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.
