Reprinted from the Montreal Medical Journal, December, 1895. 
ANEURISM OF THE ARCH OF THE AORTA.1 
By J. G. Adami, M.A., M.D. 
Professor of Pathology, McGill University; Pathologist to the Royal Victoria 
Hospital. 
The specimen about to be described, while possessing a certain amount 
of interest in itself,is more especially interesting inasmuch as the patient 
from whom it was obtained at the autopsy had been under observation 
for several years, and further, had formed the subject of a lecture 
delivered in the Montreal General Hospital by Dr. James Stewart, and 
published in the series of International Clinics? Thus, apart from 
the fact that there is a very complete history of the case, the speci- 
men is of value as demonstrating very clearly the explanation of the 
symptoms noticed during life and commented upon at some length by 
Dr. Stewart in the above-mentioned lecture. The clinical history of 
the case is contained in the case-books at the General Hospital, at the 
Royal Victoria Hospital and at the Longue Pointe Home for Incurables. 
I shall here give it very briefly, only referring to the special points in 
connection with the aneurism, for, superadded to this history of the 
aneurism, there is a long and interesting history of ataxic paraplegia. 
The patient, James L., first experienced pain in the chest in the early 
part of the summer of 1891. In the first week in August he began to 
complain of hoarseness; in the middle of October he entered the Gen- 
eral Hospital, and a definite diagnosis of aneurism of the transverse 
aorta was made, the diagnosis being based upon the following points:3 
1. Pain of a persistent character in a limited area of the chest (left 
infraclavicular region; relieved by change of posture. 
2. Hoarseness, 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. Pulsation 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 cartilage. 
5. Tracheal tugging. 
6. Marked difference in the pulse at either wrist, the pulsation being 
far more voluminous on the right side than on the left. 
1 Read before the Montreal Medico-Chirurgical Society, March 8, 1895. 
2 International Clinics, Second Series, Vol. III., 1892, p. 49. 
3 Vide Dr. Stewart's lecture, loc. cit. 2 
7. The left pupil was found 2 mm. smaller than the right. 
With rest and potassium iodide the pain, hoarseness, and cough dis- 
appeared, but even after five months' rest in the hospital there was 
no essential improvement of the fundamental state. Since 1892 the 
notes reveal no special addition to this list of symptoms ; the ataxic 
condition, hpwever, became more marked, and the patient's life has 
been spent mainly in the hospital. 
The autopsy was performed at the Royal Victoria Hospital on 
February the 28th, 1895, the body having been brought from the 
Home at Longue Pointe on account of the more thorough post-mortem 
facilities. Upon opening the thorax there was no evidence of absorp- 
tion of the sternum or ribs; the right lung was very large and full 
and presented a condition of acute bronchitis ; the left lung was not 
half the size of the right and had a flabby collapsed feel; on section it 
had a dark collapsed appearance, with some oedema and bronchitis, as 
in the right lung. The main bronchus was pressed upon by the aortic 
aneurism, but did not show definite constriction or any sign of per- 
foration. 
The aortic arch was seen to be dilated and to have depressed the 
heart, so that the auricular ventricular groove, at a point just below the 
origin of the aorta, corresponded to a line joining the upper borders 
of the fourth chondrocostal articulations. The heart itself was very 
fatty, and the right ventricular' muscle was profoundly infiltrated with 
fat; the left ventricle was somewhat dilated (as was also the right) ' 
the coronaries were dilated and showed .patches of fatty degeneration, 
beginning 2 cm. and 1.5 cm. beyond the origin of the right and left 
respectively. Immediately above the valves the aorta was already 
larger than normal (9 cm. in circumference); it rapidly expanded into 
a general fusiform aneurism, with greatest giving way and some 
sacculation upwards and backwards beyond the origin of the innomi- 
nate artery, so that the back wall of the main pouch was formed of 
the eroded left halves of the fourth, fifth and sixth dorsal vertebrae. 
The maximum depth of the aneurism at the autopsy was 11 cm. 
(about 4 inches), its breadth from before backwards was 15 cm. It 
ended in a line with the under margin of the transverse aorta, the 
descending aorta being of normal dimensions. Neither in the aneurism 
itself nor in the dorsal aorta could calcareous plaques be detected, 
although there were rare fatty patches of fair size. Above and behind, 
the cavity was filled with dense laminated clot. 
Turning now to the more special features of the aneurism it may be 
pointed out that the aneurism pressed upon and flattened the trachea; 
the left bronchus, while passing outwards and forwards immediately 3 
beneath the aneurism, appeared at the autopsy to be relatively little 
affected. Judging from the condition of the left lung the pressure of 
the aneurism upon this bronchus must have led to relative obstruction 
with consequent partial collapse of the lung. The left subclavian and 
left carotid appeared, from the development of the aneurismal sac 
upwards and backwards, to arise not from the apex of the arch, but 
from the front of the transverse portion. The innominate artery was 
the seat of a fusiform dilatation up as far as its bifurcation ; the 
carotid and subclavian, while not aneurismal, were distinctly larger 
than normal. 
The specimen, therefore, demonstrates most clearly the origin of 
the cardinal symptoms in aneurism of the transverse aorta. The great 
expansion of the tube upwards, backwards and downwards must of 
necessity have exerted great pressure upon the recurrent laryngeal 
and sympathetics of the left side ; the position of the left bronchus 4 
also, passing close beneath the aneurism from behind forwards, explains 
very clearly the production of the phenomenon of tracheal tugging.1 
In this position each expansion of the aneurism with the wave of blood 
propelled from the heart must have resulted in pushing the bronchus 
downwards, and it is this downward pull that is felt in these cases 
when the lower part of the larynx is held between the fingers. 
The specimen also shows very clearly why the radial pulse was so 
much larger and fuller than the left; the innominate was placed in 
the direct line of the current and wave of blood propelled up the 
ascending portion of the aorta, whereas the left subclavian had, by the 
backward extension of the aneurism, been pushed forwards, so as to 
appear as though given off obliquely upwards from the front of the 
arch. In such a position, in consequence of the almost valvular orifice, 
both blood current and systolic wave could enter less easily. 
11 have to confess that at the time of reading this paper before the Medico- 
Chirurgical Society I was unaware of how prominent a part had been played by our 
Montreal physicians in emphasizing the value of this sign in the diagnosis of 
aneurism of the transverse aorta. Practically, after Surgeon-Major W. S. Oliver 
(Lancet, II., 1878, p. 406) first noted the condition, the late Dr. George Ross, in his 
article on aneurism in Wood's Reference Hand-Book of the Medical Sciences, was 
the first to lay stress upon its value, and the late Dr. Richard L. MacDonnell was the 
first in an admirable article in the Lancet (I., 1891, pp. 535 and 650) to give a full ex- 
planation of its causation. He showed, as this specimen demonstrates so fully, that 
tracheal tugging is due to pressure by the aneurism either upon the last inch of the 
trachea or upon the left bronchus.