(10) Carotid arterio-venous aneurism.—Wounded at Paardeberg. Entry (Mauser) to the right side of the Pomum Adami, exit at anterior margin of left trapezius, two inches below the angle of the jaw. There was some hæmorrhage at the time from the exit wound, but no hæmoptysis; about four hours later, however, in the Field hospital bleeding was so free that an incision was made with the object of tying the common carotid. During the preliminary stages of the operation bleeding ceased and the wound was closed without exposing the vessel. The patient remained a week in the Field hospital, and then made a three day and night's journey in a bullock waggon to Modder River (40 miles), and fourteen days later he was transferred to the Base hospital at Wynberg, when the condition was as follows. Operation and bullet wounds healed. Considerable extravasation of blood in the posterior triangle. Beneath the sterno-mastoid in the course of the bullet track, swelling, thrill and pulsation over an area 1½ inch wide in diameter. Loud machinery murmur audible to the patient when the left side of the head is placed on the pillow, and widely distributed on auscultation. The left eye appears prominent, but the pupils are normal and equal in size. Voice weak and husky, and there is cough. Laryngoscopic examination showed the cords to be untouched, but some swelling still persisted. No headache, but giddiness is troublesome at times. Pulse 100, regular but somewhat irritable.
The patient was kept quiet in the supine position for a month, and during this time the condition in many ways improved. The voice improved in strength, the pulse steadied, falling to 80, the prominence of the left eye disappeared, and all the blood effusion in the posterior triangle became absorbed. Meanwhile the aneurism contracted at first, until it became oval in outline, with a long axis of 2 inches by 1½ broad extending in the line of the wound track, but mainly situated in the exit half. During the last fortnight, however, it remained quite stationary in size, and as it showed no further signs of diminution in spite of the favourable conditions under which the patient had been placed, it was considered best to try to ensure its consolidation by a proximal ligature. Thrill had become slightly less pronounced, and was less evident to the patient himself, but was otherwise unchanged. The probabilities in this case seemed rather in favour of wound of the internal carotid artery, and it was decided to bare the upper part of the common carotid, follow up the main trunk, and if possible apply the ligature to the internal branch. On April 12, 61 days after the injury, the classical incision for securing the common carotid was made, and the sterno-mastoid slightly retracted. It was found that the sac of the aneurism extended over the bifurcation of the artery, reaching to the wall of the larynx. The omo-hyoid muscle was therefore divided, and the artery ligatured beneath, in order to ensure against any interference with the sac. Some difficulty was met with, for on opening the vascular cleft the vein was exposed and found to completely overlie the artery: although it was on the left side of the neck, the position of the vein was so completely superficial that there seemed no doubt that it had been displaced by the development of the aneurismal sac. A striking appearance was noted on exposure of the vein, the coats of which vibrated visibly, quivering in exact consonance with the palpable thrill. On tightening the silk ligature all pulsation ceased in the aneurism, and the vibratory thrill in the vein became much lessened.
The patient made a good recovery, only disturbed by a slight attack of vomiting, and at the end of a week the wound had healed, and pulsation in the aneurism had completely ceased. The thrill persisted as before.
Six months later, a small sac still exists beneath the sterno-mastoid. The pulse still reaches 110-120 in pace. The purring thrill is very slight. The condition gives rise to little or no trouble. Pulsation is strong in the external carotid artery, there is little in the common carotid. The voice is strong and good. This aneurism is either at the bifurcation of the common carotid, or on the immediate commencement of the internal carotid. Ligature of the external carotid will probably cure it.
(11) Arterio-venous aneurism, probably affecting both carotids. Wounded at Paardeberg. Entry (Mauser), at dimple of chin immediately below mandibular symphysis. Exit, at margin of right trapezius, the track crossing the carotids about the level of normal bifurcation. The patient was lying on his back with the head down when struck. Some hæmorrhage from the exit wound occurred at the time, and later on the way to Jacobsdal this was so profuse as to be nearly fatal. A considerable hæmorrhage also occurred on the tenth day. The patient made the journey to Modder River safely, and was then under the charge of Mr. Cheatle. A large diffuse pulsating swelling developed on the right side of the neck, with well-marked thrill and machinery murmur. During the next three weeks the swelling steadily contracted, and the patient was sent down to the Base one month after receiving the wound, when the condition was as follows. There is no evidence of any fracture of the jaw. On the right side of the neck a large aneurism fills the carotid triangle, extending from the mid-line backwards to the margin of the trapezius, and from the level of the top of the larynx upwards to the margin of the mandible. The wall is fairly firm, pulsation is both visible and palpable, and a well-marked thrill and machinery murmur are present. The latter annoys him by its buzzing when the head rests on the right side. The pupils are equal. Pulse somewhat irritable, about 100. The voice is weak and husky, and there is difficulty in swallowing solids. The actual swelling is somewhat remarkable in outline, on the one hand following up the course of the external carotid and facial arteries, and on the other extending backwards in the line of the wound track towards the exit. The patient was kept on his back with sandbags around the head during the next fortnight. For the first eight days such change as occurred was in the direction of localisation and contraction, but during the last six, evident extension occurred both backwards and downwards; this extension was accompanied by severe pain in the cutaneous cervical nerve area of the neck. The larynx became pushed over 3/4 of an inch to the left of the median line, and the extension beneath the sterno-mastoid downwards raised a doubt as to whether the common carotid could be exposed without encroaching on the walls of the sac. Owing to indisposition I had not been able to see the patient for some days, but now, after consultation with Major Simpson and Mr. Watson, it was decided that the best plan would be to expose and tie the common carotid as high as could be safely done. The operation was performed six weeks after the injury, and somewhat to our surprise offered little difficulty. The carotid was exposed at the upper border of the omo-hyoid, only a small amount of infiltration having occurred in the vascular cleft. No dilatation of the jugular was noticeable, and when a silk ligature was applied to the artery all pulsation was controlled, and the thrill in the vein disappeared completely. The after progress was satisfactory, but four days later the wound was dressed, as the patient's temperature had risen above 100°. The tumour was consolidated: no pulsation could be felt, but there was little apparent diminution in its size. A loud blowing murmur was audible, especially at the posterior part of the swelling.
On the morning of the fifth day the patient mentioned that he again heard the whirr during the night. There had been no sign of any cerebral disturbance and the pupils had remained equal throughout.
A week after the operation the stitches were removed, there was evidence of some blood clot in the lower part of the wound, and this later liquefied and was let out on the eleventh day. At that time a slight bubbling thrill could be felt at the upper part of the tumour, also slight pulsation in the line of the external carotid and at the most posterior part of the sac. The latter was much contracted, diminished in size and apparently solid, so that it was hoped that such pulsation as existed was communicated. Ten months later, no trace of the aneurismal sac exists. Neck normal, except for purring thrill. Voice strong and good. Pulse 100. Following his usual work.
(12) Carotid arterio-venous aneurism.—Wounded at Paardeberg. Aperture of entry (Mauser), at the posterior border of the left sterno-mastoid, 1 inch above the clavicle; exit, near the posterior border of the right sterno-mastoid, 2 inches from the sterno-clavicular joint. The injury was followed by very free hæmorrhage, mainly from the wound of entry, some 'quarts' of blood escaping; at any rate his clothes were saturated. The voice was hoarse and weak, and there was much difficulty in swallowing; for the first twenty-four hours he could swallow nothing, but gradual improvement took place. The patient was carried two miles to the Field hospital, and three days later travelled 36-40 miles in a bullock waggon to Modder River. Thence he travelled to Orange River 55 miles by train on the next day. A swelling was first noted when the wound was dressed some seven days after the injury. No evidence was ever existent of gross damage to either trachea or œsophagus beyond the initial dysphagia. The hoarseness of voice due to left laryngeal paralysis slowly improved, and was probably the effect of concussion or contusion of the left recurrent laryngeal nerve. During the patient's stay at Orange River a large pulsating swelling with a strong thrill developed. This was at first diffuse, but under the influence of rest it steadily contracted and localised. During this period the patient was seen several times by Mr. Cheatle, who noted considerable temporary enlargement of the thyroid gland.
At the end of eight weeks he had been allowed up some days, and travelled 570 miles to Wynberg. The aneurism was about 1½ inch in diameter, smooth and rounded, extending just beneath the left clavicle and nearly the whole width of the sterno-mastoid, but well defined in all directions. There was well-marked expansile pulsation, purring thrill along the jugular vein and over the tumour, and loud machinery murmur widely diffused along the whole neck and into the thorax. The voice was still weak and husky, but there was no dysphagia or dyspnœa. The left pupil was larger than the right.
The patient acquired enteric fever at Wynberg and when convalescent was sent to Netley, whence he returned home. The aneurism caused little discomfort. It may possibly have been of the inferior thyroid artery.