present in each case, nor are they when present distinctive of
pulmonary aneurism. Dysphagia is mentioned in but a single case,
dyspnoea is not constant, and cyanosis was at times absent. Also, the
physical signs were not constant. Even if all were present they might
be produced, as has been the case, by aneurism of the left wall of the
aorta, infiltrated lung-tissue, or by a solid tumor lying over the
vessels. The locality of the cardiac hypertrophy and dilatation aids in
establishing the diagnosis. If it is on the left side of the heart,
aneurism of the aorta is indicated; if it is on the right side,
pulmonary aneurism. These aneurisms tend to rupture into the
pericardium sooner or later.
Dissecting aneurism of the pulmonary artery has been observed once. It
was of small extent.[1]
[Footnote 1: _Bul. de la Soc. Anat. de Paris_, 1881, pp. 589-591.]
Stenosis of the Trunk or Main Branches of the Pulmonary Artery.
Narrowing of the trunk or of one of the main branches of the pulmonary
artery is of very rare occurrence. It may follow compression by an
aneurism of the ascending or transverse portion of the aorta,
compression by tumors in {835} the mediastinum, as from new growths or
enlarged glands; it may be caused by cicatricial contraction following
mediastinitis, inflammation of a portion of lung or of the bronchial
glands, or it may follow disease of the coats of the artery
(endarteritis).
The phenomena produced by stenosis of the trunk of the pulmonary artery
are similar to those found in stenosis at the orifice, which are
treated of in another place. They are anæmia of both lungs, accompanied
by persistent dyspnoea with occasional exacerbations (the patient
assumes a horizontal position either habitually or during the
paroxysm--a fact of true diagnostic importance [Chevers], as in all
other forms of disease of the heart and great vessels the patient
breathes easier when the shoulders are raised. But in this the dyspnoea
results from insufficiency of the supply of blood to the lungs and
system generally, and hence the recumbent posture affords relief by
removing the impediment of gravity, and thus promotes the supply of
blood to the brain), congestion, dilatation and hypertrophy of the
right side of the heart, cardiac palpitation, and finally general
venous congestion. Hypertrophy of the right ventricle is shown by
increase in the transverse measurement of the cardiac area of flatness
and increase in the force of the cardiac impulse. The artery up to the
point of constriction is dilated; the second sound is abnormally loud
and accentuated. Pulsation may be felt and a systolic murmur heard in
the second left intercostal space (observed in the right once),
propagated upward to the neck at the left of the sternum, or heard in
the interscapular space close to the spinal column.
PROGNOSIS is unfavorable.
There is nothing to be gained by treatment.
Rupture of the Pulmonary Artery.
Violent effort and great excitement have been followed by rupture of
the trunk or a main branch of the pulmonary artery. In the majority of
cases the coats were degenerated, though this was not always the case
(Chevers). Death is often instantaneous, but sometimes is delayed some
hours. In one case observed by Ollivier the duration was twenty-seven
hours.
Thrombosis and Embolism.
The pulmonary artery, from its position, is especially prone to become
plugged, either by substances coming from other parts of the body or by
coagula originating in the vessel itself. Pieces of disintegrated
coagula from the systemic veins, the contents of echinococcus cysts
ruptured into the venous current, fragments of new growths, are carried
to the heart and pass into the pulmonary artery, or large thrombi may
be detached from their position in a vein and lodge in the trunk or
main branches of the pulmonary artery.
Primary thrombosis of the pulmonary artery is very uncommon. In certain
septic conditions, in parturient women, in typhoid fever, and in
extreme anæmia thrombosis of the pulmonary artery may occur. It
commences perhaps in the right ventricle or at the pulmonary valves,
though it is also seen farther up.
SYMPTOMS.--The severity of the symptoms depends on the completeness of
the obstruction. There is dyspnoea, more or less marked according to
the size of the thrombus or embolus, pain in the præcordia, great
distress, anxiety, faintness, sense of suffocation, tightness in the
chest, palpitation, lividity and extreme pallor, cold sweats, an almost
imperceptible pulse, great restlessness, {836} and occasionally
convulsions. The mind remains clear. The symptoms develop gradually or
rapidly--in the former case depending on the slow increase of a small
thrombus--and remissions are often seen; in the latter case depending
on the sudden lodgment of an embolus of large size. Sometimes the
symptoms are extremely marked, and death takes place in a few minutes.
The appearances are not those of asphyxia, and death is usually
attributed to want of arterial blood-supply to the brain and medulla
oblongata, and not to suffocation or paralysis of the heart.
Percussion shows a normally resonant chest. Auscultation gives normal
breath sounds with free inspiration and expiration. There is very
likely a basic systolic murmur conducted along the course of the
pulmonary artery, but this is not constant. The cardiac second sound
and impulse are increased. At the post-mortem examination the heart is
found in diastole, the left cavities and pulmonary veins empty, the
right cavities filled with blood, and the cardiac veins strongly
distended.
DIAGNOSIS.--The diagnosis is often uncertain. When not developing with
extreme rapidity the symptoms are very similar to those caused by
stenosis of the pulmonary artery, and in the suddenly fatal cases they
are almost identical with rupture of the heart or rupture of a thoracic
aneurism, or even angina pectoris. The history of an antecedent
thrombus or of a disease of the heart which is likely to be accompanied
by thrombus, together with the absence of physical signs, render a
diagnosis many times probable.
PROGNOSIS.--To be regarded as of the gravest character.
TREATMENT.--In the rapid cases death occurs before anything can be
attempted. In the less severe cases absolute rest must be enjoined, and
free stimulation with brandy, ammonia, and ether attempted. It might be
worth while to place the patient with the head lower than the body, to
favor the flow of blood to the brain.
DISEASES OF THE SUPERIOR MESENTERIC ARTERY.
Aneurism.
Aneurism of both the superior and the inferior mesenteric arteries
occurs. The former is the more frequent, though still a rare disease.
The symptoms are pain in the epigastric and lumbar regions, a globular
pulsating tumor in the median line, the pulsation being accompanied by
a bellows murmur. The tumor has been seen in at least one instance to
be so large as to press on the renal arteries. Rupture is apt to take
place with the signs of internal hemorrhage. The cause of the disease
is the same as of aneurism elsewhere. Embolism is said to be a not
infrequent precedent. The aneurism is seldom larger than a hen's egg,
and is usually globular.
A positive DIAGNOSIS of the locality of the aneurism is not possible.
The TREATMENT must follow individual indications. Compression has been
successful in a few instances.
Embolism.
Several cases where the superior mesenteric artery was found at autopsy
to be completely occluded by coagulated fibrin were mentioned by
Tiedemann in a work published in 1843. Virchow first described the
characteristic {837} post-mortem appearances which follow this lesion
in his _Gesammelte Abhandlungen_, and since then records of cases have
been numerous.
CLINICAL HISTORY.--In by far the majority of cases there is an evident
source for an embolus. Pain in the abdomen is the first symptom, and
usually remains one of the most prominent throughout. At first it may
be a dull aching just below the borders of the ribs, but soon there is
superadded paroxysmal pain resembling colic, and which may at times
even be relieved by pressure. The occurrence of this colic in cases
where embolism might happen ought to put the physician on his guard for
other symptoms; for, though insufficient in itself to establish a
diagnosis of embolism, the presence of a colic resisting treatment in
the course of cardiac disease justifies the suspicion that this may be
the case. The pain is usually located near or above the umbilicus.
Intestinal hemorrhage occurs in nearly every case; death may take place
before any change in color of the stools is observed or any blood
appears at the anus, but on post-mortem examination blood is found in
the intestine. The cause of this hemorrhage is the infarction of the
intestine analogous to that which takes place in other organs supplied
by end arteries, the superior mesenteric having been proved
experimentally to be functionally such an artery, owing to its great
length, the extent of tissue supplied by it, and the comparative
smallness of the vessels with which it anastomoses on the borders of
its territory. The collateral circulation is thus so long in being
established that ample time is allowed for those disturbances of
nutrition in the walls of the vessel which render them permeable and
allow the blood to escape. In view of the hemorrhage certain other
symptoms are readily accounted for, as, for example, pallor of the face
and surface of the body, the considerable and rapid fall of the
temperature, syncope, hæmatemesis, diarrhoea, and melæna. These two
latter symptoms are important though inconstant. There is reason to
believe that the first effect of the embolism is to paralyze the bowel
and prevent peristaltic action. Diarrhoea is of frequent occurrence,
and may be profuse, the stools remaining of their natural color; or
fresh blood may be passed at first from the rectum, followed by the
continuous passage of tar-like masses; or the stools may be of pulpy
consistence, mixed with blood, or consisting of tarry blood. Lastly,
profuse hemorrhage may take place in which the stools resemble
tar-water. The character of the blood does not give any kind of clue to
the locality of the lesion.
Vomiting is a frequent symptom, and may consist of altered blood of
variable consistency. A fall in temperature can often be determined by
the thermometer, especially after severe hemorrhage. Not rarely the
temperature is normal or may be even increased, especially if secondary
inflammation has set in.
Tension and tympanitic swelling of the abdomen may occur or fluid may
be detected late in the case, these being evidence of peritonitis.
PATHOLOGY.--Before proceeding to consider the pathological changes
occurring in embolism, a few words on the blood-supply of the intestine
might perhaps render what follows clearer. The superior mesenteric
artery supplies the whole of the small intestine except the first part
of the duodenum; it also supplies the cæcum and the ascending and
transverse colon. The inferior mesenteric supplies the descending and
sigmoid flexure of the colon and the greater part of the rectum. The
anastomoses are as follows: The pancreatico-duodenalis, a very small
artery and a branch of the hepatic, anastomoses with the first branch
of the superior mesenteric, also a very small artery and given off
under cover of the pancreas. The middle colic artery anastomoses with a
branch of the inferior mesenteric. Both these arteries are given off
from the main trunks of the arteries.
The experiments of Litten in 1875 show that the superior mesenteric
artery, {838} though not so anatomically, is functionally a terminal
artery, the anastomosis not being developed with sufficient rapidity in
case of extensive embolism to ensure the integrity of the circulation.
1. The result of sudden total closure by embolism of the trunk of this
artery, therefore, is precisely like that of ligature of this artery in
animals, and is first to produce sudden abdominal pain, attacks of
colic, vomiting, uncontrollable intestinal hemorrhage, death. The
intestine from the lower transverse portion of the duodenum to the
middle of the transverse colon is found to be suffused, brown-red,
blackish, or grayish. All the layers are swollen; innumerable capillary
extravasations of small and great extent are seen, with venous
hyperæmia and oedematous infiltration. In other words, there occurs
necrosis with oedema and hemorrhage in all those portions of the
intestines which are supplied by this artery.
2. Closure of large branches by embolism gives rise to infarction of
the portion of intestine concerned, followed by death. The symptoms
differ only in intensity, if at all, from the preceding. A case has
been seen where there was every reason to believe that embolism had
occurred, and yet the patient recovered. (The patient, suffering from
acute rheumatism complicated with peri- and endocarditis, suddenly
developed profuse intestinal hemorrhage of tar-like color, which was
repeated twice. Colic pains, tympanites, depression of the temperature
of the body, followed. At the same time symptoms of embolism of various
other arteries were present. Recovery took place after eight weeks.)
This result of course depended on the subsequent perfection of the
collateral circulation.
3. Closure of the smallest branches may produce the same kind of
symptoms as the above, though less in degree. Limited portions of
intestine have been found to be in a gangrenous condition from embolism
of very minute branches, more especially when the embolus extended well
into the artery. In place of gangrene of the intestine ulcers of the
mucous membrane have been seen independent of typhoid fever or
tuberculosis. Considerable stenosis has followed such ulcers.
The affected portion of intestine in embolism is found to contain a
variable amount of blood mixed with the other contents of the gut.
Peritonitis, dry and limited or general and accompanied by effusion, is
the rule. The mesenteric glands are found enlarged and succulent, with
perhaps here and there necrosed spots. Thrombosis of the corresponding
veins is not uncommon. Large collections of blood under the peritoneum
and in the mesentery have been observed. The color of the mucous
membrane has been slaty, and a diphtheritic appearance has been
observed.
DIAGNOSIS.--The following are the most important points in forming a
diagnosis: 1. A source exists from which an embolus might be derived.
2. Profuse and even exhaustive intestinal hemorrhage sets in, which can
neither be explained by primary disease of the intestinal walls nor by
hindrance to the portal circulation. 3. There is a rapid and
considerable fall of the temperature. 4. Pain in the abdomen comes on,
which may resemble colic and be very severe. 5. Finally, tension and
tympanitic swelling of the abdomen occur, and there may be fluid in the
abdominal cavity. 6. Evidence of embolism of other arteries may have
been obtained before the symptoms of embolism of the superior
mesenteric artery come on, or such evidence may appear at the same time
as the latter. 7. Palpation may reveal the presence of collections of
blood between the folds of the mesentery.
PROGNOSIS.--The prognosis in embolism of the superior mesenteric
artery, though not absolutely bad, is exceedingly grave. It must be
borne in mind that the symptoms of occlusion of one of the large
branches are similar to those where the main stem is involved, while
the probabilities of recovery in the former are much greater, as
already explained, from the shorter extent of {839} the anastomosis.
There is evidence that recovery from the immediate effects of embolism
may take place even where subsequent ulceration has been so great as to
cause complete closure of the intestine through cicatrization. (A case
is related by Parenski where the patient was operated on for stricture
of the bowel, and only at the autopsy was it discovered that the
stricture was due to cicatrization from ulceration caused by embolism
of one of the branches of the superior mesenteric.) There are at least
three cases of recovery on record where occlusion of the main stem was
supposed to have taken place; but inasmuch as the situation of the
embolus cannot be determined with certainty if the patient recovers,
these cases are open to the suspicion that one or more of the larger
branches only were occluded. The profuseness of the hemorrhage, though
it may imperil the life of the patient from exhaustion, bears no
constant relation to the gravity of the case. Copious and repeated
hemorrhages per anum took place in cases of recovery, while in other
fatal cases this symptom was entirely absent. Extreme fetor of the
stools must be regarded as of evil omen, as it may be the evidence that
gangrene of the bowel has taken place.
TREATMENT.--One of the first symptoms calling for relief is the colic,
which is best met by morphia given subcutaneously or by suppository.
For the hemorrhage ergot by the mouth and alum enemata have proved
serviceable, or the application of ice to the abdomen. The lowering of
the heart's action by sedatives is to be avoided when we remember that
their use would lower the blood-pressure, and thus tend to retard the
establishment of the collateral circulation.
Thrombosis.
The symptoms of thrombosis have not been determined apart from
embolism, and it is doubtful if the affection proves fatal unless the
extent of artery involved is very considerable or the formation of the
thrombus is very rapid, for the anastomosis is gradually made
compensatory. In either of the latter cases the symptoms are identical
with embolism, and the pathological appearances are the same. With
regard to treatment, general indications must be pursued.
Endarteritis.
This disease is met with, but it is usually slight and unaccompanied by
symptoms.
DISEASES OF THE INFERIOR MESENTERIC ARTERY.
Aneurism.
Aneurism of this artery has been seen after death. The diagnosis could
not be made, in all probability, during life. Pain might be a prominent
symptom, though not necessarily, as many of the aneurisms of the
abdomen are unattended by any symptoms. Rupture is not unlikely as a
termination.
Embolism.
Embolism has been observed. Sudden pain in the abdomen comes on,
followed by vomiting and diarrhoea. The patient looks miserably; the
{840} belly is drawn in and painful on pressure almost exclusively in
the left iliac region. Severe spontaneous colic-like pains continue,
with occasional vomiting and diarrhoea. At first the stools are
feculent and pap-like; then they begin to smell bad, and even stink.
Red blood is passed. Soon there is a mixture of blood and slimy masses.
Finally, the stools are slimy, blackish, almost tar-like, and have a
terrible odor, and are passed with griping and tenesmus. Occasional
vomiting still continues. The pulse becomes smaller and more frequent,
and gradually irregular and intermittent. Soon collapse and death
follow.
The predisposing and exciting causes are the same as in embolism of the
superior mesenteric artery.
The duration is usually short, lasting from a few hours to three or
four days. The termination is ordinarily fatal, though doubtless cases
of recovery have occurred, as stated under Embolism of the Superior
Mesenteric Artery, the size and position of the embolus not precluding
the possibility of the establishment of collateral circulation.
Complications are varying degrees of peritonitis, evinced by
tympanites, pain, and tenderness, either localized or diffused, and
later by the occurrence of effusion. Sequelæ, when the disease is not
immediately or rapidly fatal, are ulceration of the colon with
subsequent cicatrization and contraction.
PATHOLOGY.--The mucous membrane of the descending colon, sigmoid
flexure, and rectum is somewhat swollen, strongly reddened, and
contains ecchymoses and extensive suffusions of blood; or the color may
be blackish or slaty and the surface sloughy.
DIAGNOSIS.--The diagnosis can only be made by exclusion. The same
points are to be carefully verified as in embolism of the superior
mesenteric artery, only the pain and symptoms are in a different place,
and the secondary peritonitis also begins on the left.
PROGNOSIS.--The prognosis is very grave, but recovery may take place,
contractions or constrictions being left behind.
TREATMENT.--The treatment combines perfect rest, the exhibition of
wine, opium, vegetable astringents, and the subcutaneous injection of
morphia.
ANEURISM OF THE HEPATIC ARTERY.
The tumor varies in size from a hazelnut to a child's head, and is
egg-shaped. Pain in the epigastrium and right hypochondrium or upper
abdominal region is a characteristic symptom. At first the pain is not
severe, and is occasional, recurring after a pause of several months'
duration; later it becomes very severe and lasting. The abdomen is not
tender to the touch or on pressure during the remissions from the
attacks of pain, but after rupture of the aneurism, whether temporary
or lasting, it is very severe. The abdomen is sometimes distended, at
others not. The tumor, owing to its position, cannot be felt, nor can
pulsation be detected, as the wall of the aneurism consists of
connective tissue and blood-clot, and the stream of blood coming from a
small artery is slow. In but a single case has increase in size of the
spleen and liver been observed. The functions of the stomach and
intestines remain normal in spite of the pain. The locality of aneurism
of the hepatic artery is such as to readily cause temporary or lasting
icterus--a phenomenon which occurs in perhaps two-thirds of the cases.
Rupture, with the ordinary signs of internal hemorrhage, seems to be
the usual termination. Inflammatory processes or fever does not follow
hemorrhage into the abdomen. {841} If perforation occurs into the
gall-bladder, a gall-duct, or the intestine, the hemorrhage may appear
to be moderate. In such instances repeated discharges of blood may
occur from the intestine, or at the same time may be thrown off from
the stomach.
There is no means of determining how long aneurism of the hepatic
artery may exist without giving any kind of sign of its presence.
Judging from analogy, it is very probable that a considerable time may
elapse before the disease is observed. Since pain in the abdomen is the
first pathological indication, and rupture the last, we may measure the
probable duration of the disease by these phenomena and also by the
clinical course. This was not over ten days in two cases, and in three
cases it was three to four months. Since aneurisms of the hepatic
artery, even when they have reached their greatest dimensions, are not
palpable, the pains which appear with them have in themselves no
diagnostic worth. The same is true of the icterus which appears sooner
or later. It is only after rupture has occurred that all the chances
are so placed that a comprehensive estimate of them may be made and a
diagnosis arrived at by exclusion. The fact that the function of the
stomach remains unchanged in spite of rupture (hemorrhage), and the
totally unchanged character of the blood-clots vomited, enable us to
locate the situation of the hemorrhage as outside the stomach. If at
the same time there is an alternate relation between the occurrence and
disappearance of the icterus and the hemorrhage, the inference is
admissible that the latter is located in the immediate vicinity of the
gall-ducts. Other peculiarities of the blood-clots passed at stool are
perhaps the imprints of the valvulæ conniventes of the jejunum.
The DIAGNOSIS of aneurism of the hepatic artery is usually impossible.
Aneurisms of the splenic, renal, and other abdominal arteries are
recorded, but not in sufficient numbers to warrant a detailed
description of them.
DISEASES OF THE COELIAC AXIS.
Aneurism.
Aneurism of the coeliac axis, when the tumor is large, is accompanied
by very much the same symptoms as aneurism of the abdominal aorta. The
disease is rather uncommon.