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

by Unknown

2. Right pulse more altered than the left, the aneurism involves both the aorta and the innominate artery.

3. Right pulse alone affected, the left remaining normal, the aneurism is confined to the innominate artery.

4. Left pulse not affected, the aneurism is situated beyond the innominate.

5. Both pulses aneurismal. This occurs sometimes with aneurisms of the arch which involve the large vessels.

Varicose aneurism can only be suspected by exclusion. Thurman emphasizes one symptom which is significant when heard, but it is rare. This sign is an intense superficial souffle, accompanied by a frémissement cataire, and situated over the opening of the aneurism. It is continuous in time, though louder during systole; and this element of continuity serves to distinguish it from the ordinary bruits of aortic aneurism or valvular lesions. When there is a varicose communication between the aorta and the vena cava superior or the right auricle, the souffle will be extended along the right border of the sternum, with its maximum at the level of the second intercostal space. If the aneurism opens into the pulmonary artery or the upper part of the right ventricle, the souffle will be heard along the left border of the sternum. When the signs are manifested as the result of some excessive effort, and are accompanied by præcordial pain, Thurman thinks them almost conclusive of varicose aneurism of the ascending aorta. He adds a few other symptoms likely to be present, but less characteristic of this particular lesion. These are anasarca, venous congestion, dilatation of cutaneous veins, dyspnoea even to orthopnoea, cough with sanguinolent sputa, a bounding pulse, and less frequently general feebleness, with diminution of the animal heat. These signs have a general significance, however, except when the vena cava superior is involved, and there the venous congestion and oedema occupy the upper half of the body. We have, however, previously seen such phenomena limited to the upper part of the body, resulting from pressure upon the vena cava.

T. Gallard has related a very interesting case of an arterio-venous aneurism of the arch of the aorta communicating with the vena cava superior. This case furnished all the ordinary signs of a tumor of the mediastinum with compression of the vena cava superior. It emitted a souffle which began with the first cardiac sound and persisted through the short interval of silence and to the end of the second sound. This souffle was especially pronounced at the base of the heart, and Gallard diagnosed a communication with the vein above mentioned. The autopsy revealed the accuracy of the diagnosis.

Hayden says that aneurisms opening into the heart, the pulmonary artery, or the vena cava have, so far as he knows, without exception, arisen from the ascending aorta. The simple projection of an aneurism into one or more of the chambers of the heart is attended only by symptoms of obstruction to the blood-current, and he knows of no symptom characteristic of a communication between an aneurism and the heart. When the sac opens into the pulmonary artery there occur sudden and most urgent dyspnoea and blood-expectoration, without spasm or stridor. If aneurism of the ascending aorta has been primarily determined, then the sudden eruption of such symptoms would be almost pathognomonic of this accident.

DIFFERENTIAL DIAGNOSIS.—We have enumerated a large number of symptoms, direct and indirect, which are grouped about aortic aneurism. It is an unknown thing, however, for any one aneurism to present the entire group in one tableau. A few only appear in a given case, and the possible kaleidoscopic combinations of the whole number are almost infinite. There are also numerous other conditions of the thoracic organs which produce groups of phenomena closely resembling those of aneurism, and requiring critical analysis.

An aneurism is a tumor, and the majority of its symptoms are simply signs of a tumor. It is necessary, therefore, to determine whether the tumor at hand is a solid growth or an expanded vessel. This is always difficult when the tumor is beyond reach. It may be pulsatile from lying upon the aorta. The following points, therefore, should be carefully noted and tested:

1. A solid tumor may be pulsatile, but it is never distensile.