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.