Extracted from the 
TRANSACTIONS OF THE COLLEGE OF PHYSICIANS OF 
PHILADELPHIA, 
THIRD SERIES, VOLUME VIII. REPORT OF A CASE OF OCCLUSION OF THE VENA 
CAVA SUPERIOR, AND OF A CASE OF 
HEART TUMOR. 
By / 
ARTHUR V. MEIGS, M.D., 
PHYSICIAN TO THE PENNSYLVANIA HOSPITAL 
[Read December 3, 1884.] 
A man seventy-two years of age was admitted into the 
ward of the Pennsylvania Hospital Sept. 18, 1888, and 
gave the following history : For thirty five years he worked 
as an iron-moulder, but during the past year he has been 
gaining his living as a peddler. He was always very strong 
and well until during the last two years, when he has had 
some pain in the lumbar region which has increased in the 
last three weeks, and during that time he has not slept well. 
The day of his admission he was standing by the edge of the 
river looking at some object upon the water, when suddenly 
and for the first time in his life he was seized with vertigo, 
and fell into the water. When brought to the hospital the 
following was noticed as to his appearance and condition : 
He is tall andsgpare, having lost much flesh in the last few 
years, and stoops moderately. The skin is slightly yellow 
and the tongue furred. The radial arteries are markedly 
stiffened. The veins on the right side of the abdomen and 
chest are enlarged, the largest being half an inch in diameter ; 
those upon the left are comparatively slightly enlarged. 
Prominent veins extend also toward the right axilla. He 
cannot say how long these veins have been enlarged, as he 
never gave them any thought, but is sure that they were not 14 
always so. Examination of the heart reveals a murmur 
which precedes the impulse and the carotid beat. There is 
slight visible impulse in the epigastrium. At the base of 
the heart, the sounds are almost inaudible, but they can 
be heard beneath the sternum; no accentuation of the second 
sound can be distinguished at the base, although at the apex 
the second sound is loudly accentuated. The hepatic dill- 
ness in the nipple line begins at the sixth rib, and extends 
slightly below the costal arch. The radial pulse is irritable, 
but the beat is not increased when the arm is elevated. 
September 21. It was noted, the cardiac impulse is in the 
fifth interspace two inches to the left of the sternum and is 
rather feeble; there is somewhat more forcible impulse 
beneath the lower end of the sternum and some visible 
throbbing of the abdominal aorta. Percussion one inch to 
the left of the sternum shows the cardiac dulness to begin 
in the third interspace, and there is flatness at the fourth 
rib level. Transverse percussion at the fourth rib level 
shows dulness, beginning at midsternum and extending 
to the left about four inches. There is distinct impulse 
in the second interspace to the left of the sternum, and this 
appears to precede the apex impulse; there is also impulse 
in the second right interspace, which also precedes the apex 
beat. There is dulness on percussion in the first interspace 
to the right of the sternum and in the third interspace. The 
percussion resonance at the corresponding areas on the left 
side is natural. There seems to be impaired resonance upon 
percussion over the upper part of the sternum. The presysto- 
tic murmur at the apex is distinct. At the pulmonary area 
the sounds are very faint but distinct, and the same is the 
case at the aortic area. At the ensiform cartilage both 
sounds are distinct, but the first is rather thumping, and is 
accompanied by a faint blowing murmur which is synchro- 
nous with the beat of the carotid artery. There is no undue 
pulsation of the arteries of the neck, and the veins are full, 
but do not pulsate. There is a systolic murmur audible in 
the carotids which is increased by pressure ; this is also dis- 
MEIGS, OCCLUSION OF THE VENA CAVA SUPERIOR. 
15 
11net in the subclavians. There is marked systolic murmur 
in the femorals and in the abdominal aorta as low down as 
the umbilicus. Lung examination shows slightly impaired 
percussion resonance at the right apex, while the note is full 
at the left. The respiratory sounds are slightly more feeble 
at the right than at the left apex. Posteriorly the percus- 
sion note is short, but not markedly dull. The respiratory 
sounds are unusually feeble. 
23c/. The radial pulse is delayed. Pressure upon the en- 
larged veins at the lower third of the sternum causes the 
portion of them below the spot pressed upon to become less 
prominent and full, and produces a sensation of fulness over 
the eyes. The veins in the right iliac region tend to be 
enlarged. 
28th. When the patient is in the erect position, the veins 
on the left side of the chest between the nipple and the 
sternum are enlarged. The collection of veins is somewhat 
cone-shaped, and extends from the umbilicus to the ensiform 
cartilage, the base being at the umbilicus, which it partly 
surrounds. The veins going toward the axillae and those 
upon the upper part of the sternum are also enlarged. 
Measurement of the chest on a level with the nipple shows 
a circumference of thirty-three and five-eighths inches. 
During ordinary quiet breathing the chest expansion is only 
one-eighth of an inch, and the extreme expansion on forced 
inspiration is only one inch. Percussion gives a sound 
almost dull over both lungs anteriorly and over the upper part 
of the left lung posteriorly ; over the lower portions the note 
is fuller, but still very short. Anteriorly the respiratory 
murmur is exceedingly feeble on both sides, almost wanting 
on the left. Posteriorly the respiratory sounds are very 
feeble, more so above than below. The treatment consisted 
at various times of iron, iodide of potassium, and strychnia. 
During the whole time that he was in the hospital he com- 
plained bitterly of vertigo, and finally became very much 
disheartened, and on the morning of December 12th cut his 
throat, severing the left external jugular vein. After he 16 
MEIGS, 
had lost a great deal of blood, the vein was ligated and he 
lingered until December 20th, when he died. 
The clinical history was taken by Dr. Charles Baum, and I 
am indebted to Dr. Da Costa for the opportunity of continuing 
the history of the case after I gave up the charge of the ward. 
The post-mortem examination was made and the note of it 
furnished by my colleague Dr. Longstreth, who is patholo- 
gist to the hospital. It was the Resident Physician, Dr. W. 
J. Taylor, who first drew attention to the facts that pressure 
upon the enlarged external veins caused a sensation of fulness 
in the head and suffusion of the eyes, and that the blood 
current was downwards in these veins, and it was from these 
symptoms principally that I was enabled to make the diag- 
nosis. 
Fig. 1. OCCLUSION OF THE VENA CAVA SUPERIOR. 
17 
Autopsy.—The first step in the examination was to inject 
the venous system. An opening was made on the right side 
of the neck, and the large vein was raised up in the middle 
cervical portion. The injection-matter used was gelatine 
colored with carmine. The mass flowed with comparative 
ease, and was very soon seen flowing and distending the 
superficial enlarged venous branches over the front of the 
thorax, at its lateral parts, and at and around the umbilicus. 
Allowing time for the warm mass to harden, the exami- 
nation was continued by dividing the ribs and clavicles in 
the line of the nipples, and separating the whole mass of the 
anterior abdominal muscles from the skin. Raising up this 
anterior mask of the thorax and abdomen, the abdominal 
aorta and the inferior vena cava were dissected free; the 
stomach, liver,and diaphragm were freed from their posterior 
attachments. In the neck, all the vessels and muscles, 
together with the trachea and oesophagus, were raised up. 
In the thorax the conjoined organs were cut free from the 
vertebrae. Thus, the whole mass of organs from the thorax 
and abdomen were removed en bloc, and their dissection was 
proceeded with from the posterior aspect. 
In the left pleural cavity, placed superficially just beneath 
the membrane, was seen a large venous trunk about one-half 
an inch in diameter, situated on the bodies of vertebrae and 
extending from the arch of the aorta to the attachment of 
the diaphragm below. This vessel was the left azygos ; it 
was on the left side of the aorta. In dividing the tissue of 
the posterior mediastinum, the veins of communication 
between the spinal and intercostal vessels were found unusu- 
ally large, from £ to J inch in diameter, and were thus in 
condition to carry a large amount of blood from the upper 
part of the trunk and the head downwards to be emptied 
into the abdominal vena cava. On removing the organs, the 
injecting material was found to have filled the veins to the 
arms and neck on each side, the spinal and intercostal vessels 
in the thoracic portion, numerous large veins in the dia- 18 
MEIGS, 
phragm, converging directly towards the inferior vena cava, 
and also the abdominal portion of that vessel. 
In dissecting the neck, numerous large veins (several one- 
quarter inch in diameter), were found passing behind the tra- 
chea, and they served as a communication from the right to 
the left side. They commenced at about the level of theepi- 
sternal notch and descended into the thorax passing towards 
the left, and terminated in the beginning portion of the left 
innominate or transverse vein. The left innominate vein at 
this part was very much enlarged, and as the vessel advanced 
towards the right side to join the vena cava, it was found to 
be converted into a flattened fibrous cord, and this portion 
was pretty tightly adherent to the surrounding tissues and 
the branches from the arch of the aorta lying in contact 
with it. 
A probe passed downwards within the right jugular was 
stopped by an obstruction at a point where the right innomi- 
nate vein joined the fibrous cord in which the left innomi- 
nate terminated. From the posterior wall of the right 
innominate, the probe entered the mouth of a moderate sized 
vessel which passed downwards into the thorax; its termi- 
nation and communications could not be traced; it was 
supposed to communicate with the right azygos vein, but 
this vessel could not be found. 
On removing the heart the pericardium was found normal. 
The heart was large ; its weight was not taken, as a consider- 
able portion of its auricles were left in connection with the 
specimen. Both the right and left ventricular walls were 
thicker than normal. 
The mitral orifice was narrowed at its auricular aspect, but 
its outlet in the ventricle was of normal size. The anterior 
segment was rendered rigid by the deposit in it of calcareous 
matter. This deposit extended from near the free border, 
centrally through the leaflet, and terminated within one of 
the cusps of the aortic valve. The mitral orifice was thus 
not only partially obstructed, but the auricular aspect of the 
leaflet was roughened by the calcareous nodular deposit. OCCLUSION OF THE VENA CAVA SUPERIOR. 
19 
The aortic cusps were all three materially affected ; one 
was rendered rigid through one-half its depth by the cal- 
careous deposit extending from the mitral valve, another 
cusp showed a slightly projecting ridge of deposit on its 
ventricular aspect along the line of junction with the oppos- 
ing cusp, of firmly organized fibrous material, while the 
third cusp was thickened, less pliable than normal, but 
smooth. 
The other orifices and valves showed nothing especial to 
note. 
The opening of the inferior vena cava appeared larger 
than normal, perhaps half as large again. The opening of 
the superior vena cava was found obliterated. A very fine 
probe could be forced in about an inch, by tearing tissues at 
the normal site of the cava. It was found, therefore, that 
the obstruction existing above in the innominate vessels was 
complete and extended to the auricle. 
The aorta and its principal branches were very much dis- 
eased. Commencing at the aortic orifice, the whole vessel 
was somewhat dilated, though not aneurismal, and this con- 
dition extended to the abdominal portion. Its walls were 
thicker than normal and very rigid. In most parts of the 
tube atheromatous changes with calcareous degeneration had 
taken place, so that in squeezing the vessel between the 
fingers, the calcareous deposits cracked under the pressure 
with a gritty sound. 
The cause of the compression and final obliteration of the 
calibre of the superior vena cava with its branches seemed 
to be due to the rigidity of the aorta together with conden- 
sation of the surrounding connective tissues, probably of 
inflammatory origin. All the connective tissue around the 
arch of the aorta and first portion of its principal branches 
was increased in amount and very dense, and firmly adherent 
to the under surface of the sternum as well as posteriorly to 
the bodies of the vertebrae. It was in this tissue that the 
obliterated venous trunks were found, and to which the 20 
MEIGS, 
tissue adhered so firmly that it was difficult to separate the 
two in dissection. 
The venous blood from the head, upper extremities, etc., 
found its way to the heart by means of the greatly enlarged 
veins lying on and around the spinal column posteriorly, 
particularly the left azygos, as well as anteriorly through 
the enlarged internal mammary vessels, and the superficial 
thoracic and abdominal branches. Most of the blood evi- 
dently came downwards to the level of the diaphragm and 
thence found its way directly into the inferior vena cava. 
Other portions of the blood descended from the superficial 
portions of the thorax into the abdominal vessels and thence 
by the lumbar branches to the abdominal vena cava. 
Fig. 2. 
Rough diagram showing collateral circulation. 
The examination of the brain showed a notable fulness of 
the vessels of both the external and the internal membranes. OCCLUSION OP THE VENA CAVA SUPERIOR. 
21 
Small patches of opacity were found on the arachnoid in 
some places, along the line of the sulci over the convexity. 
Some of the convolutions showed in places slight degrees of 
atrophy, and the furrows between them were widened, and 
at these parts there had accumulated a small amount of clear 
subarachnoid fluid. 
The brain substance showed no especial alterations. The 
vessels of the circle of Willis presented themselves as India- 
rubber-like tubes, patulous and rigidly elastic. Ho calca- 
reous degeneration of their tunics was found. The same 
conditions were visible in the beginning portions of the 
principal branches leading from the circle. 
This case was a rare one, and of more than usual 
interest for several reasons. In the first place, there 
were unusual opportunities for studying the condi- 
tions, both ante and post mortem, and the physical 
signs were such that the diagnosis was made during 
life. The enlargement of the veins of the surface led 
to the suspicion that one of the cavse was occluded, 
and it was decided that it must be the cava superior, 
because when the large external veins were emptied 
for the space of an inch or two with two fingers, the 
blood evidently flowed much more rapidly and forci- 
bly downward when the finger nearest the head was 
first removed than it did upward when the lower 
finger was first removed, and this was the case as 
much when the patient lay in bed as when he stood, 
thus showing that the current in the enlarged exter- 
nal veins was downwards. Further reason for think- 
ing that the return circulation from the head found 
its way back to the heart partly by the external veins, 
was that if they were compressed there was at once pro- 
duced visible congestion of the veins of the face and 
suffusion of the eyes and a sensation of fulness in the 22 
MEIGS, 
head. The presystolic murmur in the heart was very 
marked and unmistakable, and at all times present 
while the patient was under observation, and abun- 
dant cause for its presence was found in the calca- 
reous deposit with stiffening and roughness of the 
anterior flap of the mitral valve. The systolic mur- 
mur at the base of the heart and in the arteries was 
caused by the stiffening and roughness of the aortic 
valve flaps and of the thoracic and abdominal aorta. 
It was suspected during life that the arteries of the 
brain would be found to be stiff, and this was the case; 
still it is very likely that the vertigo with which the 
man suffered, and of which he complained more than 
of any other symptom, may have been partly due to 
the obstruction to the return circulation from the 
brain caused by the blood having to find its way 
through much smaller and more tortuous routes than 
the natural ones, and this view would seem to receive 
further confirmation from the fact that there was 
found some flattening and shrinking of the brain con- 
volutions. The cause of the dulness on percussion 
over the upper part of the right side of the chest 
anteriorly and the upper part of the sternum, which 
was so distinctly made out, was not understood dur- 
ing life, but the post mortem showed abundant cause 
for it in the very great amount of hard fibrous tissue 
around the ascending aorta and veins in that region, 
and here apparently was the seat of origin of the 
whole pathological process. It seems most likely 
that the changes which finally caused a complete oc- 
clusion of the whole of the vena cava superior and 
the larger portion of both the innominate veins had 
its origin in a periarteritis, which must have begun OCCLUSION OF THE VENA CAVA SUPERIOR. 
23 
around the ascending or transverse portion of the 
aorta. This must have proceeded gradually, with a 
constant increase and condensation of the tissues 
around the aorta and veins, until at last there was 
produced the large amount of hard fibrous tissue 
which the post-mortem examination showed to exist 
in that region. 
A man, twenty-six years of age, was admitted to the ward 
July 21,1880. No history of previous disease was obtained, 
except that he had had frequent attacks of ague, and eighteen 
months ago had typhoid fever. One year ago he had a 
chancre, but it was followed by no secondary symptoms. In 
March (four months ago) he was upset from a boat, and after 
being two hours in the water was taken out unconscious. 
Since that time he has noticed that he has had more or less 
shortness of breath, but felt fairly well and was able to be 
about until one week ago, wThen his left arm became para- 
lyzed, and the next day the leg became weak so that he 
walked with difficulty. Upon admission he was suffering 
very much from dyspnoea, and his breathing was very rapid, 
being forty-eight per minute. The pulse was frequent and 
weak. In walking he dragged the left leg, and the arm on 
the same side hung powerless, and was much swollen and 
oedematous, both feet and legs being also oedematous. The 
face was drawn to the right, the muscles of the left side 
being flaccid, but the tongue was protruded without deflec- 
tion to either side. The speech was rather mumbling. 
The urine was normal. 
July 22. A more careful examination of the heart revealed 
a faint mitral systolic murmur, and that the heart was hy- 
pertrophied. There were numerous coarse moist rales audi- 
ble over the lungs, and there was evidence of some pleuritic 
effusion. 
23d. Condition much the same, but he is more stupid and 
has frequent attacks of dyspnoea. 24 
MEIGS, 
25th. He is unconscious, and passes his urine in bed. The 
heart murmur is more distinct. 
Is sinking, and died July 27th. 
Post-mortem examination showed the pleural sacs to con- 
tain slightly over a quart of clear serum and that the heart 
was much enlarged. The fluid and enlarged heart occupied 
so much space in the thorax that the lungs were much com- 
pressed ; they felt firm to the linger, hut were crepitant 
throughout, although they were not more than half the nat- 
ural size. The heart was both dilated and hypertrophied. 
The right side showed nothing of interest, the valves being 
normal. The left ventricle and auricle were both much 
dilated and hypertrophied ; this condition was very marked 
in the auricle. The mitral opening was narrowed, the valve 
flaps being stretched across it. When looked at from the 
auricle there was seen a tumor springing from the posterior 
flap of the valve and projecting into the auricular cavity, 
which was about three-quarters of an inch to an inch in 
diameter, and about half to three-quarters of an inch in 
height. This mass was made up of two different layers, the 
lower smooth and rounded and the upper rough and uneven, 
and there were numerous little shreds like rootlets hanging 
from its surface. There was also on the anterior flap of the 
valve a spot which was much roughened, and had minute 
vegetations attached to it. This was probably due to ulcera- 
tion from friction against the tumor on the other cusp. The 
aorta was narrow and the valve flaps much thickened, so 
that the valve was incompetent. The liver was about natu- 
ral in size, but the capsule was much thickened. The spleen 
also was natural in size, but rather firm and its capsule 
thickened. The kidneys appeared natural. The brain pre- 
sented considerable softening of its right side; this was of 
the lower parietal lobule and the upper adjoining part of 
the temporo-sphenoidal lobe ; there did not appear to be any 
involvement of the motor tract. Upon examination of the 
middle cerebral artery it was found to divide primarily into 
three branches. The first of these was patulous, but the two 
posterior ones were blocked with emboli. OCCLUSION OF THE VENA CAVA SUPERIOR. 
25 
Dr. Simes sent me the following report of the results of an 
examination of the tumor:— 
“ I have made a microscopical examination of the growth 
and find it to consist histologically of cells, fibrous tissue, and 
granular debris. The cells are such as are found in embryo- 
nal connective tissue, and appear to be more especially con- 
fined to the peripheral portion of the tumor. The fibrous 
tissue is of the ordinary kind, consisting of delicate fibrils 
and cells. The granular debris is apparently a metamorpho- 
sis of the cells and fibres. I was unable to see any vascular 
structures. These histological characters, in connection with 
the macroscopical appearances and clinical history of the 
case, would lead one to consider the new formation as syphi- 
litic in nature—a gumma.” 
Fig. 3. 
The conditions presented by this patient when he 
came to the hospital and his history at once sug- 
gested that the cerebral symptoms were due to em- 
bolus. The distinct murmur heard at the apex of the 26 
MEIGS, OCCLUSION OF THE VENA CAVA SUPERIOR. 
heart, together with the signs of hypertrophy and the 
general symptoms pointing toward rapidly increasing 
heart failure, were abundantly sufficient to warrant 
the belief that a fragment of vegetation had been 
washed from the left side of the heart into some one 
of the cranial bloodvessels. It struck me also that 
the origin of the heart disease might be syphilitic. 
To this suspicion I was led by the history, and be- 
cause pnly the year before I had seen a case with a 
somewhat analogous condition which I reported to 
the College.1 The two cases, although in some re- 
spects parallel, presented points of marked difference, 
both in the symptoms presented, in the histories, and 
in the different modes of death. In the first case 
there could be obtained no history of syphilis, either 
initial lesion or secondaries, but the man had been 
out of health for two years; there was, however, ad- 
vanced disease of the kidney, and uraemic convulsion 
had occurred; the man finally died with a very slow 
pulse and in a certain sense rather suddenly. In the 
case reported to-night, the history of chancre occur- 
ring a year before death was clear, but, as in the first 
case, no secondary signs had appeared; the man 
thought himself well until about four months before 
his death, which was at last caused by the cerebral 
embolus, and he died with the usual rapid and irregu- 
lar pulse of mitral disease. 
1 Transactions of the College of Physicians of Philadelphia, 3d series, 
vol. v., 1881.