Substernal aneurism : cases and observations on its diagnosis, and relation to disease of the heart / by A. Halliday Douglas.

  • Douglas, A. Halliday (Andrew Halliday), 1819-1908.
Date:
1863
Catalogue details

Licence: Public Domain Mark

Credit: Substernal aneurism : cases and observations on its diagnosis, and relation to disease of the heart / by A. Halliday Douglas. Source: Wellcome Collection.

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    as occurs in such an experiment as the following:—Let an india- rubber hag, with a tube attached, be distended with water, by means of an elastic forcing bag having a valve in the nozzle which communicates with the tube. The sudden expansion of the forcing bag (its diastole) is followed by the audible flap of its valve; but when the india-rubber bag is fully distended the sound produced at the valve is now heard in the distant bag, intensified and having a cavernous tone, from the diffusion of the sonorous wave in the globular bag of fluid, though at a distance of several feet from the valve of the forcing bag. As a general rule, the character of an endocardial or arterial murmur has no diagnostic value,—it may be harsh or soft, musical or blowing. It is otherwise, however, with the cardiac second sound, which is liable to changes in its intensity and in its timbre. Increased loudness or sharpness of the second sound, in the aorta or in the pulmonary artery, accompanies a variety of con¬ ditions of the heart and of its action, and these possess more or less diagnostic value ; but the timbre of the second sound is apt to acquire a peculiar intensified, ringing or metallic, quality of great diagnostic value. The difficulty of describing the quality of a sound has led to a vast number of terms being employed to desig¬ nate this one. In clinical teaching I was accustomed to style it u intensified, with a hollow metallic ring or boom.” Dr Stokes terms it u ringing second sound.” Dr Walslie u twanging” or u pumping.” The most recent reference to it is by Dr J. W. Begbie,1 who adopts the name of u accentuated second sound.” In the year 1836, Dr Henderson2 demonstrated the importance of this altered timbre of the second sound, and compared it to the closing of a pump-valve. Dr Henderson’s patient was a man about 50. He presented dull percussion on the left front, as low as the sixth rib, with well-marked impulse. u After the slow impulse in these parts had terminated, and while the heave of the chest produced by it was subsiding, a remarkably clear and loud sound was audible, bearing a very striking resemblance to the sudden shutting of a pump-valve in the immediate vicinity of the ear. The sound was of nearly equal intensity at all points where the impulse existed.” In this case, the heart was of natural size. A large aneurism occupied the space from the left clavicle to the fifth rib in front, and it extended to the spine. The aneurism commenced an inch from the aortic valves, and involved the left wall of the arch as far as the origin of the left subclavian artery. The sac contained a maze of laminated clots, with a dirty grumous-looking fluid intervening. The u equal intensity” of the sound in this case probably arose from the size of the sac, its diffused proximity to the surface, and possibly the extent of its communication with the aorta. The case was admirably suited for unfolding the value of this state of the 1 Edinburgh Medical Journal, No. 96. June 1863. 2 Edinburgh Medical and Surgical Journal, vol. 45.