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 ANKUHISM UK THE ARCH OF THE AORTA.' 
 
 Hy .(. G. ADANfi, M.A.. M.I). 
 
 Prol'i'ssor of ratliolo^y, Mcdill I'nivcisKy ; I'iitliolonist to tlio Hoyal Victoria 
 
 Hospital. 
 
 Tlio spociinen altout to l>t' di'scriltLHl, \v hilo pussossing a certain ainonnt 
 of iiiton'st ill itsi'U',is iiio)-e ('specially intcrt'stinj^' inasniucli as the patient 
 from whom it was olitaineil at the autijps^' had been under observation 
 for several years, and fuither, had formed the subject of a lecturi- 
 delivered in the Montreal General Hospital by Dr. James Stswart, and 
 published in the series of Interno.tioiud Clinics.' Thus, apart from 
 the fact that tl . is a very complete history of the case, the speci- 
 men is of value as demonstrating very clearly the explanation of the 
 symptoms noticed durint^ lift- and commented upon at some length by 
 Dr. Stewart in the above-mentioned lecture. The clinical Idstory of 
 the case is contained in the ca.se-books at the General Hospital, at the 
 Royal Victoria Hospital and at the Longue Pointe Home for Incurables. 
 I shall here give it very brieHy, only refei-ring to the special points in 
 connection with the ai\eurism, for, superadded to tliis history of the 
 aneurism, there is a long and interesting history of ataxic paraplegia. 
 The patient, .James L., first ex]ierience«l ])ain in the chest in the early 
 part of the suiiimei' of l<S!)l. In the Hr.st week in August he began to 
 complain of hoarseness; in the middle of October he entered the Gen- 
 eral Hospital, and a detiniti! diagnosis of aneurism of the transverse 
 aorta was imide, the diagnosis being based upon the following points r"* 
 
 1. Pain of a persistent character in a limited area of the che.st (left 
 infraclavicular region; relieved V)y change of posture. 
 
 2. Hoarsene.ss, amounting at times to almost complete extinction of 
 the voice. Upon laryngological examination Dr. G. W. Major found 
 the left vocal cord paralyzed and standing in a mid position between 
 extreme abduction and extreme adduction. 
 
 3. Cough of a brassy nature. 
 
 4. Pidsation synchronous with, but distinct from, that of the heart. 
 The centre of the pulsatile area was situated at the junction of the 
 second left rib with its cartilaire. 
 
 5. Tracheal tugging. 
 
 0. Marked dirterence in the pulse at either wrist, the pulsation being 
 far more voluminous on the right sitle than on the left. 
 
 I ■ ■; 
 
 • Read before the Montreal Medieo-CIiirurKieal Society, March 8, 1895. 
 ■^ Infernativnal Clinicn, Second Serie.s, Vol. III., 1892, p. 49. 
 •' Vide Dr. Stewart's lecture, loc. eit. 
 
ADAMI — ANEURISM OF TFIE AORTA. 
 
 411 
 
 I ' 
 
 7. The left pupil was fouml 2 mm. smaller tliaii tlio riolit. 
 
 With rest and pota.s.sium ioiliilo tin* pain, lionrsfnoss, and cougli dis- 
 .ippcanMl, liut Hvcii ai'fcci- five months' rest in the hospital thoro was 
 11(1 cssmtial improvement of tiic fun<lamental state. Since IS92 the 
 notes i-eveal no special addition to this list oi' .syinj.toms ; the ataxic 
 condition, however, lieciime more nwii-ked, and the patient's life has 
 lieen Hp"nt mainly in the hos])ital. 
 
 The autops}- was performe<l at the Uoyal X'ictoria Hos{)ital on 
 l''eliruary the 2(Sth, 1895, the hody havinjr heen hroujirht from the 
 lloMK! at Longui! Pointe on account of the more thoroui,di post-mortem 
 liicilities. Upon openine; tlie thora.x tlii-re was no evidence of absorp- 
 tion of the sterinnn or I'iUs; the ri<fht lun*; was very lar-fe atid full' 
 and presented a condition of acute Iti'oncliitis ; the K'ft lung was not 
 half the size of the righ.t and had a Habhy colla,p.sed feel ; on section it 
 liaii a dark collapsed appearance, with some ci'dema and bronchitis, as 
 in the rijifht lung. The main bronchus was pressed upon by the aortic 
 aneurism, but did not show definite constriction or any sign of per- 
 loration. 
 
 The aortic arch was .sen to be dilate<l and to have depressed the 
 heart, so that the ain-icular ventricular groove, ;i t a point just below the 
 irigin of the Jiorta, coi're.spondcil to a line joining the upper borders 
 of the fourth chondrocostal articulation.s. The heart itself was very 
 fatty, and tlu^ right Vv'ntricniar nniscle was profoundly infiltrated with 
 I'at ; the left ventricle was .sonujwhat dilated (as was also the right); 
 the corollaries were dilated ami .showed patches of fatty degt>neration, 
 Iteginning 2 cm. and 1.5 cm. Iteyond the origin of the right and left 
 respectively. Immediately above the valves the aorta was already 
 larger than normal (!) cm. in circumference) ; it i-apidly expanded into 
 a general fusiform aneurism, with greatest- giving way and some 
 sacculation upwards and backwards beyond the origin of the innomi- 
 nate artei-y, so that the back wall of the main pouch was formed of 
 the eroded left halves of the fourth, tifth and sixth dorsal vertebrae. 
 The nui?xii4ium depth of the aneuri.sm at the aiitopsy was 11 cm. 
 (ahout 4 inches), its lireadth from before backwards was 15 cm. It 
 I'lided in a' line with the under margin of the transverse aorta, the 
 descending aorta being of normal dimensions. Neither in the aneurism 
 it>ilf nor in the dorsal aorta could calcareous placiues be detected, 
 ilthough there were ran fatty patches of fair size. Above and behind, 
 I lie cavity was filled with dense laminated clot. 
 
 Turning now to the more special features of the aneurism it may be 
 i'ointed out that the aneurism pressed upon and flattened the trachea ; 
 i'le left bronchus, while passing outwards and forwards immediately 
 
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 \1>AMI ANKt'lUSM OK I'llI': AoKTA. 
 
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 l)t!neatli the iiiniiiisiii, iippcat'od nt tlu; iiutopHV to !»»■ n-lutivfly littK; 
 .•iffi'C'tcd. .Iutl;;iii(i[ tVdiii tlic condition of the left Iniii^ tlii' j)n'ssurc of 
 tlic aiicurisiii upon tliis lironclins must lm\t' led to relative olistruction 
 with conse(|Uent pnitial collnpse of the hnii^'. Tiie left sulttdavian and 
 left carotid appeni'ed, from the development of the aneunsuial sac 
 upwards and ImeU wards, to arise not fiom he apex of the arch, hut 
 from the front of the tiansverse porti<iii. The innominate artery was 
 the sent of a fusiform dilatation up as far as its hifnrcation ; tlie 
 carotid an<l siiliclaviiin, while ni>t amnrismal. wei'e distinctly hirp-r 
 than normal. 
 
 The specimen, therefore, demonstrates most clearly the on<,'ui of 
 the cardinal symptoms in aneurism of the transverse aorta. 'J1u! ureat. 
 expansion of the tuhe upwards, haclc.ard.s and downwards mu; ' of 
 necessity have tjxerted oreat pressure upon tin- recurrent lary. ,,.al 
 and sympathetics of the left side ; the position of the left bronchus 
 
 li: 
 
AHAMI— ANEUUISM i)V THE AOIHA. 
 
 4ia 
 
 also, passing closo Id'neath tlic aneurism from licliind forwards, explains 
 vi-ry cit'urly the productiiwi of the pliiiinnicnon of tracheal tiij;-^dni^,' 
 III this position eachexpansion of the anenrism with the wave of hlood 
 propelled from the heait must have r(!sulterl.in pushing- the l»rt)nchus 
 ilowiivvards, and it is this downward pull that is felt in these eases 
 when the lower ])art of the larynx is held lietweeii the tinj^ers. 
 
 The specimen also shows very clearly why the radial pulse was so 
 much lai'ger aiiil fullei' than the left ; the innoMiinate was placed in 
 
 (lie direct line of the curient and wave of lil I propelled up the 
 
 iiscendint;' ])oi'tion of the aoita, whereas the left sulicla\ ian had, l>y the 
 liackwani extension of the aneui-ism, lieen ])ushed foi-wards, so as to 
 appear as though given (;H' oiilirpiely upwai'ds from the fi'ont of the 
 iuch. In such a position, in consetpience of the almost valvular orifice, 
 liotli hlooil current and systolic wave couhl enter less easily. 
 
 ' I have tit confess that at the tiinc of rfiidiiiK llli^ piipcr licfoiv (lie Medico- 
 I 'liii'uixieul Society I was unaware of liow proiiiiiicnl a part liad heeii played l)y our 
 .Moiilreal physicians in einpliasi/iiiK tlie value of this si^jn in tlie dia^cnosis of 
 aneurism of tiie transverse aorta. I'racI ically. after Siu^eon Major W. S. Oliver 
 {/.ininl, 11., IK7S, p. KK() tirwl noted the conditioi:, the lale Dr. (!eorfj;e {{oss, in his 
 article on aneurism in W'odiI's lir/frrncf //a lul-Hook d/ //ir Mrilii'ii/ Srieiircs, was 
 liie lirst to lay stresH upon its value, and Die late Dr. itichard L. MarDonnell wa.sthe 
 lii-st in an admirable article in the lAitnrl (1., IHill, pp. .~>:C> and (i'ldi to \i,\\v a full ex- 
 planation of its c.'iu.sation. He showed, as this specimen <leiiionsti'ates so fully, tlmt 
 tracheal tug^;inn' is due to pressure liy the aneurism either upon the last inch of tiie 
 Lrachea or upon the left bronchus. 
 
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