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 {808} 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.
When one cannot reach the sides of the tumors in front, one can resort
to Stokes's plan. Place the flat of one hand upon the front of the
chest, and the other hand upon the back. By this means the expansile
character of the pulsation may sometimes be determined.
Many intra-thoracic aneurisms present a double impulse or two distinct
blows to the hand during the cardiac systole; and when these blows are
too faint to be felt, they may still be registered by the sphygmograph.
This double impulse is not characteristic of aneurism of the aorta,
because it may also be felt in aneurisms of the large branches of the
arch. Bellingham thought that the second blow was due to a reflex wave
from the aortic valves, and was therefore diastolic in rhythm. Jaccoud,
however, showed that it occurs even with great insufficiency of the
aortic valves, thus excluding reflex waves. François Frank also proved
that both blows were systolic in rhythm. He thinks they are due to the
fact that the blood enters the aneurism en deux temps. The blood,
rushing in at the beginning of the systole, gives a sudden distension
of the partially relaxed sac-walls, and thus causes the first impulse.
Then the bulk of the blood-waves, following more slowly on account of
greater resistance, produces a second elevation more or less
pronounced.
Balfour states that aneurismal pulsations are usually more forcible
than those of the heart, and that this point has not received the
attention which it merits. If the sac contains much fibrin the impulse
is feebler than that of the heart.
W. S. Oliver describes a new sign of aneurism and the method for
detecting it. Place the patient in the erect position and direct him to
close his mouth and elevate his chin to the fullest extent. Grasp the
cricoid cartilage between the fingers and the thumb, and push it gently
upward. If an aneurism of the arch of the aorta be present, its
pulsation will be plainly transmitted up the trachea to the hand. The
act of examining will also increase the laryngeal distress if such be
present.
The frémissement cataire, or thrill imparted to the hand by an
aneurism, has been frequently described. It is very characteristic when
felt, but Powers says it is not of frequent occurrence. He has felt it
in eight cases of aneurism, but four of them were complicated by
regurgitant disease of rheumatic origin, and all were probably of the
fusiform kind.
Pulse.--Partial or total obliteration of a large vessel, dilatation of
the aorta, compression of an artery by a tumor, may produce a radial
pulse {809} similar to that of aneurism. Moreover, we may find the
radials differing from each other in persons who are perfectly healthy.
It follows, therefore, that, taken by itself, the pulse does not
contribute very decisive evidence of an aneurism. When the diagnosis of
an aneurism is established or confirmed by other signs, then the added
evidence of the pulse does possess some value. The finger will often
detect the following characteristics of an aneurismal pulse:
1. Delay.--The pulse at the wrist is normally from 11/100 to 14/100 of
a second later than the cardiac impulse. With aneurism this interval
may be prolonged in one or both radials, and the additional delay may
amount to 4/100 of a second. This sign of delay is of most value when
the pulse in one wrist loiters behind its mate. The relative delay of
the impulse of the aneurism itself and of the carotid artery may give
useful information. If the beat of the tumor precedes that of the left
carotid, then the tumor is nearer the heart, whereas the aneurism is
evidently beyond the left carotid when the beat of the latter precedes.
2. Diminution in Volume.--The pulse in one radial may be much smaller
than in the other or altogether absent.
3. Diminution in Force.--The pulse of one side may convey a less sudden
and less forcible blow to the finger. This diminished suddenness of the
sensation imparted to the finger corresponds to the sloping up-stroke
of the sphygmographic tracing.
4. Thrill.--Under certain rare and not very clearly defined
circumstances the pulse imparts a sensation of thrill to the finger.
Mahomed says this probably occurs when the entrance to the aneurismal
sac is very narrow and the aneurism is directly in the course of the
vessel. It may also be occasionally produced by the rigidity of the
wall of the vessel or by a partially-dilated clot vibrating in the
blood-stream.
Under the enthusiastic and elaborate study of Mahomed the sphygmograph
has attained a certain degree of usefulness. Though difficult in its
application and limited in its results, yet many of the points
demonstrated by it are of sufficient importance to justify their
consideration. The sphygmographic tracing of the normal pulse is shown
in Fig. 50.
[Illustration: FIG. 50. AB. The Up-stroke. ABC. Percussion Wave. E.
Aortic Notch. D. Dicrotic Wave.]
Now, the points which distinguish an aneurismal tracing from the normal
are--1, a sloping up-stroke; 2, impairment or loss of the percussion
wave; 3, obliteration of the secondary waves; 4, diminished volume of
the curve; 5, vibratile waves; 6, a different blood-tension.
[Illustration: FIG. 51. Right and Left Radial Pulse in Aneurism of
Aorta.]
In comparing the curves shown in Fig. 51, taken from Powell's article
upon aneurism, it will be noticed that the up-stroke AB is more sloping
in the curve of the right wrist than in that of the left. The
percussion and dicrotic waves are entirely smoothed out into an almost
uniform wavy slope. As one writer has expressed it, an aneurism acts
like an air-chamber in an engine, and tends to break up the
intermittent pulse into a steady stream. The relative difference of the
blood-tension of two arteries is determined by the relative amount of
pressure required of the instrument to develop the tracing. This amount
of pressure is sometimes greater and sometimes less on the affected
side.
In comparing the tracings from the radials the following points are to
be noted: 1. Is there any difference in the percussion waves?--_i.e._
is the up-stroke more sloping or the apex less pointed in the one than
in the other? 2. Is the tidal wave equally high and sustained in both?
3. Is the dicrotic wave equally developed?
{810} If a difference exist in the tidal wave alone, it need not, and
probably will not, be due to aneurism. It is the loss of the percussion
wave and of the dicrotism which characterizes aneurism.
It must be conceded here that the use of the sphygmograph and the
interpretation of its tracings are beset by the greatest difficulties.
Mahomed, to whom I am chiefly indebted for these sphygmographic
details, declares that the use of the instrument requires great care
and skill, and it may easily lead to error. "No one should attempt to
use it who cannot readily obtain similar tracings from the two radials
of a healthy person." Great care in the application of the instrument
should be exerted, and we must guard against all causes of transient
excitement. It is well to let the patient see the instrument applied to
others before attempting it on him, in order that he may not fear it.
The patient must be placed in a comfortable position, with both arms
alike, and the points of application of the instrument must be alike on
the two sides. The amount of pressure on the two sides must be equal,
or the difference carefully noted. Moreover, one should never be
contented with one tracing, but a number on each wrist should be taken.
If, then, the two radials appear to differ, the precautions must be
redoubled, and the pulse tested again on another day. Inequalities of
the tracings may be produced by abnormal distribution of the radials,
and an old fracture or other injury of one arm may affect the flow of
blood in the arm.
Paralysis of the arm, by interfering with the vaso-motor nerves, and
thereby with the venous return of the blood, may alter the character of
the pulse. A tumor external to the artery, either intra-thoracic or
extra-thoracic, will produce aneurismal pulse and endarteritis, or
congenital contraction of the aorta may so block the artery as to
produce diminished pulse-waves. It may be said that the sphygmograph is
incapable of distinguishing between an endarteritis and an aneurism.
On the other hand, the instrument is very useful in distinguishing
between an aneurism and a tumor compressing an artery, because in the
latter case the up-stroke and percussion wave remain normal, whereas in
the former they are strongly modified, as described above. With
aneurism of the ascending aorta both radials must be similarly
affected, if at all, and in these cases the sphygmograph teaches very
little. If the right radial is alone or mainly affected, then the
aneurism involves the innominate and arch together. When an aneurism of
the innominate includes the aorta, then the whole sac forms virtually a
dilated aorta, and no difference in the radials will appear. Hence it
follows as a corollary: Given an innominate aneurism, if the radials
remain equal the aorta is certainly involved. When the left radial
pulse is alone affected, the aneurism lies beyond the brachio-cephalic
branch, and may or may not involve the left subclavian.
{811} The sphygmograph is of less avail in aneurisms of the descending
portion of the thoracic aorta or of the abdominal aorta. It may be of
service in affording information regarding the condition of the aorta
itself with reference to an operation, and it may also be of service in
determining the upper limits of an aneurism under the following
conditions: A case is reported which presented all the physical signs
of aneurism of the descending aorta, but the sphygmograph showed that
the left radial was affected, and thereby proved that the aneurism
extended as high as the left subclavian at least.
While the foregoing facts prove that the sphygmograph by itself affords
very inconclusive and untrustworthy evidence, yet when the presence of
a tumor and other physical signs prove the existence of an aneurism,
the written pulse-record will often be the guide to the accurate
placement of the tumor, and thereby will often furnish decisive
indications in the selection of the method of treatment.
Auscultation.--The typical aneurismal bruit is not an ordinary souffle,
but it is an accentuated booming sound of a very peculiar character.
Many writers describe it as a systolic jog or shock. Occasionally this
bruit de battement is double--_i.e._ one hears two shocks, so to speak,
just as one feels a double impulse. No satisfactory explanation for
this reduplication of murmur has yet been given. The aneurismal murmur
is almost invariably systolic. Balfour reports two cases of a diastolic
murmur heard with abdominal aneurism. One of these cases was observed
by himself and the other by Wickham Legg.
When this peculiar booming sound is heard over a circumscribed dull
patch, it is very distinctive of aneurism, but its absence possesses no
eliminative value. Many aneurismal tumors are absolutely quiet, and
some of them give only a soft murmur like an ordinary cardiac souffle.
Associated with the aneurismal sound one also hears the normal heart
sounds much intensified. This is peculiarly noticeable of the second
cardiac sound, which acquires a ringing, booming, accentuated character
when heard over an aneurism. Johnson thinks that this intensification
of the heart sounds is due to the sudden tension of the walls of the
sac. Balfour in referring to the same phenomenon considers it of
greatest diagnostic value, and thinks that proper emphasis is not
ordinarily given it.
A fundamental rule in the examination of a suspected case of aneurism
is to auscult over every inch of the thorax, front and back. Not only
the intrinsic signs of the tumor itself are important, but all
testimony from the neighboring organs must be collected and weighed.
The modification of the respiratory sounds have already been mentioned.
Stokes attaches great importance to this fact, that "over one lung,
more rarely over both, the breath sound has often communicated to it a
peculiar sonorous vibrating quality, probably by conduction from the
laryngeal stridor present."
Valvular complications of the heart are not necessarily associated with
aneurism. Cases are reported, however, where a tumor is situated so
near the aortic orifice as to interfere with its closure, and thus
induce the ordinary phenomena of aortic insufficiency.
Of course when valvular disease is coincident with aneurism the
customary signs will be added to those of the tumor, and must be
carefully distinguished.
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 {812} 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 {813}
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.
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 {814} 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.