lie comfortably in bed, with his shoulders elevated by pillows, and he
should be cautioned not to jump or move during the operation. Three or
four needles should be inserted about one centimeter and a half from
each other, and about thirty millimeters in depth. One will recognize
that the needles are well in the aneurism when they exhibit movements
synchronous with the sac itself. One of the needles is then attached to
the positive pole of the battery, while the negative pole is attached
to a sponge and pressed upon the outside of the chest. The galvanic
current is allowed to pass for ten or twenty minutes, when it is
gradually reduced to nothing. Then the positive pole is transferred to
the second needle, which is similarly treated, and so on until the
three or four needles have each been used in turn. After stopping the
current leave the needles quiet for some moments; then withdraw them
gently, so as not to disturb the clots, cover the punctures with
charpie in collodion, and apply ice or cold-water compresses if any
inflammation occurs. Sometimes morphine may be required on account of
pain, but the crises of pain, dyspnoea, and other painful phenomena of
the aneurism are calmed almost immediately.
The cure of an aneurism by electrolysis must not be expected from one
session. More often several sessions are required, but the repetitions
should be separated by four to five weeks, so that time may be allowed
to develop the full benefit of the preceding operation, and to heal any
secondary inflammation which may have been produced.
Acupuncture.--Constantine Paul conceived the idea of applying simple
acupuncture to aneurism. He treated one case as follows: Four needles
were introduced into the sac, and allowed to remain there fifteen
minutes. Little or no pain was experienced. In three days there was a
notable diminution of anxiety and dysphagia. A second introduction was
made four days later, which was followed by still greater improvement.
The patient felt so much better that he insisted on leaving the
hospital. Paul thinks that electrolysis and acupuncture produce an
endarteritis which thickens and strengthens the pouch-wall.
{821} Abdominal Aneurism.
This lesion is much more rare than aneurism of the thoracic aorta.
Among 551 cases of aortic aneurism accumulated by Crisp, only 59 were
abdominal. I find no one particular point of the abdominal aorta which
is especially liable to aneurism, but in general terms the upper part
is more often affected than the lower. Of 103 cases noted by Lebert,
only 3 occurred at or near the bifurcation. Abdominal aneurisms are
twelve times more frequent in men than in women, and they are more
common between the ages of twenty to forty than after that period.
They form adhesions with all the neighboring organs and tissues, and
thus develop a certain number of pressure symptoms. These symptoms,
however, are by no means so diversified or numerous as in the cases of
thoracic aneurism.
Abdominal aneurism is invariably false after it has attained cognizable
size, and it causes death in various ways. Oftentimes it kills from
exhaustion by reason of intense pain, which prevents sleeping or
eating. Again, by blocking up the arterial supply to neighboring
organs, as in the lower aorta itself, it will cause secondary diseases
which produce death. The most common termination, however, is by
rupture. The sac may rupture into the peritoneum, retro-peritoneal
tissue, bowels, bladder, pleural cavity, vena cava, or into the spinal
column. Lebert says he has never found a case of external rupture
through the skin, but Bramwell reports a case of rupture into the
retro-peritoneal tissues and subsequent escape of blood through a
bedsore.
SYMPTOMS.--In a large majority of cases pain in the back is the first
symptom which heralds abdominal aneurism. This pain may precede the
appearance of a tumor for weeks and months. At first the pain is
usually due to a stretching of the nerve-plexus which surrounds the
dilating vessels, and hence it is of a neuralgic character. It is
intensely severe and shooting. Beginning in the lumbar region, it
shoots down into the hips and knees, or through the abdomen to the
epigastric and umbilical region. It is usually more or less continuous,
but subject to great exacerbations. Motion, change from reclining to
upright posture, acts of coughing and sneezing, increase it. One
peculiarity of this pain is that it is increased by eating and
drinking. This is explained by the fact that the taking of food and
drink increases the amount of blood and thereby stretches still more
the sensitive wall of the aneurism. The pain often obliges patients to
keep in bed, and even there the relief is very slight, so that death
may result from the exhaustion of sleepless days and nights.
When the aneurism encroaches upon the vertebræ there is added a
gnawing, grinding pain which is constant, and is relieved but little by
change of posture. Pressure upon the stomach and bowels and upon the
nerve-plexuses which supply these organs produces dyspepsia, vomiting,
constipation, and a tendency to accumulation of gas in the bowels. This
interference with the nutrition of the body invariably causes marked
cachexia, so that a patient who has suffered some time from abdominal
aneurism will look as if he were affected with cancer.
Pressure upon the renal vessels causes atrophy of the kidneys and
hemorrhagic impactions. Patients may die with uræmic symptoms, such as
convulsions, dropsy, and stertor.
Pressure on the bladder causes painful micturition, which is a not
uncommon symptom of this complaint. Pressure upon the aorta itself
below the seat of the tumor will produce symptoms of obliteration of
that artery, and will be treated of under that head. Rupture of an
abdominal aneurism into the vena cava produces orthopnoea, pallor, and
dropsy. Smith reports such {822} a case in which gangrene of the right
leg followed a puncture to relieve the dropsical tension.
Physical Signs.--The aneurismal tumor often appears suddenly after a
preceding interval of pain or after some sudden strain. It may show
itself in the epigastrium, iliac regions, or about the umbilicus. It
presents the classical symptoms of expansile pulsation and souffle. But
these are often wanting. Every case should be auscultated both front
and back, because the murmurs are sometimes more audible behind than in
front. François Frank calls attention to the fact that manual pressure
upon an abdominal aneurism will produce an increase of tension in the
vessels of the lower extremities. This rise of tension is caused by the
forcing of the blood in the aneurism out into the lower vessels.
If the pressure be now suddenly removed, the general pulse will almost
entirely disappear for one to two pulsations. This is due to the
aspiration of the elastic wall of the tumor, which goes back to its
original size. The reverse of these phenomena is true in case the tumor
is solid and lies across the artery.
Scheele of Dantzig draws attention to a new diagnostic sign, which he
considers pathognomonic. This is a suddenly-heightened pressure in the
region of the aneurism when both femorals are compressed. This test is
not without danger, however, as Sandsby found in one case which he
compressed for ten to fifteen seconds. There was a momentary
retardation, and then increase of impulse in the tumor, with an
increased loudness of the systolic murmur. Directly after, the patient
complained of a sharp attack of pain which continued during the day,
and that night death followed from rupture of the tumor.
DIFFERENTIAL DIAGNOSIS.--A few diseases of the chest and abdomen may
simulate this affection, and require to be eliminated in the diagnosis.
A gravitating empyema may present symptoms of abdominal aneurism. The
distinguishing points are the signs of an effusion in the left chest,
the reducibility of the tumor by pressure, and the absence of a thrill
or bruit.
A case is reported of a vast aneurism of the thoracic aorta which grew
downward until it pointed in the right iliac fossa. It was considered
an abscess with pulsations from the iliac arteries. It would seem as if
the only safeguards against mistake in such cases were great skill in
examining the whole breadth and depth of every doubtful case and a
knowledge of the fact that eccentric developments may occur. Aneurism
of the abdominal aorta may be simulated by excessive pulsation of that
vessel. This condition appears usually in nervous, weak people, and is
often the occasion of great alarm. It occurs frequently in anæmia, and
may follow hæmatemesis from gastric ulcer, and thus lead to a fear of a
ruptured aneurism.
The diagnosis is easy if the abdominal wall is thin enough, so that the
aorta can be reached and felt. If the abdomen is distended by gas, the
diagnosis may be more difficult. Duckworth reports a case where it was
necessary to give ether and entirely relax the muscles of the abdomen
before a satisfactory examination could be made.
Finally, in examining the abdominal aorta by auscultation, one should
be careful about any murmur which may be heard. It may be due simply to
pressure of the stethoscope upon the vessel. Constriction at a low
point of the oesophagus, which causes an accumulation of food above and
a dilatation of the tube, may closely resemble aneurism. Hayden refers
to a case which exhibited dysphagia, epigastric pulsation with
tenderness and percussion dulness, pain in the back and shoulder, and a
tearing or raking sensation at the epigastrium on attempting to
swallow.
No opinion regarding an abdominal aneurism should be formed until it is
certain that the bowels are not loaded with fecal accumulations.
Evacuation {823} of the bowels, therefore, is a proper preliminary to
an examination for abdominal aneurism. The condition of the bladder and
uterus must also be carefully noted, and the bladder should be emptied.
TREATMENT.--Excellent results have been obtained by the Tufnell method.
Compression of the aorta above the tumor has been recommended, and has
been followed by good results. One case is reported in which the
tourniquet was applied four inches above the umbilicus on three
occasions, the patient being under an anæsthetic. The first session
lasted half an hour, the second three-quarters of an hour, and the
third for one and a half hours. The tumor was as large as a
cricket-ball, and it became solid in forty-eight hours after the last
application. Three weeks later there was no evidence of an aneurism to
be found. Another case is reported of one compression of five hours,
and another of ten and a half hours. One case in England required
fifty-two hours of pressure under chloroform.
These results encourage one to persevere in repeated sessions in case
of failure at first. But a word of caution must be given to avoid
injury to the abdominal organs during pressure.
Rupture of the Aorta.
Although very frequent in connection with aneurism, rupture of the
aorta is otherwise relatively rare. It almost never happens in a normal
aorta, but a few cases are reported where the arterial wall is
described as merely thin. Usually the rupture occurs at a spot weakened
by atheromatous disease, and is produced by sudden strains, falls, or
blows upon the chest, or by rapid exercise of the arms. Congenital
narrowing of any part of the aorta will produce so much strain behind
the obstruction as to cause rupture. Fernand reports such a case in a
boy fifteen years old. The ascending and transverse portions were
dilated, and the inner surface was covered with small red vascular
plaques. The remainder of the aorta was contracted to the size of the
iliac vessels.
Men and women are both liable to rupture, but the former more than the
latter. One would suppose that women during the terrible strain of
childbirth would be especially liable to such an accident, but I have
found only one such case reported. This woman, thirty-eight years of
age, died suddenly during the first stage of labor, and a living child
was extracted five minutes later by forceps. The rupture was seated one
and a half centimeters above the aortic valves, and reached nearly
round the entire circumference of the artery. Heinricius reports the
case,[1] and says that he has been unable to find any similar case
recorded. I have found one case of rupture of the aorta during the
sixth month of pregnancy, but not associated with any sign of labor.
[Footnote 1: _Cent. f. Gynäkol_, No. 1, 1883.]
The majority of the ruptures occur in the immediate neighborhood of the
valves or within two inches of the same. It is a very rare thing to
find a rupture of the transverse or descending portion of the arch. One
case is reported of a girl twelve years of age who was trampled upon by
a pony and never rallied. The descending aorta was found ruptured, and
the tear was apparently produced by the nipping of the vessel between
the vertebral column and the heads of three left ribs, which projected
forward and could be protruded still farther by pressure upon the
sternum.
When the inner coat of the aorta ruptures and the blood escapes, it
immediately forms a pocket between the arterial tissues, and then one
of two things may occur: the escaped blood may coagulate solid, and so
fill up the opening and prevent further leakage. This occasionally
happens; more often, {824} however, the escaped blood pushes along,
dissecting apart the tissues of the artery, and advancing until it
finds some point of escape. Sometimes the blood bursts back into the
aorta and rejoins the main current. In such cases the separation of the
tissues continues transversely until the entire circumference of the
aorta is included, and then the vessel forms a double tube. When the
blood does not re-enter the aorta, it may push ahead until it reaches
the iliac arteries, which is not at all uncommon. While advancing in
this direction the blood also dissects backward toward the heart, and
finally bursts into the pericardium. Almost invariably in these cases
the pericardium is found more or less full, and the pressure of a large
amount of blood in the pericardium upon the heart no doubt contributes
largely to the fatal result by obstructing the action of that organ.
There may be two pints of blood in the pericardium. Death by rupture is
by no means instantaneous. As a rule, the victims continue to live
several hours, and even days, after the initial accident.
If the escaped blood coagulates and plugs, several months may elapse
before death, as in a case examined by myself. A washwoman while
shaking out a heavy piece of wet cloth in November was suddenly seized
with severe pain in the chest. This pain continued with other
distressing symptoms which disabled her for work, but she did not die
until the latter part of the following January. The autopsy revealed a
rupture, plugged by a clot, two inches above the aortic valves.
Rupture is usually announced by sharp pain coming on during exertion.
There may also be a sense of choking, but this is not invariable.
Generally, the head is clear, and there is no paralysis, but
occasionally the patient will swoon and appear collapsed. This of
course depends upon the size of the rent and the freedom of the escape
of blood. The heart is excited and rapid. The pain is located in the
front of the chest or in the epigastrium, and the victims are a prey to
great anxiety. Excessive trembling and inability to restrain muscular
movements have been noticed. Profuse sweating, together with vomiting
and evacuations of the bowels, may occur. Often the only record is,
"Obscure symptoms, referable to the heart." There are no
characteristics or pathognomonic symptoms of rupture of the aorta.
Death is the invariable result, sooner or later, and no treatment has
yet been devised to remedy the evil.
Perforation of the Aorta.
This accident causes death very rapidly, but not always instantly.
Instances are reported where patients, after the piercing of all the
arterial coats, have lived from one hour to three days. A case is
reported of a boy sixteen years old who swallowed a needle. It passed
through the wall of the oesophagus into the descending aorta, where it
remained impacted. Blood poured out into the connective tissue and
acted as a plug. Food escaped from the oesophagus, and putrefaction,
hemorrhage, and death occurred in ten days.
Occlusion of the Aorta.
Occlusion of the aorta is produced by the formation of a clot. Such
clot may occur in any part of the aorta. It may extend out from the
heart or from the ductus Botalli. Such localization of the clot,
however, is comparatively rare, and the most common seat of occlusion
is in the abdominal aorta. The clot is usually associated with an
aneurism, but it may sometimes be occasioned by an atheromatous patch.
The attack is always abrupt and {825} unheralded by any prodromata. The
effect of the clot is to cut off the blood-supply to all organs below
the obstruction and disturb the nutrition and function of the same.
SYMPTOMS.--The attack is sudden, and begins with a shooting pain in the
abdomen or sometimes under the sternum. Almost immediately the patient
loses power over his legs and falls completely paraplegic. At the same
time there is an intense desire to stool, which rapidly increases to
involuntary evacuations. This lesion may be accompanied by intense pain
at the anus. The abdomen may be very tender to pressure. The head is
always clear, and the inability to stand is not associated with
giddiness. There is no anxiety of the face, and often no sign of
distress there.
In a few moments the legs become cold and numb, and patients complain
of a sense of deadness in them. The reflexes are entirely abolished. If
the renal arteries are occluded the urine is suppressed at first, but
reappears as soon as collateral circulation is established through the
capsule. The urine rapidly becomes albuminous and foul smelling from
the cystitis which develops. In the course of forty-eight hours bullæ
appear upon the legs and thighs, bedsores appear over the sacrum;
violent cystitis and inflammation of the rectum follow. Some patients
live long enough for gangrene of the lower extremities to form.
Great thirst is present, and vomiting with hiccough may aggravate the
suffering. The bodily temperature rises above 100° F., while the
temperature of the legs falls. It may reach 94° F. There is usually no
pulsation perceptible in the abdomen or legs, except in rare cases,
when the occlusion is incomplete.
DURATION.--Death results from exhaustion, and occurs in a few days. Two
weeks is a long time for life to continue under such circumstances. One
case is reported, however, where the occlusion was evidently imperfect
and the man survived seven months. Collateral circulation was
developed, and the epigastric was mentioned as very much enlarged.
TREATMENT.--The treatment is wholly symptomatic. Pack the extremities
for warmth and protect from bedsores if possible.
Stenosis of the Aorta.
PATHOLOGY.--In 1789 attention was first called to a peculiar
constriction of the thoracic aorta at the insertion of the ductus
arteriosus Botalli. Careful search for this lesion since that date has
discovered a series of cases, so that in 1878, Kriegk was able to
report 55 instances of it. This constriction is a definite, locally
circumscribed lesion, always limited to the same region, and is
entirely independent of all other affections of the aorta, although it
may itself be the cause of atheroma and aneurism. Beyond the locality
specified stenosis of the aorta is an extremely rare affection, except
as the result of outside pressure or of local arteritis. Kriegk says he
found only two cases of stenosis of other parts of the aorta, although
he searched through forty years of medical literature. A few instances
of complete obliteration of the aorta have been recorded, and some
instances of universal narrowing of the aorta from congenital
obstruction in the heart are given.
The constriction at the ductus Botalli is a congenital lesion, and
consists of a sinking in of the superior wall of the aorta just at the
insertion of the ductus arteriosus or a little above or a little below
the same. This sinking may extend to and involve the origin of the left
subclavian artery, but this is not usual. The lower wall of the aorta
rarely exhibits any depression.
The ascending and transverse portions of the aorta, together with the
main branches, become very much enlarged. As the aorta approaches the
{826} constriction, its dilatation does not terminate abruptly, but the
vessel tapers down to the stenosed section in a funnel shape. Beyond
the stricture the descending aorta may recover its normal size or may
remain smaller than natural.
In many cases the aorta, barring the stenosis, is perfectly healthy,
but the increased pressure behind the obstruction tends to develop
atheroma, aneurism, hypertrophy of the heart, and rupture.
Naturally, the lower part of the body must be deprived of a portion of
its quota of blood except for the compensatory circulation which
develops. This collateral supply may be so complete that the person
affected is unconscious of any circulatory deficiency, and may live an
active life to old age. An Austrian officer born with this lesion was
able to serve in all the campaigns from 1790 to 1815, and then died one
day sitting at a card-table. Another man lived ninety-two years with
his aorta constricted. The collateral communication between the upper
and lower segments of the aorta is established by means of the deep
arteries of the neck, the transversus colli, the dorsalis scapulæ, the
subscapularis, the intercostals, and the lumbar arteries. The internal
mammary also communicates directly with the epigastric artery. These
vessels become enormously dilated, so that the superior intercostal,
for instance, may equal the femoral in size.
[Illustration: FIG. 52. A, Appearance of Aortic Arch in Early Foetal
Life.--B, Stenosis of the Aorta.]
ETIOLOGY.--The lesion is a congenital one, and results from a defective
development of the aorta. In early foetal life the descending aorta is
a continuation of the ductus Botalli, and the aortic arch looks like an
independent communicating vessel. (See fig. 52, A.) As the arch
develops, however, it gradually forms a more direct union with the
descending portion, until finally the longitudinal axes of the two
parts form one uniform curve and the ductus Botalli becomes a side
branch. At birth there is physiologically a slight nicking of the upper
wall of the aorta at the point where the two sections are joined, and
the stricture we are studying seems to be merely an exaggeration of
this physiological mark. Just how the depression becomes established is
not clear and the explanations given are not satisfactory.
SYMPTOMS.--Indications of this lesion are usually very obscure or
absent, and it is only discovered at the autopsy. Severe headache is
sometimes complained of, and dyspnoea, cough, hæmoptysis, and vertigo
may occur if the stenosis is excessive.
Physical Signs.--One of the most marked signs is the conspicuous
beating of the dilated arteries around the shoulders and ribs. These
arteries may be seen and felt. If the patient is very fleshy, however,
they may be {827} concealed. There is usually a marked contrast between
the arteries of the upper and lower extremities. The former are full
and strong, while the latter are weak and barely perceptible. In many
cases it is almost impossible to feel any pulse in the abdominal aorta
or in the crural arteries. A loud murmur is also described as occurring
over the aorta. This murmur is post-systolic, and does not correspond
to any of the ordinary aortic murmurs.
DIAGNOSIS.--This lesion has rarely been suspected, much less diagnosed,
during life, but a better knowledge of its peculiarities may lead to
more frequent recognition of it hereafter. When the collateral
circulation is fully established, stenosis of the aorta could hardly be
mistaken for anything else. The resulting excessive dilatation of the
great vessels at the root of the neck may simulate aneurism, and it
should be borne in mind that aneurism is liable to follow stenosis.