Volume 1

Green's Encyclopedia and dictionary of medicine and surgery / edited by J. W. Ballantyne.

Date:
1906-1909
Catalogue details

Licence: Attribution-NonCommercial 4.0 International (CC BY-NC 4.0)

Credit: Green's Encyclopedia and dictionary of medicine and surgery / edited by J. W. Ballantyne. Source: Wellcome Collection.

Provider: This material has been provided by The University of Glasgow Library. The original may be consulted at The University of Glasgow Library.

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    symptoms relating to them may be found, such as vertigo, headache occurring at night, mental symptoms, such as melancholia, etc. Course and Tekminations.—The course of abdominal aneurysm is generally a very chronic one. In traumatic cases, in which we can often trace the l)eginning, the patient sometimes for a considerable time complains only of pain, in- creased by exertion, or of general weakness, especially at night ; in the non-traumatic cases similar symptoms arise, and the patient seeks only medical advice when a pulsating tumour is to be felt, of which the patient is himself often conscious, comjjlaining of a throV)bing sensation. In other cases the symptoms may simulate for some time those of a malignant tumour (of stomach, kidney, etc.). In a number of recorded cases the aneurysm gave I'ise to no special symptom till siiddenly rupture occurred, or till symptoms of paralysis set in : when rupture occurs, one notices sudden collapse, great pallor, profuse clammy perspiration, and a thready pulse ; this train of symptoms is soon followed by death, or the more urgent symptoms may subside, and the patient improves and lives for some time, when a second and fatal rupture occurs. Evidence of several ru])tures of various dates has thus been found in not a few cases. Most cases of abdominal aneurysm terminate fatally. Death is most commonly due to rupture, which may take ])lace into pleiu-a, bronchi, medi- astinum, pericardium, into the peritoneum, or retro-peritoneal tissue, when it may infiltrate various tissues, such as psoas muscle, and burrow along, and in one case the blood found its way through a sloughing bed-sore to the extei'nal surface ; or the aneurysm may rupture into the stomach, duodenum, colon, pelvis of the kidney, bladder, vena cava, spinal canal, or gall-bladder. The rupture in some of these organs, such as the duodenum, pelvis of the kidney, may not prove inunediately fatal, but may produce ha3niateniesis and hfematuria respectively ; with- out rupture death may take jjlace from general exhaustion, jaundice, obstruction of the aorta, or of superior mesenteric artery. In some few cases, cure has been spontaneous ; in other cases, treatment has brought about a complete cure ; in many cases the patient im- proves for a time, but eventually death from rupture occurs. Differential Diagnosis.—Here we may dis- tinguish between (1) cases in which there is pulsating abdominal tumour ; (2) cases in which there is an abdominal non-pulsating tumour; (3) cases where the aneurysm extends upwards, simulating aneurysm of thoracic aorta ; or (4) cases in which paraplegia forms the principal symptom. Ad 1. There is no difSculty in diagnosing the aneurj'Sni from epigastric pulsation of a dilated heart; to distinguish aneurysm from a pulsating abdominal aorta, as a rule, is easy enough when we bear in mind that the pulsating aorta is found more often in women generallv affected with neurasthenic symptoms, that the pulsations can often be followed to the bifurca- tion of the aorta, and that it is not expansile, it may disappear sometimes, and especially if tlie patient be examined under chloroform. A solid tttmouT 2^'>'essi'ng on the abdominal aorta is, in most cases, easily differentiated, for the tumour can often be lifted off the aorta, or it can be moved away (cases of pyloric cancer, movable kidney), or other secondary tumours are found, as in tumours of the omentum, of the retro- peritoneal glands; or some of the abdominal organs are found enlarged—liver, spleen (leuco- cythfemia, Hodgkin's disease). In some cases the diagnosis may be very difficidt or even impossible. One case I may mention in which the patient complained of excruciating abdominal pain localised over the epigastrium, and also of pain over the lowest dorsal vertebra; the patient emaciated rapidly ; no tumour could be felt, but there was a loud systolic bruit over the left lumbar region; the patient had profuse diarrhoea, but the stool, which was examined often, as the case was thought to be one of tubercular enteritis, showed no increase of fat. At the autopsy, cancer of the tail of the pancreas encii'cling the aorta was found. If the tumour extends upwards, it may simu- late pulsating empyema ; if the examination of the heart and the absence of the other signs of empyema should not give sufficient data, the application of the Rontgen rays should clear up any difficulty. This new method of physical examination would also help us to distinguish abdominal aneurysm from aneurysm of the descending thoracic aorta by watching the move- ments of the diaphragm in relation to the tumour. If the pulsation is noticed on the back, a systolic bruit is most constantly heard, and this would help us to distinguish it from peri- nephritic abscess or abscess from caries of the vertebra', along with other symptoms, such as redness of the skin, pyi'exia, etc. Ad 2. In cases in which the tumour is not pulsating, the distinction from ffecal accumula- tion is not difticult (doughy inelastic feel, posi- tion of the mass, history of the case); from malignant disease of the kidney or colon it may be more difficult, also if it extends downwards it may simulate tumour springing from the pelvic organs or arising from the walls of the pelvis—regard must be had to the histor}' of the case, the presence, character, and distribu- tion of the pain, and, as in most of the pub- lished cases of this form of aneurysm the vertebnc found much eroded, the skia- graph w'ould form an important aid in the diagnosis ; also the retardation of the pulse in the femorals.