THE chief diseases to which bloodvessels are liable and degeneration of their walls with loss of elasticity, and consequent abnormal dilatation. In the veins the condition produced is that known as Varicosis, in the arteries the ultimate result is Aneurism.
In the case of the veins disease is less serious than in the arteries. The internal strain is less severe, and is caused by the downward pressure of the weight of the blood and not by the onward pressure of the heart’s contraction. Then there are the valves of the veins to distribute the force of the blood’s weight. Rupture of a varicose vein is a comparatively rare occurrence considering the commonness of the affection. With aneurism it is altogether different. The distention goes on increasing steadily unless the disease is checked by treatment, and when the strain can no longer be borne by the diseased walls, rupture inevitably takes place, and unless the rupture is exceedingly minute death immediately follows.
Many cases of what is popularly called “breaking a blood-vessel” are of this kind.
But all arteries that are degenerated do not necessarily give rise to aneurism. The case of Andrew M.(XX.), is one in point. In this case the disease of the artery only led to hypertrophy of the heart. In other cases, as in the arteries of the brain, disease may lead to ruptures of greater or smaller extent without the formation of aneurism. In these cases the rupture gives rise to attacks of apoplexy. Aneurism may form on the arteries within the skull, and when it does it is generally fatal before reaching a large size. The most dangerous places in which an aneurism can form cranial cavity. In these localities the arterial wall is comparatively unsupported and the continued pressure of the heart’s contractions soon expands the aneurism to the limits of its distensibility. In the localities where the arterial wall has solid structures to support it in the process of distention, the pressure has to wear them away before it bursts the vessel.
An intra pericardial aneurism-that is, one which springs from that portion of the aorta which is enclosed within the pericardial sac-is, unfortunately, quite impossible to diagnose. It is hardly to be guessed at; as it never reaches a size large enough to be discovered by physical signs.
I will now relate a case in point. The patient was under my care just over a year. She had many symptoms which could not be ascribed to the aneurism and indeed she had a complication of diseases.
CASE XXXIII.-ANEURISM, ETC. RUPTURE WITHIN PERICARDIUM.
Hannah S-, 46, came to my clinic at the Homoeopathic Hospital on the 25th of April, 1885, complaining of the following symptoms :- Burning pain in chest; tightness and burning pain from under scapulae, up the spine and through each breast, first one and then the other. Has had pain in back for years. Has had a dry hacking cough night and day for two months. Has a headache at the vertex as if she had been felled. Catamenia have ceased for fourteen months; she has flushes and perspirations. Sleeps heavily.
She is very nervous, cries at the least thing. Has much worry.
Tongue white, appetite very bad; for drinks she takes tea and also beer. Is gouty.
Treatment Ignat. 3, four times a day.
(She had a sister die of cancer and she fears it herself.
An aunt has severe heart disease. Her mother gave me some additional particulars after death which may be best given here : All her life she was delicate. As a child she suffered much from cough and used to be short of breath. At the age of 21 she was thought to be in a consumption, and a physician who was consulted about her (Dr. Fuller), told her mother to get her away at once to Hastings or the South of France.)
May 9th.-Chest very much better, but has neuralgia badly. Face flushed. Feels well.
Treatment Argent nit. 5, alternately with Ignatia.
June 6th.-Head much better, but feels very weak. Backs of eyes affected. Tongue quite white in morning. Repeat.
August 29th.-She has been at the sea-side. Her head is bad and the pain seems to have affected the eyes, which were much inflamed and red all over last week; now the sight is dim. Has sharp pains in left breast. Has had sixteen abscesses in it in former times.
The pain is sharp, shooting from the region external to the breast to a nodule situated above the centre of the upper edge of the gland, the size of a hemp seed. This nodule is very tender to touch, but it cannot be otherwise distinguished from similar nodules situated along the opposite border. The left breast is very lumpy. She never nursed with her right.
Tongue coated, white as milk in the morning. Bowels confined.
Treatment Bryon. I, four times a day.
September 12th.-Pain and soreness nearly all gone; only a pricking left, not stabbing as before. Eyes rather bad. Repeat.
October 10th.-Her back is very bad since the pain left the chest. It extends up the whole spine and there is ringing in the ears. The mistiness of vision is increased.
Treatment Gelsem. 3, four times a day.
October 24th.-Has had no headache for a fortnight. Has much pain up the spine to the nape. Feels the pain in the left breast now and then; occasionally in the right breast also.
Treatment Conium 3, alternately with Gelsem.
At Christmas she was laid up at home with an attack of pleurisy, and she did not attend at the hospital again until April 14th, 1886, upon which date I find the following note:- Eyes much better. The chest has never quite got over the attack of pleurisy. Has cough in the morning; not much phlegm. Is very short of breath.
Examination. Lungs : Increased vocal resonance and fremitus on right side, no friction.
Heart: First sound accentuated at apex. Action hurried.
Treatment Arsen iod. 3x two grains night and morning. Bryonia I, four times a day.
April 21st.-Was very well till yesterday, when she had several spasms of pain in the left side coming on in the afternoon. She attributed this to the cold winds.
Treatment Iodium 2x, Bryon. I, every two hours alternately,
April 28th.-The pain was better till yesterday, when it came on worse, and to-day it is very bad, She has lost rest and is hysterical. The chest is tender. She becomes much distended. The pain is continuous, burning. Has flushes. Tongue white. Appetite very bad. Has much wind. Bowels confined when she takes milk. Pulse frequent.
The pain does not catch the breath as it did. She does not feel it after being in bed four hours. If she moves her right arm, she feels faint at once and then the pain comes on.
Treatment Aconite 1x, one drop four times a day.
May 5th.-Pain came on badly from 11 o’clock this morning. Before this was very free from it. Bowels confined. Pulse 120. Feels quite well in general health. Always had neuralgia worse in morning.
Treatment Calcarea phos. 6x, two grains night and morning. Aconite 1x, four times a day.
May 16th.-Has kept very well up to last night, when the pain was very sharp and left a red spot on the shoulder. Pulse 120.
Treatment Calcarea phos. 6x, two grains night and morning. Bryon. 1, four times a day.
May 26th.-Pain very much better. Has had the easiest time since last October. She can turn on her side now. Pulse 116.
She has a good deal of flatulence, with choking in the throat and hysterical symptoms. Tongue white, appetite poor. Repeat.
This was the last day of her life. Early the following morning the patient’s son came to me in great agitation to say his mother had been taken suddenly with a fit, that she was quite unconscious, “her face having gone different colours.” A quarter of an hour later I was at her house and found her quite dead in the spot where she had fallen. She had taken her breakfast as usual; seemed quite well; had done some household duties and was in the act of making her boy’s bed when she fell. Her mother mentioned that a month before she had had a curious sensation at the heart, which compelled her to throw herself on the bed: she felt as she had never felt before.
I will now give my notes of the Autopsy which took place the day after her death.
Body well nourished. Chest resonant. On opening the chest the right lung was found slightly adherent on inner aspect, emphysematous and oedematous, congested at the base, puckered and somewhat fibroid at apex; bronchi filled with sticky mucus. Left lung less emphysematous than right in upper lobe; emphysema in patches, as if recent, in lower lobe; less congested than right and no oedema; a good deal of bronchial congestion.
Heart: Pericardial sac contains a currant-jelly clot weighing about 3 ounces. Heart firmly contracted; valves on right side healthy. Mitral valve slightly thickened. Aorta much diseased; an aneurism about the size of a Tangerine orange (containing scarcely any organised clot), beginning within the pericardium, had opened by a small rupture into the sac. The muscular substance of the heart was soft and fatty.
On opening the abdomen the omentum was found joined by adhesions to the abdominal wall and pelvic viscera. The liver was much adherent to the abdominal wall. The kidneys showed signs of interstitial nephritis, fibrous spots being evident in the substance of the organ and the capsules adhering. The uterus contained a fibroid tumour the size of a walnut: the ovaries were contracted from chronic inflammation.
I have given this case in full to show how serious a disease may exist without giving any definite signs of its presence. Had the aneurism been altogether outside the pericardium, it would have attained a much larger size before rupturing and would probably have reached some spot where its pulsations would have been felt externally. Looking back over the case I am inclined to attribute the persistent pain up the spine to the presence of the aneurism.
The pain complained of on April 21st was undoubtedly due to it and perhaps ought to have made me suspect its presence. But the alleviation of the pain under treatment made the supposition a less likely one; and the presence of other evident morbid conditions in the lungs and elsewhere still further masked the case.
There is another point in the case worth noting, and that is the presence of hysterical symptoms. As is not unfrequently the case, these symptoms, so far from being an indication that the disease was imaginary or nothing of consequence, had their origin in the presence of some grave organic change.
I will now give a case in which the aneurismal tumours were outside the pericardial sac altogether. In this case there was no difficulty about the diagnosis, and the treatment was attended with the best results.
CASE XXXIV.-ANEURISM OF THORACIC AND ABDOMINAL AORTA, WITH VALVULAR DISEASE AND HYPERTROPHY OF THE HEART RELIEVED BY Lycopodium, AND PRACTICALLY CURED BY Baryta carbonica.
The patient was a labourer, 36 years of age. When he first came to me he had been incapacitated from work for sixteen months. He complained chiefly of pains about the chest. There was found to be a large aneurism springing from the arch of the aorta and extending into the right side of the chest, and another, smaller one, from the upper part of the abdominal aorta. There was also extensive valvular disease of the heart, and hypertrophy.
He first received Lycopodium 6, two drops three times a day. This was continued for a fortnight. There was improvement in the symptoms at first, but as he then seemed at a standstill I changed the prescription to Bary.-carb. 3x, three grains three times a day. I was led to give this medicine in this form by the success of the late Dr. Torry Anderson in a case reported by him a short time before. I have given the same medicine in higher attenuations, and also Baryta muriatica, in similar cases, but without encouraging success. The prescription was amply justified by the result in this instance. The patient improved steadily, and when he last came to see me, nearly two years later, he was then in full work as a labourer on the railway just as before his illness. He said he felt better than he had done at any time since he was first taken ill; he could see better; the pupils were equal, and responded equally to light. The size of the thoracic tumour, as indicated by percussion, was diminished.
The power of Bary.-carb. over the heart and arteries is suggested by the following symptoms taken from Allen :”Violent long-lasting palpitation.” “Palpitation of the heart when lying on the left side.” “A fullness in the chest with short breathing, especially on ascending, with stitches in the chest, especially on inspiration.” “Dull stitches under the sternum, deep in the chest, followed by a bruised pain at the spot.” “Throbbing in the back and severe pulsation during rest.” “Great weakness; can scarcely raise herself in bed; if she does, the pulse immediately becomes rapid, jerking, and hard, and after several minutes scarcely perceptible.” “In the morning, at 8.0, suddenly feels as if the circulation ceased; a tingling in the whole body extends into the tongue and the ends of the fingers and toes, with anxiety for fifteen minutes; then feels deathly tired.”
I will now give particulars of the case in more detail. The sphygmograms show increased resiliency of the arterial walls under treatment.
Jesse F., 36, labourer, short, squarely built, fair; admitted June 27th, 1884. He complained of pain in the lower part of the chest, and some headache. He had never had rheumatic fever. Fifteen years before he had primary syphilis, but no secondary symptoms. In other respects his health had been good. Four years before he had suffered from giddiness for a month; never giddy since.
About sixteen months before he had pain in the loins and hips on getting up in the morning, and was compelled to give up work in consequence. Two months before admission he felt tightness in both hypochondria, and gnawing and shooting pains; in the epigastrium he had a great pain, as if something were stuck through him. He then went into St. Thomas’s Hospital, where he remained five weeks, but received no benefit. He then tried to work, but was compelled to desist as the pain came on again.
When admitted, the pain was just at the level of the nipples. Occasionally it became easier in front and then came on at the back of the chest; it was aggravated by his work, especially when he stooped. He never fainted; did not suffer from headaches. Had always taken food pretty well, but had pain after it. This very often caused him to vomit; a symptom which had been especially troublesome the last two months. The pain made him restless in bed, could not find an easy position; he used to lie best on his right side. He got short of breath when the pain came on, and on exertion. Lately the pain has been worse on the right side, with a numb sensation down the left arm. No difficulty at all in walking. Bowels confined, have been for a long time; has had to take opening medicine. Pulse very collapsing; the arteries can be seen to jump and lengthen out; they are tortuous.
The recoil is very smart and quick. Arteries not well filled during diastole. Left pulse is slightly delayed; very little, but just enough difference to be noticeable.
Physical examination on June 28th gave the following result :-Cardiac dullness reaches to episternal notch, and bulges to the right side for about one inch. The dullness is not much increased downwards. Apex-beat in nipple line. Expansile pulsation can be felt in episternal notch. Very apparent pulsation in the epigastrium. On palpation there, about three inches below the xiphoid cartilage, and a little to the left side, a pulsating swelling can be felt, and the part is very tender.
In the Mitral Area, systolic and diastolic bruits. Aortic Area: short and rather rough systolic, heard in the vessels of the neck, and a long blowing diastolic, heard all over the dull area and episternal notch, and continued some distance to the left side in the line of the aortic arch. In the Left Auricular Area a systolic bruit is heard. No dullness behind, and no bruit to be made out.
The femoral pulses are equal. No bruit to be made out in them.
The preceding sphygmogram was taken on this day.
The right pupil is often very large; but it varies a good deal; to-day it is the same size as the left. It reacts to light. He has a cough, but not much expectoration.
When the pain is bad he has some difficulty in breathing. He has been hoarse at times; this comes on irregularly. He loses his voice, so that he can hardly speak. Right back duller than left, breathing feebler, increased vocal resonance and fremitus. Bruit audible all down the spine. The spine is not tender. There is a tender spot about the angle of the left scapula, but nothing abnormal is to be heard there.
Treatment Lycop. 6, two drops three times a day.
I afterwards gave Hydras. 0, gtt. iv. in a wine-glassful of water night and morning, in addition to the Lycop.
July 2nd.-Temp. last night 101.2 degree; this morning 99 degree. Slept better last night. Pain on right side (hypochondrium) and through to back. A little soreness in epigastrium on swallowing. Bowels moved naturally; pupils equal; no hoarseness.
July 3rd.-Feels better. Bowels better, Has pain in epigastrium after swallowing. Pains in right hypochondrium if he lies on that side. No pain when he lies on his back.
July 5th.-No pain at present. Takes food pretty well.
Yesterday he drank water with his dinner, and had a good deal of pain. Pupils equal to-day; yesterday the right was the larger.
July 9th.-Pains not gone, though better than they were. On examining fundus of eye, arteries were seen plainly pulsating. Taking food well. July 12th.-Had a good deal of pain the last few nights. Pupils still unequal. Taking food very well. Has not much pain when he moves about.
He was now put on Bary.-carb. 3x, gr. iii. ter die, the others being left off.
July 16th.-The pain seems a little better this morning. Is taking food well. Bowels regular.
July 19th.-Has no pain in the day-time; pains come on at night after lying down.
July 26th.-The pains are better. He seems better in every way. Pupil has returned to normal size (after being dilated by atropine for examination). Takes food well.
Exam.-Examination on this day showed comparative dullness above right clavicle. The degree of the dullness radiating from the right sternoclavicular joint is much less, and the extent of it much smaller than it was.
The corresponding part on the left side gives also a rather flat note. There is still pulsation in the episternal notch. The apex beat is not felt. No pulsation felt in scrobiculus cordis. Mitral area: first sound not quite pure, followed by a loud diastolic bruit. Tricuspid area : first sound, followed by a marked diastolic bruit. Pulmonary area: systolic and diastolic bruits.
Posteriorly.- The right side about the upper and inner angle of the scapula is slightly duller than the left. The breath sounds are not quite so loud as on the left side, and the cardiac bruit is more audible. Otherwise the two sides are alike.
The bruits are audible over the dull area above the right clavicle, and above the dull part; not so loud in the corresponding part of the left chest. The systolic bruit is heard in the carotids.
July 30th.-Still some pain in the right side, low down in the lumbar region, worse when sitting; not felt at all when walking.
The patient went home on the 31st, and subsequently saw me as out-patient. The improvement had gone on steadily. He continued taking the Bary.-carb.
When he visited me on the 2nd of August I took the following sphygmogram :-
On February 20th, 1888, the patient again presented himself at the hospital. He had been at labouring work on the railway ever since June, 1887, and he managed it as well as ever, lifting and carrying heavy weights as this kind of work entailed. The physical signs showed still further improvement, though the cardiac bruits still remained and there was still a little difference in the pupils.
This case I call a practical cure; the patient was restored to his usual health and usefulness. The aneurism had consolidated and contracted, having become firm enough to resist the pressure of the blood stream even under great exertion. The crippled heart valves remained unaltered but the strength of the heart was so far improved that these defects gave rise to no symptoms.
The Baryta carbonica accomplished, tuto et jucunde, the end aimed at by the heroic and dangerous measures of allopathy which generally seriously damage the patient, even when successful. Among them is the insertion of an electric wire within the sac of the aneurism to promote clotting. This has often proved fatal. Another remedy is Iodide of potassium in massive doses. This drug acts specifically on the heart and is used in the homoeopathic form according to its indications by homoeopathists; but even as used by the allopaths it has met with some measure of success. But at what a price! The patient is lowered by the powerful drug to such a degree that very frequently he never recovers the drugging. Another method is reducing the blood-pressure to a minimum degree by means of starvation. The patient is put on “absolute diet”-that is to say just given enough food to keep him in life and no more.