No. 476.

LONDON, SATURDAY, OCTOBER 13. [1832-33.

ST. THOMAS’S HOSPITAL.

CLINICAL LECTURE*

DELIVERED BY

JOHN ELLIOTSON, M.D., F.R.S.

Physician to the Hospital, andPROFESSOR OF THE PRINCIPLES AND

PRACTICE OF MEDICINE,

IN THE UNIVERSITY OF LONDON.

DOUBLE ANEURISM OF THE ABDOMINAL

AORTA.

I HAVE before me, Gentlemen, a veryextraordinary case of aneurism of the ab-dominal aorta. You will recollect that onthe 7th of this month, a man was admittedwith a pulsating tumour in the median line,just below the umbilicus, about the size ofa very large orange. This tumour was ex-

tremely tender. It pulsated very strongly,could be felt circumscribed, and was nearlyglobular. The man’s pain was very severe,even when the tumour was not touched.He had not only tenderness, but extremepain in the tumour, around it, and likewisein the loins ; on listening to it, I merelyfound a strong single impulse at the mo-ment of the pulse everywhere else. Iheard no bellows sound, but some few davsafter, on pressing it with the stethoscopeas much as he could bear (he could notbear much pressure), a bellows sound

* This lecture belongs to the clinicalcourse which was publislled in THE LANCETduring the summer, and was delivered onthe 24th of November last. It presents a

very satisfactory reply to the absurd non-sense which has been printed elsewliere

relative to the usefulness of publishingclinical lectures delivered " on the text oftwo or three patients." An accident pre-vented its insertioa at an earlier date.

could be heard, and certainly it is a fact,that when he came in there was no bellowssound whatever, merely a dead single im-pulse. No doubt whatever could exist asto this being an aneurism of the ahdo-minal aorta. The situation of it in thecourse of the aorta, its strong pulsatingcharacter, and its circumscribed form, all

clearly showed its nature, and accord-

ingly on his bed was written 11 aueurysanaam’tae abdominalis."

It was evidently proper to take bloodfrom him, on account of the inflammationwhich was going on around, the great painand the great tenderness. He was bled toa pint before I saw him, and some purga-tives were given, which produced relief.The blood I found was butts·. This youwill commonly find when you bleed for ananeurism, and there is any degree of in-flammation. Ile was bled afterwards to apint, and not finding much relief from

this, ia fact, mere temporary relief, thirtyleeches were applied every day upon theabdomen, not of course for the purposeof lessening or curing the tumour, but witha view to lessen his sufferings, these

being even of an inflammatory nature. Hewas greatly relieved by this. His painwas much reduced, although he still hadpain ; but of course it was to be expectedthat he would suddenly die. That wasalmost sure to be the result.

’ On the 20th of this month, he was sittingup while his bed was being made, and I

understand that suddenly, while retiring tobed again, he became perfectly white, andfdint, and presently died.

Post-mortem Examination.1

On opening the body there was found, aswe expected, an aneurism of the abdominalaorta, and not only this, but somethingwhich one could nut have expected. The

e character of the aneurism was very differentfrom what one might have supposed, forwe found as you will perceive, two aneu-

risms instead of one. This could not havebeen previously imagined. I have neverseen or read of an instance similar to it.

66

You yiU see here (pointing to the pre- Igra9ation. See engraving, Fig. 1.) the aortajust-at its commencement in the abdomen,that is to say, where it passes the dia-phragm. Here is its bifurcation (a, Fig. 1);

here is the coeliac artery (a, Fig. 2) withits three divisions, the first going to thespleen, the second to the stomach, and thethird to the liver.

Now it appears that, exactly at theorifice of the cceliac artery (turningthe preparation 1’Ound so as to show both

sides of it. (b, Figs. 1 and 2) is an aneuris-mal pouch. Here is the aorta running I

down, and here is an opening leading intothis pouch. Now this is the more commonsituation of an aneurism of the abdominalaorta. It is generally about the caeliacartery.

67

The tumour, however, in this man’scase, as I have already stated, was belowthe umbilicus, as nearly as possible aboutthe division of the aorta into the iliacs.There was the pulsating tumour which we eall pronounced to be an aneurism. Here isone renal artery (c, Fig. 1), and instead ofthe other you will observe two (d, Fig.1).Now just below the mouth of the aneurismis a second opening. Here is the aorta

running down below ; this is the first mouth(e, Fig. 1), leading, you will observe, to

this pouch (b, Fig. 1), and here is a secondmouth (f, Fig. 1). It is very common inthe chest to see the thoracic aorta with twoor three aneurisms. In fact, it is verycommon when aneurisms exist in one partof the body to find them also in other situa-tions. You are aware that no surgeonwould think of operating for a poplitealaneurism until he had ascertained, as far aspossible, whether there was one anywhereelse, more especially in either the chest orthe abdomen, but I do not remember havingseen an instance of two aneurisms in theabdominal aorta. That, however, is nothingwonderful on account of the occurrence

being so frequent in different parts ot thebody. The wonder in this case arises fromthe circumstance, that just below the open-ing, there proceeds along (neck (a, g, Fig. 1)which leads into the second aneurism. Hereis the aneurism between my right finger andthumb, which we all observed during life

(h, Fig. 1). Here is a long neck, notthe aorta, but an aneurismal neck, lead-ing to it from the inferior opening.

Here then we have an aneurism with aneck larger than the aorta itself, the aortalying quite insignificantly by its side(i, Fig. 1). Two aneurisms must havebegun in this aorta,-the one forming a

pouch immediately upon, and openinginto, the aorta,-the other extending downin the form of a long canal, and the end of thecanal dilating out fully into a large aneuris-mal pouch. Here you seethe aneurism whichwe all observed during life. I am notaware of there being any such case uponrecord; but one cannot tell, for there are

so many medical records. At any rateI have never read of a similar instance.This is the anterior part of the specimen(Fig. 1), and you find that the aneurismalpouch has extended between the layers ofthe mesentery. They have formed itsouter coat. You know that towards thespine the layers of the mesentery are notquite close to each other, as they are nearthe intestines, and the aneurism was forceddown between them. Here is one portion ofthe layer which gives the aneurism its outercoat, and here at the back is the other.The superior aneurism, which gave no signduring life, remained in its usual state ; butthe inferior one, with this long neck, burstat its lowest part. Here you see where theman’s life was let out. There is the little

opening (k, Fig. 1) which destroyed him ina minute or two. I presume there has been

nothing left but the layers of the mesentery.The afrected part became thinner andthinner until, at last, it cracked. This is notthe result of ulceration, for you perceivethere is a slit. Had there been ulceration,it would not have been of this longitudinalform. It is a clear rent, occurring at thelowest part. Here you see a portion whichhad formed adhesions, nature having fortifiedthe part as well as she could, externally, byforming an adhesion to a fold of the intes-tine. Here is the mesentery, and here isanother fold of intestine just united to it.Nature generally attempts, in the same

way, to prevent mischief arising from ulce-ration in the alimentary canal. Were shenot to do so, fluid might immediately be.come effused, and endanger life. Fre-

quently. however, her efforts at adhesionare fruitless, and in this case she has notsucceeded well. You observe that thereis a great degree of blackness, but thatis merely an eflusion of blood from the

rupture. When a part ruptures, of coursethe blood goes into the cellular membrane

(which exists everywhere throughout thobody), and produces ecchymosis.

Remarks.Now as to the cause of this, it was

clearly the result of mechanical violence.The man was only 27 years of age, and at thatperiod of life you rarely have disease of thearterial system, or of the heart, unless it bethe consequence of inflammation induced

by some external cause. It is at the middleperiod of life, and after that, that the ar-

68

teries and the heart fall into a state of or-ganic disease without our knowing why.This man was too young-not for the pos-sibility of such an occurrence, but certainlyfor its probability. In addition to whichwe must take into account that the arterialsystem was healthy in other parts. Even

the rest of the aorta is healthy. There areno pieces of bone formed upon it. It lookshealthy as far as it can be examined.But we have information of the month in

which this happened. Two years ago (thisis very interesting), on the 10th of May, I

1830, the man had a hundred weight and aquarter of fish fall upon his loins, whichwould of course inflict a shock upon thewhole of his abdominal organs. His backwas also involved in the injury. The fol-lowing morning he was brought to the hos-pital, and placed under my care. He wasthen treated as labouring under inflamma-tion of all the ligaments of the spine, andof the peritoneum. He was well cupped andleeched, and in fact, treated for inflamma-tion in the quarter which had been afiected

by this injury. He left the’ hospital at theend of five weeks apparently quite well.There was no reason to imagine that any-thing more had happened than that all theparts had been thrown into violent inflam-mation from the mechanical injury, and Itherefore had merely to treat the inflamma-tion. On the 16th of June, however, 1831,the symptoms of inflammation returned, andhe came again into the hospital for perito-nitis, but not now for an inflammation of thespine, or parts connected with it. There wastenderness of the whole abdomen on pres-sure ; great feverishness, quickness of pulse,and so on. He was treated in the usual

way for common peritonitis-by bleeding,starving,, purging, and so on, and he againwent out, apparently quite well. It wasnot until the present month, I understand,that ho again experienced illness, and thenhe discovered, a short time before his ad-mission, the pulsating tumour which con.stituted the lower aneurism.Now there can be no doubt at all that the

blow upon his loins caused this aneurism.It is a very common thing for aneurism ofthe thoracic aorta to be produced by me-chanical violence. I am sure that withinthese two years I have had four or fivecases of aneurism of the aorta in the chest,which were clearly referable to external

injury. One patient had fallen down, andpitched against something. Another hadhad a severe blow on the front of his chest,and some little time afterwards, when itwas imagined that the blow had done noharm, they were both surprised by experi-encing great difficulty of breathing, withpain about the right side of the sternum, or.perhaps a at the sternum, and at length tB

I decidedly pulsating eircumseybed tumour.They died afterwards as a matter of course,and an aneurism of the aorta was found idthe ascending aorta, or in the arch. Thiswas nearly just such a case. It is quitecertain, I think, that this aneurism is to bereferred to the injury-at least the injurywas quite sufficient to explain it, and fromthe man’s constitution and age, we couldnot expect that it arose from anything else.It is, however, impossible to say whetherthe accident ruptured the coats of theartery instantly, or whether it merelyproduced such a degree of injury to them,such inflammation, such a disease of thecoats, that at last they ruptured. You ofcourse know that in aneurism there is veryfrequently-more frequently than not-arupture of the inner and middle coats ofthe artery. These coats split, or they partlyulcerate and then partly split, and theouter coat is pushed out into a pouch. Thatis the usual origin of an aneurism. Occa-

sionally you will find that before this hap-pens the artery will be dilated at one spotinto a pouch, and sometimes there is nothingmore than this, the whole three coats ofthe artery being dilated into a pouch. Butin other cases you will find that after beingdilated to a certain extent, the inner andmiddle coats being brittle or soft, give way,and the outer coat only is pushed out.Now and then there is no preceding dila-tation, but the inner and middle coats sud.denly give way, and you have the aneurism.Now in this man it is possible that at the

time of the accident, the inner and middlecoats were a little split, and the blood gra-duuily forced the outer coat farther andfarther until two aneurisms were produced,or the occurrence might have been theeffect of inflammation, softening, or brit-tleness, or other structural changes takingplace in the aorta in the inner and middlecoats, and then, after a certain time, of theirgiving way. I do not see that it is possibleto know whether the coats gave way im-mediately, or whether some disease waspreviously set up for a certain time. Whenaneurism arises, not from the mere dilata-tion of the three coats, but from a ruptureof the inner and middle coats, then yougenerally find the mouth of the aneurismsmall ; but if it be a dilatation, you find themonth pretty large. When it is an injuryof the inner and middle coat, and a dilata.tion only of the outer, then you will usuallyfind the opening of the aneurism small,with an edge extending forwards, a littleway externally, as you observe in the spe-cimen now before you. You see that theopenings are small, compared with the sizeof the aneurism. That is usually the casewhen it is a rupture. Of course there ismore or less disease set up around thi#

69

6pening. An aneurism could not e*ist

long, without the artery becoming more orless diseased. It is possible, however,that the coats may become diseased beforethey split.We must, however, take into account

that the aorta in this man is thinner thanusual, and I understand from Mr. Nordbladthat all the arterial system appeared to beof an unusual character, considering the pa-tient’s age. I do not suppose there wasdisease of the aorta before the accidentoccurred, but it is very likely that this manhad naturally a thin state of the aorta, andthat therefore it split at the very momentthe accident occurred.As to the treatment of such a case, it

would be impossible, I imagine, to do any-thing more than lessen symptoms, and pro-tract the patient’s life. All that I could doin this case, was to urge quietude, enjoinlow diet, bleeding, general and local, andkeep his bowels free. I could not imaginethat had he been starved down to a skele-ton, the affection would have been cured.It is said that cases of aneurism have beencured by starving, such as, I suppose, JohnBull would not submit to. It is said thatin some countries abroad, where personshave not such an aversion as we have hereto submit to meagre diet, cases of aneurismhave been cured, but I never saw Valsalva’splan put into practice. The aorta, how.ever, has been tied, and therefore it was

my duty in this case to let Mr. Green, mysurgeon, see it, in case he might havethought proper to employ surgical aid,where medicine was only of such partialand temporary use. Of course I knew hewould not, but it was my duty to consulthim. If this had been a private case, therewould have been a consultation of surgeons,as well as physicians, in order to see whe-ther permanent relief could be obtained.You now see that if the attempt had beenmade, no doubt it would have failed. Theaneurism did not arise in the situation inwhich it appeared. It was seated at thelower part of the aorta, at its bifurcation, ’,and no ligature there would have done anygood. Here is the bifurcation, and weimagined that during life the aneurism wasseated where I now point out, and conse-quently you will perceive, that had theaorta been tied there, the aneurism wouldhave thriven the more. There would havebeen less blood passing away from theaorta, and probably the man would have died iimmediately from the great quantity ofblood now sent into the sac, because theaneurism arose from the highest part of theabdominal aorta. Then again, there can beno doubt, as Mr. Nordblad hinted to me,that this neck of the aneurism would have ebeen mistaken for the aorta. In all pro-

bability, on opening the abdomen, suchwould have ’been the case, and, had it beentied, one aneurism might have been im-

proved, while the other would not. Hadthe ligature been placed on such a substanceas this neck, it is probable that ’ulcerationwould have occurred, and the fatal termi-nation been hastened. The state of the

parts proves that the operation would notonly have been lseless, but in the highestdegree injurious.

SUDDEN DEATH-MOTTLED KIDNEYS-FRE-

QUENCY OF ALBUMEN IN THE URINE.

THERE was opened the same day, a manwho died suddenly, and who had been ad-mitted but a few days before. He had beenin another hospital for some external ul-ceration, and after leaving it he was foundin the streets cold and apparently dying,and was therefore brought here. ,

I found, on examination, that his breath-ing was very laborious, his face bloated,his lips purple, he eructated prodigiously,and all his eructations smelt of gin. To aU

appearance he was dying. His pulse wassmall, but that furnished no objection to

bleeding, because we saw there was greatcongestion within-such congestion that Icould hardly hear respiration. I thought itpossible that he might have been ill sometime without its having been known, thatapoplexy was commencing, and that hewas half drunk with the liquor which hehad evidently taken.The treatment under all these circum-

stances appeared to be, to take away acertain portion of blood, for the purposeof lessening the great load both in thechest and head, for he was exceedinglydrowsy ; and also to give him an emetic,for the purpose of removing what was veryevidently in his stomach. These means hadthe desired effect ; he was all the better forhaving his stomach emptied, and for losingten ounces of blood. I understand that hewas much better after it for a time ; buttwo days subsequently he was taken ex-ceedingly cold again ; his face began to bepurple and bloated, and he was presentlydead-dead before any one could attend

him.There was found no reason for death inhis head, nevertheless he might have hadgreat congestion at the time of the fit, whichafterwards went off. There was found,however, great ossification of the valves ofthe aorta ; here is one ossified low down,another ossified at the edge, with a largepiece of bone at its junction with the nextvalve.Now this morbid state gave rise to no

bellows sound, there was no indication ofit when I examimed him, and I did not

70

know of its existence during life. I ex.amined his chest carefully, but all that Idiscovered was less breathing than usual,and I thought this might be taken off bybleeding. The reason why there was noauscultatory signs was clearly this, the cir.culation was going on so very feebly at thetime I saw him, that the opening into theaorta was sufficiently large for the small quan.tity of blood that was attempted to be passedthrough it : the heart was scarcely acting.When that is the case, you have frequentlyno signs of obstruction. After the mostviolent disease of the heart, where you havehad the strongest signs on auscultation, sothat you have made a most accurate diag-nosis, if you see the patient j ust before he ex-pires, you find many of these signs disap.pear ; the circulation being so feeble, thedisease of the heart does not give rise tothe symptoms which it did when the cir-culation was vigorous. If you examine apatient when a certain state has arrived,you are seldom able to pronounce with cer-

tainty (and it is the same at the close ofother diseases) what is the affection, al-

though if you had seen the patient perhapsa day before, you would have ascertainedit with the most perfect ease. This was aninstance where no auscultatory signs wereafforded.

I do not know the reason for his suddendeath, unless it was the instantaneous ces-sation of the action of the heart, that beingin a state of disease. It is a fact that per-sons with various diseases of the heart aresubject to die in a moment. I think thatwhen I first saw him he had been greatlyexposed to cold. The whole surface of the

body was chilled; there was great conges-tion in the interior, and the large quantity ofspirits he had taken had increased the con.gestion both in the head and lungs.You will find that this man had what are

called mottled kidneys ; but the appearanceis now no longer to be seen. Now Dr.Bright has mentioned that when this is thecase the urine is albuminous. I had someof his urine saved, there being plenty inThe bladder, and from the specimen I nowshow you, you see the quantity of albumenwhich it contained. I took one portionfrom the mass, and on applying heat to itin a spoon it became very turbid. I thentook another portion, and added to it a

little vinegar, and then a small quantity ofthe prussiate of potassa. You must havea little vinegar in order to seize the potassa,and then the albumen precipitates, but ifthe fluid be cold, precipitation does not takeplace immediately. This specimen, whenI first added the test, was quite clear; itwas placed on the mantlepiece in the apo-thecary’s shop, and when I next came tothe hospital the precipitation which you

now see had occurred. I think in most ofthese cases of disease of the kidney, theurine is albuminous, but whether when theurine is albuminous there is always diseaseof the kidney is another question. I do notbelieve that it is the case, and for this rea.son: I have seen persons when in perfecthealth catch a cold, which has been follow.ed by dropsy and albuminous urine ; butfrom purging and the use of other means,the dropsy and albuminous nature of theurine have ceased. Thus there is no reasonto suppose that albumen in the urine alwaysindicates structural disease of the kidney.The escape of albumen into the urine mayarise from a mere functional derangementof the kidney, and because, when a persondies having albuminous urine, you find or.ganic disease of the kidney, I do not thinkthat we are on that account to say, thatwhenever the albuminous appearance occurs

during life, he must be labouring under

structural affection of that organ. Supposea patient has violent gastrodynia, attendedwith cramp and vomiting, so that he retainsnone of his food, or vomits it shortly afterit has been taken. After a certain periodhas elapsed, he perhaps dies, and we findI disease of the stomach, either ulceration or; scirrhouspylorus. This continually happens.But suppose a person has all the symptoms ofthis aftectiGn, gastrodvnia, and discharge ofwater from the mouth, and by medicaltreatment we cure him ; there is no reasonto say that these symptoms must havearisen from structural disease, because wefound that to be the fact in the case whichterminated fatally. We have no right tosay that, though apparently in good health,he is going about with an organic dis-ease of his stomach. The same remark

applies with equal force to the case of thekidney ; we have no right to say there isstructural disease when a patient gets well.The duty of proof lies with the other

party. We cannot assert that the man has sno organic disease: we cannot assert that

any living being has no organic disease;but no one has a right to expect us to be-lieve he has, unless there is something likeproof. We cannot assert that any particu-lar person has not a tubercle at the top ofhis spleen; but no one has a right to expectus to believe it without proof. If numerous

persons were opened who had made albu-minous urine, and the kidneys were invari.ably found diseased, it would not be fair toconclude, that albuminous urine always de-notes organic disease of the kidneys, be-cause the albuminous state of UI ioe mighthave originally been dependent on func-tional derangement, and only ultimately onstructural : just as a man shall be dyspepticfor thirty years, and at last die of ulceratedstomach. The ultimate organic disease doe

71

not make us suppose the dyspepsia wasoriginally more than functional. To de-nounce a man’s kidneys because he makesalbuminous water, is acting like Moliere’stwo doctors, who visit and will prescribefor M. de Pourceaugnac, a worthy gentle-man in perfect health, as far as he knows :- ‘ Parblieu je ne suis pas malade," he ex-claims. "Mauvais signe," replies the doc-tor, " lorsqu’un malade ne sent pas son mal."" Je vous dis qu’je me porte bien," again saysthe good man. "Nous savons mieux que vouscomment voits vous portez," again replies thedoctor ; "et nous sommes medecins qui voyonsclair da?7svotre constitution."

I may mention, that Dr. Mackintosh, ofEdinburgh, the author of the Practice ofPhysic, bearing his name, was in town afew days ago, and while walking round thehospital with me, he informed me, thatseveral medical students in Edinburgh haddiscovered albumen in their urine after par-taking of pastry. One of them being out ofhealth examined his urine, and found it tocontain albumen, at which he was muchfrightened, knowing the Edinburgh doc-trine. He mentioned the circumstance tothe others, and they also found they hadalbuminous urine, and on investigationthey afterwards found that they had beenall eating of the same description of pastry.It, therefore, appeared to be only a func-tional occurrence, induced by a degree ofindigestion. If Dr. Mackintosh have goodauthority for all this, as he no doubt has,it would show, to all intents and pur-poses, that though an albuminous stateof the urine may sometimes arise froman organic disease of the kidney, yet it

may also occur from a mere functional dis-turbance of that organ. This has alwaysbeen my opinion, and I still am convincedit is the fact. Indeed Dr. James C. Gregorydoes not differ from me. He truly repre-sents my opinion to be, 11 that we cannot

necessarily conclude from the presence ofalbuminous urine, that the kidneys are theseat of those morbid conditions (organicdisease or great congestion)," and adds,that "these statements do not altogetheraccord with the result of our experience inthe infirmary of this city." Yet in the nextline he allows that "the urine becomesalbuminous at times in certain peculiarstates of the general system, M)tco?t?)Mtedwith organic alterations of structure in thoseorgans." Now this is precisely my opinion.He then states, that when besides beingalbuminous, the urine is also below its naturaldensity and quantity, and continues so for alength of time, with dropsy, or obstinate

vomiting, or diarrhoea. ; the kidneys are

almost always organically diseased. This isquite another thing, and I should not thinkof denying it.

REMARKABLE CASES

INDICATIVE OF THE TRANSMISSION OF

MALIGNANT CHOLERA

BY

HUMAN INTERCOURSE.

By L. BRAULT, M.D., &c. &c., Vendome.*

A MAN named Poilpret (Pierre) lived atthe extremity of one of the faubourgs ofVendome, which for five weeks had beenafflicted with the cholera. On the morningof the 6th of July he left Vendome in chargeof a public vehicle, and shortly before ar-

riving at the village of Lisle, distant abouttwo leagues north of Vendome, be wasseized with symptoms of cholera. He wastaken to an inn in the village, where hewent to bed and died in twenty-four hours.Up to this time the commune of Lisle hadbeen exempt from the disease.The widow Etienne Chevallier acted as

Poilpret’s nurse, assisted him to the day ofhis death, remained beside the body, placedit in the shroud, and never left it for 27hours, when it was interred. This femalewas about 55 years old, in good health, ofnaturally gay and lively character, and per-fectly fearless respecting the functions shehad fulfilled. On the second day after theinterment of Poilpret, namely, on the 10thof July, while engaged at field labour about,noon, she suddenly experienced colic pains,and urgent and severe diarrhoea soon set in.In four hours she took to bed, and in thiscondition she remained till the next day atnoon, when vomiting and cramps were

superadded to the previous symptoms. Inthe course of the day, blueness, coldness,absence of the pulse, rice-water evacu-ations, and all other symptoms of the truemalignant cholera occurred. It is needlessto pursue here the details of symptoms, orof the treatment under which she recoveredby the 26th of July.The widow Montafie of the same village

lived next door to the little inn wherePoilpret (the first case) died, and she oc-

cupied a room separated from the patient’sby a thin mud partition. She was agedabout 50, of bad health, addicted to intem-perance. On the 14th July she was seizedwith the first symptoms of cholera, and shedied on the second day.

’

The widow Ratier, also an inhabitant ofLisle, amiddle-aged woman of weak frame,but in good health, made frequent visitsto both the preceding patients, and sheshrouded Montafie, who was buried on themorning of the 17th. Ratier continued

Journal Hebdomadaire, September, i§33.