beyond the level of the thoracic
wall. Part of this tumour was solid, but part, rather beneath
the middle, was soft, painful to touch, projecting conically,
and pulsating fluidly. Dulness extended for fully five inches
round the centre of the tumour, passing below into the liver
dulness. The pulse in the right arm was smaller than that
in the left. The heart's apex beat between the sixth and
seventh ribs and one inch to the left of the nipple, but there
were no indications of hypertrophy, and the cardiac dulness
was normal. There was cardiac displacement but no hyper-
trophy, and there were no abnormal murmurs to be heard
either over heart or tumour. The right pupil was somewhat
dilated. There was considerable pain in the right side and
down the right arm, but this was much less than formerly.
After the patient had somewhat recovered from the frightful
condition he was in when admitted, a belladonna plaster was
applied over the tumour, and the chlorodyne was gradually
stopped as the cough lessened. It had almost entirely ceased
by 12th August, at which date the patient looked, and ex-
pressed himself as feeling much relieved. The pulsation in
the tumour was much less forcible than formerly, and the
tumour itself was flatter and felt more solid. On 31st



DISEASES OF THE HEAKT 457

August an icebag was substituted for the belladonna plaster
for a few days, but had to be given up, as, though it felt
comfortable enough and relieved the distressing pulsation, it
increased the cough very much. At this date he expressed
himself as feeling very comfortable, and able to breathe and
swallow easily, both of these acts having been hitherto
attended with much uneasiness, the tumour was also gradu-
ally decreasing in size.

Eeid was kept in hospital till 20th March 1869, when he
was discharged to go to his home in London. Thus this poor
dying creature was, after nine months' treatment, able to be
discharged in a comparatively active condition, and both
looking and feeling well. A cast taken from the projecting
tumour about a month after admission, and one taken on the
morning of his discharge, show the marked diminution in its
bulk. In a letter from my resident, the late Mr. Frank H.
Hodges, he says, "I called on Peter Eeid on 28th April,
and found him in a very satisfactory condition ; the tumour
has considerably diminished in size (since his discharge) ; he
is quite free from cough, and goes out for a constitutional
daily."

The next case is evidently not one of saccular, but rather
of true aneurysm (dilated aorta) with diseased arterial coats,
and gives very evident proof of what can be done for the
relief even of these cases by the treatment recommended.

Case XLY. Thomas Moody, aged thirty-nine, a slater
from Crossgates, Fife, admitted to Ward VII. on 11th July
1868, He stated that for sixteen months he had complained
of severe pain across the upper part of the sternum, and a
feeling of breathlessness. On percussion dulness was marked
across the whole of the upper part of the sternum. The
cardiac dulness was normal, or nearly so ; the apex beat in
the normal position between the fifth and sixth ribs. The
first sound was normal, the second wanting and replaced by
a double murmur ; the second or diastolic portion of this was
loudest at the aortic cartilage (the second right). This



458 CLINICAL LECTURES ON

double murmur was propagated upwards into the arteries,
and its systolic portion was louder and rougher over the left
carotid artery than anywhere else. The finger pressed deep
into the tracheal fossa came in contact with a pulsating body.
The other organs and systems were natural.

Moody got thirty grains of potassium iodide three times
a day ; he was confined to bed, and had his food and drink
somewhat restricted.

The patient very speedily expressed himself as greatly
relieved. In a fortnight the rasping murmur over the left
carotid was much softened; the pulsation in the tracheal
fossa was still perceptible, but not so distinctly as formerly.
He was discharged at his own request on 3rd August 1868.
In this case there was no history either of rheumatism or
syphilis.

The case now to be related, on the other hand, is not only
a well-marked but also quite a remarkable case of aneurysm
of the aorta, one of itself quite sufficient to attract attention
to the treatment propounded, and which, as one of a series,
affords indeed a very marked illustration of the benefits to
be derived from it.

Case XLVI.^ Andrew Jamieson, a carter, aged forty,
admitted into Ward II. under Professor Bennett's care on
31st January 1868. About eighteen months before admission
this patient had an attack of pleurisy on his left side, but
with this exception he had been always healthy. About
twelve months ago, without known cause — as he is not
specially aware of having strained himself, though constantly
in the habit of lifting heavy weights into his cart — he began
to feel a severe and constant aching in the left side of his
chest, over a spot about the size of a crown piece about two
inches above the nipple. This pain was much increased on
exertion or on stooping. To relieve this pain he unavailingly
applied several mustard poultices, and took a quantity of

^ The history of this case is partly condensed from the Clinical Records of
Ward n.



DISEASES OF THE HEAET 459

cod-liver oil. Xotwithstandiag his sufferings he continued
at work till July 1867, but was then compelled to give in.
The pain was now more severe than ever, his breathing short
and wheezing; he had a troublesome cough, worse upon
exertion ; he had a choking feeling when he stooped, and a
difficulty in swallowing any solid food, the bolus seendng to
stick just opposite the upper margin of the sternum. His
voice was now also weak and somewhat hoarse — vox cmserina
— and he felt a disagreeable pulsation in his chest. For
these symptoms he sought relief in Glasgow Infirmary, and
finally came to Edinburgh. Up to the period of his admission
the pain had spread very much across the upper part of his
chest, but he does not think that the other symptoms had
increased ; he has never had either headache or haemoptysis.
The left radial pulse is almost imperceptible. The right
radial pulse is 84, of moderate strength, and slightly jerking.
Cardiac dulness not noted. The heart's apex beats three
inches below and a little external to the nipple line. Only
the first sound is heard at the apex ; at the base both sounds
are audible and are normal. Over the upper part of the left
chest anteriorly there is a distinct bulging, most marked over
the second rib and second intercostal space. Over a spot
about the size of a crown piece there is a distinct impulse
communicated to the stethoscope. Over the left chest there
is dulness on percussion from the cla\dcle to within two
inches of the nipple line ; this dulness extends across to the
opposite sterno-cla'vdcular articulation (vide Fig. 34). Over
this dull area a double blowing murmur is to be heard, " the
second sound, however, being very feeble, and heard most
distinctly over the sternum, opposite the articulation of the
second rib, also heard over the great vessels at the root of
the neck." -^ At the right pulmonary apex the inspiration is
harsh and the expiration prolonged. Over the left apex

^ I quote the ipsissima verba of the report. The -n-ords ' ' second sound "
may have referred to the diastolic murmur, but as the points alluded to are
off the tumour, the statement may be quite correct.



460



CLINICAL LECTURES ON



anteriorly the double murmur referred to completely obscures
the sounds of respiration ; everywhere else they are normal.
The patient has a frequent and loud cough, of a clanging,
metallic character, without expectoration. He complains of
severe, dull aching pain on the left side of the chest, from
below the clavicle to the level of the nipple ; this pain
occasionally extends to the right side. He gets only occa-
sional short snatclies of sleep, partly owing to the pain
referred to, and partly to the frequent recurrence of a
choking sensation referred to the throat. His tongue is
clean, appetite bad, but bowels regular. Urine, specific





Fig. 34.



Fig. 35.



gravity 1"030, with deposit of urates, but otherwise normal.
There is a slight puftiness of the integuments over the upper
part of the sternum, and the veins over the dull area are
visibly enlarged.

Up to I7th February his treatment was limited to the
use of narcotics for the relief of the cough ; at that date he
was put upon twenty grains of potassium iodide three times
a day; this he continued to take, though somewhat irregularly,
and the report on 9th June is — " Since last report he has
continued much the same. He sometimes complains of pain
in the chest, still has cough with profuse purulent expectora-
tion, and loud sonorous rhonchi both anteriorly and posteriorly.



DISEASES OF THE HEART 461

He continues to take the sedative draught and iodide mixture.
On percussion the dulness is found to have extended more
towards the right side, now reaching to about the middle of
the clavicle {vide Fig. 35)." ^ On 23rd June it is stated that
the patient complained of great pain in the chest, which
seemed to be increased, and for which he frequently had
poultices applied. He also complained of great weakness, for
which he got two ounces of port wine daily. His breathing
was, however, easier, and the cough and expectoration greatly
diminished. The pulsations over the now greatly enlarged dull
area are, however, much increased, and the double blowing
murmur is more distinct than formerly. Posteriorly the
blowing murmur can also be distinctly heard about the sixth
dorsal vertebra. 20th June. — Complains of pain in the left
side being increased; poultices ordered. 27th June. — Still
complains of great pain in his left side ; for this he got a
hypodermic injection of about one-third of a grain of morphia.
He continued to improve slightly. On 16th July it is stated
that the patient feels very well, has little cough or expectora-
tion ; he takes his food well and has little pain. On 23rd
July the patient is said to be continuing better, his breathing
easier, cough and expectoration almost gone, and for the last
two or three days he has been walking about the ward,
though not yet able for much exertion. He continues the
use of the iodide. At this time. Ward II. being closed for
the autumn, he was put under my care in Ward YII. Shortly
after this he walked the whole length of the ward to the
water-closet, which is somewhat draughty ; this was followed
by a return of his cough, copious purulent expectoration, and
violent pain in the left shoulder and over the large pulsating
tumour, on the left of which a small projection of about an
inch square was thrown out; over this there was a red blush.
Jamieson was strictly confined to bed, a belladonna plaster

1 Figs. 34 and 35 have been accurate!)' copied from drawings by Dr.
Bennett's clerk. The dark spot to the left indicates the place where the red
projection subsequently to be mentioned was thrown out.



462 CLINICAL LECTURES ON

was applied over the tumour, thirty grains of potassium iodide
given three times a day, and an opiate mixture for his cough.
In a few days his symptoms were much relieved. A further
exertion, however, coupled with exposure to the damp air of
a newly-washed ward, brought on a violent exacerbation of
the cough with a great increase in the size of the tumour,
which was wholly covered by a red blush. There was com-
plete loss of pulse in the left arm, accompanied by coldness
and excruciating pain in the limb ; the expectoration was
copious and purulent, and occasionally both streaked and
stained with blood. His left arm was ordered to be swathed
in flannel; the tumour to be covered with a belladonna plaster;
to take his iodide mixture four times a day ; to continue his
cough mixture, and to have fifteen minims of chlorodyne i^ro
re nata as often as required. The order being to keep the
cough quiet at all hazards, he took for many days two drachms



Online LibraryGeorge William BalfourClinical lectures on diseases of the heart and aorta → online text (page 40 of 43)