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

by Unknown

Drummond of England has recently contributed a new sign of aneurism. It is a familiar fact that after sudden exertion, and with the heart acting violently, one can hear in the mouth during expiration a well-marked whiff proceeding from the glottis. Under normal conditions of the chest this whiff is only heard after exertion, and never during perfect repose. Now, Drummond has noticed that this oral whiff, as he terms it, occurs regularly in many cases of aneurism of the aorta. When the sign is well marked the whiff is audible in the trachea with the mouth shut, but disappears on compressing the nostrils with the fingers. The whiff may be double, synchronous with both the expansion and contraction of the tumor. The sign does not exist in cases of valvular lesions of the heart without aneurism. As indicated above, this sign possesses a diagnostic value only when it is observed under conditions of absolute bodily and cardiac composure. One should make a patient lie quietly for a while before examining him for this sign.

Percussion.—Circumscribed dulness is always present when the tumor reaches the chest-wall. Owing to the globular shape of the tumor, its size is usually larger than the area of dulness would seem to indicate. There is no abrupt line of demarcation, but the dulness shades off gradually into the surrounding pulmonary resonance. The dull patch is most frequently situated to the right of the sternum and on a level with the second and third ribs. More rarely it may be found on the sternum or to the left of the same. If the neighboring lungs are solidified from any cause, the percussion signs of the aneurism will of course be obscured.

Localization.—When the signs of aortic aneurism are all conclusive, the next point in the diagnosis is to determine the probable seat and extent of the tumor.

In a general way, it may be stated that the physical signs of an aneurism of the ascending aorta are grouped about the upper two right intercostal spaces. Tumor of the transverse portion presents itself at the manubrium, and aneurism of the descending aorta may be detected in the upper interscapular region to the left of the spinal column. Balfour says that the aneurism is probably about the middle of the transverse portion when the point of greatest pulsation is situated at the middle of the manubrium or from that to the fourchette above, and the veins of the root of the neck are congested.

An aneurism of the left extremity of the transverse portion usually points below the left clavicle. There are many startling exceptions to these rules. One case is reported where an aneurism of the ascending aorta pointed at the left of the sternum and pressed upon the left bronchus. Another case of aneurism of the descending aorta passed behind the oesophagus and compressed the right bronchus. An innominate aneurism occupies the episternal notch, and usually appears first along the tracheal edge of the sterno-mastoid muscle. As it increases in size it will extend across the episternal notch and push out the inner end of the right clavicle. It may appear first under the end of the clavicle, but then it is at the cardiac end of the vessel and involves the aorta.

An innominate aneurism must be distinguished from a low carotid aneurism. The latter usually appears between the sternal and clavicular portion of the sterno-mastoid muscle, and its pulsations can be felt by pushing the finger into this space when the muscle is relaxed. Cockle said that he knew of no instance of a carotid aneurism distending the episternal notch. Barwell also mentions the fact that the ear on the affected side will gain color more slowly than its mate after pinching when the aneurism is situated upon the carotid.

It is always serviceable, and often essential, to determine whether an aneurism of the innominate also involves the aorta. If the tumor appears first under the sterno-costal articulation, the aneurism probably extends on to the aorta. Again, if the radials are both equal, the tumor undoubtedly includes the aorta, for reasons already explained in connection with the pulse-curves. If the right pulse alone is affected, we can eliminate aortic complication. Barwell also states that innominate aneurism involving the aorta presents the following symptoms: The pulsation, dulness, and abnormally loud heart sounds are on and to the right of the middle line. The various congestions are on the left side, and do not encroach upon the right side until later. This venous symptom is especially marked on the left pectoral.

A subclavian aneurism may cause confusion when it occupies the first third of the vessel. Such an aneurism, however, is an elongated oval in shape, and is partly covered by the clavicle, and this bone will move up and down in front of it with movements of the shoulders.

I have emphasized the unreliable character of the pulse as a diagnostic sign of aneurism, but when other signs of this lesion are well marked the pulse furnishes some evidence regarding the locality of the tumor. The following summary of the pulse-signs serves as a useful guide, therefore, in examining the pulse.

1. Both radials affected alike, the aneurism is limited to the ascending aorta.