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.
2. The shock of a solid tumor is not markedly stronger than that of the
heart (Balfour).
3. There is no accentuation of the second heart sound (Walshe), nor
bruit of a booming character (Hayden).
4. In the sphygmographic tracing of a tumor-pulse the up-stroke is
never sloping, and the percussion wave remains well marked.
5. Variations in the position and size of a tumor, and also in the
pressure phenomena, are important. An aneurism varies constantly in its
size and in its mural tension; hence all its signs vary
correspondingly; whereas with a solid tumor in the mediastinum the
phenomena are more constantly progressive. An aneurism which is visible
and palpable upon the external chest-walls will sometimes recede within
the thorax, whereas solid or cancerous tumors never act thus.
Abscess of a gland in the episternal notch may closely simulate
aneurism of the innominate. Mahomed and Golding-Bird report such a
case. The imitation was so close in this case as to balk a number of
very careful observers, and no absolute diagnosis was reached until the
sudden rapid increase of the growth and of acute superficial
inflammatory symptoms revealed the probability of pus. The abscess was
supposed to result from the pressure of a collar-button. A companion
case was reported by the same author where an actual aneurism of the
innominate presented such neutral signs that no diagnosis was reached
until the patient was etherized and an exploratory incision was made
down to the sac. It is well to remember that an aneurism may rise and
fall with deglutition and with coughing and straining when it is
adherent to the trachea. A case is reported of a very vascular sarcoma
attached to the manubrium sterni and projecting into the episternal
notch, which presented the double murmur, pulsation, and pressure
symptoms of an aneurism, and was diagnosed as such, the mistake being
discovered only at the autopsy. In such very obscure cases I know of no
reliable or distinctive signs on which a diagnosis may be established:
the only resort seems to be to await developments. In process of time
the appearance of cancerous growth in other parts of the body will
often throw light upon a thoracic tumor. Occasionally aneurism of the
aorta may simulate insufficiency of the aortic valves. Guttmann reports
a case which presented all the classical symptoms of aortic
regurgitation and none of aneurism. The autopsy revealed a large
aneurism of the ascending aorta and the aortic valves intact. The aorta
itself was notably dilated throughout, and it is probable that the
change in the arterial walls affected the proper systolic {815}
contraction of the aortic orifice, so that insufficiency resulted.
Chronic endarteritis of the aorta may produce aneurismal signs.
Dujardin-Beaumetz reports a case where there were contraction of the
left pupil, sudden reddening of the left side of the face, transient
aphonia, intermittent dyspnoea, suppression of the left radial pulse,
and a double souffle along the track of the aorta; and yet the autopsy
revealed simply endarteritis of the transverse portion of that vessel,
without the least dilatation. Many of the symptoms of this case could
be explained by the extension of the inflammation to the sympathetic
nerves.
Many aneurismal signs connected with the voice, eye, and vascular
supply of the heart may be produced by the implication of either vagus
in neighboring inflammation. Chronic empyema of the left side will
sometimes pulsate synchronously with the heart and simulate aneurism.
The following points are important:
1. Such pulsations occur only on the left side.
2. There is always a disproportion between the pulsations, which are
feeble, and the extent of dulness, which is large.
3. There is absence of expansile pulsations.
4. There is usually ample evidence of the presence of a pleuritic
effusion, displacement of the heart, etc.
5. Aneurism may be coexistent, however, and therefore it may sometimes
be advisable to make an exploratory capillary puncture before opening
the chest freely.
Berard reports a case of empyema which formed a tumor on the left side
of the sternum, which pulsated and looked like an aneurism. Finally,
the tumor burst and discharged pus.
DURATION.--The progress of aneurism of the aorta is very rapid, and in
the majority of cases the fatal termination is not delayed many months.
In 40 cases where the duration of the disease was well defined, I found
that 20 of them died within one year, 9 lived for two years, and 3
lingered five years. About 75 per cent., therefore, died within two
years.
TERMINATION.--Rupture of the sac is a frequent cause of death. In 106
cases analyzed by me, 39 terminated in this manner. The seat of the
rupture and the organs into which the blood escapes vary according to
the location of the sac.
Aneurisms of the ascending aorta burst most frequently into the
pericardium, right auricle, right ventricle, right pulmonary artery,
and rarely externally. Tumors of the transverse portion burst into the
trachea, left lung and left bronchi, left pleural cavity, oesophagus,
and externally. Those of the descending aorta empty into the
oesophagus, left pleural cavity, and spinal cord.
The most frequent point of rupture appears to be into the pericardium,
as 13 out of 39 ruptures emptied into that cavity. It will also be
noticed that the right side of the heart and the left pleura and lung
are the chosen seats of hemorrhage. I found no case of rupture into the
left side of the heart.
The bursting of an aneurism is not always an immediately fatal
accident. The so-called weeping aneurism may pour forth small amounts
of blood for weeks and months. Neligan reports a case of external
rupture near the second rib on the right side which discharged blood at
intervals for more than a year. At times the bleeding was with
difficulty arrested, and yet the aneurism finally solidified and the
patient left the hospital calling himself well. Another man with an
external aneurism thought it was a blood-boil, and squeezed it with his
chin to favor the flow until he fainted. The bleeding then ceased, and
never occurred again. He died one year later of typhoid fever. Such
cases, however, are very rare, and usually when an aneurism bursts
externally the death is sudden and tragic.
{816} Rupture of a sac into the pericardium or pleural cavity may not
prove fatal for several hours, and the patient will exhibit the
ordinary symptoms of internal hemorrhage. Rupture into the heart or
pulmonary artery causes great dyspnoea and distress, and death follows
rapidly.
Aneurism may cause death indirectly by starvation from pressure on the
oesophagus, or by suffocation from occlusion of the trachea. The pain
and distress occasioned by the tumor may cause death from exhaustion.
Pain at times is so great that the sufferers can neither lie down nor
stand, and, deprived of rest and food, they wear out. A few patients
die from intercurrent accidental diseases or complications, but it may
justly be said that the death of a patient with aneurism is usually
directly referable to the tumor itself.
TREATMENT.--Aneurisms of the aorta occasionally solidify by the
formation of a clot, and thus a spontaneous cure is established.
Unfortunately, however, such a result is a rare exception to the rule
of steady progress to death.
A number of methods of treatment have been advocated, and some of them
present here and there gleams of hope for some cases. The aim of all
these methods is to produce coagulation of the blood in the sac, either
by mechanical means or by the chemical action of drugs.
The introduction of fine wire has been attempted. A canula is plunged
into the aneurism, and then either short pieces of wire are dropped
into the sac or one long wire is pushed in. Murchison introduced
twenty-six yards of steel spring into an aneurism of the ascending
aorta. This method is attended with great danger, and has not been
successful, and is therefore abandoned at present.
The hypodermic injection of ergotin into the sac was also recommended
by Langenbeck, but it has not met with success.
Pressure upon the aorta can only be applied to cases of abdominal
aneurism, and here it has been successful. The pressure must be applied
under ether, and great care must be exercised not to injure the other
abdominal organs.
The starvation method was first advocated by Hippocrates, and was
espoused later by Valsalva. The idea of this treatment was to render
the blood more coagulable by making it less watery and richer in
fibrin. Valsalva commenced by bleeding a patient freely, and then
reduced his meat and drink until only half a pound of pudding was
allowed morning and evening. The bleedings were repeated at intervals
until the patient was too weak to lift his hand from the bed on which
he lay. The vital objection to this treatment is that starving renders
the blood less coagulable, though it may lower tension. Copland has
seen aneurisms previously quiet begin to grow and end fatally on the
starving and bleeding method.
A few years ago Valsalva's method was resurrected by Tufnell, but was
modified somewhat in detail. The bleeding was omitted and the starving
was less vigorous. Tufnell's three rules are--rest, restricted diet,
and medicine. The rest must be absolute repose in bed, and must
continue two months or ten weeks at least, without the patient sitting
once erect. By this means Tufnell reduces the frequency and force of
the heart-beats, and thereby lessens the number of distending blows
upon the interior of the aneurism. This is of course a very tedious
treatment, and many patients will be unwilling to submit to it. Others
who are unable to appreciate the gravity of their disease, and seek
merely relief from their subjective suffering, will refuse to continue
the treatment as soon as they obtain such relief. Hence the ingenuity
of the physician will often be taxed to the utmost in devising means
and measures for controlling refractory patients and lessening the
tedium as much as possible for all.
The room of confinement should be light, cheerful, and airy, and should
{817} command a view of outdoor life if possible. Tufnell urges the
choice of a south room, because the presence of sunlight is very
restful to the spirits, while absence of the same is depressing. The
bed should be made as comfortable as possible, and with mechanical
contrivances to obviate the necessity of raising the patient. It should
not be too narrow, and should be of a height most convenient for the
nurse attending. Tufnell recommends a large water-cushion, not over
full, under the hips. The sheets and protectives should be drawn taut
and pinned to the sides of the bed to prevent wrinkling. No movement
should be allowed the patient except to turn upon his side now and
then, and occasionally upon his face in case such movement relieves
dorsal pain. A urinal and bed-pan should be at hand, and a pleasant,
agreeable nurse who will be willing to read to, converse with, and
amuse the patient as desired.
The diet recommended by Tufnell is as follows: Breakfast: Two ounces of
white bread and butter; two ounces of cocoa or milk. Dinner: Three
ounces of boiled or broiled meat; three ounces of potatoes or bread;
four ounces of water or light claret. Supper: Two ounces of bread and
butter; two ounces of milk or tea. This makes an aggregate of ten
ounces of solid and eight ounces of fluid food in the twenty-four
hours, and no more. Thirst is liable to be present at first, especially
in the summer months; and this may be relieved by holding a pebble in
the mouth or by occasionally sucking a piece of ice. Tufnell thinks
that the diminished amount of fluids reduces the duty of the heart and
renders the blood thicker and more fitted for deposit. If the patients
are very intolerant and restless, it is better oftentimes to indulge
them in a little more liberal diet, but only enough to appease them and
keep them in control.
Medicinal Agents.--As rest is the great refrain of his method, Tufnell
recommends anodynes and soperfacients at night. For mere restlessness
he prescribes the following combination: Lactucarium, 20 grains;
extract of hyoscyamus, 10 grams--made into six pills, two to be taken
at bedtime. The bowels will naturally be constipated, owing to rest in
bed, and for this he recommends compound jalap powder. Too much
purgation should be avoided, as irritation of the bowels will hasten
the circulation. Obstinate constipation, however, must not be allowed,
or anything which can produce straining. The instant such a condition
manifests itself, enemata by tepid water should be administered.
The principal symptom to contend with is pain, and for this purpose
opiates should be used freely according to the exigencies of the case.
In one case it was found that smoking twenty grains of stramonium at
bedtime would produce a quiet night. This was discovered accidentally
by the patient, who began to smoke the stramonium under the false
impression that he was suffering from asthma.
Maclean recommends the use of eucalyptus globulus for the relief of the
distress due to irritation of the pneumogastric nerve.
Issues and blisters upon the back are not advisable, as they interfere
with the recumbent position. Relief to dorsal pain will often be
obtained by change of position, by turning upon the side or upon the
face. Sometimes the application of a heated flat-iron, with the
protection of brown paper, over the tender portion of the spine will
relieve the boring pain. Iron may be used in anæmic cases.
We have been explicit in giving the details of the Tufnell method for
two reasons. In the first place, the Tufnell method means to many
people simply putting a man to bed, but it also means keeping him there
for a prolonged interval of time; and this is a difficult task, and one
that requires great ingenuity and patience in its execution. In the
second place, when any method is attempted it should be carried out
conscientiously and literally in {818} every detail, and then the
results obtained can be legitimately scored to the credit or discredit
of the method. But it is neither fair nor honorable to pretend to
follow a method, and, neglecting important details, accredit the method
with the failures which follow. Tufnell claims to have cured many
cases, and he declares that absolute recumbency is the price paid. With
regard to the prospects in individual cases, he says that with a strong
pulse at the wrist and an excessively strong action of the heart, and a
healthy state of the cardiac valves and of the aorta in general, the
aneurism is difficult to cure. On the contrary, when the aorta in some
part of its course is dilated into a cavity, with its walls so plated
with atheroma as to be passively recipient of the blood, and not
capable of transmitting it with force, the cure is comparatively easy.
If this be true, it would appear that the Tufnell method is best
adapted to just these cases which are least amenable to the surgical
methods of treatment.
The use of iodide of potash for aortic aneurism was first advised by
Nélaton and Bouillaud in 1859, and this treatment has found its warmest
advocate in Balfour. The points in favor of this treatment are its
simplicity, the ease with which it can be carried out, and the frequent
happy results which have followed its employment. The drug may be given
with an infusion of cinchona in doses of 20 grains three times daily.
It almost invariably lessens the amount of pulsation in an aneurism,
and rapidly diminishes the subjective discomforts of the patient.
Balfour rejects entirely the starvation diet, and even bodily repose.
He allows his patients to keep about their ordinary employments while
under treatment. Kämmerer has shown that iodide of potash destroys the
albuminates in the blood, and therefore Balfour is inclined to feed
more freely than he formerly did. He avoids any unnecessary amount of
fluids in the food, but as the iodide of potash produces free diuresis,
this point does not require special attention. Balfour's theory is that
iodide of potash lowers the blood-tension of the artery, and also
brings about a thickening and contraction of the aneurismal sac. He
says: "Post-mortem examinations teach us that under the influence of
iodide of potassium coagula are only occasional and concomitant, and
that the essential relief is obtained by thickening and contraction of
the wall of the sac."
Barwell's Operation.--During the latter part of the last century a
French surgeon named Brasdor conceived the idea of placing a ligature
beyond an aneurism in cases where it is impossible to tie between the
tumor and the heart. A few years later Wardrop carried this idea one
step farther, and suggested tying the branches of an aneurismal artery
when the main vessel cannot be reached, and Cockle recommended tying
the left carotid for aneurism of the aorta. In this way the idea of
distal ligature for aortic aneurism was worked up. The operation was
attempted a number of times, but was not attended with great success at
first. Recently, Barwell of England has revived the operation and
elaborated its details, so that now it is attended by encouraging
success. Barwell says that one should try the milder measures first,
but when a case has resisted the effects of rest, diet, and medicine,
then it is time to consider the practicability of surgical
interference.
Barwell's operation consists in ligating the carotid and subclavian
arteries, and he performs it for aneurisms of the innominate and of the
aorta also. Contrary to the ordinary teaching that the inner coat of a
vessel must be ruptured in order to ensure the coagulation of the blood
after a ligature, Barwell declares that such a rupture of the inner
coat is a positive detriment to the operation, and more likely to lead
to secondary hemorrhage. He simply endeavors in his tying to bring the
inner surface of the artery into contact, and hold it thus; and in
order to accomplish this without cutting the arterial tunics, he
discards the round ligature in favor of a flat one. {819} Catgut is
unsafe, because it is liable to decompose, even in a preservative
fluid, and it is also too readily absorbable in a wound. After
considerable experimenting, Barwell has adopted the aorta of an ox as
the best material for a ligature. The aorta should be obtained
perfectly fresh from the butcher. Peel away the outer cellular coat,
and then with a pair of scissors cut the middle and inner coats
spirally round and round, taking care to keep the breadth equable. The
ribbon thus obtained is very elastic, and must be suspended with
weights (two to four pounds) attached to it. In this way, the ribbon
dries in about six hours into a horny or vellum-like substance. Any
irregularities of surface can be easily scraped off, and the cord
stored in antiseptic gauze. About fifteen or twenty minutes before it
is needed a piece of ribbon can be picked out and soaked in a 3 per
cent. solution of carbolic acid, when it will be ready for use. Care
should be taken not to bend these ribbons when in the dry state or
fibres in them will crack and render them fragile. In view of such
chances a piece should be soaked and tested by pulling. (For details
regarding the surgical work of this operation one should consult the
ordinary authorities upon surgery.)
The manner of the action of the distal ligature is not clear. Brasdor
and Wardrop supposed that it reduces the force and velocity of the
blood in the aneurism. But the tension and blood-momentum are still
transmitted to the sac. Holmes thinks that a clot forms on the proximal
side of the ligature and extends down the artery into the sac.
Bennet May, in a recent discussion of this operation, says that 35
cases of double distal ligature for aneurism at the root of the neck
have been recorded up to the present time. In 29 operations the two
vessels were tied simultaneously. In 6 cases the subclavian artery was
tied at varying intervals after the carotid. 23 of these cases died
outright or were hastened to a fatal termination by the operation. In 6
cases the progress of the disease was apparently not affected by the
operation. A practical cure is claimed for the remaining 6 cases. One
patient lived four and a half years, another three and a half years,
and the remainder are living from two years downward.
It is a noticeable fact that all the recoveries except one follow
operations performed since 1877, and the betterment in result is due to
improvements in the method of operating. Barwell acknowledges, however,
that "success in great measure depends upon a judicious selection of
cases, while want of judgment or insufficient care in examination will
most certainly bring a valuable operation into disrepute." He submits
the following conclusions from his own experience--
I. An aneurism commencing suddenly, especially if traceable to some
traumatism or over-exertion, is more likely to be benefited by
operation than one arising gradually and without assignable mechanical
cause.
II. Distinct sacculation is a most desirable condition; fusiform
dilatation of the innominate indicates almost certainly a similar
condition of the aorta and widespread arterial disease.
III. The absence of other aneurisms of the aorta should be determined
if possible.
IV. Absence of rasp-sound along the aorta or any other indication of
extensive atheroma should be verified.
V. Aortic incompetence (obstruction, regurgitation, or both), unless
very slight, is a decided objection, as is also mitral disease or
considerable hypertrophy of the heart.
VI. Patency of the vessels leading to the brain should be investigated
by making a few seconds' pressure on the carotids alternately and then
simultaneously.
VII. Absence of visceral disease must be ascertained.
Electrolysis.--Like all other methods of treating aneurism,
electrolysis has {820} had enthusiastic advocates and bitter opponents.
Cuisselli began employing it in 1846, and was able to report 4
successful cases in 1869. He says that success may be looked for when
one can diagnosticate that the aneurism is slightly developed, is
lateral, and communicates with the artery by a limited opening. The
heart and vessels otherwise must be in good condition. Balfour
recommends electrolysis as a dernier ressort in cases where an external
rupture is imminent. He says that four cells of a Bunsen's battery are
sufficient, as more than four cells cause pain and require the use of
chloroform. Balfour inserts both electrodes. Robin, however, strongly
insists that the use of both poles produces greater pain, is more
destructive to the neighboring tissues, and gives unsatisfactory
results in the aneurism. He advises one to place the negative electrode
upon the skin outside, and introduce the positive needle. This
invariably determines the formation of a coagulum which is more firm
and more resistant to the finger than the ordinary clot of stagnant
blood. This clot is always small, whatever the strength of the electric
current, but it forms a nucleus for further coagulation in the sac. The
negative pole should not be introduced into the sac, according to
Robin, because it forms only a soft diffluent clot which readily breaks
up and floats away. The negative pole also is much more destructive to
the surrounding tissues than the positive pole, and its withdrawal is
almost invariably followed by hemorrhage. The coagulation is more rapid
and more energetic when the needles are oxidizable, as iron or steel.