Varicose Aneurisms of the Aorta and 
Superior Vena Cava. 
BY 
WILLIAM PEPPER, M. D., 
Professor of Medicine in the University of Pennsylvania and Provost of the University, 
AND 
J. P. CROZER GRIFFITH, M. D., 
Physician to St. Agnes and the Howard Hospitals, and Assistant Physician to the Hospital of the 
University of Pennsylvania. 
FROM ' ' A 
THE AMERICAN JOURNAL OF TIIE MEDICAL SCIENCES, 
October, 1890. ' M.% VARICOSE ANEURISMS 
OF THE 
AORTA AND SUPERIOR VENA CAVA. 
BY 
AVILLIAM PEPPER, M.D., 
PROFESSOR OF MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA AND PROVOST OF THE UNIVERSITY, 
AND 
J. P. CROZER GRIFFITH, M.D., 
PHYSICIAN TO ST. AGNES AND THE HOWARD HOSPITALS, AND ASSISTANT PHYSICIAN TO THE HOSPITAL 
OF THE UNIVERSITY OF PENNSYLVANIA. 
REPRINTED FROM THE 
AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
OCTOBER, 1890. VARICOSE ANEURISMS 
OF THE 
AORTA AATD SUPERIOR VEHA CAVA.1 
By William Pepper, M.D., 
PR0FES80R OF MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA AND PROVOST OF THE UNIVERSITY, 
AND 
J. P. Crozer Griffith, M.D., 
PHYSICIAN TO ST. AGNES AND THE HOWARD HOSPITALS, AND ASSISTANT PHYSICIAN TO THE HOSPITAL 
OF THE UNIVERSITY OF PENNSYLVANIA. 
There is, perhaps, no pathological condition whose symptoms are 
usually more characteristic than are those of obstruction to the normal 
flow of blood in the superior vena cava. Such a condition may be 
brought about by compression by tumors or aneurisms, by inflammation 
and consequent thrombosis of the vein itself, by rupture of an aneurism 
of the aorta into the vena cava, by penetration of a malignant growth 
into the vessel, or by bands of inflammatory tissue constricting it from 
without. 
The characteristic symptoms consist in intense oedema and cyanosis 
coming on rapidly or slowly, and limited to the upper half of the body; 
together with such secondary symptoms as would naturally follow these 
conditions. It is difficult to conceive of any cause suddenly operating 
to bring about obstruction, yet failing to produce these effects. Only 
when the cause operates very slowly does it seem possible that the symp- 
toms may be slight, or even absent, the collateral circulation having 
become established. 
Rupture of an aneurism of the arch of the aorta into the superior vena 
cava, one of the causes referred to, is so rare an occurrence that we have 
been interested in looking into the history of the affection, in connection 
with a case occurring under our own observation, with the hope of 
determining whether there exist any symptoms which would permit of 
a diagnosis during life. 
1 Read before the Association of American Physicians, May, 1890. 4 
PEPPER, GRIFFITH, ANEURISMS OF AORTA. 
The following history of the case is imperfect in some points, owing 
to the patient’s slight knowledge of English, as well as to the difficulty 
which he experienced in talking on account of the great dyspnoea from 
which he suffered: 
Tak Sing, Chinaman, aged forty-eight years. Was admitted to the 
Hospital of the University of Pennsylvania, September 22, 1888. His 
parents are both dead, of causes unknown. Nothing else can be elicited 
in the way of family history. He has been a cook on a man-of-war, and 
since 1876 has been working in a laundry. Although on close question- 
ing he says he has noticed numerous small varicose veins over his thorax 
for four months, he claims that he has always been a healthy man until 
four weeks ago. At this time he had been working very hard in his 
laundry, and sleeping in a cold, damp cellar for several nights, after 
which he was attacked by a severe pain in the chest, which prevented 
him from sleeping. He was also unable to lie down at night, presumably 
from dyspnoea. He noticed that his neck and shoulders were swelling, 
the left side being more swollen than the right. After this the chest 
became swollen, and he says that his feet were so likewise. The notes of 
the case make no reference to the condition of the arms. It could not 
be positively determined whether oedema first appeared at this time, or 
whether some had existed four months before, at the time the varicose 
veins of the chest were first noticed. 
A week before admission he began to have difficulty and pain in 
swallowing, and could only take milk and soup, and occasionally a frag- 
ment of meat. A Chinese physician was summoned from New York, 
who applied the moxa to both sides of the neck, the shoulders, and the 
elbows, but his condition continued to grow worse. Three days ago a 
watery discharge from the left ear began. He has had no trouble in 
emptying his bladder, though he has passed less urine than usually. He 
has had some cough with expectoration since he was first taken sick. 
When first examined by us he was found suffering from extreme 
dyspnoea, and complaining greatly of a burning sensation about the 
chest; but whether this was felt internally or on the surface of the skin 
could not be discovered. He sat erect or leaning forward in bed, entirely 
unable to lie down, and able to sleep but little. The eyes were suffused, 
the temporal veins congested, the tissues of the face cyanosed and very 
cedematous, the tongue clean. The neck was symmetrically and very 
greatly swollen, pitting and tender on pressure. No enlarged glands 
could be detected in it. The tissues of the chest were everywhere 
cedematous, giving the impression that the patient was a stout man. The 
surface of the thorax was covered with numerous small varicose veins. 
The arms, forearms, and hands were cedematous, and somewhat cyan- 
osed. The pulse was small, well filled, and the tension possibly slightly 
increased. 
The oedema ceased entirely below the thorax, without any sharp line 
of demarcation, and the hips and legs were those of a slightly built man. 
The feet were cold. 
The astounding contrast between the size and appearance of the upper 
and lower part of the body would have been ludicrous had not the 
extreme distress of the patient removed any feeling but that of pity. PEPPER, GRIFFITH, ANEURISMS OF AORTA. 
5 
The supra-condyloid and inguinal glands were distinctly enlarged. 
The examination of the lungs was unsatisfactory on account of the 
extreme cedema of the subcutaneous tissues. The respiration was costo- 
abdominal and symmetrical. Anteriorly the right side seemed everywhere 
duller than the left, but there was no impairment behind. Vocal resonance 
was normal. Numerous fine mucous rales could be heard during inspira- 
tion over both bases posteriorly, though more on the right side, and with 
slightly prolonged and bronchial expiration. In front on the right side 
there were a few fine rales, heard chiefly on inspiration, and the respiratory 
murmur was feeble. Auscultation of the left lung showed nothing amiss. 
The determination of the cardiac dulness was also unsatisfactory on 
account of the oedema, but it appeared to extend from the third rib 
doAvnward, and laterally from the right border of the sternum to the 
nipple-line. The apex-beat was in the normal position, and was rather 
forcible. A thrill could be felt over the apex and base. Auscultation 
at the aortic cartilage revealed a loud, musical murmur of a very pecu- 
liar character, reminding one of the sighing of the wind. Being loudest 
and highest-pitched with the cardiac systole, it died away very considerably 
during the diastole, and lowered its pitch by several tones, to rise again 
both in volume and pitch with the next systole. It was thus continuous, 
and had a distinctly venous quality, although unlike a venous hum in 
that it was distinctly rhythmic. The systolic portion of this murmur 
was transmitted very distinctly under the right clavicle, and, indeed, 
everywhere over the right chest, both in front and behind, and also into 
the vessels of the neck and down the arm as far as the elbow. It could 
be heard faintly and distinctly at the pulmonary and xiphoid cartilages, 
but not at the apex. The abdominal organs appeared to be normal. 
Dr. C. M. Hay, at that time Resident Physician to the Hospital, made 
careful notes at short intervals during the time the patient was under 
observation, and abstracts from some of these show the course of the 
disease: 
Sept. 25. The patient’s condition is practically unchanged. Nitro- 
glycerin has been given several times without effect, but he now appears 
to feel better after purgation with elaterium. 
26th. Urine is acid, highly-colored, quantity small, albumin in 
moderate amount, specific gravity 1022. No casts, blood, epithelium, or 
pus. 
28th. In spite of the elaterium and pilocarpine the oedema and cyanosis 
are more extreme. The patient sleeps very little, and breathes with 
considerable difficulty, and has attacks of coughing. The pulse is weak 
and irregular; that at the right Avrist appears stronger than, though 
synchronous with, that at the left. The oedema, however, interferes 
with an accurate examination. The murmur is the same as at first. 
Respiration on the right side is fainter than on the left, and the percus- 
sion on this side seems everywhere duller. 
30th. General condition the same. He complains of great burning 
in the throat and chest, especially on swallowing his whiskey. 
Oct. 1. Expectorated this morning about a tablespoonful of blood- 
stained mucus. Swallows considerable food, but Avith pain and diffi- 6 
PEPPER, GRIFFITH, ANEURISMS OF AORTA. 
culty. The chief complaint still is of the burning pain in the chest, 
aggravated by swallowing whiskey. There is a faint systolic murmur 
heard at the apex, and probably transmitted to this spot. The venous 
murmur at the aortic cartilage and under the clavicle is plainer, and 
the loudest portion of it almost synchronous with the first sound of the 
heart. 
3d. The oedema is greater. The left arm is more cyanosed and 
oedematous than the right, being \ inch greater in circumference at 
the elbow. 
5th. Dropsy and cyanosis of the upper half of the body still greater, 
the swelling being more marked on the left side of the face and neck, 
and in the left arm, than on the right side. The left forearm measures 
1 inch more than the right. No oedema of the lower part of the body. 
The patient still complains of intense burning pain after each dose 
of stimulant. He is subject to attacks of stupor of short duration, 
and at times is very irritable. 
6th. The oedema is still greater in the left arm, but the right arm is 
much less swollen than it was a week ago. The oedema of the chest 
is slightly better. The right side of the chest anteriorly is still duller 
on percussion than the left. Posteriorly there is no material difference. 
No evidence of pleural effusion. Respiratory sounds normal on both 
sides. The venous murmur is of the same character as before, but is 
of a little lower pitch, and is loudest at the end of inspiration. The 
patient has for a week been taking iodide of potash, tincture of nux 
vomica, and tincture of digitalis; also codeia and pilocarpin p. r. n., and 
dry cups over the chest at intervals. 
9th. There is to-day some oedema of the scrotum. 
10th. Condition worse. Cyanosis very extreme. Swelling of the 
scrotum has disappeared. 
12th. Dyspnoea more marked, and respiration labored and noisy, 
expiration being especially prolonged and stridulous. There is undoubt- 
edly an area of percussion-dulness on the right side, extending down- 
ward to the upper border of the third rib, and transversely toward the 
left as far as the left edge of the sternum. The respiration on the right 
side is much louder and fuller than on the other, but in other respects 
there is nothing worthy of note. The heart sounds cannot be distinctly 
heard on account of the noisy respiration, and the venous murmur is not 
heard either at the aortic cartilage or under the right clavicle. Ex- 
amination of the throat made by Dr. Reeves shows the half-arches of the 
palate covered with a muco-purulent secretion, and the larynx filled with 
the same. There seems to be a partial paralysis of the right abductor 
muscles, but the difficulty attending the examination renders the observa- 
tion uncertain. There are diffuse redness and extreme congestion of the 
whole of the interior of the larynx, with a diffuse oedema of the larynx 
and trachea. The patient being in great agony, dry cups were to-day 
applied with marked relief. The presence of occasional stupor and of 
irritability is still noticed, and in a few instances he has seemed to be 
wandering in his mind, though it was not possible to determine this writh 
certainty. 
13th. The expectoration is distinctly more frothy and serous, and less 
purulent than during the preceding week, and contains to-day slight 
traces of blood. The patient breathes with much difficulty. PEPPER, GRIFFITH, ANEURISMS OF AORTA. 
7 
14f A The oedema has increased greatly in the entire upper half of the 
body. Respiration is stridulous and very labored, but has been relieved 
slightly by dry cupping. Numerous large and small mucous rales are 
audible throughout the chest, especially on the right side. 
15th. At about noon, yesterday, blood oozed from the conjunctiva, and 
the sputum was tiuged with blood. At 5.30 p. m. he had an attack of 
choking, and expectorated with great difficulty about fof bright, 
arterial blood. At 6 p. m. he became very drowsy, and gradually grew 
more stuporous and unconscious. The pulse began to fail, the cyanosis 
became almost black. Cheyne-Stokes respiration developed and con- 
tinued until death at 8.45 p. m. 
The temperature throughout the disease tended to be subnormal, as 
shown in the accompanying chart. Only once did it reach an elevation 
of 98° Fah. 
Autopsy three hours after death: Man below medium height. No 
rigidity or ecchymoses. Cyanosis much less marked than during life. 
Upper half of the body oedematous. No oedema below the waist. Lower 
extremities emaciated and shrivelled. On incision through the skin 
there is profuse venous oozing. On opening the thorax the tissues of the 
anterior mediastinum appear matted together, and everywhere oedorna- 
tous. Pericardium contains about an ounce of bloody serum. Heart as 
a whole not hypertrophied. Valves normal. Right auricle large, and 
its walls look thicker than normal. The index-finger enters the superior 
cava from the auricle for slightly over an inch, but then is tightly com- 
pressed. The inferior cava admits two fingers to the first joint. The 
coronary arteries are pervious and not calcified. The aorta is a little 
dilated, and 1J inches from the aortic valves is an orifice the size of a 
half-dollar on the postero-lateral aspect of the convexity of the arch. 
This opening looks into an aneurismal sac projecting to the right and 
posteriorly, and of the size of an orange (see figure). The tissues around 
the sac are thickened. It is bounded on the right by the right lung, 
which it compresses, and to which it is adherent. Posteriorly it lies 
against the trachea and oesophagus and the right bronchus. The sac 
has everywhere thin walls, and is full of dark, moderately firm, non- 
laminated coagula. 
The subclavian and innominate veins are pervious. At the junction 
of the right internal jugular and right subclavian veins is a globular 
thrombus the size of a large pea, lying behind one of the valves. The 
upper part of the superior cava is much thickened, and is compressed 
by the aneurismal sac, which lies directly upon it. At its termination in 
the vense innominatse it does not admit the tip of the little finger passed 
into it from above, and this narrowing continues throughout the course 
of the vein to a distance a little over 1 inch above the auricle. A 8 
PEPPER, GRIFFITH, ANEURISMS OF AORTA. 
probe passed through the vein from above enters sometimes into the 
auricle, sometimes directly into the aneurismal sac. The oesophagus 
is tightly compressed by the aneurism, and the trachea is flattened in 
a lateral direction from the right side. The aneurism laid open shows 
within it and passing through it the thickened and compressed superior 
vena cava, and in the wall of the latter an irregular erosion f inch in 
length in a vertical direction, beginning about 2 inches above the aneu- 
rism, and involving one-half of the circumference of the vein. The edges 
of this opening are irregular but smooth, and unoccupied by coagula. 
A probe passed from the right auricle enters the aneurismal sac through 
the same opening. Just above the bifurcation of the trachea, at the 
point where this tube is flattened, there is an erosion of the cartilage, 
and possibly a small though not discoverable communication with the 
aneurism, since much blood is present in the trachea and bronchi. The 
recurrent laryngeal nerves are uninvolved. The lungs show extensive 
fibroid adhesions to the costal pleurae on both sides, especially at the 
bases. There is no pleural effusion. The bases of the lungs are collapsed. 
At the apex of the right lung there is a cavity the size of a marble. The 
kidneys are distinctly fibroid, and the capsule slightly adherent and thick- 
ened. The brain reveals nothing of importance. The azygos vein does not 
appear to be dilated. The opening of the vein into the vena cava lies 
above the commencement of the constriction, and cannot be discovered. 
An extended search through medical literature has brought to light 
only 28 cases of this lesion, including one (Case XVIII.) in which the PEPPER, GRIFFITH, ANEURISMS OF AORTA. 
9 
symptoms were quite typical, but in which recovery took place. With 
our own case the total number, therefore, equals 29. Brief abstracts of 
the salient features in the clinical histories of these cases are as follows: 
Case I.—Reported by Beevor. Lancet, 1832-33, i. 800, and ii. 63. 
Previous history: Not given. 
Symptoms following the rupture: Enormous turgidity and varicose condition 
of the veins over the chest, which inosculated freely with the epigastric veins, 
etc. (Edema of the head and upper extremities [and chest?]. Auscultation 
revealed the presence of an aneurism. Man very rapidly sank, and latterly 
had terrified notions about his situation, thinking he was among thieves, men 
of blood, murderers, etc. 
Duration of symptoms following rupture: Not stated. 
Autopsy: An aneurism of aorta, capable of holding a pint of fluid; had 
produced interstitial absorption of sternum. Vena cava quite impervious for 
| inch, beginning 1 inch above right auricle; and just above the obliteration 
was a rent in the coats, which led directly into the enlarged aorta beneath. 
The azygos greatly dilated ; entered cava just above the point of obstruction. 
At entrance of left subclavian [innominate?] was another and larger rent 
leading also into the aorta, and constituting a second communication between 
arterial and venous systems. Heart normal. 
This case is quoted by Peacock {Trans. Path. Soc. Lond., xix. 127) 
as identical with the following. They are, however, distinct, as the first, 
with autopsy, was reported March 5, 1833, while the second patient did 
not die until August 4, 1833. 
Case II.—Reported by Thurman. Mecl.-Chir. Trans., 1840, xxiii. 323. See 
also Lancet, 1832-33, ii. 666. 
Previous history: Coachman, aged forty-one ; intemperate ; much exposed 
to wet and cold. For a long time cough, dyspnoea, and palpitation. 
Symptoms following the rupture: For a few days pain in neck and shoulders, 
replaced by swelling and purple color of face, then, in a few days, of chest, 
especially on right side, and of right arm. Clusters of veins, almost varicose, 
over chest and back. Pulse 100, rather hard. Sense of weight and stiffness 
over shoulders. Dizziness, stupor, confusion of mind. Dulness on percussion, 
distinct impulse, and vibratory murmur under right clavicle and to right of 
upper part of sternum. Same murmur, not so loud, over right carotid and 
origin of aorta. Some crepitation over both sides chest behind, especially 
above. (Edema became extreme; spread to left arm, and slightly to ankles 
and scrotum some days before death. Cough worse; dyspnoea finally ex- 
treme; expectoration difficult and tinged with blood. Toward end delirium 
almost constant. 
Duration of symptoms following rupture: About 2 months. 
Autopsy: Heart large; ventricles dilated ; valves normal. A diffuse, true 
aneurism of ascending aorta, size of fist, commencing with pericardium and 
extending for 1£ inches above the valves, principally on right side. Vena 
cava behind aneurism; a round perforation } inch across and with smooth 
edges, J inch above entrance of azygos vein, opened into sac. Lungs crepitant. 
Pleural adhesions both sides. 
Case III.—Reported by Reid. Edinb. Med. and Surg. Journ., 1840, liii. 95. 
Specimen also studied by Thurman. Med.-Chir. Trans., 1840, xxiii. 
Previous history: Tinsmith, aged thirty-five; intemperate; long been sub- 
ject to palpitation. 
Symptoms following the rupture: After lifting heavy weight had uneasy sen- 
sation in chest as though something giving way. Soon oedema and lividity 
of upper part of body, and confusion of mind. When examined after three 10 
PEPPER, GRIFFITH, ANEURISMS OF AORTA. 
weeks showed great oedema and lividity of arms and chest, and especially 
of face and neck. Conjunctive injected. Much dyspnoea; some cough and 
difficulty of deglutition. Urine scanty. Heart’s impulse strong; apex de- 
pressed. Double bellows-murmur over cardiac and sternal regions, especially 
upper part of latter; the systolic portion more prolonged, the diastolic shorter 
and sharper. Extended dulness over heart and upper part of sternum. Later 
oedema increased, with slight swelling of scrotum. Orthopnoea; delirium ; 
died suddenly. 
Duration of symptoms following rupture: 4 weeks. 
Autopsy: Aorta at origin suddenly dilated, forming aneurism size of fist, 
limited to sinuses of Valsalva. Projected into anterior and left part of right 
auricle, and here it had termination of superior vena cava stretched over 
its outer surface. This portion of the auricle and the termination of cava 
communicated with sac by two oval openings with defined, rounded edges. 
Would barely receive tip of little finger. Cava pervious, but must have been 
compressed by the aneurism. Heart hypertrophied ; left ventricle dilated; 
valves healthy; pericardium universally adherent. About a quart of serum 
in each pleural cavity. Lungs compressed, small; contained considerable 
blood and frothy serum. 
Though this is really an instance of perforation into the right auricle, 
the superior cava was involved as well, and the case may, therefore, with 
propriety be included here, particularly as the symptoms were purely 
those of rupture into the cava. 
Case IV.—Reported by Young. Edinb. Med. and Surg. Journ., 1841, lv. 63. 
Previous history: Gentleman, aged fifty-six; temperate; well until attack 
of rheumatism. In a year another attack, and at same time loud, ringing 
cough lasting some weeks. 
Symptoms following the rupture: Some months later, without premonitory 
symptoms, suddenly taken at night with deep blackish-purple color and great 
swelling of face, neck, and chest as far as second rib. Veins of forehead and 
temples very prominent. Headache. No dyspnoea. Next day respiration 
rather difficult; great restlessness; headache persisted. Pulse small and com- 
pressible. Over middle of sternum an impulse stronger than that over heart. 
No thrill or murmur anywhere. Chest had become oedematous, which hin- 
dered percussion being employed. Dyspnoea became excessive, and great 
dysphagia developed; both apparently due to swelling in neck. Respiration 
bronchial in back, with rales. No further examination of heart, probably on 
account of excessive restlessness. Patient talked incoherently. Death. 
Duration of symptoms following rupture : About 2| days. 
Autopsy: Livid color almost entirely gone, and oedema much less. Peri- 
cardium adherent to sternum. Heart not hypertrophied; valves normal 
except aortic, which was thickened, and orifice dilated. Aneurism of 
ascending portion and of arch, holding 1J pounds. Vena cava stretched 
over sac and adherent to it; a perforation in vein over inch in length, 
with retracted, thin, and irregular edges, and situated at about the level of 
the entrance of azygos vein; opening into right wall of aneurismal sac. 
Case Y.—Reported by Law. Dublin Med. Journ., 1842, xxi. 433. 
Previous history: Man, aged forty-two; always well up to onset of the 
symptoms. 
Symptoms following the rupture: Took a morning walk, and, not feeling 
well, lay down ; face suddenly became swollen and dark purple. When seen 
next day, face, upper part body, hands and arms deeply livid; face, neck, 
upper part chest very much swollen. Suffusion and serous infiltration of eyes. 
Veins of neck hard and cord-like. Heart-sounds heard beyond ordinary 
limits, especially toward right subclavicular region; in other respects heart 
normal. Examination of lungs negative. Repeated examinations of heart PEPPER, GRIFFITH, ANEURISMS OF AORTA. 
11 
and lungs gave no other results. No pain; but distress, discomfort, oppres- 
sion. Very feeble pulse at wrists; strong in femorals. Subjective symptoms 
increased. Intellect became torpid, but no coma, and patient died suffering. 
Duration of symptoms following rupture: 6 days. 
Autopsy: Aneurism size of small orange from posterior and right side of 
ascending aorta. Beginning 1 inch above its entrance into heart, the walls 
of the vena cava were thickened for about 1 inch, and closely approximated 
by the pressure of aneurism. At this point was an unobstructed circular 
perforation about 2 lines in diameter opening into sac. Partial adhesion 
between opposite sides of vein. Aortic valves normal. 
Case VI.—Reported by Cossy. Archives Gen. de Med., 1845, ser. 4. 
t. ix. 33. 
Previous history: Woman, aged forty-five; began fourteen years before to 
have slight attacks of palpitation and oppression. These gradually increased 
in intensity and duration. Finally palpitations became painful, but did not 
interfere with her work. 
Symptoms following the rupture: Without further premonitory symptoms 
woke one morning with dizziness and some swelling, and violet color of face 
and right arm. Two hours later extreme dizziness, and consciousness lost 
for several minutes. By evening face and arms greatly swollen, the right 
more than the left. Swelling increased. Examination ten days later showed 
face, arms, and neck much swollen and intensely violet; right arm larger 
than left. Chest not affected. Giddiness ; sense of painful tension in head ; 
continual noise in right temple and ear. Numerous veins outlined on face ; 
none seen on arms. A distinct shaking of chest with heart’s impulse, but 
without heaving or thrill. Heart seemed enlarged. A very loud, long, 
widely diffused, rasping, systolic murmur heard with maximum intensity 
under sternal end of right clavicle. Here complete dulness on percussion, 
but no pulsation or thrill. Posteriorly murmur loudest in right infra-spinous 
fossa. Above internal half right clavicle a pronounced systolic pulsation 
and thrill extending into vessels (veins) of neck of this side only. Radial 
pulse feeble, narrow, synchronous on two sides. Dry cough; slight dyspnoea ; 
no rales. Dulness and feeble breathing behind on right side below. Later 
veins of forehead and the jugulars became a little more prominent. Sleepi- 
ness'and then coma developed. 
Duration of symptoms following rupture .-11 days. 
Autopsy : Brain very pale. Hydropericardium. Hydrothorax both sides. 
Heart hypertrophied; valves normal. An aneurism size of hen’s egg situated 
on convex portion of ascending aorta below origin of innominate. Vena 
cava on its posterior wall and adherent to it. A perforation 9 mm. high and 
5 mm. broad, situated 15 mm. below entrance of innominate vein, opened 
into aneurismal sac. Cava only 26 mm. wide here, but below, at entrance of 
azygos, was 55 mm. wide. Azygos not dilated. 
Case YII.—Reported by Mayne. Dublin Quart. Journ. Med. Sci., Novem- 
ber 1, 1853, 257. 
Previous history: Woman, aged fifty; laborious work. Well until forty- 
fourth year. Then dyspnoea, cough, and palpitation on going up stairs 
began. Had had since then several attacks of severe oppression, relieved 
by venesection. Symptoms grew worse, prevented regular work. Stooping 
especially bad, as it produced dyspnoea and swelling of eyelids, face, and 
hands. 
Symptoms following the rupture: While stooping suddenly felt as if 
strangled ; persistent, intense feeling of suffocation; giddiness; remarkable 
change in color of face; breathing greatly embarrassed; absolute ortho- 
pnoea. Examination next day showed deep plum color and great oedema of 
face, neck, shoulders, and upper part thorax. Veins enormously distended, 
and in many places varicose. Eyes seemed starting from head, and showed 
extensive sub-conjunctival oedema. Occasional short cough without expec- 
toration. Pulse jerking, like aortic regurgitation. Dulness on percussion 12 
PEPPER, GRIFFITH, ANEURISMS OF AORTA. 
bounded by left edge of sternum and line from sternal third of right clavicle to 
within 1 inch of nipple. A very strong heaving systolic impulse in second 
and third right intercostal spaces; vastly greater than at apex. Over impulse 
a very distinct thrill, and a remarkably loud, single, systolic, widely-diffused 
superficial bruit; maximum at second right costal cartilage; so loud that 
heart’s action could not be accurately explored. Respiratory murmur in- 
audible over upper part right chest in front. No rales anywhere. Purring 
tremor felt in right subclavian and internal jugular veins. None in left. 
Temporary improvement followed venesection ; then obstinate vomiting, 
stupor, drowsiness, delirium, convulsions, death. 
Duration of symptoms following rupture: 8 days. 
Autopsy: Congestion and cedema of parts supplied by superior cava. 
Right internal jugular nearly as large as small intestine. Serum in brain 
cavities. Lungs healthy ; their mucous membrane very vascular. Heart 
healthy. Aneurism of aorta in shape of enormous dilatation occupying 
entire arch and about 2 inches of descending portion. Right and left in- 
nominate veins and superior cava adherent to surface of sac. Left innomi- 
nate and cava considerably constricted where adherent; but below, from 
point of entrance of azygos, cava of normal size. Opening size and shape 
of shirt button-hole on right side of sac into vena cava; its edges sharp and 
irregular, as if recently made. 
Case VIII.—Reported by Goupil. Thbse de Paris, 1855, No. 50, vol. vi. 
Previous history: Cavalry officer, aged fifty-eight; always some shortness 
of breath, which had increased during last twelve years. Odema of lower 
extremities at times for several years. 
Symptoms following the rupture : After fit of anger lost consciousness. This 
followed by violent palpitation and excessive dyspnoea, with rapidly-increas- 
ing oedema, cyanosis, and dilatation of veins of upper part of body. At base 
and at right side sternum a soft, prolonged, systolic murmur, and a stronger 
and harsher diastolic murmur. Suffocative attacks, restlessness, headache, 
and attacks of fainting developed. Pulse rapid, small; heart’s action violent; 
death. 
Duration of symptoms following rupture : 1 month. 
Autopsy: Left ventricle hypertrophied. No disease of valves. Aorta 
atheromatous; became dilated immediately above the valves. An aneurism, 
size of hen’s egg, began 5 cm. above the valves, and, projecting backward 
and to right, pressed on right auricle, superior cava, right bronchus, and 
pulmonary artery. Vena cava compressed; and just below entrance of 
azygos vein an oval perforation into aneurism, 35 mm. in circumference, 
with irregular, red, eroded edges. The portion of vena cava below the 
entrance of azygos flattened and much smaller than above. Azygos vein 
dilated. Double hydrothorax. Lungs compressed. 
Case IX.—Reported by Tripier. Thlse de Paris, 1863, p. 63. Quoted by 
Peacock. Trans. Path. Soc., London, 1868, xix. 140. 
Previous history: Travelling merchant, aged fifty-five; temperate; always 
well except occasional dizziness. 
Symptoms following the rupture: Taken suddenly at night with vertigo and 
dyspnoea, followed by very marked swelling and lividity of head, neck, face, 
arms, and upper part trunk, with distention of veins. Nothing remarkable 
about respiration. Sounds of heart normal; but 3 cm. from right side 
sternum beneath clavicle was dulness, pulsation; soft, feeble systolic murmur. 
Pulse small and frequent. Great agitation, followed by delirium and lapsing 
into coma, with increased evidences of obstruction of venous circulation. 
Death. 
Duration of symptoms following rupture: 15 days. 
Autopsy: Aneurism, large as fist, egg-shaped, projected to right and pos- 
teriorly from aorta above the valves. Adherent to pulmonary artery and to 
vena cava. Vena cava, though flattened and contracted where in contact 
with aneurism, was permeable throughout, and again expanded below. A PEPPER, GRIFFITH, ANEURISMS OF AORTA. 
13 
perforation into aneurism of button-hole shape, 2 cm. long, situated 2£ cm. 
from commencement of vein. Its edges slightly broken, and very fine and 
close together. Fluid in pericardium. Slight hypertrophy of heart. No 
disease of valves. Great congestion of membranes and substance of brain. 
Case X.—Reported by Eastes. Med. Times and Gaz., 1864, i. 393. See 
also report by Gull. Lancet, 1864, i. 409. 
Previous history: Arsenal laborer, aged thirty-four; cough and dyspnoea 
more or less since Crimean war, and carrying load always caused cough and 
soreness across chest. 
Symptoms following the rupture: About five weeks before seen, face, neck, 
and right arm began to swell and grow purple ; left arm slightly so. Dys- 
pnoea much worse, especially on exertion. Examination showed great 
cyanosis and oedema of upper half of body; veins of thorax engorged ; 
cough severe, with frothy sputum. Decided dyspnoea; no dysphagia. 
Pulse small, regular, weaker on right side. Diastolic thrill over right side 
chest. A soft, whizzing, and very distinct murmur of venous character over 
aorta; diastolic at commencement of arch, but both diastolic and systolic, 
but chiefly the former, passing upward and over middle of arch. Maximum 
intensity at third right costal cartilage. The murmur had a continuous churn- 
ing sound, like that in enlarged vessels in thyroid gland. No sound in right 
side neck. Percussion normal. Coarse crepitation at bases, both lungs pos- 
teriorly ; bronchial breathing at right side in front. Dyspnoea, cough, and 
oedema increased. Erysipelatous inflammation set in. Death. 
Duration of symptoms f ollowing rupture : About 7 weeks. 
Autopsy: Aneurism, size of fist, on right and posterior wall ot ascending 
aorta; its mouth extending from 1 inch above valves to innominate. 
Superior cava lay in front of sac. At its back part, just above auricle, was a 
perforation into sac, size of lead-pencil and with smooth edges everted 
toward the vein and evidently not recent. Aorta atheromatous. Heart of 
natural size. Lungs crepitant; much mucus in the tubes. Fresh pleuritic 
adhesions between right lung and pericardium. Recent pericarditis with 
effusion. 
Case XI.—Reported by Gallard. L’ Union AIM., 1865, xxvii. 564. 
Previous history : Basket-maker, aged sixty; always well except for attacks 
of oppression with cough at times, terminated by abundant expectoration. 
Symptoms following the rupture : Suddenly in middle of night extreme diffi- 
culty in breathing and a violet coloration of face. When seen next day 
very marked cyanosis of face, neck, arms, and upper part of trunk, with 
some coldness and oedema. Cyanosis became intense. Injection and some 
chemosis of eyes. Subcutaneous veins swollen without pulsation. (Edema 
of entire upper half of body developed, alike on both sides. Dulness 
extendng under sternum to under right clavicle, and a vibratory tihrill over 
dulness. A widely-diffused systolic and diastolic murmur; its maximum 
intensity under right clavicle at the position of the dulness, where it was 
strong and rasping. Weak at apex ; heard under clavicles and in carotids ; 
heard down back. Its maximum intensity in back was at .right of fourth 
dorsal vertebra. Pulse same force in two radials. Voice a little rough ; 
respiration frequent, labored, a little noisy. No dysphagia. Next day un- 
conscious ; stertorous ; very great oedema; general coldness ; insensibility of 
skin and mucous membranes; feeble, rapid pulse; death. 
Duration of symptoms following rupture: About 2 days. 
Autopsy: Ascending and transverse portion of arch very much dilated. 
The ascending portion had sacculated aneurism. Vena cava compressed 
and adherent between aneurism and arch of aorta; so narrow that a uterine 
sound could hardly pass. Perforation into sac, size of a silver 20-centime 
piece, situated just below entrance of azygos vein. A clot contained in 
aneurism obstructed it and projected through it. Trunk of azygos slightly 
flattened, compressed by calcareous gland. Innominate and azygos veins 
voluminous and engorged. Aorta atheromatous. Nothing to note in heart. 14 
PEPPER, GRIFFITH, ANEURISMS OF AORTA. 
Case XII.—-Reported by Hayden. Dublin Quart. Journ. Med. Sci., 1866, 
xli. 434. 
Previous history: Mason, aged thirty-three; intemperate; always well; 
strained himself in lifting heavy stone, and felt acute pain in dorsal region 
and could not work for some days. Two weeks later felt sudden faintness 
and a weakness in limbs; passed off in few minutes. About this time seen 
at hospital, and slight hoarseness and cough noticed. 
Symptoms following the rupture: In three weeks more seen again, and pre- 
sented the symptoms of the lesion. Deep cyanosis and oedema of entire 
upper part of body down to diaphragm. Conjunctivas injected with dark 
venous blood. Especially face and neck deep purple. No thrill in veins of 
neck. Chest covered with tortuous veins in groups. Temperature of upper 
half body low, and man complained of chilliness in that part. Pulse small, 
regular, rapid. Cough and expectoration. Respiration 24. No dysphagia. 
Percussion less resonant to right of sternum from clavicle to nipple, and respira- 
tion feeble here and down to infra-spinous fossa behind. Elsewhere loud, 
with muco-crepitant rales. Prsecordial dulness increased ; impulse strong; 
no thrill; apex behind ensiform cartilage. Over base double murmur; the 
systolic coarse, loud, maximum intensity at junction of third right costal 
cartilage, with sternum, heard in carotids, diffused over chest, especially on 
right side, also heard in right infra-spinous fossa. The diastolic murmur con- 
fined to region of base, heard over lower portion of sternum ; replaces second 
sound. A feeble impulse and thrill felt at seat of maximum intensity of 
systolic murmur to right of sternum. Engorgement grew worse; some diffi- 
culty in swallowing; slight delirium, then drowsiness. Death quiet. 
Duration of symptoms following rupture: Over 10 days; not over 3 weeks; 
exact time uncertain. 
Autopsy: Lungs hypersemic, oedematous. Pericardium entirely adherent 
to heart. Heart and valves showed nothing of importance. Aneurism as 
large as apple of moderate size, with opening into it from aorta about J 
inch above valves. Compressed right branch of pulmonary artery, right 
bronchus, and vena cava. Vena cava pressed forward and outward by it; 
occluded from entrance into auricle up to £ inch below entrance of azygos 
vein. The opposite sides of intima of cava at its opening into auricle were 
partially adherent, probably congenitally, leaving one passage on each side; 
the one admitting a probe, the other the little finger. Three perforations 
existed from the sac into the cava; one the size of a three-penny piece, the 
others much smaller. Their edges were thin, jagged, and bordered by red 
areolse on the lining membrane of the vein. 
Case XIII.—Reported by Jacoby. Berlin. Jclin. Wochenschr., March 28, 
1870, 158. 
Previous history: Railway employee, draughtsman, always been well 
except heinidrosis of upper half body ; did not know whether of lower half 
of body as well. First symptom a hindrance of motion in neck and some 
swelling there. Next day same. 
Symptoms following the rupture: On this second day, as he leaned over his 
drawing, had sudden sense of being unwell; blueness and swelling of face 
and neck developing in course of two days. On third day intense blueness 
with oedema, and coldness of upper half body; sharp, zigzag color-line of 
demarcation at lower part of thorax ; sclerae dark bluish-red ; jugular veins 
prominent, very full. Sweat over whole upper part body. Radial pulses 
isochronous, small, compressible; left pulse much weaker than right. No 
dyspnoea at first, but sense of oppression. No pain. Percussion and aus- 
cultation of lungs normal. Heart’s impulse feeble. No pulsation or thrill 
in upper part chest. Loud buzzing murmur of greatest intensity at position 
for listening to aortic valves; loudest with systole, but continuous; and 
lasting, though not so loud, through diastole; widely diffused over chest. 
Not heard behind to left of vertebral column over the aorta. Not heard in 
femorals ; faint in carotids. Besides murmur, two normal sounds could be PEPPER, GRIFFITH, ANEURISMS OF AORTA. 
15 
heard at apex. (Edema increased; very little urine voided; dyspnoea de- 
veloped, then orthopnoea. Some roughness of voice. Very somnolent. 
Death with symptoms of slow carbonic dioxide poisoning. 
Duration of symptoms following rupture : 7 days. 
Autopsy : Cyanosis largely disappeared ; cutaneous ecchymoses both sides 
thorax; oedema persistent. Double hydrothorax. Nothing characteristic 
in lungs. Heart small; valves normal. Large saccular aneurism of ascend- 
ing aorta, 9 cm. broad in widest part. Lining of sac atheromatous, uneven, 
and with numerous small aneurismal dilatations in the wall, of size of pea 
to that of walnut. Aneurism evidently an old one. Vena cava, at about 
its entrance into auricle, narrowed to size of crow’s quill, and closely adhe- 
rent to one of the little aneurisms of the size of cherry; and a slit-like 
perforation 4 lines long with smooth edges opened into this. A colorless old 
clot projected through it from the sac, and thus still more narrowed lumen 
of cava. Shortly above this very narrow part cava resumed normal size. 
Bronchi, oesophagus, and trachea not compressed. 
Case XIV.—Reported by Farrington. Phila. Med. Times, January 3, 
1874, 216. 
Previous history: Woman, domestic, aged sixty-one ; moderate indulgence 
in alcohol; no venereal history ; rheumatism seventeen years before, other- 
wise always well. About a year previously small tumor appeared right side 
of chest near sternum. No cause known unless it was repeated straining 
in lifting clothes-baskets. In about two months sharp pain down arm to 
elbow; sometimes in chest in region of tumor. These pains persisted. Voice 
hoarse for eighteen months No cough ; no dyspnoea. 
Symptoms following the rupture: After great excitement there developed 
intense cyanosis and great dyspnoea. Extremities cold; pulse small, rapid, 
short, sharp; no difference between the two sides. Pulsating tumor with 
dulness and thrill, extending 3 inches to right of sternum from second to 
fourth rib. Also double murmur, with greatest intensity over this region, 
transmitted into vessels of neck; diastolic portion loudest. Systolic murmur 
at apex also. Lungs normal. Symptoms persisted with great restlessness and 
an attack of vomiting. 
Duration of symptoms following rupture: About 15 hours. 
Autopsy: Aneurism, size of apple, from junction of ascending and trans- 
verse portions of arch, projecting forward and to the right. Vena cava 
compressed by aneurism, and in the wall of the vein, at junction of innomi- 
nate veins, was a transverse slit, J inch in length, communicating with aneu- 
rism. Aorta showed chronic endarteritis. An aneurismal sac in descending 
aorta, pressing on upper lobe left lung. Heart not hypertrophied. Aortic 
valves thickened and slightly insufficient. 
Case XV.—Reported by Bonnarel. Thlse de Paris, 1875. 
Previous history: Coachman, aged fifty-six; intemperate; always well 
until eighteen months previously, when an attack of dyspnoea necessitated 
rest from work for a time. Since this occasion respiration been somewhat 
oppressed. 
Symptoms following the rupture: Without known cause dyspnoea greatly 
increased and cyanosis appeared. When seen after eight days exhibited 
orthopnoea; face, neck, upper extremities, and upper part trunk cyanosed, 
more on right than left side; small vessels distended, especially on nose and 
cheeks. Face and upper extremities [and thorax ?] oedematous. Nopedema 
of lower part trunk or lower limbs. No pain. Voice harsh. No venous 
pulsation in swollen jugular veins. Left radial pulse weaker than right. 
Apex-beat lower than normal; no thrill. A strong, not harsh, systolic, 
blowing sound heard with maximum intensity at inner part first right inter- 
costal space. Heard also over base ; also posteriorly along spine. Respira- 
tion scarcely audible on right side. On left side sibilant rales. Dyspnoea 
and cyanosis increased; death. 
Duration of symptoms following rupture : 16 days. 16 
PEPPER, GRIFFITH, ANEURISMS OF AORTA. 
Autopsy: Entire arch aorta, particularly ascending and transverse parts, 
enormously dilated ; 35 cm. its greatest diameter. Displaced vena cava and 
right phrenic nerve and the lungs somewhat, especially the left. Flattened 
right bronchus slightly. The dilated aorta presented several secondary 
aneurismal dilatations, one of them size of egg. Vena cava remarkably 
elongated ; its walls intimately adherent to those of aorta. A slit-like per- 
foration, 1 cm. long, opened into aorta about 13 cm. above the aortic valves. 
About 5 mm. above this was another perforation, round, 6 mm. in diameter, 
with ragged edges. Heart hypertrophied; valves normal. Some fluid in 
pleural cavities. 
Case XVI.—Reported by Schnaubert. Ejened. klin. Gaz., St. Petersburg, 
1881, i. 81, 105. 
Previous history: Butler; aged forty-two; moderate drinker; never syph- 
ilis ; fifteen years ago kicked in chest by horse, but soon recovered; three 
years ago asthma and palpitation, which soon disappeared. 
Symptoms following the rupture: After great exertion at nocturnal conflagra- 
tion had chill; then sense of heat in head, dysphagia, swelling of face and 
neck. Examination two days later showed head, neck, arms, and chest down 
to third rib bluish-red and considerably swollen. Veins distended, but not 
pulsating. Mucous membrane of mouth and throat purple and conjunctive 
injected. Some difficulty in swallowing. Vomited several times. Dulness 
on percussion, extending from middle of sternum to 3 cm. to right of its 
right edge and down to fourth rib. No pulsation in any part of chest. Loud, 
rasping, double murmur over area of dulness and over sternum ; less distinct 
posteriorly over centre of left scapula. Radial pulses equal. Respiration 
rather stertorous; 24 in the minute. Some somnolence. Noises in the ears. 
Temperature in the axilla 36° C. Later, cyanosis and oedema reached to 
lower ribs. Murmur was sometimes absent, sometimes only systolic or dias- 
tolic, sometimes double. Dulness extended somewhat. Hydrothorax devel- 
oped. (Edema reached to hips and penis. A slight pulsation at times felt 
in region of subclavicular dulness. Dyspnoea; hallucinations; increasing 
cyanosis ; delirium; death. 
Duration of symptoms following rupture: 5 weeks. 
Autopsy: Aneurism, size of hen’s egg, starting about 5 cm. above aortic 
valves and extending toward right. Compressed right branch of pulmonary 
artery and the vena cava. Was adherent to right lung. Vena cava greatly 
distended; but about 5 cm. above the heart much narrower, compressed by 
aneurism, and filled with thrombus. In centre of compressed portion was a 
circular perforation, J cm. in diameter, opening into sac. Compact, adherent 
thrombus in right jugular. Right auricle and ventricle distended. Lungs 
cedematous. Bloody mucus in bronchial tubes. Hemorrhagic erosions in 
stomach. 
Case XVII.—Reported by Halla. Zeitschr.f. Heilkunde, 1882, iii. 122. 
Previous history : Smith; aged sixty ; always healthy; severe work. 
Symptoms following the rupture: Suddenly, while lifting iron, developed 
cyanosis and oedema of upper half of body. Left arm swollen before the right. 
Jugular veins dilated; dense network of dilated veins on thorax; some 
dyspnoea; drowsiness ; more or less dysphagia. When seen after sixteen days 
exhibited extreme cyanosis and oedema of upper half of body, with irregu- 
lar line of demarcation in region of navel. Dense network of veins on chest. 
Eyes jfrominent. Some slight oedema of genitals and upper part thighs, and 
some dyspnoea and dysphagia. No tumor visible on chest. A diffuse, weak, 
systolic trembling without thrill felt from under right clavicle to right nipple; 
stronger than apex-beat. Very marked thrill on left side of neck, especially 
above left clavicle; weaker thrill on right side neck. A percussion-dulness 
extending about 3 fingers’ breadth from middle line toward sternal end right 
clavicle, and joining the cardiac dulness extending nearly to right nipple- 
line. A very loud, sharp, blowing, systolic murmur heard with greatest 
intensity over aortic cartilage, widely diffused, prolonged into diastole. Two PEPPER, GRIFFITH, ANEURISMS OF AORTA. 
17 
normal sounds at apex. Aortic and pulmonary second-sounds present. A 
very loud systolic murmur heard above and below left clavicle ; weaker mur- 
mur in carotids and under right clavicle, and in last position was louuest 
during expiration. Left pulse slightly smaller than right; both show influ- 
ence of respiration. Respiration anteriorly vesicular, weak on left side; 
posteriorly rough and broncho-vesicular except right upper part, where was 
vesicular. Tongue swollen ; voice hoarse; paralysis of right posterior crico- 
arytenoid, with oedema of larynx. Later, double hydrothorax; catarrhal 
and (edematous swelling of bronchial mucous membrane; increasing oedema, 
dilatation of veins, dyspnoea, dysphagia, and cyanosis; expectoration tinged 
with blood; chemosis of conjunctiva of right eye; increasing laryngeal 
oedema and stridor; oozing of serum from skin. Temperature had been sub- 
normal ; urine scanty, no albumin. Death after short sopor. 
Duration of symptoms following r upture : 30 days. 
Autopsy: Aneurism of aorta, larger than fist, beginning 3 cm. above valves 
and reaching to innominate artery, projecting to right; interior atheromatous. 
Contained several small dilatations. Vena cava behind and to right of 
aneurism; its whole length, except lower 2 cm., as well as about 3 cm. of 
left innominate vein adherent to sac. Cava compressed, the greatest nar- 
rowing being just below entrance of azygos vein. 1 cm. above azygos was 
a slit-like perforation, 7 mm. long, with smooth, rounded edges, opening into 
aorta. At this point cava began to widen again. 
Case XVIII.—Reported by Damaschino and Lavin. La France Medicate, 
1882, i. 805, 819. 
Previous history: House-painter; aged fifty; always healthy. Twenty-two 
years before had strained himself lifting; felt sense of oppression inchest 
for some hours, but always well since. 
/Symptoms following the rupture: Suddenly, after stooping and lifting weight 
of 150 pounds, his iriends noticed that his face was blue. No pain, oppres- 
sion, or palpitation. Cyanosis spread to whole of head in a few hours. 
By next morning, face, neck, and right arm swollen. By afternoon, left arm 
aiso, and he felt constriction in throat, and general feebleness. By evening, 
all upper part body exhibited venules, in five days a little roughness of 
voice, and veins of face, arms, trunk, including subcutaneous abdominal 
veins, commenced to develop. When seen six days after onset there was 
cyanosis of skin and mucous membrane, oedema of upper portion of body, 
distention of veins, and development of network of venules. Both arms very 
(jedematous, especially right. Upper part thorax slightly prominent, espe- 
cially right side. Apex-beat feeble in sixth interspace close to sternum. 
Cardiac dulness seemed enlarged, but oedema prevented accurate determina- 
tion. On right side a dulness from middle of clavicle to fourth interspace, 
extending about 3 fingers’ breadth to right beyond sternum. A thrill at 
upper part right side, reaching above clavicle. A centre of pulsation in third 
interspace at right edge of sternum and a second centre at apex, not so Avell 
marked. In second interspace to right of sternum a rough, systolic murmur 
and a blowing, diastolic murmur, the two being almost, but not quite, con- 
tinuous. 3j cm. below middle of right clavicle was a very intense and 
actually continuous murmur, with systolic reinforcement. It was remark- 
able, especially during the reinforcemeut, for the peculiar sonorous and 
vibratory character. It was transmitted with the same characters to the 
base of the neck and even to the lower part of the thorax posteriorly on the 
rignt side. It disappeared at the right border of the vertebral column, and 
here could be heard in contrast the double aortic murmur first described, 
with the same characters as heard at the centre for this murmur at the base. 
Rulse regular. A double murmur heard in femorals. Axillary temperature 
normal, though the patient complained of feeling cold. Lungs normal. 
Cough and some bloody expectoration. No palpitation or pain. Some ver- 
tigo and oppression on walking. Patient improved, and after being under 
ooservation nearly one month the oedema disappeared entirely from the face, 
arms, and neck, and almost from the trunk, and there was but very faint 18 
PEPPER, GRIFFITH, ANEURISMS OF AORTA. 
cyanosis when at rest, though it returned on quick motion. All the veins of 
trunk, upper extremities, and roots of thighs very greatly developed. 
Duration of symptoms following rupture: Patient left hospital practically 
well, in the condition described, with collateral circulation well established.' 
Case XIX.—Reported by Glasgow. St. Louis Cour. of Med., 1884, xi. 407, 
and 1885, xiii. 1. 
Previous history: Physician; aged fifty-seven; previous good health, ex- 
cept for several accidents. For some months, dyspnoea on unusual exertion. 
Symptoms following the rupture: On lifting a man he felt sudden rush of 
blood to upper part of body. Face and hands swollen and purplish. No 
dyspnoea or pain. Soon entire upper part body swollen, oedematous, and 
cyanosed. General enlargement of superficial veins, with spots of ecchymoses. 
Eyes half closed; pulse soft, full, jerking like that of aortic regurgitations. 
Dulness over sternum for 3 inches in breadth, and from second to fourth 
ribs. Strong heaving impulse here, with exquisite thrill, especially at right 
edge of sternum. Double murmur heard at aortic cartilage and transmitted 
over sternum and prsecordium; diastolic portion ended musically. Over 
rest of chest only single systolic murmur could be heard; this audible in 
larger arteries, even in brachial. Appreciable pulsation in liver, and disten- 
tion of large superficial veins of abdomen. A second examination, after 
somewhat over a month, showed remarkable improvement in everything 
except an increased percussion-dulness and occasional great swelling of legs. 
Soon after this great dyspnoea on exercise began to develop, hydrothorax 
and general oedema appeared, dulness of aneurism increased greatly, but 
impulse could only be felt in third interspace to left of sternum. Systolic 
bruit faint; respiration feeble. Finally, there was increasing oedema, greatest 
on left side face, neck, and chest; marked cyanosis and dyspnoea. Death. 
Duration of symptoms following rupture : 7 months. 
Autopsy: Lungs engorged; large amount of fluid in pleural cavities. 
Heart enlarged; right auricle enormously dilated; left ventricle hyper- 
trophied ; valves healthy. Globular aneurism, 4| inches in diameter, occupy- 
ing first portion of arch, extending to innominate artery. Compressed left 
innominate vein and pulmonary artery. Walls of aneurism atheromatous. 
A perforation, size of goose-quill, into vena cava situated at upper right side 
of sac; closed by a thick plate of laminated fibrin. Superior cava greatly 
dilated; the opening into aneurism immediately below entrance of innomi- 
nate veins. Azygos vein greatly enlarged. Inferior cava greatly distended. 
Case XX.—Reported by Wetterdal and Wallgren. Upsala Ldkarenforenings 
Forhandlingar, 1884-5, xx. 825. 
Previous history : Man ; aged thirty-four; always done hardest work with- 
out difficulty. Probably had had syphilis, but nut certain. Used alcohol to 
excess. 
Symptoms following the rupture: Suddenly, while putting forth violent 
exertion, had a chill; felt a sense as of something sticking in throat; gen- 
eral sense of soreness in thorax; headache. In half-hour blueness in face 
and hands, and dizziness. On reception into clinic that afternoon patient 
complained of dyspnoea and severe headache and dizziness on sitting up. 
Face, arms, and upper part trunk very cyanotic, with a well-defined line of 
demarcation at lower part thorax. The larger veins much swollen. Great 
oedema of the cyanotic portions, with distention of the veins. Cardiac dul- 
ness not enlarged. No abnormal dulness in chest, and no heart-murmurs or 
abnormal pulsation. No pulsation in jugular veins. Above right sterno- 
clavicular articulation and toward right external jugular vein was a booming 
sound with cardiac systole. Radial pulses isochronous. Dyspnoea, head- 
ache, and oedema rapidly increased. Ten hours after admission gave sudden 
cry and died. 
Duration of symptoms following rupture: Less than 24 hours. 
Autopsy : Sacculated, fist-sized aneurism of ascending aorta, closely adhe- 
rent to superior cava. In vena cava 4 cm. above heart was a perforation PEPPER, GRIFFITH, ANEURISMS OF AORTA. 
19 
into aneurism 7-8 mm. in diameter; its edges sharp, a little swollen, and 
inverted toward vein. Lungs cedematous. 
Case XXI.—Reported by Turner. Transactions Path. Soc. London, 1885, 
xxxvi. 148. 
Previous history: Man, aged forty. History of venereal disease; always 
hard work ; no sudden strain or assignable cause. 
Symptoms following the rupture : Disease began with dyspnoea. When seen 
after seven weeks there was dyspnoea; much swelling of upper parts; face 
dusky; superficial veins enlarged, especially over chest. Loud to and-iro 
bruit over aortic valve and apex; obscure pulsation over upper part sternum ; 
evidence of pressure on right bronchus; some huskiness of voice and contrac- 
tion of right pupil. Death from increasing pulmonary obstruction. 
Duration of symptoms following rupture: 23 weeks. 
Autopsy: The ascending aorta much elongated, with a large sacculated 
aneurism projecting toward the right. Probably was a dissectmg-aneurism 
originating in a transverse rupture of the vessel. Mouth of aneurism on con- 
vexity of vessel extending from f of an inch above free border of aortic 
curtains upward 2-3 inches. Sac had compressed, closed, and finally passed 
through the vena cava, completely separating its proximal and distal portions 
and projecting between them. Distal portion looked like a short arterial 
trunk given off from aneurism near its upper border. There was free passage 
of blood from sac into vein. Aorta quite atheromatous. Aortic valves cal- 
careous; orifice stenosed. Mitral valves thickened. End of trachea and right 
bronchus compressed by aneurism. [Right?] lung congested, cedematous, 
and adherent to chest-wall. Much effusion in left pleural cavity. [Proximal 
portion of vena cava probably’pervious, as it is not stated to the contrary.] 
Case XXII.—Reported by Shannon. Report of Surgeon-General of Army 
(U. S.), 1886, p. 101. 
Previous history: Sergeant. No history of previous trouble, except that for 
few days had had slight dizziness on stooping. 
Symptoms following the rupture: At once, alter great excitement, felt a terri- 
ble rushing of blood to head. Vision grew dim, strength failed, had to be 
assisted to room. Could talk. Face very blue and swollen ; ears especially 
cyanosed ; eyes protuberant, with bloody tears; varicose, greatly distended 
and pulsating jugulars. Respiration only a little accelerated and noisy; 
constant effort to clear nostrils; voice like one with bad cold in head. Neck 
swollen, finally extremely engorged. No blueness or swelling of arms. Vom- 
iting at times. Heart regular, normal. A murmur at second right costal 
cartilage with second sound; heard at first examination, but repeated aus- 
cultation afterward failed to find it again. Respiration somewhat bronchial 
and noisy. Pulse full, soft. No unconsciousness or paralysis at any time. 
Not even stupid until near end. Thirst constant. About two hours after 
first commencement had severe pain between scapulas lasting until death. 
Patient laydown; later effort to rise produced some dyspnoea. All symp- 
toms next increased in intensity. Finally, terrible attack laryngeal dyspnoea 
ended in death. 
Duration of symptoms following rupture: 6 hours. 
Autopsy: Cyanosis of face disappeared shortly after death. Lungs con- 
gested. Old adhesions of limited extent of pericardium to aorta. No pleural 
adhesions. A true aneurism of aorta extended from just above coronary 
arteries to innominate artery, where it became fusiform, and continued in 
transverse aorta to and including the opening of left subclavian artery. 
Aneurism 8 inches long on total convexity, 3 inches deep, 3£ inches wide, 
involved chiefly right upper posterior part of vessel. In posterior wall a 
small lacerated opening apparently recently torn, leading into distal portion 
of vena cava close to innominate veins. Proximal portion of vein obliterated 
in sac-wall, except J inch nearest to heart, which was patulous but narrowed. 
Left superior intercostal size of either innominate vein. No cedema of glottis 
found. Heart inJrmal. 20 
PEPPER, GRIFFITH, ANEURISMS OF AORTA. 
Case XXIII.—Reported by Christianu. Spitalul. Bucuresci., 1887, vii. 74. 
Previous history: Saloon-keeper, aged sixty-one; intemperate; never syph- 
ilitic; previously always well. For some time cough, which became worse 
two weeks before seen ; occurred in paroxysms which threatened suffocation ; 
of late accompanied by severe pain in chest and swelling of neck. Exami- 
nation showed some cyanosis and swelling of face, neck, thorax, and upper 
extremities. Swelling elastic rather than like oedema. Livid patches con- 
taining distended veinules. No murmurs; pulse strong, not accelerated. 
Respiration not accelerated; no dyspnoea. Dulness under right clavicle to 
third interspace and from middle line of sternum to 4-5 cm. to right of right 
sternal border. Some subcrepitant rales in lower part lungs. After three 
weeks somewhat improved and left hospital. 
Symptoms following the rupture : Returned in two days with symptoms much 
aggravated and with orthopnoea. In one week more systolic murmur present, 
best heard in the region of the aorta, and in three days more both systolic and 
diastolic murmur, best heard in right supra-spinous fossa. Tremor of chest- 
wall, with thrill in third and fourth interspaces in front. Cyanosis, oedema, 
and dyspnoea increased and became extreme. Eves projected and were 
bloody. Systolic murmur became so loud that could be heard on simply 
approaching ear to chest. Finally, restlessness, delirium, cyanosis of whole 
body, stertorous respiration, great oedema of nostrils, death by suffocation. 
Duration of symptoms following rupture: 16 to 18 days. 
Autopsy: Heart hypertrophied. Aorta and large vessels atheromatous. 
Aneurismal dilatation size of goose-egg from origin aorta up to transverse 
portion of arch. Vena cava adherent to sac, compressed, and a small perfora- 
tion 1 cm. in diameter, with irregular edges, connected the vein and the 
aneurism. Azygos vein much dilated. Lungs, liver, spleen, and kidneys 
congested. 
The exact time of the rupture in this case is not clear. If it occurred 
two weeks before the patient was first seen, the duration of the acute 
symptoms would be about seven and a half weeks. The fact that im- 
provement occurred, and especially the possession of irregular edges by 
the perforation, as though it had been recently formed, indicate that the 
rupture most probably took place at the time the great aggravation of 
symptoms with the development of orthopnoea occurred. 
Case XXIV.—Reported by Gulliver. Transac. Path. Soc. London, xxxviii. 
1887, 120. 
Previous history. ] [This was simply a card patho- 
Symptoms following the rupture. V logical specimen, unattended by 
JJuration of symptoms following rupture. J clinical notes.] 
Autopsy: Arch of aorta much dilated and diseased. At top of ascending 
portion was a circumscribed aneurismal dilatation which communicated with 
superior vena cava by a circular perforation size of goose-quill. Left internal 
jugular entirely closed by a clot, and the innominate at its termination had 
its lumen entirely obliterated by the pressure of the aneurism ; and its open- 
ing into the vena cava was quite invisible. Cava elongated, being stretched 
by the aneurism. 
Case XXV.—Reported by Arkle and Bradford. Brit. Med. Journ., 1888, 
ii. 1387; Transac. Clin. Soc. London, 1889, xxii. 69. 
Previous history: Shoemaker, aged sixty-one; never rheumatism or syph- 
ilis; winter-cough for last six years; always well in other respects. Twenty 
months previously began to have pain in right mammary region of a dull, 
aching character; also dyspnoea, worse on the least excitement. 
Symptoms following the rupture : About nine days before entering hospital 
seized with pain and swelling in neck. In a few days considerable swelling PEPPER, GRIFFITH, ANEURISMS OF AORTA. 
21 
of right arm. On admission was an almost black cyanosis of face, most 
marked on right side. Head and neck cedematous on right side, but little 
on left. Right arm greatly swollen and pitted. Chest slightly cedematous, 
especially on right side. Left side chest and left arm but little swollen. No 
cedema of lower portion of body. Some dilated veins along borders of ster- 
num, and a ring of them horizontally around base of thorax. Respiration 
labored, accelerated. Paroxysms of coughing in which cyanosis was much 
increased. Some impairment of resonance in right infra-clavicular region in 
second and third interspaces, reaching the edge of the sternum. Visible 
pulsation in these interspaces. Numerous bubbling rales over chest. A 
thrill over the dull area, and a loud murmur. This murmur peculiarly harsh, 
continuous; loudest in systole; gradually diminishing in diastole; audible 
all over right infra-clavicular region, but maximum intensity in second right 
interspace some 2 inches from sternum. Apex in sixth interspace outside 
nipple-line ; systolic murmur here not conducted into axilla. Aortic second- 
sound inaudible at base and apex. Cyanosis increased. Died suddenly. 
Duration of symptoms following rupture : About 10 days. 
Autopsy: A sacculated aneurism involved whole of ascending and greater 
part of transverse portion of arch; projected upward and to right; was flat- 
tened from before backward. Sac displaced right lung and reached surface 
of chest in second and third right interspaces. Superior vena cava lay 
behind aneurism and was compressed by it. About 1J inches from com- 
mencement of vein, just above spot where it passed through pericardium, 
was a perforation into aneurism ; diamond-shaped ; 1 inch in diameter, with 
distinctly rounded edges. No appearance of any recent tear or rupture of 
any kind. Aortic valves insufficient; other valves normal. 1J pints fluid in 
right pleural cavity, rather less in left. 
Case XXVI.—Reported by Kraus. Prag. med. Wochenschr., 1888, 119, 
130. 
Previous history: Revenue officer,aged fifty-two; sixteen months previously 
began to suffer from cardiac asthma, with dyspnoea and pain in region of 
heart and in left arm. In following month noticed that neck and region of 
chin were swollen, and felt as though mucous membrane of throat was 
swollen. Respiration was through all this decidedly, though varyingly in- 
terfered with, though the attacks of asthma were less prominent. Gradually 
veins of neck swelled, and cyanosis of face developed. Six weeks before 
symptoms of rupture appeared the chest became cedematous gnd exhibited 
bluish spots and distended veins. 
Symptoms following the rupture: Suddenly there occurred very severe attack 
of dyspnoea amounting to orthopnoea; palpitation of heart; praeeordial 
anxiety ; very deep cyanosis. Was brought on same day to hospital in this 
state. While under observation exhibited rapid, shallow, noiseless respira- 
tion, with attacks of dyspnoea; pulse small and rapid, but slower during 
asthmatic attacks, alike in both radials. On face, neck, and upper part 
thorax cyanosis, elastic oedema, and dilatation of veins. Eyes prominent. 
Noise in ears. Left arm cedematous, and later right arm also; hand and 
fingers not cyanotic. Lower half body not affected; no sharp line of de- 
marcation. An indistinct pulsation to right of sternum from second to fifth 
rib; no distinct dulness here; a thrill from third to fifth rib on right side, 
which later disappeared and then returned. Apex-beat could not be distinctly 
located. Rough, blowing, systolic murmur, with maximum intensity in 
second right intercostal space; rather widely diffused, and heard in carotids. 
Examination of lungs negative, except some dulness in lower portion with 
faint bronchial breathing here and a few rales. Cyanosis, oedema, and 
attacks of dyspnoea varied, but finally grew worse. (Edema of larynx; of 
genitals; and slightly of upper parts of thighs. Sopor; hallucinations; 
unconsciousness; death. 
Duration of symptoms following rupture : 40 days. 
Autopsy : About 2 quarts fluid in each pleural cavity. Lungs congested ; 
cedematous; lower portion atalectatic. Mitral and aortic valves a little 22 
PEPPER, GRIFFITH, ANEURISMS OF AORTA. 
thickened; lateral leaflets of latter adherent to each other. Dilatation of 
whole ascending aorta beginning a finger’s breadth above valves. 3 cm. 
above sinus of Valsalva of posterior leaflet was a secondary sacculated aneu- 
rism size of walnut; projecting from posterior and right side; in intimate 
contact with root of right lung, and displacing vena cava to right. Vena 
cava fused with sac and entirely obliterated for 4J cm. above heart; above 
this much dilated. About opposite entrance of greatly dilated azygos vein 
were two smooth-walled perforations from cava into sac; the one the size of 
a pea; the other that of a hemp-seed. 
The author believes that the rupture took place some time before the 
acute symptoms developed, and claims that the character of the per- 
foration shows this beyond doubt. Other cases which we have 
abstracted prove, however, that the smoothing of the edges of a per- 
foration takes place very rapidly, and that there is consequently no 
reason to believe that the rupture did not occur at the time at which 
the sudden increase of the symptoms would indicate. 
Case XXVII.—Reported by Sisley. Lancet, 1889, i. 1184. See also note 
by Ewart. Lancet, 1889, ii. 312. 
Previous history: Laborer, aged thirty-five; temperate; scar on penis; 
rock-fever at Gibraltar; no history of accident. For some mouths cough, 
but no shortness of breath. Eyelids were puffy and face somewhat swollen 
on returning from work in evenings. This condition only seen at night, and 
had always disappeared by morning. 
Symptoms following the rupture : On one occasion went to work, but, not 
feeling as well as usual, went into hospital for advice; though not considering 
himself seriously ill. Face and neck were deeply cyanosed; eyelids puffy 
and ears almost black. Arms slightly cyanosed ; rest of body natural color. 
No pain; no paralysis. Mental state clear, but was drowsy. Pulse full, 
regular. Respiration not noisy or accelerated. Double murmur over 
middle of sternum; nothing else abnormal on physical examination of chest. 
After venesection a venous pulse was observed in jugulars and cephalic veins. 
Face and arms became gradually more cyanosed; respiration difficult and 
noisy, with expiratory stertor. Became more drowsy, and finally comatose. 
Died about two hours after admission. 
Duration of symptoms following rupture : Less than 12 hours. 
Autopsy : Saccular aneurism f inch above posterior leaflet of aortic valve. 
Sac measured about 1J inches in transverse diameter, and 2 inches from above 
downward. Was in contact with vena cava and right auricle. Vena cava 
quite patulous. Immediately above its entrance into right auricle was an 
opening into aneurism. This of irregular form, a little smaller than a six- 
pence, and with ragged edges projecting slightly into vein. Aortic valves 
not thickened. Right ventricle slightly hypertrophied. Lungs congested. 
Case XXVIII.—Reported by Gairdner. Lancet, 1889, i. 1238. 
Previous history : Laborer, aged forty-four. For two years been conscious 
of slight degree of pulsation in neighborhood right sterno-clavicular region, 
which caused him no concern. 
Symptoms following the rupture : Experienced a sensation as of something 
giving away near heart. No pain, hut faintness and cold sweat lasting ten 
minutes; never recurred. Swelling of face and right arm followed, but had 
considerably diminished in degree when first seen after one week. At that 
time exhibited very marked cyanosis; general anasarcous swelling of upper 
half body; some dilatation of small superficial veins all over front, especially 
ia lower sternal region, extending thence to praecordial, right hypochondrial 
and right manubrial regions. Veins of hands distended, especially on left 
side. Very loud and characteristic murmur heard all over front of chest, 
but having mainly the distribution of aortic double murmur. The ventricular- PEPPER, GRIFFITH, ANEURISMS OF AORTA. 
23 
systolic element loudest at base, and diastolic element at least relatively 
loudest toward lower sternum. Some displacement of prsecordial dulness 
downward and toward the left. Another and distinctly abnormal dulness, 
easily demarcated from the pnecordial, occupied entire manubrium of 
sternum, and extended both to right and left; but its limits in former direc- 
tion were difficult to state, owing to anasarca. Appreciable, but not very 
definite, pulsation in jugular fossa. A faint tracheal quality in respiratory 
murmur, as heard at upper sternum. Pulse rapid, decidedly stronger in right 
wrist than in left; in latter not abnormal, but in former had character of 
unfilled arteries. Pupils normal. But little cough. No signs of laryngeal 
implication. Respiration without difficulty at first; finally stertorous, but 
was no dyspnoea. 
Duration of symptoms following rupture : 15 days. 
Autopsy: Transverse portion of arch of aorta generally dilated, but with 
two more localized aneurismal dilatations; one extending to right, other to 
left. The first of these compressed superior vena cava and was adherent to 
it, forming a round bulging into interior of vein, corresponding to middle 
and upper third of this vessel. On summit of bulging a rounded perfora- 
tion, I inch in diameter and If inches below origin of innominate vein. 
Ca.se XXfX.—Reported by Pepper and Griffith in this communication. 
A review of the salient features of these cases and of the one now 
reported shows that in many instances the diagnosis is easily possible 
during life, while in others it is perhaps impossible. A correct diagnosis 
was, in fact, made by Mayne and by Glasgow, in their respective cases 
(VII. and XIX.). Gull, in the case reported by Eastes (X.), recognized 
an abnormal intra-thoracic venous communication, perhaps with an 
aneurism; andGallard in his first case (XL), as well as in that reported 
by Bonnarel (XV.), diagnosed an aneurism of the aorta, and discussed 
the probability of there being a communication between it and the supe- 
rior vena cava. Damaschino and Lavin made, with apparent reason, 
the diagnosis of the affection in their case of recovery (XVIII.). 
The recognition of the presence of varicose aneurism of the aorta and 
superior vena cava may be based upon the following principal symptoms, 
deduced from a study of the different reported cases: 
1. Cyanosis, oedema, coldness, and distention of the veins of the upper 
part of the body, with other evidences of obstruction to the circulation of 
blood in the tributaries of the superior cava. These symptoms have been 
present to a greater or less degree in all the reported cases of which 
clinical histories are given, and their diagnostic indications are evident. 
Xo lesion could produce such a condition, with its peculiar localization, 
except some great obstruction to the course of the blood in the superior 
cava. The thorax, however, does not always share the lividity and 
oedema of the head and arms; this variation depending solely on the 
position of the perforation or of the compression. If, namely, the ob- 
struction in the cava is situated below the point of entrance of the azygos 
vein, the chest will share in the venous congestion ; if, on the other hand, 
the obstruction is above the azygos vein, the removal of blood from the 
chest-wall is not interfered with, and no oedema develops. In certain 24 
PEPPER, GRIFFITH, ANEURISMS OF AORTA. 
cases the reason for the absence of thoracic oedema is not entirely clear, 
and often depends on the lack in the published report of a sufficiently 
detailed statement regarding the exact position of the obstruction in the 
cava. When the thorax is involved, there is sometimes a sharp line of 
demarcation between the upper affected and the lower unaffected portion 
of the body, marked by the numerous small varicose veins around the 
lower part of the thorax. It has happened more than once that a 
patient has shown a greater degree of oedema on one side than on the 
other. This condition may be produced in several ways. For example, 
in the case of Arkle and Bradford’s (XXV.) a long-standing obliteration 
of the left innominate vein had allowed the establishment of the col- 
lateral circulation, so that the sudden rupture of the aneurism produced 
oedema almost limited to the right side. A similar unilateral oedema 
and cyanosis of the upper portion of the body would be produced by 
communication of an aneurism with the left innominate vein, as seen in 
the case reported by Chabond (Lyon Med., 1873, No. 26 ; Virchow-Hirsch 
Jahrsb., 1873, II., 147). Another case illustrating differences in the 
swelling of the two arms is that of Cossy’s (VI.). In this the opening 
into the aneurism from the vena cava was situated close to the bifurca- 
tion of the cava, in such a position that the blood-current was directed 
into the right innominate vein, producing consequently much greater 
swelling of the right arm. In some other instances the causes of the 
slight differences observed are not apparent. When death has very 
rapidly followed the rupture of the aneurism there may have been no time 
for oedema and lividity of the arms to develop. This was the condition 
in the case reported by Shannon (XXII.), in which only the face and 
neck gave evidence of the change. The onset of the symptoms in this 
instance was extremely sudden, and death occurred in six hours. 
The cyanosis is probably not due to the admixture of arterial and 
venous blood; otherwise we should see it well marked in cases of rup- 
ture of an aneurism into the pulmonary artery. It depends simply on 
obstruction from compression by the aneurism, and from the backward 
pressure of the arterial blood into the vein. In the patient of Cliristi- 
nu’s (XXIII.) the whole body finally became cyanosed. 
Slight oedema has in some instances been witnessed in parts of the 
lower portion of the body, though always secondary to that above. Thus, 
in Thurman’s patient (II.) there was slight oedema of the ankles and 
scrotum, and in Schnaubert’s (XVI.), Halla’s (XVII.), and Kraus’s 
(XXVI.). of the genitals, hips, and upper parts of the thighs. In the 
case of Glasgow’s (XIX.) there finally developed general oedema. 
GEdema of the lower portion of the body in these cases is due, according 
to Halla, to the overfilling of the inferior cava through the necessity 
which it is under of receiving a large part of .the blood belonging to the 
superior cava. This same passive congestion explains the scanty secre- PEPPER, GRIFFITH, ANEURISMS OF AORTA. 
25 
tion of urine which has been noted in a number of instances. In a 
considerable number of cases large amounts of fluid have been found in 
both pleural cavities, while in other instances there was none. The 
difference undoubtedly depends largely on whether or not the circula- 
tion in the azygos vein is interfered with. 
Besides the cyanosis and oedema, dyspnoea may be present, either 
from the outset or later in the disease. In our own case it was intense, 
as it was in a large number of others. In others, again, it was absent, 
or slight, or not referred to by the writer. Thus in Cossy’s patient (VI.) 
it was slight, and in Gairdner’s (XXVIII.) nearly absent, and it does 
not appear to have been well marked in the case of Hayden’s (XII.). 
It is not at all essential that dyspnoea be present, as it is in the event 
of rupture of an aneurism into the pulmonary artery. Its development 
depends on various factors, such as double hydrothorax with consequent 
compression of the lungs; oedematous swelling of the mucous membrane 
of the nose, pharynx, trachea, larynx, and bronchi; oedema of the lungs; 
pressure by the tumor on the respiratory tube; over-filling of and con- 
sequent irritation of the nerve-centres with venous blood. In Shannon’s 
case (XXII.) death was directly due to an attack of extreme laryngeal 
dyspnoea. 
Still other symptoms indicating venous obstruction may be seen. 
Cough is a frequent and natural attendant on the dyspnoea, and rales of 
various sorts are often heard. There was sometimes expectoration, and 
not infrequently it was tinged with blood, as, for example, in the case of 
Thurman’s (II.), Halla’s (XVII.), Schnaubert’s (XVI.), and of Damas- 
chino and Lavin’s (XVIII.). In our own case a considerable pulmo- 
nary hemorrhage took place, due, probably, to an erosion of the trachea 
by the aneurism. Thurman claims that the dyspnoea, cough, and other 
evidences of pulmonary congestion, witnessed during life or after death, 
are due to the circulation through the lungs of an admixture of arterial 
and venous blood, and the resulting irritation by it of the bronchial 
mucous membrane. 
In some cases there has been difficulty in swallowing, probably due 
either to pressure of the aneurism on the oesophagus, or, in other 
instances, no doubt, to the excessive distention of the tissues of the 
neck with serum. Bloody tears were seen in Shannon’s patient 
(XXII.), and blood oozed from the conjunctivse in our own case, and 
in that of Christianu’s (XXIII.). A not infrequent symptom as the end 
approaches is a marked tendency to sleepiness, and, finally, coma. In 
some cases delirium was present before the coma developed. Attacks 
of faintness have also been reported, as in the case of Goupil’s (VIII.). 
In a few instances (IV., IX., XIV., XXIII.) excessive restlessness 
was noted. Headache, too, is naturally present at times. In Kraus’s 
case (XXVI.), and in that of Schnaubert’s (XVI.), there was noise in 26 
PEPPER, GRIFFITH, ANEURISMS OF AORTA. 
the ears, and in Cossy’s patient (VI.) annoying and persistent noise in 
right temple and ear, a sense of painful tension in the head, and giddi- 
ness. Giddiness was observed in a number of other cases. Convulsions 
were uncommon, though they occurred shortly before death in Mayne’s 
patient (VII.). Pain in the chest was sometimes observed, and in some 
instances was among the first symptoms appearing. Coldness of the 
upper portion of the body is a very common symptom. The temperature- 
chart of our own patient is an illustration of this fact. 
2. The suddenness of onset of the symptoms. With the recognition of 
impeded return of blood through the superior cava the diagnosis is by no 
means made. Obstruction to the flow of blood in the cava from various 
other causes may, as already stated, produce the same symptoms. Still, 
the comparative suddenness of their development in cases of varicose 
aneurism constitutes a most valuable diagnostic sigu. This rapid de- 
velopment was seen in all the cases in which the mode of onset is 
reported. Sometimes it was exceedingly abrupt. For example, in the 
case of Shannon’s (XXII.) the symptoms were intense, and immediately 
followed a degree of excitement. Young’s (IV.), Tripier’s (IX.), and 
Gallard’s (XL) patients were suddenly taken during the night with 
very severe symptoms of the rupture. The patient of Law’s (V.) became 
cyanosed and swollen without any premonition while lying down after 
a morning walk. Cossy’s patient (VI.) woke in the morning with evi- 
dences of the rupture; Mayne’s (VII.) was stooping; Jacoby’s (XIII.) 
was leaning over his drawing; Farrington’s (XIV.) had just been 
brought from the clinic in a state of great excitement; Halla’s (XVII.) 
Damaschino and Lavin’s (XVIII.), and Glasgow's (XIX.), were lifting 
heavy weights; Wetterdal and Wallgren’s (XX.) was also putting forth 
violent exertion. In certain other cases no history of at least such a very 
sudden and alarming beginning is given, and sometimes it clearly was 
absent. Thus, in the case reported by Sisley (XXVII.), though the 
onset seemed to have been sudden, the patient was not aware of any 
great change in his condition. How long a time was actually required 
for the symptoms to develop in Eastes’s case (X.) is not stated, nor is it 
entirely clear in the cases of Christianu’s (XXIII.) and Kraus’s 
(XXVI.). In Thurman’s patient (II) several days seem to have been 
needed for the swelling and cyanosis of the face to become apparent, 
and the same is true of Arkle and Bradford’s patient (XXV.). In 
Hayden’s case (XII.) it is not stated that there was any sudden onset 
so far, at least, as known to the patient. In our own case it could 
not be ascertained with just what rapidity the symptoms arose, but it is 
certain that they were not long in developing. 
It is quite evident from a study of these cases that there is no instance 
reported in which there is an account of simply a very gradual increase PEPPER, GRIFFITH, ANEURISMS OF AORTA. 
27 
in the gravity of a previously existing condition. Only a few days at 
the most were necessary for the characteristic symptoms to appear. 
The rapid development of symptoms is not, however, absolutely pathog- 
nomic of rupture of an aneurism into the vena cava, although it renders 
the fact of its occurrence extremely probable; for, although simple com- 
pression of the cava is usually slow in its onset, the symptoms may ex- 
ceptionally make themselves known with comparative rapidity. A case is 
reported by Dujardin-Beaumetz (Gaz. Heb. de Med., 1879, 2 s., xvi. 
19-23,) in which extreme venous congestion was produced in the course 
of ten days, the cause being compression of the superior vena cava by an 
aneurism, and the development of a clot in the greatly dilated azygos 
vein, in which the collateral circulation had previously been carried on. 
He admits that he has been unable to find any other case recorded in 
which the symptoms came on so rapidly. There is an instance, however, 
reported by Duchek (Pray. Vierteljsch. f. Prak. Heilk., 1854, xli. Also 
Handb. spec. Path. u. Tlierap., 1862) in which rapid development of 
the symptoms of obstruction was probably due to the sudden produc- 
tion of a thrombus in the cava. The rapid formation of a dissecting- 
aneurism could also by compression quickly produce symptoms of 
venous obstruction. 
In many cases symptoms indicating a degree of obstruction had existed 
for months or years before the rupture took place. Sisley’s patient 
(XXVIL), for example, had had for some months swelling of the face, 
which came on after the day’s work; and in Mayne’s case (VII.) swell- 
ing of the eyelids, face, and hands, and dyspnoea, were produced by 
working. Gairdner’s patient (XXVIII.) had been conscious for two 
years of pulsation in the right side of the chest. In Kraus’s patient 
(XXVI.) there had been for sixteen months very evident and persistent 
oedema of the neck and throat, and later cyanosis as well. Dyspnoea, 
cough, and palpitation, and sometimes pain, had been noticed in a large 
number of cases. In Farrington’s patient (XIV.) there had been for a 
year a small tumor in the right chest, presumably an aneurism. In our 
own case the previous existence of dilated veins upon the thorax was the 
only indication of the earlier presence of the aneurism. The existence 
of such symptoms, followed by a rapid and great increase in their 
severity, or by the accession of new symptoms, would indicate that some 
great and sudden change had taken place in the condition of the tho- 
racic viscera—the most probable being, of course, the rupture of an 
aneurism. Many cases begin without previous symptoms. These would 
equally point'to some great change in the thoracic contents. 
3. Evidence from physical examination of the presence of a tumor in the 
thorax, and the probability that this is aneurismal. No reference is had 
here to the murmurs found, as these will be discussed separately. If 
the presence of an aneurism is confirmed in this way, in addition to the 28 
PEPPER, GRIFFITH, ANEURISMS OF AORTA. 
indications already described, the diagnosis of rupture into the superior 
cava becomes greatly strengthened. In our own case the physical 
signs discovered in the chest were for the most part inconstant and con- 
tradictory, owing to the interference presented by the great oedema of the 
thoracic walls. One symptom, however, was nearly always observed, 
viz.: a degree of dulness below the right clavicle and under the upper 
portion of the sternum. A review of the reported cases shows that a per- 
cussion-dulness, occupying this same region, was frequently present. Not 
uncommonly this centre of dulness exhibited a thrill, usually systolic 
in time, though in one case (Case X.) diastolic. Thrill could sometimes 
be felt elsewhere, also. Thus, in Mayne’s and Cossy’s cases (VII. and 
VI.) a purring tremor could be felt in the internal jugular and sub- 
clavian veins on the right side. A pulsation was present over the centre 
of dulness in many instances, but absent in more. Mavne (VII.) and 
Glasgow (XIX.) describe it as strong and heaving, and in most of the 
cases where it could be felt at all it was well marked, and oftener 
stronger than the cardiac impulse. In some cases, as in those of Hay- 
den’s (XII.), Turner’s (XXI.), Kraus’s (XXVI), and Schnaubert’s 
(XVI.), it was indistinct or feeble. In Farrington’s patient (XIV) 
there was a distinct pulsating tumor visible to the right of the ster- 
num from the second to the fourth rib. In our own case neither 
thrill nor pulsation could be felt. Mayne (VII.) and Glasgow (XIX.) 
describe the pulse as jerking, like that of aortic regurgitation, and 
consider it an additional proof that an aneurismal tumor is present. 
Gairdner (XXVIII.), also, refers to the pulse as that of unfilled 
arteries. In a number of instances it is reported as small and feeble, 
but there appears to have been nothing characteristic about it. It 
is sometimes stated to have been stronger in one wrist than in 
the other. Undoubtedly the difference has depended upon the vary- 
ing degree of oedema of the arms, or some such factor, since aneu- 
risms of the ascending portion of the arch would not produce this 
inequality. A venous pulse, as seen in the case of Cossy’s (VI.) and 
of Sisley’s (XXVII.), is a very valuable indication of the presence of a 
varicose aneurism. The existence in any case of such well-recognized 
symptoms of aneurism as dulness on percussion, thrill, and pulsation, 
together with the symptoms previously described, render the diagnosis 
very probable. 
There remains to consider the last of the evidences of varicose 
aneurism: 
4. The existence of a murmur characteristic of a communication between 
an artery and a vein. When this murmur is present the existence of a 
varicose aneurism becomes practically a certainty. Thurman first ex- 
plained the nature of this murmur as occurring in spontaneous varicose 
aneurisms of the aorta, and dwelt upon its diagnostic importance, though PEPPER, GRIFFITH, ANEURISMS OF AORTA. 
29 
it was not present in the case of aneurism of the aorta and superior vena 
cava reported by him (Case II. of this series, IV. of his own). Its 
extremely loud and distinct character is due to the small size of the 
opening. The chief feature of the murmur is that it is continuous, this 
being due to the fact that the passage of blood from the aorta into the 
cava is a continuous one. During the systole the pressure is at its height, 
and the sound is consequently loudest and highest pitched. During the 
diastole the current from the artery to the vein depends on the elasticity 
of the arterial system acting upon the contained blood. The murmur 
is, therefore, still audible, though continually growing fainter and lower 
pitched, until the next systolic intensification. A perfectly typical mur- 
mur of this nature was present in our own case. It was also observed 
in the cases of Eastes’s (X.), Jacoby’s (XIII.), Arkle and Bradford’s 
(XXV.), and Damaschino and Lavin’s (XVIII.). In the first it is 
described as a soft, whizzing, very distinct murmur of a venous charac- 
ter, both diastolic and systolic, with its maximum intensity at the third 
right costal cartilage. It constituted a continuous churning sound, like 
that heard in the enlarged vessels of a thyroid gland. In Jacoby’s case 
there wras a loud, continuous, buzzing murmur, loudest with the systole, 
and heard best at the second right costal cartilage. In the case reported 
by Arkle and Bradford the continuous murmur was peculiarly harsh, 
loudest in the systole, and heard under the right clavicle, though the 
maximum intensity was in the second right interspace about 2 inches 
from the sternum. Finally, the diagnosis made by Damaschino and 
Lavin depended largely on the perfectly continuous murmur, heard 
loudest 31 c.m. below the middle of the right clavicle. It was very 
intense, and had a systolic reinforcement, and was remarkable, especially 
during the systole, tor its peculiar sonorous and vibrating character. 
A continuous murmur would seem almost necessarily to owe its exist- 
ence to a varicose aneurism. Neither a simple aneurism nor any 
iorm of valvular disease could produce the continuous sound, since there 
would need be a short interval between the systolic and diastolic por- 
tion. In our own case the peculiar continuousness of the murmur was 
noted, as well as the fact that its quality was distinctly venous. The 
etibrt was made to explain it on the ground that there existed an aneurism 
of the aorta pressing upon the cava and producing a murmur in it; and 
that during the cardiac systole the aneurism expanded and the pressure 
became greater. Consequently, the pitch of the murmur was elevated, 
since the lumen of the vein was made more narrow. This explanation 
was, we admit, fanciful, and, as the event showed, faulty. In fact, it 
was impossible that it could have been correct, since the increased 
pressure during systole would have diminished the intensity of the mur- 
mur, even though it elevated the pitch. That the peculiar continuous 30 
PEPPER, GRIFFITH, ANEURISMS OF AORTA. 
murmur is pathognomonic of a varicose aneurism was recognized and 
maintained by Thurman. Mayne and Cossy equally urge its diagnostic 
value, though showing by their own cases that the symptom is not an 
essential one. In each the murmur was systolic only, which the writers 
explain on the ground that the very marked disease existing in the arte- 
rial walls interfered with the arterial contraction during the cardiac 
diastole, and in this way produced the absence of the diastolic part of 
the murmur. In fact, in several other cases (VI., VII., IX., XV., 
XVII., XXVI., and probably II.), only a systolic murmur could be 
heard, and in still more (III., VIII., XL, XII., XIV., XVI., XIX., 
XXI., XXIII.), there was a distinctly double murmur, with an interval 
between the two parts. It is therefore evident that the continuous 
murmur is not an essential symptom of varicose aneurism, though such 
a valuable sign when present. The maximum intensity of the murmur, 
of whatever nature, was nearly always on the front of the chest, in the 
neighborhood of the first portion of the arch of the aorta, or over the 
abnormal centre of dulness. The only exception was the case of Chris- 
tianu’s (XXI1L), in which the maximum intensity of the double mur- 
mur was situated in the right supra-spinous fossa. 
The method of the production of these different murmurs in the differ- 
ent cases is not at all clear. Sometimes they may have been due to the 
passage of blood through the perforation, audible only during a portion of 
the cycle; at other times they may have been produced in the aneurism 
or in diseased aortic valves. It is a noteworthy fact that in certain in- 
stances the signs of aneurism were very meagre. In the cases, namely, 
of Young’s (IV.), Law’s (V.), Wetterdal and YVallgren’s (XX.), and 
Sisley’s (XXVII.), there was neither thrill, dulness, nor murmur dis- 
covered, and in the last three no pulsation. Shannon’s patient (XXII.) 
exhibited a diastolic murmur at the first examination, but after this 
no physical signs of aneurism couid be found. In the case reported 
by Beevor (I.) no description of the physical examination of the chest 
is given, and that reported by Gulliver (XXIV.) was only a card 
pathological specimen, unaccompanied by clinical detai s. 
Autopsy.—Little need be said under this heading since the most 
important character—the perforation—was, of course, present without 
exception. The shape of the perforation in the different cases was slit- 
like or more circular ; its size never very great—half-inch or so in length 
or in diameter—and sometimes quite small. In some cases the edges 
were irregular and ragged, but oftener. they were to a certain degree 
smooth, showing that in a comparatively short time after the rupture 
this smoothing can take place. In Glasgow’s case (XIX.) the perfora- 
tion was found closed by a thick plate of laminated fibrin. A fact 
worthy of note is that in nearly all the cases it is directly stated that 
compression of the cava existed as well as perforation. In Turner's case PEPPER, GRIFFITH, ANEURISMS OF AORTA. 
31 
(XXI.) the cava was completely divided by the aneurism, so that the 
distal portion looked like a short arterial trunk given off from the aneu- 
rism at its upper border. In our own case the production of this sepa- 
ration was well under way when the patient died. In Reid’s case (III.) 
the perforation involved also the upper part of the right auricle, at the 
position of entrance of the superior cava. Another most important 
feature bearing on the production of murmur in aneurism in general is, 
that in only 5 cases (IV., XIV., XXL, XXV., XXVI.) is disease of 
the aortic valves described. 
Diagnosis.—Enough has been said about the characteristic symptoms. 
There is no condition with which the disease could be confounded except 
that of remarkably sudden obstruction of some other nature to the 
passage of blood in the vena cava, and such cases are almost hypotheti- 
cal. From other varicose aneurisms of the aorta the diagnosis is easy. 
Rupture of an aneurism into the right ventricle or right auricle would 
produce general cyanosis and oedema. Rupture into the pulmonary 
artery could not produce the characteristic localization of oedema and 
cyanosis. The murmur would be heard at the left edge of the sternum 
instead of at the right edge. The dyspnoea would probably be intense, 
and symptoms of engorgement of the lungs would eventually be fol- 
lowed by general anasarca, as in mitral disease. 
Prognosis.—As the reported cases show, the prognosis is most unfavor- 
able. Death has supervened in every case but one. In Shannon’s 
patient (XXII.) only 6 hours elapsed before the fatal issue; in the case 
of Farrington’s (XIV.) 13-15 hours; in that of Wetterdal and Wallgren’s 
(XX.) less than 24 hours; and in that of Sisley’s (XXVII.) less than 
12 hours. On the‘other hand, patients may live days, weeks, or even 
months. Our patient lived 7 weeks; that of Kraus’s (XXVI.) 40 
days; that of Thurman’s (II.) 2 months; that of Turner’s (XXL) 23 
weeks ; that of Glasgow’s (XIX.) 7 months. In this last case the patient, 
after one month, seemed about to recover; then grew worse, and died. 
The patient of Damaschino and Lavin’s (XVIII.) was living and prac- 
tically well at the time the report was published. Although the murmur 
remained the same, collateral venous circulation had become estab- 
lished about one month after the onset of the symptoms, and oedema 
and cyanosis had about disappeared. The permanent recovery in this 
case, and the temporary improvement in Glasgow’s case, indicate that 
the disease is not necessarily fatal, though the favorable chances are 
very slight. 
Treatment.—This has proved useless. Venesection is the method 
which has been most frequently employed, but never with permanent 
benefit. Cupping, wet or dry, and free purgation may be employed. The 
strength should be sustained as far as possible, in the hope that the col- 
lateral circulation may become established, if the perforation be not too 
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