[From the Medical and Surgical Reporter, 
December 21. 1889.] 
ANEURISM OF THE AORTA SIMU- 
LATING CARDIAC VALVULAR 
DISEASE. 
BY GEORGE DOCK, M. D„ 
PROFESSOR OF PATHOLOGY, ETC., IN THE TEXAS 
MEDICAL SCHOOL AND HOSPITAL. 
Aneurism in the beginning of the aorta, 
although rare, presents as a rule such a pecu- 
liar train of symptoms, that the narration 
even of isolated cases is not without value. 
In the present case, a slight variation from 
the usual site affected has given rise to a 
group of symptoms closely resembling those 
of a much more common class of diseases. 
While engaged with a ward class one day, I 
was so attracted by the appearance of a man 
just admitted as to make him the subject of 
immediate study before the class. The pa- 
tient supported himself in an arm-chair; his 
countenance and attitude expressed intense 
drowsiness and exhaustion. His skin was 
cyanotic, the cervical veins dilated and pul- 
sating, and his respirations frequent and 
shallow. His hands and face were puffy, 
and unbuttoned shoes revealed the thick 
ankles. The whole appearance, in short, 2 
indicated advanced cardiac insufficiency. 
The history then obtained was as follows: 
M. N., 45 years old, barkeeper, born in 
France. There is no history or evidence of 
syphilitic infection. He denies alcoholic 
excesses. The patient gives a history of 
unimpaired health up to four months before 
admission, when he began to cough, to feel 
short of breath, and to lose in weight. Soon 
after, his ankles began to swell. He was 
treated for phthisis, but later his physician 
told him his heart was affected, and pre- 
scribed digitalis. Growing worse in every 
way he came to St. Mary’s Infirmary in 
Galveston. 
The patient is of medium size, heavily 
built, and moderately emaciated. The skin 
is flabby, cyanotic, and slightly icteric, as 
are also the visible mucous membranes. Ex- 
treme anasarca exists, less marked in upper 
limbs and head. The thorax is well formed. 
The apex beat of the heart in sixth inter- 
costal space in nipple line is exaggerated. 
There is a visible thrill all over the cardiac 
area, which is limited entirely to the dias- 
tole. The cardiac dulness begins above the 
fourth rib ; extends to right edge of sternum 
and to nipple line. On auscultation a double 
murmur is heard. The first, synchronous 
with the apex beat, is loud, harsh, and rasp- 
ing. It is heard equally well over apex, 
base, and aortic cartilage, and is also audi- 
ble in the axilla and in the back. It is ap- 3 
parently the same murmur heard in the 
places named. Following this immediately, 
is another murmur, blowing, long and mod- 
erately loud, best heard above apex, but audi- 
ble all over the heart area. It is synchro- 
nous with the thrill. The second sound at 
the aortic cartilage is present, though masked 
by the murmur. The pulmonary second 
sound is not markedly accentuated. The 
systolic murmur can be heard in the neck, 
though faintly. The radial pulse is 105, 
and quick, but of good tension. On the 
right side the pulmonary resonance ends in 
dulness in the fourth interspace in the nip- 
ple line, movable according to position ; on 
the left in the seventh intercostal space in 
the axilla. Respiration shallow, accom- 
panied by numerous loose rales, especially 
on the right side. The liver dulness extends 
two inches beyond the costal margin. The 
abdomen is somewhat distended, but no fluid 
can be detected in it. The tongue is flabby 
and thinly coated ; there is loss of appetite, 
constipation, and a dull frontal headache ; 
also scanty expectoration of frothy mucus. 
For several days shortness of breath has 
been so severe that patient could not lie 
down. The urine is scanty, and high- 
colored, specific gravity 1.030, and contains 
a small amount of albumin, no casts. 
The result of this examination was not as 
satisfactory as I had expected. Though the 
suspicion of valvular disease seemed con- 4 
firmed, the physical characteristics differed 
from usual in son\e particulars. The fre- 
quency of the heart beat made it difficult 
to time the murmurs and thrill, though they 
seemed to be as given above. The pulse 
seemed unusually strong, considering the 
evidences of insufficiency, but its character 
was attributed to digitalis. The suspicion 
of aortic disease was abandoned, and not- 
withstanding certain misgivings, the case was 
demonstrated repeatedly as one of double 
mitral disease, and was seen casually by 
various physicians without leading to any 
important change of opinion. Digitalis 
was pressed at first with great benefit. The 
oedema and cyanosis lessened, the dyspnoea 
was so slight that the patient could sleep 
lying down. The thrill became less marked ; 
the murmurs continuing as before. Very 
soon, however, the drug seemed to have lost 
its effect. The dyspnoea again became so 
severe that aspiration was resorted to, and 
about a pint of sero-sanguinolent fluid re- 
moved from the right pleural cavity. This 
was of but little benefit, and, with increas- 
ing weakness of the circulation, death en- 
sued. At the autopsy an unexpected con- 
dition was found. The autopsy notes bear- 
ing on the symptoms are as follows: 
“ . . . The right pleural cavity contains 
about twenty ounces of bloody serum and 
flakes of fibrin. The right lung is com- 
pressed, the lower and middle lobes col- 5 
lapsed, and non-crepitant. Their pleura is 
covered with a thin fibrinous coat; the tis- 
sue tough and bloodless at the periphery, 
but the area around the root infiltrated with 
blood. In the left pleural cavity there was 
a small amount of bloody serum, the lung 
slightly compressed, but crepitant through- 
out and oedematous. The bronchial mu- 
cous membrane is injected and covered with 
frothy mucus. The pericardium is adherent 
to the pleura on the left side, and closely 
adherent to the heart. The heart enlarged 
and both ventricles dilated. The left ven- 
tricle measures 12 cm. in length, its wall 18 
mm. at 1 cm. below the ring. The aortic 
valves are slightly thickened but not re- 
tracted ; aside from this the valves and en- 
docardium are normal. The muscle shows 
no gross lesion. All the cavities contain 
mixed clots. The opened aorta measures 8 
cm. at the insertions of the valves. The 
sinuses are not dilated. Beginning just 
above the valves is a diffuse dilatation, ex- 
tending around two-thirds of the circum- 
ference of the aorta with the convexity of 
the vessel as its middle. It is from two to 
four centimeters wide and bounded above 
by a thick band which gives the aorta a 
constricted appearance, though the lumen is 
not diminished. The surface of the aorta 
in this part is covered with atheromatous 
scars and calcareous plates and shows the 
orifices of two saccular aneurisms. The 6 
first is just above the sinus of the right 
aortic cusp. Its shape and size are such 
that it fits the thumb for a distance of two 
centimeters. It projects to the right of the 
pulmonary artery, touching the upper part 
of the right ventricle. It is empty, and its 
walls are smooth and thin. The second is 
further to the left, in the concavity of the 
aorta, just above the common insertion of 
the posterior and left leaflets of the aortic 
valve and the left coronary artery. Its ori- 
fice measures four by three cm.; the lateral 
edges are sharp and rigid, the upper border 
is formed by part of the firm band men- 
tioned above. In the widest part the sac 
measures six cm.; its depth is five cm. Its 
wrinkled walls are covered by a thin, white, 
fibrinous layer, and are marked by a longi- 
tudinal ridge in the posterior part, corre- 
sponding to the auricular septum. The re- 
lations of this aneurism were studied by fill- 
ing it loosely with wool, opening the auricles 
and examining the several cavities. On the 
right side it encroaches on the auricle and 
the superior vena cava, so that the capacity 
of the auricle is lessened about one-third 
and the lumen of the vein reduced to a nar- 
row slit. On the left, the anterior wall of 
the auricle is bulged back, forming a rounded 
prominence directly over the mitral valve 
and causing an actual obstruction. The 
branches of the pulmonary veins from the 
lower and middle lobes of the right lung 7 
cross over the tumor and are almost occluded 
by the displacement so caused.” . . . The 
other organs, especially liver and kidneys, 
showed the changes common to obstructive 
disease in the heart. The kidneys in addi- 
tion showed beginning arterial sclerosis. 
The lesions found explain the clinical 
phenomena so clearly that comment is hardly 
necessary. In an incomplete search of the 
literature of aneurisms in the beginning of 
the aorta I have not been able to find refer- 
ence to one in the concavity. Their usual 
seat is in the fljjterior wall, or still more 
rarely above the posterior leaflet, with symp- 
toms of obstruction of the pulmonary ar- 
tery or superior vena cava. The difference 
of half an inch to the left is enough to pro- 
duce the mitral symptoms and the obstruc- 
tion to the pulmonary circulation, and indi- 
rectly the systemic symptoms. The larger 
aneurism was so placed as to allow con- 
siderable expansion without rupture into a 
neighboring cavity or vessel, for notwith- 
standing its size, the walls are strong. Al- 
though the absolute rarity of such a lesion 
may bring the conclusion that it is of little 
practical value, yet it conveys an important 
lesson in the value of minute examination 
even when the condition seems plain, and 
furnishes a remarkably good example of the 
simulation of disease.