Case of Aneurism of t)~e Abdominal Aorta in a Female. 85

organs are found diseased,"" and Dr. Wilks considers that what is more remarkable than the phenomena 9 f the disease is the fact, that any other conclusion than Addison's can be arrived at concern- ing it ; and further, he says, in most cases published ': to disprove the connexion between ' bronzing' of the skin and disease of the supra-renal capsules, the pigmentation has occurred in patches, and in others there can be little doubt that jaundice, pityriasis, ephelis, and ichthyosis have been mistaken for true discolouration." Now, every salient symptom alluded to by Addison was present in my case, whilst the " bronzing" of the skin did not occur in patches, and I can safely say it could not be mistaken for jaundice, pityriasis, ephelis, or ichthyosis; on the contrary, it was general, and to such an extent as to exceed any case I ever saw or read of, and yet there was no evidence of supra-renal disease. Viewing the case fairly, as far as our pathological and histological knowledge goes, it must be called a case of tuberculosis, but with no supra-renal disorganiza- tion.

ART. VII . - -Case of Aneurism of the Abdominal Aorta in a Female. By ARTHUR WYNNE FOOT, M.D., T.C.D. ; Fellow of the King and Queen's College of Physicians.

FROM the admitted rarity of aneurism of the abdominal aorta in the female, the following case appears to be of sumcient interest and importance to justify its being put on record. The subject of it was a married woman, without any family, thirty-five years of age, who sought medical advice on the 30th of July , 1870, on account of dyspnoea, palpitations of the heart, and sleeplessness. No reference was made to the abdomen, as the seat of any annoyance, or even of any uncomfortable sensation. The action of the heart was very irregular, a double murmur was audible both at the base and i~t the apex, and the area of cardiac dulness was of more than twice the normal extent. Two years previous to the present time she had an attack of hemiplegiu, affecting the left side of the body, since when her health had not been good ; the muscles of the affected side had remained paralysed, but unwastcd. This woman continued under observation from the 30th of Ju ly till the 8th of the following month, on which day she died. During the greater part of this time the dyspnoea was continuous and extreme, preventing her from

a Guy's Hospital Reports, Vol. viii. 3rd Series.

86 Aneurism of the Abdominal Aorta in the Female.

lying down; the palpitations were severe, but intermlttent,/and all her distress arose from want of sleep, and from symptoms referable to disease of the heart. The abdomen was more than once exa- mined for the purpose of ascertaining if there were any aceumnla-- tions in the bowels, and on these occasions no tumour was detected, nor was any pain or tenderness complained of during the manipula- tion of the belly ; at no time did she suffer from pain in the back. On the night of the 6th of August she became suddenly affected with a dull aching pain predominating in the left iliac region, and accompanied with a sharp pain~ " l ike cramps," down along the left lower extremity ; on the following morning (7th) the pains continued, the left iliac, lumbar, and hypochondriac regions were occupied by a tumour which was dull on percussion, and gave to the hand a hard lumpy sensation, as if the descending colon were extensively obstructed with hardened fieces ; the pulse was under 100, weak and regular, the dyspncea had moderated, and she was able to lie flat, with- out any distress, and although her countenance was altered, it did not wear a pinched or anxious expression. Poultices were applied to the abdomen, and an enema administered, which, however, did not remove any fcecal matter from the large intestine. The following morning (August 8th) there was no alteration in the position or feel of the abdominal tumour; there was no tenderness over any part of the belly, the face was very pale, the pulse weak, respiration very feeble in both lungs, particularly in the left; she sank gradually, and died at 2 p.m. on this day.

The case was one sufficiently puzzling to cause every effort to be made to obtain an opportunity of inspecting the interior of the abdomen ; the rarity of the disease, the absence of abdominal symp- toms, and the want of violence in the symptoms which accompanied the suddenly appearing tumour, were not calculated to suggest what turned out to be the case, that an aneurism of the abdominal aorta had become ruptured, and given rise to an extensive retro-perltoneal extravasation of blood.

The body, which presented a very much blanched appearance, was examined twenty-four hours after death ; the tumour felt as it had done during life, and had not subsided after death, as many abdominal tumours so often do. When the belly was incised longitudinally, a large black mass presented itself in the situation of the tumour observed during life; in magnitude it might be estimated as representing about three pints of fluid blood ; i t was situated in the connective tissue behind the peritoneum, and had pushed the

By DR. FOOT. 87

omentum to the right side; the descending colon, relaxed and flat- tened, was moved forwards, and almost as far towards the right side as the middle line of the body. There were no appearances of peritonitis, recent or chronic, neither adhesions, nor any effusion of serum, pus, or lymph. A true aneurism of the abdominal aorta was found on the vessel immediately above its bifurcation, about the size of a full-sized lemon, but more like a pear in shape, as the broader part of the sac was inferior; the effusion of blood had taken place from an opening at the left side of the tumour, immediately above the left common iliac artery; the opening was situated at one of the most saccular portions of the dilated vessel, and presented the appearance of a squarish aperture, having a fringed margin; the mouth of the opening was obstructed by coagula, some of which were evidently of recent formation" from their colour, and the remainder were portions of the stratified fibrine, which elsewhere lined the sac. The common iliac arteries were not directly impli- cated in the aneurismal sac, but the left vessel was completely obstructed at its origin by the fibrinous lining of the sac, which had become, as it were, loosened from the inner wall of the aneurism, and had shifted its place, so as to slide over the mouth of this artery, so that a forceps passed up the left common iliae artery, did not enterth.e sac, because it was stopped when just about to do so by a dense leather-like layer of fibrin, while there was no narrowing or obstruction of any other part of this artery. The laminated coagula lining the aneurism were, at the place which corresponded to the rent in the tunics of the sac, quite softened and destroyed, present- ing an aperture corresponding in shape and size, as well as in situation, to that which gave exit to the blood; the sudden escape through this rent may have so dislodged and shifted the inner shell of the sac, as to have closed over the mouth of the left common iliac artery, as there were no symptoms during life, and no pathologlcal appearances in the vessel to indicate its having been occluded Prior to the rupture of the aneurism. The length of the anterior suri~ace of the sac, measured vertically, was 4~ inches ; its circumference at its widest part was 7¼ inches ; the artery above the aneurism was extensively atheromatous ; there was no destruction of the vertebrae or pr~vertebral structures, but the left psoas muscle was so much softened and disintegrated as to admit of its removal with the fingers. The pericardium contained several ounces of reddish serum; the heart was enlarged; the aortic valves insufficient; the cavities of the right side dilated; the four chambers contained soft

88 Aneurism of the Abdominal Aorta in the Female.

black coagula ; the arch of the aorta was dilated, atheromatous, stiff, and brittle.

Before alluding to the rare cases of aneurism of the abdominal aorta in the female, it may be well to consider the relative fre- quency of aneurism of this vessel, entirely irrespective of sex, as, on doing so, it will be found that, in liability to this disease, the abdominal aorta, even in males, ranks far behind the popli- teal, and very far behind the thoracic aorta. The most reliable tables of aneurisms of the spontaneous or non-traumatic variety are those of Crisp," a proof of their reliability is their quotation by Lebert, in his great work, b even in preference to the more recent and more extensive ones of Broca. e In Crisp's table of 551 spon- taneous aneurisms in both sexes, selected indiscriminately from the British medical and surgical journals, from the year 1785 to the year 1847, there are of the thoracic aorta 175 cases, of the popliteal artery 137, of the abdominal aorta and its branches 59. Those who put little faith in statistics on such matters, may read the forcible remarks on this subject of Sir W. Jenner, in his Clinical Lectures on the Diagnosis of Extra-pelvic Tumours of the Abdomen. d "Remember that, although by no means to be reckoned among what are called rare diseases, aneurism of the abdominal aorta is not at all common; that you will meet with a thousand cases, I was going to say, of strongly beating turnout in the abdomen, before you meet with one case of circumscribed dilatation of the aorta ; so, instead of being your first, it should be your last idea, that an abdo- minal pulsation is due to aneurism." These observations are well calculated to enhance the value, if such were possible, of the seven cases of aneurism of the abdominal aorta in the male, given with all the richness of accurate detail by Dr. Stokes, in his work on Diseases of the Heart andAorta. Of Crisp's 59 cases of aneurism of this vessel, 51 were males and 8 females. After a somewhat extensive research, confined exclusively to British works, I have been able to find the records of seven additional cases of this disease in the female, published subsequent to the appearance of Crisp's Prize Essay. In more than one of these there was the same entire absence of symp- toms referable to the cavity in which the disease existed, that was noticed in the case which suggested these remarks; and in some, death resulted from totally different causes.

• Diseases of the Blood Vessels. 1847. P. 118. b Traitd d'Anatomie Pathologique, 2 vols.~ folio. 1857. Tome 1, p. 520. e Des Andvrysmes. Paris, 1856. a British Medical Journal, 16th Jan., 1869, p. 42.

By DR. :FOOT 89

Mr. Porter" laid before the Pathological Society of Dublin, 31st January, 1857, a specimen of abdominal aneurism which occurred in a female, who dropped dead as she was walking through Dame-street. She was a prostitute, thirty years of age, and had been continually drinking for the previous three or four years. About twelve months before her death she had taken a course of mercury, and up to the previous July had enjoyed very good health. About this time she began to suffer from a pain in the abdomen, wkich she ascribed to flatulency, and took little notice of. One night as she was walking through Dame-street, her knees gave way under her and she fell to the ground. On opening the abdomen and removing the intestines, a large aneurismal sac was ~bund engaging the abdominal aorta, about half an inch below where the eoeliac axis is given off; it had given way at its posterior and inferior part, and a large quantity of coagulated blood was poured out behind the peritoneum. Mr. W. F. Barlow laid before the Pathological Society of London2 16th March, 1852, an aneurism of the abdominal aorta, taken from the body of a woman, aged twenty-nine, pale, weakly, and of irregular habits, who died in the Westminster Hospital from the effects of a blow upon the head. There appeared to have been no symptoms of the aneurism during life; it was as large as a lemon, and not unlike one in general shape, and was situated opposite the last dorsal and first lumbar vertebrm, but had not, apparently, caused much absorption of those bones. I t seemed formed entirely at the expense of the posterior wall of the vessel, the anterior appearing healthy; the cceliae axis and superior mesenterie artery were seen arising from the latter, and were not in the least obstructed. So completely full of coagulum was the sac, that the blood latterly must have flowed onwards much, as though no aneurism had existed. Dr. Keiller, President of the Edinburgh Obstetrical Society, brought before that Society, ¢ 27th June, 1860, an important case of this affection, in which an abdominal tumour had been observed during life, and had given rise to considerable differences of opinion as to diagnosis. The patient was an unmarried washerwoman, aged forty-four, admitted into hospital for a pain in her right thigh, and a swelling of the abdomen. She lay on her back with the right limb bent nearly to a right angle at the knee--this position, on account of the weight of the tumour giving her the greatest ease.

• Dublin Hospital Gazette, 1857. Vol. iv., p. 92. b Reports of Path. Soc. London, Vol. iii., p. 310.

Edinb. Meal. Jour. Vol. v i i , p. 495.

90 Aneurism of the Abdominal Aorta in tlte Female.

Above Poupart's ligament, on the right side, was a large dense hard mass, reaching up to within one inch of the edge of the seventh rib, dull on percussion, but separated from the liver by an interval of clear percussion. The surface of the mmour was tolerably smooth and even; it was quite immovable, and seemed attached to the walls of the abdomen round ; a distinct impulse was given to it from the aorta, and a vascular bruit was heard in it ; there was no tenderness of the abdomen. She died from exhaustion. The tumoltr was found to have been caused by a large false aneurism; it ~ contained very little fluid blood, but its interior was occupied by firm fibrin- ous dots, which weighed about five pounds. I t arose from the abdominal aorta, a little above its bifurcation; the opening by which it communicated with the vessel was on the right side, and admitted five fingers. The false aneurism (secondary sac) was formed anteriorly by the psoas and iliacus muscles, and by the peritoneum, posteriorly it was formed by the ilium. There was great erosion of the right ilium, Poupart's ligament was destroyed, and the right hip-joint was opened into. There was no great degree of atheroma of the aorta, and the other organs were natural. Dr. I-Ialdane exhibited to the Medico-Chirurgical Society of Edinburgh, a ~rd December, 1862, the abdominal aorta of a woman, fifty years of age, with three sacculated aneurisms springing from its anterior wall, within the space of about three inches. She was also the subject of an aneurism of the transverse portion of the arch, the size of a small apple, and was likewise affected with disease of the aortic valves, in an aggravated form. The symptoms during life, while she was under observation in the Royal Infirmary, had been wholly thoracic, and their causes had been diagnosed to be such as were found in that cavity after death. In Dr. Bennett's work, on the Principles and Practice of Medicine, b will be found the case of a woman, aged fifty, who presented a pulsating tumour in the pylorie region, attended with the symptoms of organic disease of the stomach; an aneurism of rounded form, nearly two inches in dia- meter, and almost filled with firm layers of fibrin, arose from the anterior part of the abdominal aorta, at the root of the cceliac axis and superior mescnterie artery, while at the lower part of the thoracic aorta was an aneu~rismal dilatation, about the size of a walnut, which projected to the left of the vertebral column, directly over the thoracic duct, which vessel it appeared to compress. The

* Ed. Med. Jour. ¥ol. viii., p. 669. h 4th Edit. 1865, p. 618.

By DR. FOOT. 91

study of this very complicated case is likely to prove of much use in the investigation of pulsating tumours in the epigastrium; the pro~o~'essive and extreme emaciation, and the persistent vomiting, symptoms so well calculated to banish the thought of aneurism, especially in a female, from the mind, were found to have been due to an ulcer of the stomach, and to the propinquity of the thoracic aneurism to the thoracic duct. Another case of aneurism of the abdominal aorta, which occurred in a female, aged sixty-five, whose body was dissected in the Practical Anatomy Rooms, at the Univer- sity of Edinburgh, has been carefully described by Dr. John Chiene ;~ the abdominal aorta was found extensively diseased, a large pear-shaped aneurism being connected with its lower half. Two very strange cases of abdominal pulsation in females, only one however of which was proved by post-mortem examination to have been an aneurism, are quoted on the authority of Mr. Rendle, Surgeon to the Brixton Prlson, in the JEssay on Aneurisra in tlte System of Surgery. b A strong, healthy woman, five feet eight inches high, who had never before been in prison, received a sen- tence of transportation for life. Immediately on receiving sentence, and whilst standing at the dock, she almost fainted from terror; was suddenly seized with severe pain in the epigastric region, and fell into the arms of an attendant. The pain in the epigastric region never entirely ceased, and just six weeks after, a pulsating tumour of small size was readily to be felt; this increased in size, until it was as large as the closed fist. She lived for three or four years, being constantly kept in bed and under treatment, and then passed from under Mr. Rendle's care. The second case was proved by jpost-mortem examination to be an aneurism of the abdominal aorta at the ccellac axis, and came on after receiving a severe sentence, though it could not be traced so distinctly to the sentence as in the first case. When the tumour was discovered, it was about the size of a small orange; the woman only complained of obscure pain in the part, and was at her work when first seen. She was at once sent to the infirmary, and put to bed. Twelve hours after being in bed, the aneurism ruptured, and she died in forty-eight hours. A post-mortem examination of the body was made. Both patients were women between thirty and forty years of age, and otherwise healthy.

The seven cases of aneurism of the abdominal aorta in females,

a Brit. Med. Journal, 22rid August, 1868, p. 201. b 1st Edit. 1862, Vol. iii., p. 351.

92 Case of Aneurlsm of the Abdominal Aorta in a Female.

just alluded to, and the one which I have given, added to the eight collected by Crisp, make a total of sixteen cases recorded in British works, since the year 1785, and show that, although rare, this disease in women is not so uncommon as to be at once put out of court, in making the diagnosis of a pulsating tumour in the female abdomen. My research in the medical publications of this country since 1847 has been of necessity so incomplete, that I am persuaded of the existence of many more than the seven cases which I have been able to meet with. In answer to the question of why is this disease so much rarer in women than in men, when carotid aneurism is equally frequent in both sexes, and dissecting aneurism more common in females than in males, it is usually said that the alleged predisposing causes of aneurism, syphilis and intemperance, which lead to the precursory disease of the arterial wall, do not operate so constantly in females as in males, and that from the nature of their habits and occupations, females are less obnoxious than males to the exciting causes of aneurism, such as violent muscular exertion, blows, strains, and injuries of various kinds. Some think that the influence of the periodical loss of blood during menstruation on the vascular system of the female, has not been sufficiently considered in reference to the less frequent occurrence of aneurism in women than in the opposite sex. Admit t ing that the arteries are equally liable to disease of their coats in either sex, it is difficult to avoid concluding that it is the nature of their habits and occupations which render females less liable to spontaneous aneurisms. Thus while there is no reason to believe the popliteal arteries of women, at all events in the lower classes, are less liable to disease of their coats-- aneurism of these vessels is so rare in females, that Sir A. Cooper saw but eight cases in his practice of forty years," and on the other hand, in the carotid arteries, aneurism is equally common in both sexes, because these vessels are exposed to a very similar amount of flexion and extension. The predisposition of females to dissecting aneurism may, perhaps, be attributed to the greater delicacy of a less tough connexion between the arterial tunics. W i t h reference to the remarkable latency of symptoms, which has been observed in several of the cases alluded to above, so much so that the post-mortem examination on several occasions revealed what had been quite unsuspected during life; it may be noticed that the female abdomen is wonderfully prone to keep secret the existence of conditions

• Lectures on the Principles and Practice of Surgery. Edited by Lee. 1837, Vol. i.~ p. 208.

On Diseases of the ;Lungs. 93

which might be at once discovered in the male : for this peculiarity there are anatomical and physiological reasons which are obvious and unquestionable, and which account for the wonderful tolerance on the part of females of a degree of ascites, which would in men produce much mechanical interference with respiration, the influence of sex in the case of movable kidneys, and the immense collections of fmces and urine which females can carry about, if not unconsciously, at least with much less inconvenience than the oppo- site sex are usually able to boast of. Appended to these remarks are some references on the subject of aneurism of the abdominal aorta in females, which may serve as a nucleus for a larger collec- tion of cases. The references refer simply to aneurisms of the main vessel of the abdomen, and not to those of its branches, either primary or secondary; the first eight have been taken from Crisp's table, and all except l~os. 1 and 8 have been carefully verified :--

(1.) Ward, London Medical Repository, Vol. xx. (2.) Henderson, Edinb. Monthly Jour. of Medical Science, Vol. iii., p. 613~ 1843. (3.) Green, Dubl. Medical ,Sour., Vo]. xxiv., p. 293. (4.) Shekleton, Dubl. Hospital Reports, Vol. iii., p. 232. (5.) Shekleton, DubL Hospital Reports, Vol. iii., p. 234. (6.) Hue, Medical Gazette, Vol. ii.~ p. 317, 1828. (7.) Burkitt, Guy's Hosp. Reports, 1844, p. 504. (8.) Hawkins, Medical Times, 1845. (9.) Porter, Dubl. Hosp. Gazette, 15th March, 1857, p. 92.

(10.) Bennett, Principles and Practice of Medicine, 4th ed., p. 618. (11.) Barlow, Trans. Path. Soc., London, ~rol. iii., p. 310. (12.) KeiUer, Ed. Med. Jour., Vol. vii., p. 495. (13.) Haldaoe, Ed. Med. Jour., Vol. viii., p. 669. (14.) Chiene, Brit. Med. Jour. 22nd August, 1868, p. 201. (15.) H. Coote, Syst. Surg., 1st ed. VoL iii., p. 351. (16.) Foot, Dubl. Quart. Jour., Feb., 1871.

ART. VIII.--Diseases of the Lungs affecting those who work in Dusty Atmospheres. By J. ALEXANDER ROSS, M.D. ; Resident Phy- sian, N6rth Staffordshire Infirmary.

T~OUGt[ much has been done towards the elucidation of these diseases, by Drs. Greenhow, Peacock, Parsons, &c., in this country, and by Zenker, Schirmer, and others, on the Continent, yet the clinical history of additional cases, presenting as they do different phases, may not be devoid of interest.

I intend to confine my attention to the pulmonary diseases preva- lent amongst a class of the above operatives, known as potters,