(13) Innominate arterio-venous varix.—Wounded at Modder River. Entry (Mauser) posterior margin of left sterno-mastoid, close above the clavicle. Exit in anterior axillary line one inch below the right anterior axillary fold. Soon after the injury a considerable amount of blood was coughed up, and occasional hæmoptysis persisted for the next four days. The patient was moved from the Field hospital by train to Orange River, a journey of 55 miles and some four hours' duration, on the fourth day. When examined there was slight fulness over an area roughly circular and about 2½ inches in extent, of which the sterno-clavicular joint lay just within the centre. Over this area there was faint pulsation with a strongly marked thrill and loud systolic bruit. The radial pulses were even, the right pupil larger than the left. No pain, and no dyspnœa. The right eye was partially closed, but could be opened by the levator palpebræ superioris. The patient was shortly afterwards sent to the Base, and when seen there twenty-five days after the injury, there was little change in the condition except that the fulness had disappeared, the thrill was more marked, and a typical machinery murmur transmitted along both carotid and subclavian arteries had developed. There was no headache and the man himself did not notice the bruit. Evidence of mediastinal hæmorrhage existed in the presence of subcutaneous discoloration of the abdominal wall, below the ensiform cartilage and extending slightly over the costal margin of the thorax. In the absence of an aneurismal swelling, or of the development of any further symptoms, the patient was sent home to Netley in January.
I saw this patient in Glasgow a year later. He was employed as a lamplighter, and was able to do his work well, only complaining of attacks of shortness of breath on exertion. He said these were apt to come on each evening about 6 p.m. The pulse was 100 when the erect position was maintained, and 84 to 88 in the sitting posture. The right pupil was still dilated, reacting for accommodation but little to light. The palpebral fissure was normal in size and there was little, if any, diminution in strength of the right radial pulse.
On inspection no pulsation was visible; in fact, the pulsation of the normal left subclavian was more apparent in the posterior triangle of that side. The sterno-mastoid was prominent, also the sternal third of the clavicle. On firm pressure some pulsation was palpable beneath the sterno-mastoid, but no definite evidence of the presence of a sac could be detected. Purring thrill and machinery murmur were still present, but the former was slight, and palpable only with the lightest pressure. The machinery murmur had ceased to be audible to himself, and was by no means loud or very widely distributed.
The condition had, in fact, steadily improved, and become far less obvious. The prominence of the sterno-mastoid and clavicle still present was difficult of explanation, except on the theory of an injury to the bone, or that an aneurismal sac had consolidated spontaneously.
(14) Arterio-venous aneurism, root of right carotid.—Wounded at Magersfontein. Entry (Mauser), centre of right infra-spinous fossa. Exit, 3/4 of an inch above clavicle, through point of junction of the heads of the right sterno-mastoid muscle. Range 200-300 yards. When wounded the man ran two hundred yards to seek cover. There was no serious external hæmorrhage, but the injury was followed by some difficulty in swallowing, and hæmoptysis, which lasted for the first two days. The right radial pulse was noted to be smaller than the left, and weakness in flexion of the fingers, with hyperæsthesia 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 1¼ 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 line, and the precordial dulness was somewhat increased. The pulse numbered 80 to 84. The muscles supplied by the ulnar nerve were very weak, but not much wasted, and ulnar sensation was imperfect.
The aneurism had considerably altered in form and outline; its walls were dense and firm; it extended 2½ inches upwards in the line of the carotid artery, beneath the sterno-mastoid, but projected beyond the posterior border of that muscle. The larynx was displaced 1/2 an inch to the left of the median line; the voice was still husky, although much stronger than it was; the anterior jugular vein was dilated. The purring thrill was very superficial, and chiefly palpable over the subclavian vessels. The machinery murmur was still loud, but much less widely distributed than before; it was still audible to the patient when he lay on his right side.
This case was of much interest from the diagnostic point of view. When I first saw the patient I considered the injury to have implicated the innominate vessels. Later, from the facts that the thrill was imperceptible in the episternal notch, and that the main part of the tumour was situated in the posterior triangle, that the wound was of the root of the right subclavian vessels.