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Lea diagrammea suivanta illustrant la mAthoda. 1 2 3 4 5 6 t-y li^ ;"«*': ^ ^Wl*' :S23qK AREURTSI OF THE iSCBNDIllG PORTIOH OF THE AORTIC iRCH, LEADIH6 TO EXTERNAL RUPTURE. BY JAMES STEWART, M.D., Professor of Medicine, McGill University ; Physician to the Royal Victoria Hospital. . , . and J. G. ADAMI, M.A., M.D., Professor of Pathology, McGill University ; Pathologist to the Royal Victoria Hospital. I ■ h - {Reprinted from the Montreal Medical Journal, November, 1896.) J^ ( .- y Apt^ .?M ^1. 1 K'-y- ANEUllYSM OF THE ASCENDING PORTION OF THE AORTIC ARCH, LEADING TO EXTERNAL RUPTURE. With a Note on Tracheal Tugging. _,-.-, BY -_ . y,. -^ James Stewakt, M.D., Professor of Medicine, McUill University ; Physician to the Royal Victoria Hospital, ' • AND J. G. Adami, M.A., M.D., ' ' Professor of Pathology, McGill University,; Pathologist to the Royal Victoria Hospital. The s j^cfc of these notes will he remeinbered by soine as having been one of the cases exhibited by one of lis (J. 8.) at the recent meet- ing of the Canada Medical Association in this City. The history of the patient is very full, he having been in the hospi- tal for long periods during the last two years, and very full notes of his case have been taken by Drs. Reilly, McCarthy and NichoUs. The most important points in connection with the history are as follows ; The patient, 49 years old at the time of his death, was born in Nova Scotia and gave rather a full history of circulatory disease in his family. Thus his father, who is said to have had heart disease, died at the age of 58, from the effects of overstraining himself. His father's mother had heart disease, but lived to a good old age : her father again died suddenly from heart failure. The patient entered the navy at 16, and served there until he was 25 years old. During this period he lived a life of considerable excess. He drank freely, contracted syphilis at 22, and gonorrhoea at 27. He left the navy and entered government service, and for the last twenty -four years has continued in that employment, leading a clerical and literary life. In July, 189o, after o.xcessive mental work he began to suffer from .stabbing pains in the right and left breasts. These varied in situation, severity and course. At night they changed according to the side he lay upon, appearing in the right breast when he lay upon the right side. There were also frequent pains running from the heart to the shoulders and spreading down the arms, more especially down the right arm. There were other pains from the centi'e of the back under the right axilla and over the right shoulder. It will be noted that '■^■HHUPI^^F'*" '^^ these pains were mainly on the right side and so differed from similar pains which may accompany coronary disease. The August and September of this year, 1H93, were spent at the seaside and here the pains disappeared, but they returned upon his X'eturn to work. The patient, it may be avi}w^m»> ■T'/T"" I I continued to grow .slowly, but by March, 1896, it was noticed to be slowly IcHscning in diameter, measuring 4 instead of 6 itiches across. The patient continued in the hospital until May, when he was dis- charged, showing distinct improvement in his condition since January, The diagnosis then made was Aneurysm of the Ascending Arch. In March of this year he was in the hospital again, for a few days, for examination, and then went home, returning on the liHh August. Upon re-admission he complained of transient pains, as before, in the pectorals and shooting down the right arm, then again in the back below the shoulder blades. Arcus senilis was now well marked. There was no dyspnoea save on exertion and save that when lying upon his back the patient experienced a smothering sensation. The right radial was rather stronger than the left. The transverse diame- ter of the tumour had increased from 4 to 5i inches. The skin over It was shining and glazed, there was a harsh blowing systolic mur- mur heard over the chest in front, faint at the apes. There was, as before, tracheal tugging, and the breath sounds on the right side were feeble. There was no difference between the pulses, at the be- ginning of September. The tumour steadily enlarged and upon the 8th, the skin over the apex began to give way, there being one or two small cracks from which blood oozed in small quantities. On the next day the skin over the apex looked as though the aneurysm might burst at any moment. The patient now was discharged at his desire. He was seen at home by Dr. Reilly every other day. He lived nearly four week.s after his discharge, until October 5th. Then taking his tea in bed, sitting up, the tumour suddenly burst, the blood pouring out of the upper portion of the prominence, and in a moment he was dead. The condition of the subject when he came down out of the post- mortem room is ailmirably shown by the accompanying photograph. The body was that of a somewhat emaciated adult of spare frame ; the conical bulge occupied the centre of the chest, having a transverse diameter of 14.3 cm. or about six inches. The skin over the cone was rather discoloured, having a brownish tinge. The truncated apex of the cone had its centre in the line joining the two nipples, and it formed a circular, f ungating, blood-stained mass 5 cm. in diameter, projecting 3 cm. above the level of the surrounding skin. A probe could be pa.ssed easily into this mass towards what, taking the head as north, might be described as N.W. by W. portion of the periphery, and later examination showed that the fungating mass was devoid of skin, and was in fact, a thick layer of blood-stained fibrin, which, until the fatal moment, had acted as a shield, preventing rupture. - m^' m^.— T '■ ■■ ■ ■ ' ^ t,^ 6 A small cicatrix was seen at the junction of the f^lans and skin. The chest was opened carefully, so that the whole of the aneurysm and attacltfd tissues might be taken out en innme. The ascending portion of the aorta presented largo flattemid fibroid, almost cartila- geneous plaques beginning immediately above the siimses of Valsalva- 2.5 cm. above the valves began the sacculated aneurysm, proceeding abruptly by a sharp but smoothly rounded edge out of the aorta. The mouth of the sac was 6.5 cm. across in longitudinal diameter, by 4.5 in transverse. The fibroid thickening of the aortic intima was especially thick anteriorly along what formed the lower lip of the aneurysm. This aneurysm was given off from the front of the ascending aorta, very slightly to the right ; it was noticeable that the upper edge of the opening was 2.5 cm., or about an inch below the orifice of the innominate artery. Just beyond the upper edge of the mouth, the aorta measured 9.5 cm. in circumference, that is to say, that almost immediately beyond the sac the aorta was but little larger than nor- mal. The sac was of great size from before, backwards ; when emptied after removal, it measured 8 cm. in depth. At the sternal attachment it was 11 cm. from above downwards, beginning 3 cm. below the upper border of the sternum ; in breadth it was 9 cm. The outer walls of the sac were formed of the pleurae on either side and above, save in the middle line where there was .solid mediastinal tissue ; below the greatly expanded parietal pericardium formed the outer wall. The sac was filled with fairly loose clot in the main not laminated. Even in the outer portion where this formed the thickest layer, it had a comparatively recent appearance, and was so deeply stained with pigment that lamination could not be recognized. Por- tions of the eroded sternal edges could be felt protruding into the sac on the right side ; on the left they were covered over. The main erosion or sternal orifice extended in the mid-sternal region from below the level of the third chondrocostal articulation to above the level of the 5th. The rest of the aorta showed general slight dilatation with an atheromatous condition similar to that already described. The in- nominate, left carotid, and left sub-clavian arteries were not im- plicated in the aneurysm, nor again did they show any aneurysmal dilatation, cither at their orgins or along their course ; their walls were however, distinctly thickened. The heart showed, first, an extensive hydropericardium, the cavity containing a perfectly clear limpid serum. There was no valve disease. The main feature of the organ was the hypertrophy and dilatation of the right ventricle and >.■ .I,- --* &<'•: • ;^ with this n (lofinito dilatation of the pulmonary artery, the circumfer- ence of which iuunofliutely above the valve was 9.3 cm. The reason for this condition appeansd clear when the lungs were examined ; these were found n^tracted, and while the upper lobes were slightly emphysematous, the lower lobes were in a state of partial collapse with congestion. The small size of the lung and the obstruc- tion of the pulmonary circulation were evidently due to the large mass of the aneurysm tilling up so large a portion of the thoracic ca .ty. It should be added that both upper lobes presented adhesion to the wall of the aneurysmal sac and no where else. Further, it is to be noticed that there was no adhesion between the sac and either the trachea or the bronchi ; nor upon examination did any of the main air tubes show distortion from pressure. The points of more especial importance in connection with this case are : 1. The position. — In general, aneurysms of the ascending arch are situated and expand mainly to the right. In this case, although the aneurysmal sac began .'n inch and more above the valves, the rupture had occurred in the anterior wall, slightly it i.s true to the right, but very slightly, and the expansion had been in the median area of the chest so that the erosion of the sternum was central. Indeed there was an accessory but well marked erosion on the left side in the region of the third left chondroco.stal articulation. 2. The second point to be noticed is that in this case there had been from time to time a marked difference in the two radial pulses, which with the other symptoms might well have led to a diagnosis of aneurysm originating much higher up the arch. It must be kept in mind that difference in the two radials is by no means diagnostic. In this case the regions of the innominate and the left subclavian were well outside the region of the aneurysm, and the difference in the two pulses here, must, as in other cases in which no aneurysm is found to exist, be asci'ibed in the main to the arterio-sclerotic change, affecting the two trunks to a different extent. There is, however, another possibility in this case, namely, that the aneurysm, ad- herent as it was to the chest wall, did undoubtedly bring about malposition of the aorta, and this malposition may have so affected or distorted the orifice of either the innominate or the left sub-clavian as to impede the passage of blood and of the blood-wave down one or other vessel. 3. The third point of some value is brought out in connection with the sign of tracheal tugging. It is generally taught now a-days, that tracheal tugging affordo a sure indication of aneurysm of the trans- V... %7^ m I' •*■<• ver^e portion of ih« aorta, and an I Hhowed recently to the Society, in a tasK of anouryflui of this nature, dilation of the transverse arch does ^hdoubt(!dly load easily to the production of thJH sign, and acooni- .^lishes this by pressing upt^n the lower end of the trachea and the the left bronchus as this passes underneath the arch. In the case before us there was no aneurysm of the transverse arch, and further there was no adhesion of the aneurysm of the ascending portion to either trachea or bronchus, and yet there was at least two years history of distinct tracheal tugging obtainable. The motion of the larynx and trachea must have, it seems to me, V)een brought al)out by the downward pressure of the large aneurysmal sac upon the lungs and smaller bronchi with each distension of the sac following upon the heart-beat. This case teaches us, therefore, to recognize that tracheal tugging may be a sign of aneurysm of the ascending aorta as well as one of aneurysm of the transverse arch. 4. As to the termination of this case. — External rupture is one of the more uncommon terminations of a thoracic aneurysm. According to Crisp's ^Tables this occurred six times in 136 cases of aneurysm of the ascending arch which he found recorded. :•. U- \ -::i-'>:j^ ' ,■'>■ i.'i#»»l»A'?*^--^ ■