to be smaller
than the left, and weakness in flexion of the fingers, with
hyperaesthesia in the ulnar nerve distribution, was observed.
The right pupil was also noted to be larger than the left.

The patient was sent down to the Base, and on the twenty-fourth
day the condition was as follows. A pulsating swelling existed
extending 1-1/4 inch upwards beneath the right sterno-mastoid,
from the mid line of the neck backwards to the centre of the
posterior triangle, and downwards over 2 inches of the first
intercostal space, which latter was dull on percussion. There
was some evidence of a bounding wall, but it was thin and the
tumour was soft and yielding. A loud machinery murmur was
audible over the tumour, over nearly the whole extent of the
thorax, and in the distal vessels as far as the temporal
upwards, and the brachial as far down as the bend of the elbow.
The murmur was audible to the patient with his ears closed.
Over the swelling a strong thrill was palpable; this extended
some little distance into the distal vessels and felt
remarkably superficial. It was particularly evident in the line
and course of the anterior jugular vein, and appeared to be
extinguished by local pressure. Although readily felt in the
posterior triangle, it was impalpable on deep pressure in the
suprasternal notch, a fact which seemed in favour of localising
the aneurismal varix to the subclavian artery and vein. The
right pulse was good, although smaller than the left, and was
said to have improved in volume. The right pupil was slightly
larger than the left, but reacted normally. There was no pain
or difficulty in swallowing. Weakness in power of flexion of
the fingers persisted, and there was some impairment of
sensation in the area of distribution of the ulnar nerve.

Three weeks later no material change had occurred, except that
the swelling was perhaps softer and the thrill more
superficial, and at the end of two months the patient was sent
to England.

I saw this patient a year later in Glasgow, when the condition was as
follows. He was living at home, and out of employment. He complained of
shortness of breath on exertion, and said that when he mounted stairs he
felt 'as if his heart were going to leave him.' The heart's apex beat in
the sixth interspace in the nipple