A system of practical medicine. By American authors. Vol. 3

by Unknown

Dysphagia.—This is a common symptom with aneurism, but it is not so constant in appearance as it is with other mediastinal tumors. It appears more often when the aneurism is situated upon the transverse portion of the aorta. It is frequently painful, but always variable in severity, and may disappear for long intervals at a time. Lying upon the face usually relieves the difficulty, while it is aggravated by reclining upon the back. Fluids are usually swallowed more easily than solids. Hayden says that a feeling of sharp pain in a particular part of the gullet in swallowing when aneurism is present indicates erosion of the mucous membrane and early perforation.

Pressure upon Veins.—Localized oedema and cyanosis are two common symptoms of aneurism of the aorta. The sudden eruption, the limited distribution, and the terrifying effect of these symptoms render them especially interesting. They are due to pressure of the tumor upon the veins near the heart, and particularly upon the superior vena cava. Dujardin-Beaumetz says that, thanks to the vena azygos, compression of the superior vena cava produces simply a varicosity of the neck and upper part of trunk. Should the vena azygos be simultaneously blocked, then the oedema and cyanosis will spread over the entire head, neck, arms, shoulders, and upper trunk—i.e. over all parts drained by the superior vena cava. Only two such cases have been reported, however. One case was seen by Piorry and one by Dujardin-Beaumetz. In the latter case the oedema and cyanosis of parts named above came on suddenly without apparent cause. The face was swollen, blue, and covered with red patches, and the eyes were injected. The ears were cold; the abdomen and lower limbs retained their normal color. The contrast between the upper and lower portions of the body under these conditions is very striking.

Balfour says that "a thick oedematous collar covered with large veins surrounding the root of the neck" is indicative of compression of the superior vena cava.

Pressure upon the brachio-cephalic veins produces oedema and cyanosis of the head and upper extremities; oedema of the glottis has occurred under such conditions. Sudden swelling of one arm, unaccompanied by inflammation, is suspicious of aneurismal compression of the corresponding vein, especially if it comes on suddenly after exertion. Compression of the descending vena cava or right auricle may give rise to congestion and dropsy of the lower part of the body, but these are later symptoms.

Pressure upon the thoracic duct is relatively rare. It may cause emaciation, but loss of flesh with aneurism is more often due to obstruction of the oesophagus or to dyspepsia and the exhaustion from pain and sleeplessness.

Pressure upon Bones.—Pressure of a tumor on neighboring bones causes absorption and dislocation of the same. The clavicles, sternum, and ribs are rapidly eroded by the aneurism, and are pushed forward and disarticulated. Pressure upon the spinal column causes absorption of the vertebræ and of the cartilages, until oftentimes the cord is laid bare and even subjected to direct pressure.

Inspection.—Inspecting a person suspected of aneurism, one should examine the pupils, the color of the skin, the condition of the veins of the head, neck, and arms, all movements of the neck and chest, and especially the contour of the front part of the chest.

The conditions of the pupils, skin, and veins have all been described, but the movements of the neck and chest require notice here. Any area of pulsation apart from the normal apex-impulse should be critically marked and examined. Fulness or beating in the episternal notch is significant. Cheesman reports a case where a curious pulsation was occasionally communicated to the larynx and the tongue by an aneurism situated beneath the manubrium. Every now and then the thyroid cartilage would rise and fall, and the tongue would pulsate backward and forward with each beat of the aneurism.

Inspection of the larynx quickly determines the presence or absence of paralysis of the cord, and may sometimes reveal pulsating tumors pressing upon the trachea. While inspecting the shape of the chest it is best to stand upon one side of the patient and look across the surface of the thorax. In this way slight deviations from the symmetrical become most readily apparent. If any abnormal point seems to pulsate, the fact can be rendered more obvious by pasting bits of paper upon the suspected spot and around its immediate neighborhood. Viewed thus in an oblique light, the relative movements of these pieces may be easily discerned. If a tumor be present and the diagnosis established, one should carefully note the color and condition of the skin over the prominence. As the tumor develops pressure the skin becomes tense and glossy. Then it turns red, and may be covered with livid spots and even ecchymoses. In later stages a black dried scale of flesh may be all that seems to restrain the heaving blood. Weeping of blood may take place for some time before the final break.

Palpation.—Given a prominence of the chest-wall or a localized pulsation in the abdomen, the next step is to examine the suspected part with the hands. Any tumor lying across an artery will move forward and backward with each pulsation of the artery, and conditions of this kind have been repeatedly diagnosed as aneurism. An aneurismal tumor, however, is distensile as well as pulsatile. Every tumor, therefore, should be grasped as far as possible between the two hands, to determine if it distends with each beat.