J R Army Med Corps: first published as 10.1136/jramc-04-06-03 on 1 June 1905. Downloaded from
,41
ON THE FURTHER HISTORY OF FIVE CASES OF ARTERIO-VENOUS ANEURYSM OF THE NECK, WITH SOME REMARKS ON THE CONDITION GENERALLY, AND ITS TREATMENT. By G. H. MAKINS, C.B., F.R.C.S., Surgeon to St. Thomas'8 Hospital, &,c. THE cases upon which this communication are founded have already been published in my book on the ,. Surgery of the South African Campaign," but during the period of five years which has elapsed since, they were first under treatment changes have occurred in their condition which seem to render their history worthy of continuation. In again bringing them forward I take the opportunity of raising Protected by copyright. some questions with regard to arterio-venous communications ID general. (1) CAROTID ARTERIO-VENOUS ANEURYSM. The bullet (Mauser) entered at the right side of the pomum adami, and crossing' the larynx and the course of the left caI;otid vessels, emerged at the anterior border of the left trapezius two inches below the angle of the mandible. Immediate hffimorrhage occurred from the exit wound, but ceased spontaneously. At the end of some four hours, during which the patient had been removed
'to a field hospital, the bleeding recurred, and an incision was made http://militaryhealth.bmj.com/ by the surgeon-in-charge with the intention of ligaturing the carotid artery. During the preliminary stage of the operation, however, the bleeding ceased, and the vessel was not exposed nor ligatured. The patient was kept quiet for three weeks and then sent to the Base Hospital at Wynberg. At that time the external wounds were soundly healed, but there was considerable blood extravasation in , the left posterior triangle of the neck, while swelling, pulsation and thrill were palpable beneath the sterno-mastoid, in the course of the bullet track, over an area It inches in breadth. A widely distributed machinery murmur was audible on auscultation, and this, was on September 24, 2021 by guest. troublesome to the patient himself when he lay with the left side of the head on the pillow. The left eye appeared somewhat prominent, but the pupil reacted. normally to light, and was equal in size with the right. Laryngoscopic examination showed the vocal cords to be intact, but there was swelling of the upper part of the larynx, 49 J R Army Med Corps: first published as 10.1136/jramc-04-06-03 on 1 June 1905. Downloaded from
742 Arterio-Venous Anew"ysm of the Neclc
the voice was weak and husky, and there was some cough. The patient complained of giddiness at times, but not of headache. The pulse numbered 100 per minute, it was regular, but irritable in character. During the next four weeks the patient was kept at rest in the supine position and general improvement followed. Meanwhile the swelling became localised into a definite oval tumour in the line of the wound track, 2 inches long by 1! inches wide. After the first fortnight of rest no further diminution of size occurred in the aneurysm, and it was determined to apply a proximal ligature. This procedure at once arrested all pUlsation in the sac, and materially reduced the strength of the purring thrill; but the latter was not extinguished. At the end of a week the wound was dressed and the stitches removed, when it was found that all pulsation in the aneurysm had ceased, although the thrill remained as before. Shortly afterwards the patient returned to England with the aneurysm apparently consolidated, but when I· saw him some six Protected by copyright. months later pUlsation had recurred and a small oval sac was palpable beneath the sterno-mastoid. The thrill was slight com pared with the condition prior to the operation and gave rise to little or no trouble. Pulsation was strong in the external carotid, but there was little in the common carotid artery. The patient's general condition was good, but the pulse remained from 110 to 120 in pace. I assumed that the aneurysm was either at the bifurcation of the carotid, or at the immediate commencement of the internal carotid, and proposed to ligate the external carotid, as I thought that this would sufficiently diminish the blood supply to ensure the consoli http://militaryhealth.bmj.com/ dation of the aneurysm without endangering the internal jugular vein or further upsetting the cerebral circulation. The patient, however, decided that he would rather await events, as the con dition gave rise to little or no inconvenience, and I was quite inclined to fall in with this view, provided he did not return to active service. During the next six months I saw the patient several times; he was leading an easy life at home, avoiding all strenuous exertion,
and the condition steadily improved, the pUlsation becoming less, on September 24, 2021 by guest. and the thrill slighter. At the end of five .months (eleven months from the date of ligature of the common carotid) the aneurysm h.ad apparently under gone complete consolidation, its place being occupied by a narrow oval. tumour about 1 inch in length. All pulsation had ceased, and J R Army Med Corps: first published as 10.1136/jramc-04-06-03 on 1 June 1905. Downloaded from
G. H. Makins 743 thrill was hardly perceptible. A low, continuous hum was still present on auscultation, but the most striking feature was the presence of a sharp musical systolic murmur, similar to those present with· an arterial cicatrix and contraction of the lumen of the vessel. During tbe next nine months these signs disappeared completely, and since then the patient has been continuously on active service. On March 10th, 1904, the patient wrote as follows about himself: " I am able to give a most satisfactory account of myself. My neck gives me no trouble, my voice is strong again, and I can give words of command just as I did before the wound. I went through the last manoouvres at home in September without inconvenience, and we had a most trying time." Captain Mitchell, R.A.M.C., was kind enough to send me the following report in June, 1904: "I consider the case one of perfect recovery; no signs can now be discovered in the neck to show that a varicose aneurysm has ever existed. The heart and pulse are Protected by copyright. normal. The only trouble ever experienced is shortness· of breath on severe or prolonged exertion, but this is only of. temporary duration." (The patient is 46 years of age.)
(2) CAROTID ARTERIO-VENOUS ANEURYSM. The bullet (Mauser) entered at the dimple of the chi.n, imme diately below the mandibular symphysis, crossed the car6tids just above the normal point of bifurcation, and emerged at the anterior border of the right trapezius. The patient was lying on his back
with the head down at the moment he was struck. Some immediate http://militaryhealth.bmj.com/ hffimorrhage from the exit wound occurred, and later, while being transported to the field hospital, renewed hffimorrhage' was so severe as to almost prove fatal. On the tenth day a considerable secondary hffimorrbage occurred. The patient then came under the care of Mr. Cheatle, ~t Modder River. A large diffuse pulsating swelling, with loud machinery murmur and thrill, had developed. During the next three weeks this st(ladily contracted in size, the patient being kept at rest, and one month after tbe reception of the wound the patient was con sidered fit to undertake the journey to Wynberg. on September 24, 2021 by guest. On arrival at the Base Hospital a large aneurysm filled the carotid triangle. It extended from the mid-line of the neck back wards to the anterior margin of the trapezius, and vertically from the upper margin of the thyroid cartilage to the mandible. A fairly firm wall had formed, pulsation was both obvious and palpable, J R Army Med Corps: first published as 10.1136/jramc-04-06-03 on 1 June 1905. Downloaded from
744 Arterio-Venous Aneurysm of the Neclc
and a well-marked purring thrill with loud machinery murmur was present. The latter worried the patient much when he lay with the right side of his head on the pillow. The pulse numbered 1eo and was somewhat irritable in character, the voice was weak and husky, and there was some difficulty in swallowing solids. The pupils were equal. The outline of the aneurysmal swelling was somewhat remarkable, extending on one hand in the line of the external carotid artery, on the other in .the line. of the wound track backwards to the edge of the trapezius. During the succeeding fortnight the patient was kept at .rest with the head between sand bags, and some further contraction in the size of the aneurysm was noted. A sudden increase then took place, the larnyx became pressed ! inch over to the left of the mid-line, while considerable extension downwards· along the course of the common carotid raised a doubt as to whether it would be possible to expose that vessel on the proximal side without
encroaching on the blood sac. It was determined, however, to Protected by copyright. make the attempt, and as it proved, the vessel was tied without difficulty at the upper border of the omo-hyoid. Pulsation and thrill disappeared completely on tightening the ligature. There was no dilatation of the jugular vein. ' Four days later the aneurysm was found to be solid, and appreciably diminished in size. Neither pulsation nor thrill could be. detected, but on auscultation a loud blowing murmur was audible, most marked at the posterior limits of the tumour. On the morning of the fifth day the patient stated that he had again
noticed the" whirr" during the night; and on the eleventh, slight http://militaryhealth.bmj.com/ purring thrill again became evident in the upper part of the swelling. Pulsation was palpable in the line of the external carotid, but the aneurysm itself was solid and much contracted In SIze. Ten months later no trace of the sac remained, but purring thrill was palpable and a machinery murmur audible. The pulse was still 100, the voice was strong and clear, and the patient was ·doing duty at the depot of his regiment. Since that time the patient has been continuously on duty, the thrill has decreased much, and he describes his own condition four years after the on September 24, 2021 by guest. injury as follows: "I cannot lace my boots unless my foot is raised, or my head becomes giddy. My right arm is weak, although stronger than it was; if I lift any weight it seems. to go all down my shoulder. On cold, damp days, or with sudilen changes in the weather, I feel a dull pain where the aneurysm used to be, J R Army Med Corps: first published as 10.1136/jramc-04-06-03 on 1 June 1905. Downloaded from
G. H. Malcins· 745 under my right ear. I have to sleep on my back. My nerves are improved, I can hunt on a good-mouthed horse; in fact, I am' very much better." Note received April 18th, 1905: "I am better in every way. I had a good fall out hunting, but was all right after it. I can sleep on my right side, but cannot put my head down much." This patient is on active service.
(3) CAROTID ARTERIO-VENOUS ANEURYSM. The bullet (Mauser) entered at the posterior border of the left sterno-mastoid, 1 inch above the clavicle, crossed the neck and· emerged at the posterior border of the right sterno-mastoid, 2 inches, above the, sterno-clavicular joint. The wound was attended by free hmmorrhage from the aperture of entry, "sqme quarts," apd the patient's clothes were saturated.
The voice became hoarse and weak, and there was inability to Protected by copyright. swallow anything for the first twenty-four hours. A swelling of a diffuse character was first noted at the end of seven days, this pulsated and a strong thrill was noted .. Gradual contraction and localisation followed, and at the end of eight weeks the patient was allowed by Mr. Cheatle, under whose care he h~d been, to travel to Wynberg. At that time the aneurysm was smooth and rounded in character, about 1! inches in diameter, occupying the whole width of the sterno-mastoid, and extending just beneath the clavicle. Well-marked expansile pulsation and purring thrill
were present, and on auscultation a widely-spread machinery http://militaryhealth.bmj.com/ murmur. The voice was still weak and husky, but there was no dysphagia. The left pupil was larger than the right. The patient acquired enteric fever, and when convalescent was sent home to N etley, as the aneurysm caused little discomfort. On arrival in England the patient was sent home to Canada,. as he did not wish for any operative treatment. The after history of this aneurysm is of much interest. After his return to Canada the patient contracted scarlet fever; but was later allowed to return to South Africa on active service; no inter ference with the aneurysm being deemed advisable. During 1904, on September 24, 2021 by guest. while on duty, he was running a railway hand-car, which was thrown off the track, and the patient suffered a severe fall. During the first twelve hours he appeared to have received a severe shaking only, but some five or six hours later he was seized with severe pain and dyspnooa, and twenty-four hours after the accident he J R Army Med Corps: first published as 10.1136/jramc-04-06-03 on 1 June 1905. Downloaded from
746 Arte1'io-Venous Aneurysm of the Neck expired. The medioal man who attended him said the aneurysmal sac had burst. This is the only instance in my experience in which a late rupture has been observed.
(4) ANEURYSMAL VARIX OF INNOMINATE. The bullet (Mauser) entered at the posterior margin of the left sterno-mastoid just ~bove the clavicle, crossed the thorax, and emerged in the fight anterior axillary line 1 inch below the anterior' axillary fold. Slight hremoptysis, probably due to a wound of the lung, followed, and persisted for four days. At the end of that time there was some fulness over a circular area 2t inches in diameter, of which the right sterno-clavicular joint was a little to the inner side of the centre. Over this area faint pulsation was palpable, and a strongly marked thrill. A loud systolic bruit was audible over the same limit. There was, neither pain or dyspnooa, the Protected by copyright. radial pulses were equal. The right pupil was larger than the left, and the eye was partially closed, but could be widely opened by the levator palpebne superioris. Little change occurred during the next six weeks, except that some gravitation ecchymosis appeared at the lower costal margin, pointing to mediastinal hrel110rrhage, and a typical machinery 'murmur developed, while the initial prominence noted disappeared. One year later the patient was at work as a lamp-trimmer, and beyond shortness of breath on exertion, complained little. The right pupil was still dilated, but the palpebral fissures were now http://militaryhealth.bmj.com/ symmetrical. The root of the right sterno-mastoid and the sternal third of the clavicle appeared prominent, and some pulsation was palpable beneath the muscle; but no definite evidence of a sac existed. The purring thrill was less obvious, and the machinery murmur less widely distributed. Major Geddes, of the Royal Army Medical Corps, has kindly furnished me with the following report of the man's condition in February, 1904, four years anil four months subsequently to the initial injury. The man is still earning his living as a lamp trimmer. He suffers with some dyspnooa abQut seven or eight on September 24, 2021 by guest. o'clock each evening. The pupils react equally, but the man states that his vision is dim, and that he is unable to read. The supra-clavicular fossa is deeper on the right than on the left side of the neck, and pulsation is visible in the right hollow only. No tumour is to be discovered, no thrill is palpable, and the J R Army Med Corps: first published as 10.1136/jramc-04-06-03 on 1 June 1905. Downloaded from
Cl. H. Maldns 747
"machinery murmur" which, is present is only audi~le to the patient when"he lies with the right cheek on the pillow at night. The radial pulses are equal, the rate of pulsation varying from 100 to 140. Report on Oondition on April 18th, 1905. By Dr. A. Young., , The man is regularly employed as an arc lamp ,trimmer, works about five hours a day, and on every day in the week. Since his return to Glasgow from South Africa he has kept very well, and for the past three years has been off work on account of illness on only two occasions-three days about a month ago, and four days two years since, the ailment each time being merely" cold." He feels well enough and quite up to this work. The shortness of breath which he had for a time after coming home has been quite absent for at least six months. He can climb the 18 to 20 feet ladder, which he uses in the course of his work, without any breath
lessness, and he has no trouble in climbing the two flights of stairs Protected by copyright. to his own home. His appetite is evidently not all it might be, and he says he sleeps badly, though considering the constant alteration in his working hours this is perhaps not unnatural. Very occa sionally he suffers from frontal headache of a mild type-it is bilateral and not evidently related to any special cause. He has no cough, or hoarseness, or difficulty in speech or swallowing, About once ~ day, from no obvious exciting cause, and occurring at quite irregular intervals, a pain shoots suddenly from about the middle of the right supra-clavicular fossa, along' the inner half of the clavicle, to the region of the right sterno-clavicular joint. It is of http://militaryhealth.bmj.com/ only moderate intensity and quite transient. The right pupil is still somewhat larger than the left, but it seems to react quite well, both to light and for accommodation. Ocular movements seem normal. The palpebral fissures on the two sides are alike and normal. For some temporary dimness of vision he was a patient at the Glasgow Ophthalmic Institute about a year ago for several months. From the condition which then led to his going to that institute he' states he has now fully recovered, and he has no eye trouble now.
His heart dulness is little altered from the normal, perhaps a on September 24, 2021 by guest. little enlarged to the left. The heart sounds at the apex are almost pure, but a slight suggestion of systolic bruit can be heard. At the base it is more distinctly heard, but by no means well until the stethoscope is carried either out along the right clavicle .for about 3 inches, or else upwards upon the right sterno-mastoid muscle J R Army Med Corps: first published as 10.1136/jramc-04-06-03 on 1 June 1905. Downloaded from
748 ATterio- Venous AneuTysm of the Neck for about It inches. The systolic bruit is not heard high up III the neck, nor is it more than faintly heard upon the left side. It is not audible over the axillary or brachial arteries on either side. There is practically no machinery murmur (indeed, I believe I would be justified in saying absolutely) either heard by the patient or to be heard by the examiner. . There is slight visible pulsation in the right supra-clavicular fossa, but none in the left or in the supra-sternal notch. The pulsa tion seen here is on palpation found to have a distinct expansile character. The right anterior jugular vein is not visible, but the external jugular is somewhat prominent. It is quite patent and evidently playing a much more important part than the left. There is no thrill. The prominence of the lower part of the right sterno mastoid muscle still exists, but is not great; nor is there great pro minenceof the sternal end of the clavicle. The pulse at rest (sitting posture) numbers 80, in the upright position 96, after a brisk walk from one end of the room to the Protected by copyright. other and back again, 104 per minute. Respirations are quiet and regular-about 16 per minute. The man has quite a notable degree of lateral spinal curvature, the convexity being towards the right in the upper dorsal region. A limited area, including the sternal one-third of the right clavicle and the region above, and for It inches below it, is rela tively dull to percussion, but it is not strikingly so-only when contrasted with the left side. There is evidence, it seems to me, of some aneurysmal enlarge
ment about the 'junction' of innominate with right sub-clavian, but http://militaryhealth.bmj.com/ it can hardly be of much size, and is certainly not progressing. 'rhe earlier venous communication must be, I should think, com pletely cut off now, and is evidenced by nothing beyond some disproportionate distension of one of the right superficial cervical veins, viz., the external jugular.
(5) CAROTID ARTERIO-VENOUS ANEURYSM. The bullet (Mauser) entered at the centre of the right infra spinous fossa, and crossing the chest emerged between the heads of the right sterno-mastoid muscle. on September 24, 2021 by guest. There was no serious immediate hoomorrhage, but the injury was followed by some hoomoptysis and dysphagia, lasting for two days. The right radial pulse was noted to be diminished, and there was evidence of contusion of the ulnar nerve. Twenty-four days after the injury a pulsating swelling had J R Army Med Corps: first published as 10.1136/jramc-04-06-03 on 1 June 1905. Downloaded from
G. H. Malcins 749 developed, extending I! inches upwards beneath the sterno mastoid, and 2 inches downwards over the first intercostal space. Laterally it extended from the mid-line of the neck backwards to the centre of the posterior triangle. There was some evidence of a bounding wall, but the swelling was soft and yielding. A widespread thrill and machinery murmur were present. The right pupil was larger than the left. The patient was sent home to England at the end of two months. A year later the walls of the aneurysm had become dense and firm, it extended upwards 2~ inches in the line of the carotid artery, just projecting beyond the postenor margin of the sterno mastoid. The larynx was displaced ! inch to· the left of the median line. The thrill and murmur were less marked than before, the patient had not been at work, but had lived an ordinary life with his friends; he complained much of shortness of breath on exertion. Protected by copyright. Major Geddes, of the Royal Army Medical Corps, has kindly furnished me with the following report in February, 1904, four years and three months subsequently to the initial injury. The patient now earns his livelihood as a carman. The aneurysm has not increased in size, and its walls are firm and hard; there is practically ilO change in its condition. The pulse numbers 86. There are fibrillar twitchings of the right deltoid muscle, which is wasting, as are also t~e remaining scapular muscles; the muscles of the ulnar border of the forearm are wasted, and the grip of the right hand has little power. Thus pressure on the posterior cord http://militaryhealth.bmj.com/ of the brachial plexus seems to have developed, and the man him self states that about six months before the neck had appeared more swollen .for a time. These points seem to show that the aneurysm is not altogether stationary. Report on Condition, by Dr. Archibald Young, as at March 31st, 1905. "The man is still living ·at home and seems to enjoy good health, apart from the disability connected with his injury. He has been able,for some months to take charge of a carrier's van, on September 24, 2021 by guest. which delivers small parcels over the city. This occupies him on three or four days in the week, from 9 to 11 in the forenoon and from 3 to 5 in the afternoon. He is careful never to lift anything heavy, in fact he guards himself most carefully against all exertion. If he does at any time exert himself unduly, he becomes short of J R Army Med Corps: first published as 10.1136/jramc-04-06-03 on 1 June 1905. Downloaded from
750 .A1·tm·io- Venous Ane1t1'ysrn of the Neck
breath at once, and is troubled with palpitation. At the same time (or under the same influence) the, beating on the right side of his neck becomes unpleasantly emphasised. He resides at present in a third-flat house, and the climbing of the three flights of stairs, unless taken in most leisurely fashion, not only excites palpitation and makes him very short of breath, but is apt to induce an intense nausea. This is only occasionally followed by actual vomiting. "The heart 'dulness is undoubtedly enlarged transversely, its left margin not much exceeding the normal, but the right reaching fully t inch to the right of the sternum. There is no punctate apex beat to be seen, but in the fifth and sixth interspaces and in the epigastrium there is general pulsation. "The heart sounds over the apex are almost pure, though even there cau be heard, somewhat obscuring the normal heart sounds, thesystolic aneurysmal bruit. This becomes more and more apparent as the stethoscope is carried nearer to the base and over the sternum in the direction of the aneurysmal swelling. It is Protected by copyright. heard at its maximum intensity over the clavicle at its inner end, and is conveyed well up the neck and as far as the brachial at the bend of the elbow. "I entirely/ail to observe any' purring thrill,' nor is there any evidence of 'machinery murmur.' With reference to ,this it should be stated that no such murmur is now audible to the man himself when lying on, his right side. What he does hear is simply an exaggeration of the normal carotid pulse. Of this he is very clear. "The radial pulses are not appreciably different in strength
or rhythm, and at rest beat about 76 per minute. http://militaryhealth.bmj.com/ "The sensory and motor distribution of the ulnar nerve is , still distinctly impaired, but there is practically no sign of trophic disturbance. "The man himself thinks his hand (right) somewhat stronger than it was, but it is still pretty weak as compared with the left. " The aneurysmal swelling is still very obvious. Its anterior, upper and posterior limits are well defined, but its lower edge seems to pass behind the clavicle. The' sterno-mastoid muscle passing over the sac gives it a bi-Iobed appearance. Its greatest transverse measurement is 3t inches, its upper limit reaches the level of the on September 24, 2021 by guest. upper edge of the thyroid cartilage. The inner edge reaches almost to the middle line, the larynx being displaced to the left to the extent of i inch. The aneurysm has a firm resistant wall. 1/ The expansile pulsation is not only palpable but plainly visible, even when the man is entirely at rest. There is no thrill of the , purring' type. J R Army Med Corps: first published as 10.1136/jramc-04-06-03 on 1 June 1905. Downloaded from
O. H. Malcins 751
"The same loud systolic murmur already referred to as trans mitted to other parts, is heard over the aneurysm. There is no enlargement of superficial veins. The pupils are equal and react normally. The voice is still husky, but seems quite strong. " There is little or no episternal pUlsation. " Examined in the state of rest there' is, in my opinion,now no clear evidence of venous disturbance. The symptoms and signs-the whole clinical picture-may quite well be explained with reference to a purely arterial lesion." The cases above detailed illustrate two features, viz., the general tendency towards spontaneous cure exhibited by aneurysms resulting from wounds of healthy vessels, and also the effect of proximal ligature on such aneurysms. The grounds upon which proximal ligature was chosen in the first two cases in preference to a local operation were shortly as follows :- In the first I believed the internal carotid artery and the internal jugular vein to have been in communication, and considered that Protected by copyright. it would be much more prudent in the first instance to avoid the risk of cerebral trouble, which must be allowed to be considerable when these vessels are tied simultaneously. My opinion was, that in any case the varicose aneurysm would be converted into a varix, and that this, if necessary, could be treated with less risk when the sac had been obliterated. The final result not only justified this opinion, but in addition demonstrated that an aneurysmal varix may get well spontaneously, when the force of the arterial circulation has been lowered hy a proximal ligature.
In the second case the indication for active interference was http://militaryhealth.bmj.com/ more pressing, since a secondary extension of the aneurysm was taking place. Here the same reasons which had influenced me in the first case to prefer a proximal ligature were again taken into account, but in addition to them there was reason to regard a local operation as a procedure of extreme risk, since the sac was very 'extensive, and it appeared probable that both external and internal carotids might be implicated. In any case a proximal ligature 6f the common carotid would have been needed as a preliminary precautionary measure. In this case also the course adopted seems to have thoroughly justified itself. on September 24, 2021 by guest. The two cases first seriously raised in my mind the question as to whether we are justified in laying down a definite rule that such i11juries are without exception treated as cases of woundfld artery, and I shall attempt to show that good rea~ons exist for deviating from this rule in certain instances. J R Army Med Corps: first published as 10.1136/jramc-04-06-03 on 1 June 1905. Downloaded from
752 Arte1'io-Venous Ane'J,l1'ysm of the Neck
It may be useful first to recall the possible nature of the injury to the wall of the vessels which may be inflicted by a bullet of small calibre, Experience has 'shown this to be most variable in regard to extent, In some instances both artery and vein may be com pletely divided. In such injuries, which are not very uncommon, the development of an arterio-venous aneurysm is unlikely, and no question can exist as to the necessity of ligaturing the four open ends of the vessels at the earliest possible moment. With regard to the latter point, however, it is interesting to note, that clinically the accident is not always easy of prompt discrimination, since cessation 6f pulsation in the distal vessels does not always follow CLougheed).l It is the lesser degrees of injury which are most likely to be followed by the form of aneurysm under consideration . .These consist either in clean perforations, or in the removal of more' or less elliptical portions of the vessel wall. With regard to the ultimate result of such injuries, there is
abundant evidence to show that: (1) Such wounds of the wall may Protected by copyright. cicatrise efficiently without the formation of an aneurysm; (2) that when four openings in the two vessels are made the two correspond ing to the adjacent sides of the artery and vein only may remain patent, while the openings of primary entry and final exit may cicatrise without the formation of an aneurysm; (3) that an ellip tical wound of an artery may cicatrise not only without the forma tion of an aneurysm, but even without the occurrence of any gross primary h::emorrhage into the tissues adjacent.2 The probability of sound cicatrisation is also supported by the large number of
wounds accurately crossing the lines of vessels in which neither http://militaryhealth.bmj.com/ primary or secondary hremorrhage is observed, while still further evidence is afforded by signs of partial arterial obstruction often seen under these circumstances, such as local vascular murmurs, and marked diminution in force and volume in the distal portion of the vessels.3 The occurrence of partial and incomplete healing of the same nature is also suggested by bursts of secondary hremorrhage some times observed in wounds, the closure of which is delayed by sepsis or some other cause, and again by the late discovery of many on September 24, 2021 by guest.
1 "Surgical Experiences in South Africa," p. 125. 3 See a case reported by Johnston, "Stevenson's Wounds in War," Second Edition, p. 449; and similar observations were made by other surgeons, Sir W. MacCormac, &c. 3 "Surgical Experiences in South Africa," p. 113; l.c., p 112. J R Army Med Corps: first published as 10.1136/jramc-04-06-03 on 1 June 1905. Downloaded from
G. H. Makins 753 aneurysms, a frequent experience, generally too r~adily referred to want ?f observation on the part of the s~rgeon under whose care the patient initially came. Cicatrisation of the vessel wall may be aided by the adhesion of a neighbouring structure; thus in a case of nerve injury, reported by Major Freyer, "the musculo-spiral nerve was found glued to the axillary artery by a small tarry-looking blood clot, the disturbance of which gave rise to profuse hffimor rh age from an opening in the vessel. There was no extravasation of blood into the tissues, and no indication before operation (which was undertaken on the eleventh day after the injury), that the . artery was wounded." 1 In a somewhat similar case of Sir W. Stokes, the wound of the artery was practically plugged by the intrusion of the musculo spiral nerve. In a case mentioned on p. 13, the sartorius served the same purpose. The temporary plugging or compression of a vessel by a bullet is a much less common event with those of small calibre than with those of larger ,size, but a somewhat remarkable Protected by copyright. substitute is found in instances in which small bullets have not bnly perforated vessels, but have run along their lumen for a considerable distance and obstructed their channel. 2 Non-perforating wounds, involving some part of the thickness of the arterial wall only, come for all practical purposes into the same category as the injuries already dealt with. In either class of case it is difficult to estimate the frequency with which secondary yielding of the scar takes place, but in all. probability the chances of this accident are somewhat greater than our present eXPEilrience
allows us to determine. As to the special conditions which lead http://militaryhealth.bmj.com/ to the development of an arterio-venous aneurysm in cases of gun shot wound of the vessels, beyond the fact of perforation of both artery and vein, we are, for the most part, only in a position to theorise. One or two points, however, appear open to no doubt. First, it is clear that the force of the heart's action in any given case must be of ffitiological importance, and in this connection it is obvious that the quieter the patient can be, kept after the infliction of the wound, the greater will be his chances of escaping further trouble. Secondly, the absence of any primary hffimorrhage into the tissues, observed in many cases where the vessel cicatrises, on September 24, 2021 by guest. is an important factor, since the collection of blood in continuity with the vascular wound at once furnishes a potential cavity liable
1 JOURNAL OF THE ROYAL ARMY MEDICAL OORPS, vol. iL, June, 1904, p. 682.
2 Le Cadlwee, No. 2, 1901, p. 21, M. Schloffer, Flobert. J R Army Med Corps: first published as 10.1136/jramc-04-06-03 on 1 June 1905. Downloaded from
754 ' Arterio- Venous Aneurysm of the Nee!;; to become later the aneurysmal sac. The occasional development of a simple varix seems to prove that the lumen of the vein as the vessel in which the blood-pressure is the lower, may offer and encourage an opportunity for a diversion of the stream and the maintenance of the communication. A case of Major Freyer's, already alluded to, furnishes an example. "Both artery and vein were found to have clean holes punched in them, the anterior wound in the artery was occluded by a firm clot which was firmly attached to the sartorius muscle over it; the artery and vein communicated by corresponding apertures, and the hole in the posterior wall of the vein was healed. No extravasation of blood had taken place, although the vessels (femoral at the apex of Scarpa's triangle) were of such large size." 1 Given the formation of an arterio-venous aneurysm, the arrange ment may present many variations equally difficult to explain or foretell. In another place 2 I have adverted to the anatomical arrangement of certain vessels as calculated to favour the develop Protected by copyright. ment of either aneurysmal varices or arterio-venous .aneurysms respectively. In the case of the latter the most varied conditions may be met with in the relative part taken by either vessel in the formation of the swelling attributed to the aneurysm. Thus we may find :- (1) That the apparent aneurysmal swelling depends either upon a great dilatation of the proximal portion of the artery, or of the distal portion of the vein. (2) The aneurysmal sac may be in connection with the artery
alone, the communication between the artery and the vein being http://militaryhealth.bmj.com/ merely a small patent aperture. (3) The sac may lie between the two vessels and separate the artery and vein more or less widely. (4) Both vessels may have a large lateral communication with a large sac. (5) The arterio-venous communication may take place through an opening in an intervening structure, as in the subclavian varix, operated upon oy Matas,S in which the communication traversed the anterior scalene muscle. The position of the sac is, probably determined by two factors, on September 24, 2021 by guest. one, the liability to spread in the direction of least resistance, and
1 "Stevenson's Wounds in War," Second Edition, p. 449. • "Surgical Experiences in South Africa," p. 131. " Trans. Amer. S~~rg. Assoc., 1901, vol. xix., p. 237. J R Army Med Corps: first published as 10.1136/jramc-04-06-03 on 1 June 1905. Downloaded from
G. H. Makins 755
secondly, and more important, the tendency of the sac to. occupy the space produced by any collection of blood formed at the time of the initial injury. As has been pointed out elsewhere this space is, as a rule, more constantly to be found in the exit than in the entry portion of the wound track. Some interesting work on the experimental production of aneurysmal varices has lately been carried out by Vignolo and by ]'ranz.1 Vignolo excised elliptical portions of. the walls of the common carotid artery and internal jugular vein, also of the femoral artery and vein in dogs. The vessels were then accurately anastomosed by suture. Some of the animals died from hffimorrhage, in others a typical aneurysmal varix was produced and the following changes were observed. The vein dilated rapidly with the development of pulsation and thrill, while considerable dilatation of the distal veins of the head in
cases of union of the carotid and jugular, or oodema of the lower Protected by copyright. limb when the femoral vessels were. anastomosed. The artery suffered by atrophy of the muscular coat, while the vein became thickened by inflammatory hyperplasia and dilated. Certain effects were also observed in the general circnlation; thus when the femorals were anastomosed an increase in the systolic wave, with a corresponding decrease of the diastolic wave, of the pulse. In the case of the cervical vessels this .alteration was not observed, but merely a sinking of the blood pressure; a difference in result explained by Vignolo on the ground of the absence of valves in the cervical veins and .consequent want http://militaryhealth.bmj.com/ of obstruction in the distal circulation. Another interesting observation was the uniform tendency of the condition to undergo spontaneous cure, as the result of throm bosis occurring in the distal segment of the vein. These experiments support the conclusion that the main factor in the development of an aneurysmal varix rather than an arterio venous aneurysm, lies in a sufficiently close approximation of the walls of the adjacent vessels and the absence of a primary collec tion of blood at the seat of injury. They also illustrate a similar tendency to spontaneous improvement, or cure, observed in arterio on September 24, 2021 by guest. venous communications in man. That this tendency to spontaneous cure may be supplemented by the lowering of the local blood-pressure by the application of a
I Centralblatt fiir Chirurgie, 1902, p. 1060. Ibid., 1904, p. 22. J R Army Med Corps: first published as 10.1136/jramc-04-06-03 on 1 June 1905. Downloaded from
756 Arterio-Venous Aneurysm of the Neclc proximal ligature, has been shown by the cases above detailed as well as by others under various surgeons.l Treatment.-No general rule can be laid down for the treatment of arterio-venous aneurysm, but in each case the method must be made to suit the location of the aneurysm and the special conditions which may exist. Of the latter the most important are the indi vidual characters of the aneurysm, the condition of the neighbouring soft parts and the date at which the aneurysm comes under observa tion. Each may have.a distinct bearing on the choice of procedure. , The methods from which we have to choose may be summarised as follows :- Local incision or extirpation of the aneurysm, the vessels being ligatured immediately beyond the confines of the sac. The application of a proximal ligature to the artery alone in as near contiguity to the aneurysm as possible (Anel's operation) ; not at the "seat of election," unless this corresponds with the latter indication. Protected by copyright. The preliminary application of a proximal ligature, followed at a later date by incision of the sac and clearance of its contents. Suture of the openings in the vessel wall. It may be said, at once of this method, that it is at present in its infancy and is suited to vessels of large size only. It may be well to at once eliminate cases in which primary hremorrhage is still continuing, since here there can be no true aneurysm, and no doubt can exist as to the propriety of ligature at the point of injury.
When primary hremorrhage has ceased, however early the case http://militaryhealth.bmj.com/ may come under observation, two points arise for consideration: (1) Will an arterio-venous aneurysm develop? To which question, in the light of present experience, we can only give an uncertain answer. (2) Can we assume that the tendency to spontaneous cicatrisation of the wounded vessels will be increased by the appli cation of a proximal ligature? There is no doubt evidence in favour of this possibility, but it is mainly derived from the result of operations for simple arterial hrematomata, and in view of the almost constant sequence of localisation and consolidation of the primary swelling up to a certain point, it is in most cases better on September 24, 2021 by guest. to temporarily maintain an expectant attitude.
I Ker, " Surgical Experiences in South Africa," p. 153; Cecil Birt, Brit. Med. Journ., vol. ii., 1902, p. 641; Freyer, JOURNAL OF THE ROYAL ARMY MEDICAL CORPS, vol. ii., No. 5, p. 558; Treves, Brit. Med. Journ., vol. i., 1902, p. 1135. J R Army Med Corps: first published as 10.1136/jramc-04-06-03 on 1 June 1905. Downloaded from
G. H.' MaJcins 757
The degree of consolidation of the wall of the aneurysm of course depends in the main on the age of the tumour. As a general rule a firm and well-defined wall is in favour of the probability of obtain ing complete consolidation if the force and amount of the blood , supply be lessened by proximal ligature, but in cases of old standing the probability of further cicatrisation and contraction of the opening of communication between the artery and vein is naturally less, since the latter has probably reached its permanent condition and size. . Extensive extravasation of blood into the surrounding soft parts in recent cases is a condition of great moment, since it gives rise to pressure upon the vessels on the enliugement of which increase of the collateral circulation depends. In the neighbourhood of the knee this is especially marked and it is well to bear in mind that this contraindication to a distant proximal ligature may persist for some time. A good example of this is furnished by the following case, for Protected by copyright. the notes of which I am indebted to Dr. Archibald Young. A wound crossing the popliteal space was followed by the development of an arterio-venous aneurysm. This filled the space transversely, its upper and lower limits being somewhat indefinite. Signs of pressure existed in considerable neuralgic pain in the distribution ,of both the popliteal nerves, but there was no enlarge ment of the superficial veins and the pulse in the posterior tibial artery was good. The femoral artery was ligatured low down in Hunter's canal, twenty-four days after the injury. No attempt at
the development of any collateral circulation followed. On the third http://militaryhealth.bmj.com/ day evidence of commencing gangrene was noted, and later the limb was amputated. The popliteal space was found to be filled by a large cicatricial mass, the superficial part of which encircled and filled up the space between the internal and external popliteal nerves, as high as their origin at the bifurcation of the sciatic, and as low as the space between the two bellies of the gastrocnemius. The artery and vein were closely attached together and immediately above the point of formation of the vein its anterior and posterior walls exhibited a perforation '5 centimetre in diameter. Similar openings were on September 24, 2021 by guest. found in the wall of the artery, and in the tissue which firmly bound the vessels together a small cavity extended l' 5 centimetres in a downward direction. A probe passed into the arterial opening found its way into a large irregular blood sac situated between the femoral condyles and surrounded by very dense connective tissue. 50 J R Army Med Corps: first published as 10.1136/jramc-04-06-03 on 1 June 1905. Downloaded from
758 A1'terio- Venous Aneurysms of the Neck
The sac, entered bya probe passed through the anterior wall of the artery, seemed to extend from· the level of the upper margin of the condyles to the lower angle of the popliteal space (about 5 centimetres), and transversely corresponded to the space between the condyles (about 1'5 centimetres). A dense plexus of veins surrounded the sac,· the lymphatics were dilated and a number of glands were enlarged. The catgut ligature which had been applied to the femoral artery was still in situ, the vessel contained clot on the proximal side, the distal portion was collapsed; in the sac itself was recent clot. "All the articular vessels were dissected with much difficulty from the dense cicatricial tissue surrounding them, and their incor poration in this must have interfered with any attempt towards the establishment of a collateral circulation by their aid." The mode of communication of the vessels concerned in the aneurysm is no doubt a matter of importance in regard to the probability of cure by the application of a proximal ligature. It Protected by copyright. is difficult to draw any conclusions on this subject, except to say that the entry of an additional small vessel into the sac itself is a very unfortunate condition in so far as the cure of the varix is concerned. Such vessels are most commonly in connection with the venous element. A good example of the condition is figured in a case of extirpation by Guinard.1 In this case a thin-walled sac the size of a turkey's egg, contain ing a small amount of clot,communicated laterally with the femoral artery by a short channel the· size of a pencil. The artery and vein
were closely applied, the communicating opening being of the size http://militaryhealth.bmj.com/ of a lentil; the opening on the distal wall of the vein had cicatrised firmly, and just below a tributary vein entered. Such vessels are no doubt the cause of failure occurring after the application of ligatures immediately above and below the communication in pure varices. The situation of the aneurysm is, however, the most important point in the determination of the method of treatment. Neck. --A special difficulty met with in this situation, perhaps only equalled in the instance of the deep and superficial femoral vessels, is the exact localisation of the point of communication. on September 24, 2021 by guest. Thus in the cases detailed above, of those at the root of the neck, in one (No. 3) some doubt for a time existed whether the inferior thy roid or the common carotid was the vessel implicated (temporary
1 Bull. et Mem. de la Soc. de Ohirurg. de Paris, tome xxviii., p. 1125. J R Army Med Corps: first published as 10.1136/jramc-04-06-03 on 1 June 1905. Downloaded from
G. H. Malcins 759 swelling of the thyroid gland, irregularity of the pupils, and paresis of the muscles supplied by the recurrent laryngeal nerve raising the question). In No. 2 doubt existed as to whether one or both of the carotids was wounded, in Nos: 4 and 5 the localisation to either innominate, carotid, or subclavian, had to be considered, and in No. 5 time alone allowed the carotid to be definitely fixed upon as the wounded trunk. Again, in considering a local operation, we have to consider the risk to the cerebral circulation of simultaneous ligature of both carotid artery and jugular vein. Lastly, the extreme severity of the operation itself, as judged by the accounts of recorded cases, seems to render the local incision of the aneurysm inadvisable, except under circumstances of extreme l urgency. Cases published by Dr. Clark and by Matas 2 support this opinion. . My own view, therefore, is in favour of allowing time for the consolidation and contraction of the sac, and then the application Protected by copyright. of a proximal ligature, when practicable, in' all cases involving the great vessels of the n.eck. Upper Extremity.-My personal experience and published cases show that a proximal ligature may with safety and a good chance of success be applied to the vessels above the elbow, and for wounds at the elbow itself this procedure is to be generally preferred. In the mid-arm a local operation is simple, and in the forearm the same may be said. In either of the latter situa- . tions a local is to be preferred to a proximal . operation, as more nearly approaching the ideal and necessitating no obvious risks. http://militaryhealth.bmj.com/ Trunk.-The iliacs are the vessels particularly likely to demand treatment. In the case of these vessels some difficulty may arise in localising the aneurysm to the external or internal branch again; the sacs in the retroperitoneal tissue are liable to be extensive and irregular. For these reasons the transperitoneal type of operati()n is to be preferred." A proximal ligature will probably suffice, and in the case of the internal iliac is obviously to be preferred. Lower Extremity.-It is here that most judgment is needed, on September 24, 2021 by guest. both in regard to operative difficulties, and to the somewhat " unsatisfactory results .that have been observed to follow the appli cation of a proximal ligature.
1 "My Experiences in South Africa," H. E. Clark. , Matas, Tran8. Amer. Surg. A880C., 1901, vol. xix., p. 237. J R Army Med Corps: first published as 10.1136/jramc-04-06-03 on 1 June 1905. Downloaded from
760 .Arterio-Venous Aneurysms' of the Neck
Difficulty in exact localisation of the wound may exist in two situations, first in the region of the superficial femoral and the pro funda and its branches; secondly in the calf, where doubt may arise as to whether the posterior tibial or peroneal vessels are concerned when the track is transverse, or whether the anterior or posterior vessels are implicated in antero-posterior tracks. Embarrassment to the operator has occurred under all these circumstances, and necessitated the alteration of procedure to meet existing' diffi culties. Again, attention may be called to the technical difficulty in dealing with the aneurysm locally when the wound in the anterior tibial artery lies close to the point at which the vessels pierce the interosseous membrane. As to the occurrence Of gangrene of the limb after proximal ligature of the vessels, this in my experience is particularly to be apprehended when the seat of election has been chosen indepen dently of the exact seat of the aneurysm, and when the lesion is of the popliteal vessels. A case has been already recounted Protected by copyright. illustrating the probable explanation of the failure of develop ment of the collateral circulation and its causes. To this may be added art instance in which a proximal ligature applied some months after the development of the aneurysm was followed by an immediate good result, but in which the patient lost his leg as the result of gangrene supervening on a trivial -injury a few weeks later. In a third case I saw the application of a proximal ligature to the popliteal vessels for an aneurysm of the calf fol lowed by the development of well-marked muscular ischremia and its attendant troubles. http://militaryhealth.bmj.com/ In speaking of the treatment of arterio-venous aneurysms generally, while theoretically no doubt can exist as to the ideal nature of a strictly local operation dealing immediately with the vascular wounds themselves, experience has shown that in many instances the procedure is difficult, dangerous both to life and the integrity of ueighbouring structures,' and in some instances impossible. ,Local operations involving interference with the aneurysmal sac should therefore be confined to such situations as ~llow them to be readily and safely performed and to the smaller vessels generally. Such operations. may also be indicated when on September 24, 2021 by guest. slighter methods have failed to ameliorate the conditions existing. Ligature of the artery at the seat of election is to be avoided, as not only unpromising, but as also, especially in the lower extremity, dangerous. A ligature placed as near as possible above the aneurysmal J R Army Med Corps: first published as 10.1136/jramc-04-06-03 on 1 June 1905. Downloaded from
G.H. Makins 761 sac has been shown to be safe, to afford a reasonable prospect of cure, and not to prejudice a further operation, should this become necessary in the case of failure. Where convenient it may be reinforced by a second ligature placed on the distal side of the sac, or in certain situations by' the ligation of an important proximal anastomotic vessel (e.g., anastomotica magna, in low operations on the femoral) (Freyer). In conclusion, I must express my indebtedness to Dr. Archibald Young, Major Freyer, C.M.G., Major Geddes, Dr. Colin Sewell and Captain Mitchell, who have aided me with information, or in following up the history of the cases recorded .. Protected by copyright. http://militaryhealth.bmj.com/ on September 24, 2021 by guest.