350 Case o/ Innominate Aneurysm.

5. The cervical sympathetic is not affected. The pupils are normal. The ophthalmoscopic appearances are normal.

6. The analgesia present in the right side of the head has bee~ mentioned; otherwise the cranial nerves are unaffected.

The chief points of special interest in this case a r e - (l) ~he exclusively unilateral distribution of the phenomena, and (2) their wide extent on the right side of the body. I t is common for one side to be involved more than the other, but generally there is some degree of involvement of both sides. I t is usual for the symptoms of syringomyelia to be confined to the arms and upper part of the t runk : in this case the analgesia exists over the right half o~ the hear[ and body which receives its nerve supply from the brain and spinal cord as low as the 3rd lumbar segment.

ART. XtX.--Se~ud to a Case o] Innominate Aneurysm reported in 18987 By JAMES CRAm, M.D. Univ. Dubl. ; Fellow and Registrar R.C.P.I. ; Physician to the Month Hospital and Co. Dublin Infirmary.

ON December 16th, 1898, I brought under the notice of the Medical Section of the Royal Academy of ~ediciae in Ireland a case of innominate aneurysm which had become entirely quiescent by prolonged rest, sparing diet, and the adminis- tration of iodide of potassium internally.

The patient, who was then 65 years of age, presented the physi- cal signs of an innominate ancursym in June of 1897. He was confined to bed for something over two months when the sym- ptoms and physical signs having largely subsided he insisted on going to the South of France. There he continued to carry out the principles of treatment already enumerated, and at the close of the year 1897 he was entirely free from alI symptoms. I examined him carefully 18 months after the onset, and unless for a slight prominence and diminished resonance where the tumour had presented, there were absoluiely no other physical signs of an aneurysm to be found. In subsequent years he spent the greater part of his time at Continental health resorts, but I saw him during his periodic autumnal visits to Dublin. He

Read before the Section of Medicine in the Royal Academy of Medi- cine in Ireland, on Friday, March 3, 1905. [For discussion on this paper see p~ge 381.]

By DR. JAMES CRAIG. 351

grew strong, lead an active outdoor life, and never eomplaSned of illness. In the spring of 1904 he was at Wiesbaden. On Sun- day, April 24th, he was at a dinner party, and enjoyed himself thoroughly ; on the following Wednesday he remained_ indoors, as he felt out of sorts ; that night he suddenly sat up in bed, blood began to pour from his mouth, and in a few moments he was dead.

Dr. Altdoffer kindly wrote to me as follows : - - " At the post-mortem examination it was found tha t the a~eurysm of the innominate, which you diagnosed, had become consoli- dated and did not give any trouble, but tha t there existed a second--much larger- -aneurysm of the thoracic aorta, which had perforated into the cesopha~s close to the stomach, so situated tha t i t probably could not be diagnosed at all. I t is most astonishing that , according to all accounts, the pat ient should have felt so well up till a few days before his death."

Drs. Stein and Altdorfer made the following report : - -

P~,'otocol o/ the post-mortem examination. " On lifting the sternum, one notes on the inner sicle of the

manubrium sterni a greyish red tumour of the size of an apple attached to the inside surface of the bone, which has destroyed the latter to more than half of its depth.

" On loosening the sternum completely, the surface of the above-mentioned tumour bursts, and one notes that f~hexe is a cavity in tJae interior filling up partially with eoagula of blood.

"Bo th cavities of the pleura contain a few drachms of a clear amber yellow fluid.

" The apex of the left lung is slightly fixed by adhesions. " The stomach is extremely distended and dark-coloured. " T h e organs of the chest cavity are taken out altogether. " T h e cavity of the pericardium contains about two wine-

glassfuls of a clear amber yellow fluid. " The surface of the heart is covered with plenty of fat. The

heart muscle is in a state of fatty degeneration. The aortic valve is incompetent and rigid. The walls of the aorta are covered with many hard plates of different sizes.

" T h e cavity of the above mentioned tumour under the upper and:of the~sternum represem~s a dilatation of the anonyma. The we,ll of this dilatation measures about one inch in thickness.

" There is a second dilatation on the areus of the aorta

352 Case o/ Innominate Aneurysm.

expanding into the mediastinum posterius. The cavity of this dilatation is of the size of the head of a new born child, the walls are very thin. A part of the w~dl is fixed by adhesions to the anterior surface of the spine, and bursts while loosening it.

"The anterior surface of the oesophagus is closely attached to the wall of the dilated aorta. The interior surface of the cavity is covered with plenty of the above mentioned hard plates. On the back of the cavity is a small spot where the wall is completeiy destroyed ; there is an open passage to the interior of the oesophagus.

" The stomach and the upper parts of the small intestine are filled with dark-coloured blood.

" Liver, spleen, kidneys, are without particular changes. " The lungs partially contain air ; the other parts and the

bronchi are filled with blood and coagula. " Diagnosis :--Aneurysm of the anonyma ; aneurysm of the

areus aortee. Spontaneous perforation into the oesophagus; myoearditis; arteriosclerosis. Death by bleeding and suffoca- tion.

" Wiesbaden, the 28th of April, 1904. " DR. 1VIED. ALBERT E . STEIN. " M. ALTDORFER, MED. DR."

I am sure that my hearers will agree with me in oonsidering the case to be one of unusual interest.

The consolidation of the innomina~e aneurysm was in itself an interesting fact, but the sudden death of the patient from the rupture of another and much larger aneurysm, seven years after the onset of the one which became quiescent, is worthy of note.

There is no evidence at what period the fatal aneurysm began to develop, and while it may be possible tha t it existed at a date prior to the appearance of the one on the innominate artery, it is much more likely that its onset was of a subsequent date. Owing to the absence of symptoms until the day of death it might be assumed that the formation of the aortic aneurysm had been a very recent occurrence, but its adhesion to the spine and its adhesion to and erosion of the oesophagus must~have been the result of prolonged pressure. That such pressure should exist without the production of pain is difficult of conception, and can be explained only by the yielding nature" of the structures in front of this portion of the aorta.