At a meeting of the Edinburgh Medico-Chirurgical Society in 1850, a Professor Miller spoke about an unusual case from his own practice. The patient was suffering from what the doctor described as an inguinal aneurysm* – a balloon-like swelling in an artery in the groin:
The man was about sixty years of age, robust and florid; he had been a soldier, and had since led a wandering, irregular life. Three years ago he received a kick in the groin, from which date the swelling commenced. Six months before his admission into the Edinburgh Infirmary he had been in the Glasgow Infirmary, where he had refused to submit to operation. In the interval he had lived much more irregularly and intemperately than before, and had used greater exertions in walking, the consequence of which was that his health had become much impaired, and the symptoms of the local disease had undergone a great aggravation.
The day after his admission he fell into a fever; doctors treated him by removing 17 ounces of blood from his arm.
Shortly after his health was found to be much improved, and, in compliance with his urgent request, an early day was fixed for the operation. In the night, however, following this announcement to the patient, he was found frantically dashing a medicine bottle against his head, and before he was discovered had inflicted two or three wounds in the temple, by which he lost from eight to ten ounces of blood. His head was bound up, and everything, as was believed, removed from beyond his reach with which he could hurt himself.
His terror of the operation is understandable. Repairing aneurysms was a hazardous business, pioneered by the great surgeon Sir John Hunter in the late 18th century. Though there had been some notable successes, the risks were enormous. If left untreated, the aneurysm would inevitably burst, causing fatal blood loss. Even if the operation saved the patient’s life, it might obstruct blood flow to the affected limb, causing necrosis and necessitating amputation.
In about two hours after, however, the patient in the next bed heard liquid trickling from this man’s bed to the floor, and, the nurse being called, it was found to be a stream of blood. When Dr. Thomson, the clerk in charge, was summoned, who was still up to watch the result, he saw a stream of blood issuing from the tumour as large as the stream discharged from a full-sized catheter in emptying the bladder.
In other words, an awful lot of blood.
On placing his finger on the aperture, no further loss of blood took place. After being faint for a while, the patient became violent, and severely bit another clerk, Dr. Keith, who was leaning over him. Although no more blood was lost in his struggles, he quickly became faint again, and did not recover, death taking place about three-quarters of an hour after the discovery of the bleeding.
Though a large aneurysm might easily rupture on its own, this accident was one of the patient’s own making.
A pocket corkscrew was found in the bed; it belonged to himself, and he had contrived to secrete it at the time his clothes were searched. Dissection showed a considerable aneurism springing from the common femoral. All the arteries in the body were found much diseased, and there was an aneurism of the aorta, commencing immediately below the origin of the left subclavian, and extending for some inches downwards. The other organs of the body were in general free from disease.
There are several possible causes of such generalised vascular disease – but the most likely culprit is syphilis, which in its later stages attacks the walls of the blood vessels. Until the early 20th century most aneurysms were syphilitic in origin, though in the antibiotic era this diagnosis is rare.
It was fortunate the operation was not performed, and Mr. Miller truly says, “Reviewing all the circumstances of the case, a conviction is forced upon one, that the suicide only anticipated by a few days the inevitably fatal result.”
*Note for pedants: ‘inguinal aneurysm’ is an imprecise and archaic diagnostic term, since it does not specify which artery was involved. ‘Inguinal’ indicates that it was in the groin area, but there is no inguinal artery. Today this would be diagnosed as a femoral aneurysm.