No. 1613.

JULY 29, 1854.

Clinical LectureON

A CASE OF

TRAUMATIC CAROTID ANEURISM.Delivered Jan. 16th and March 27th, 1854, at the

Toronto General Hospital, Canada,BY W. R. BEAUMONT, ESQ., F.R.C.S. ENG.,

LATE PROFESSOR OF SURGERY IN THE UNIVERSITY OF TORONTO.

GENTLEMEN,-The case to which I am about to call your at-tention is of so great importance in surgery, and of such ex-

ceedingly rare occurrence, that although cut of office as a teacher,I am still unwilling that it should pass by without endeavouringto impress it on your minds. This is one reason which inducesme again to give a clinical lecture; another reason is that I wishto explain to you the grounds on which I have adopted thetreatment at present pursued, instead of risking the perform-ance of an operation necessarily attended with the greatestdifficulty and danger. The case you have, probably, all heardspoken of, as one of traumatic aneurism of the common carotid.Before, however, proceeding with the case, I will briefly explain,for those students who are not acquainted with the subject, theimportant commonly-existing differences between traumatic andspontaneous aneurisms. The term aneurism is usually appliedto a sac, the interior of which communicates with the interiorof an artery, and consequently receives arterial blood and pul-sation at each contraction of the left ventricle of the heart. Thiscondition always exists at an early stage of the disease, but maycease under certain curative changes. A traumatic aneurism,as its name implies, arises from the wound of an artery, and asthe perforation of the vessel takes place from without, all thecoats of the artery are divided, and therefore none of them canenter into the composition of the walls of the aneurismal sac,which are composed of condensed cellular tissue, and it may beof other tissues also, cut at the time the artery is wounded.A traumatic aneurism is termed circumscribed when its bloodis contained in a small cavity not extending far from the im-mediate vicinity of the wounded artery, (which is the conditionin the case I am about to read to you;) and an aneurism istermed diffused when its blood is contained in a larger cavity,which has gradually become increased in dimensions by the im-pulse of the blood, so as to extend from the wounded vesselamong parts more remote from the vessel. That form ofaneurism called spontaneous, is no doubt always preceded bysome degeneration of the artery, unfitting it to resist the im-pulse given to the blood by the contractions of the left ventricleof the heart. In sonie few cases, ulceration perforates all thecoats of an artery, and thereby may produce a false, and usuallydiffused, spontaneous aneurism. In other cases it has been found,though rarely, that all the coats of an artery remain entire, andbecome dilated into a sac or pouch, producing that which hasbeen considered by some as alone constituting true aneurism.Of such dilatation of all the coats of an artery in cases ofaneurism, examples have been recorded. Scarpa, however,who from his numerous dissections of aneurisms is one of thevery highest authorities on this subject, stated, many years ago,that " aneurism, in whatever part of the body it is formed, andfrom whatever cause it arises, is never occasioned by the dila-tation, but by the rupture or ulceration of the internal andmiddle coats of the artery, and consequently that these coatshave not the smallest share in the formation of the aneurismalsac." It is only the outer elastic coat of arteries, composed of- condensed cellular tissue, which, according to Scarpa, entersinto the composition of the walls of the sac. He was no doubt.-°ong in the universality of his proposition, but only in itsuniversality. Hodgson and Wardrop, who at a later periodpublished esteemed works on the subject, both express a positiveopinion that aneurism does sometimes commence by dilatationof all the coats of an artery, but that in such cases as theaneurismal sac enlarges, the inner coat or coats are ruptured,and consequently the rest of the sac is formed only of the outercellular coat, or the contiguous parts, so that the lining mem-brane of the artery is continued from the artery only over theadjoining part of the sac. This partial extension of the polishedlining membrane of the artery over the adjoining part of thesac, is very clearly seen in a preparation of a large aorticaneurism in the museum of the University of Toronto.

In traumatic aneurism, the formation of the aneurismaltumour is almost always more sudden than in spontaneous- - .

aneurism, because, in the former, there is less resistance to theimpulse of the blood, and consequently to the increase of thetumour, which minor degree of resistance in the sac of atraumatic aneurism is due to the absence of the outer elasticcoat of the artery in the composition of the walls of the sac.This latter circumstance is of importance in regard to thetreatment of the case I am about to detail to you, for in myopinion it forbids the performance of Brasdor’s operation-i. e.,the tying of the artery on the distal side of the aneurism, bywhich the impulse of the blood against the walls of the sacwould be immediately increased; and if this augmented impulseof the blood should cause the walls of the sac to give way, acircumscribed aneurism would become converted into a diffusedaneurism, or an extensive extravasation of blood, a conditionfar more unfavourable to the patient than that of a circum-scribed aneurism.

I will now proceed with the case. The patient, Joseph S-, aged twenty, was admitted, under my care, into theToronto General Hospital, on the 2nd of January, 1854. Hehad the appearance of a healthy subject, though reduced inflesh and strength by the large loss of blood which he hadsustained. He stated that it was about eight weeks beforehis admission, between six and seven in the evening, that hehad been stabbed in the neck, and in two or three other places,which had occurred suddenly, without any fight or struggle.Almost immediately after being stabbed he fell insensible,from the loss of blood, having walked, he thought, abouttwenty paces before falling. He remained unconscious, or

nearly so, till the next morning, (i. e., for about twelve hours,)when, in the act of sneezing, a second haemorrhage took placefrom the wound, to which adhesive plaster only had beenapplied the previous evening. His mother stated that he hadlost so much blood, that at times during the night she thoughthe was dead. On the following morning, immediately afterthe second haemorrhage, the edges of the wound were broughttogether by three points of suture; after which, there had beenno further bleeding. He had observed no swelling in the neckbefore the suture was made, but on the same day a small,roundish swelling commenced at the seat of injury, whichswelling had gradually increased in size up to the last fevrdays. There had been no pain in the swelling, but throbbinghad been present from its commencement.On examination, a very prominent tumour was found on the

left side of the neck, seated close to the clavicle, and extendingtransversely from the inner to the outer border of the sterno-cleido-mastoideus, having made its way through the cut fibresof the muscle. The tumour was distinctly circumscribed,somewhat conical in form, and circular at its base, which wasabout two inches in diameter. On the summit of the tumourwas a stretched and thin cicatrix, about one inch and a quarterlong by half an inch broad. The direction of the long diameterof the cicatrix was oblique, and rather nearer to a horizontalthan to a vertical line. We do not know the weapon withwhich the wound was made, nor do we know whether itspoint was directed horizontally, as in making a thrust, and sopiercing the artery on the same horizontal plane as that onwhich the cicatrix is placed; or whether the weapon had beenheld as a knife or dagger usually is held in the act of stabbing,and its point directed downwards. In the latter case, the

artery would be pierced considerably below the level of thecicatrix. The tumour pulsated strongly. To the touch, it

gave a distinct vibratory sensation or thrill, and to the ear aloud bruit de soufflet. By compression, the sac could be

emptied; and by firm pressure on the carotid distal of thetumour, the sac became much more tense and resisting to thetouch, and, I believe, somewhat larger, which latter circum-stances I consider the best evidence of the tumour being aneu-rismal, and of the aneurism being carotid. His pulse was 84,and moderate as to force and fulness; his appetite good. Iordered ten minims of tincture of digitalis three times a day,spoon diet, and perfect quietude.

On the 9th of January, a week after admission, the tumourand his pulse remained the same. He was now bled to tenounces, (the blood containing three ounces and a half of serum,and six ounces and a half of coagulum.) His diet was restrictedto a pound of bread and a pint of milk per diem, and thedigitalis was continued as before. On this day, I made a castof the tumour, in order to ascertain with accuracy any increaseor diminution in its size.On January the 15th, thirteen days after admission, and six

after bleeding, the tumour appeared smaller, pulsated lessstrongly, and its vibratory feel was less marked. Pulsationhad occasionally been observed in the external jugular vein,which I conceive may have been caused either by a commni-

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cation between the currents of blood in the common carotid of the day, and therefore may very justly be looked up to asand in the internal jugular, or by the aneurismal tumour the highest authority we have. Mr. Guthrie gives the follow-striking at each pulsation the external jugular, with which ing cases, which I take as precedents for the treatment I havevein the tumour was nearly in contact. The pulse had been adopted :-Colonel F was wounded by an arrow, opposite72 for the last three or four days, and the patient felt rather the bifurcation of the right common carotid, which caused aweaker than on admission. considerable loss of blood at the moment. The wound healed,

So far, gentlemen, the progress of the case has been favour- and some time afterwards a small pulsating swelling-anable, and I think we may reasonably expect that its conclusion aneurism-was observed at the part. Sir Astley Cooper ad-will be satisfactory. If, however, the tumour should increase vised that, as it did not increase, nothing should be done. Mr.and its walls threaten to give way, we may be forced to an Guthrie was afterwards consulted by the patient at Badajos,operation as the only chance of saving the patient’s life. I after the siege of that place, at which time the aneurism hadhave recently made a dissection of the parts concerned, not increased, nor did it up to the time of the patient’s death,without in the least disturbing them from their natural which occurred in action the year afterwards, the tumour notrelations, and, I believe, that deligation of the artery on the having been interfered with by any operation.cardiac side of the wound .would be an operation both Pierre Cadrieux, aged thirty-two, received, in Nov. 1811, amost difficult and dangerous to accomplish. Of some of wound from the point of a sword, which, entering above thethese difficulties and dangers I will speak. The carotid in clavicle, wounded the subclavian artery and vein, as was pre-this case must have been wounded very low down, and it sumed, where they pass over the first rib. The bleeding wasmay have been wounded just above the part where it is terrific, and the man fainted, remaining as if dead. He wascrossed by the left brachiocephalic vein, a wound of which placed under the care of Baron Larrey in the hospital in Grosvein might necessitate the performance of an operation, and Caillon. The next morning the wound did not bleed, but a,

would, in all probability, be fatal. A small wound in this pulsating swelling had formed above and below the clavicle,vein, or in the lower part of the internal jugular, it is true, and a peculiar thrilling sound could be felt and heard deeplymight by possibility be treated as Guthrie has done in the in the direction of the axillary vein. The wound healed onlatter vein, (but high up in the neck,) i. e., by taking up with the eighth day, and on the twentieth the aneurismal swellinga tenaculum the margins of the opening, and then placing a had disappeared, but the thrill remained with the pulsations.fine ligature around the opening, only in such a manner as to of the veins of the neck. In 1815, about four years after-interfere but little with the current of blood through the vein. wards, the Baron again saw the patient, who had no pulsationI believe, however, that this procedure would be impracticable in the axillary, radial, or ulnar arteries, but the limb retainedon a vein lying at the bottom of a deep hollow, filling at every its warmth and sensibility. Nothing is said of the subclavianmoment with blood flowing from the wounded vein itself. The vessels, which we may therefore suppose were free fromleft common carotid on the level of the sterno-clavicular arti- aneurismal swelling.culation, you know, lies at a great depth from the surface, and Delpech, in a nearly similar case of wound, in which he-is moreover in rather close contiguity with the two large believed the common carotid was wounded near its origin,veins I have mentioned, and also with the left subclavian and which was followed by a terrific haemorrhage, which almostartery, and with the nervus vagus. At the bottom of a deep destroyed the patient, acted in a similar manner, .and with thewound filled with blood, it would be difficult to isolate and same successful result.carry a ligature around the carotid with the certainty of not Mr. Guthrie says, " These cases show the propriety ofinjuring any of these important parts. Some smaller veins, that rule I have endeavoured to establish, of letting largesuch as the anterior jugular, or inferior thyroid, might, if arteries alone until they bleed and demand attention. Therewounded, embarrass the operation by their bleeding. Any can be little doubt that if Larrey and Delpech had tried to;such veins might be tied in two places, and cut between the perform operations on these arteries they would have lost theirligatures, if they could not conveniently be drawn aside. If patients. It is time enough to put men’s lives in jeopardyeventually, in this case, the aneurismal sac should seem about when the necessity for doing something is manifest." to burst, I should endeavour to place a ligature around the It is this advice of so eminent a surgeon as Mr. Guthrie,-artery on the distal, (though this might not be necessary,) as advice founded on the results of these and other analogous cases,well as on the proximal side of the wound, on account of the -which induces me to abstain from any operative procedurelarge retrograde current of blood which would take place into until such shall seem the only chance of saving my patient’sthe aneurismal sac if a ligature were placed only on its life. The treatment I have adopted is usually termed Val-proximal side. Mr. Guthrie has recorded, in his work on salva’s. It consists in means tending to diminish the impulse" Wounds of Arteries," a case in which, after he had tied of the blood against the aneurismal sac,-viz., venesection,the common carotid on the cardiac side of a wound in this occasionally, the blood being abstracted in quantities whichvessel, the haemorrhage from the retrograde current of the patient can bear, and without lessening too much the pro-blood alone was nearly as great as that before the appli- portion of fibrin to the watery part of the blood; secondly,cation of the ligature, and was only arrested by deligation in spare and unstimulating diet; thirdly, in perfect quiet bothof the artery on the distal side of the wound also. Sup- of mind and body; and, fourthly, in the administering ofposing, however, that in S-’s case the operation were medicines capable of lowering the force and frequency of theaccomplished without any mishap, there would still be the contractions of the heart. These means tend to favour thedanger of a fatal haemorrhage, when the vessel should be spontaneous cure of aneurism, which may be accomplisheddivided by ulceration at the place of deligation, though this is partly by the slow contraction of the sac, when it ceases to beless likely to occur than in a case of spontaneous aneurism, distended by a superior force, and partly by the deposit ofbecause, in the former case, the artery may be presumed to be fibrin in layers on the interior of the sac, layer after layer athealthy. Besides the danger from haemorrhage, a fatal result last rendering the contents of the sac solid, the fibrin becomingmay follow from other causes. Experience has shown, that eventually partly absorbed and partly organized. The case, Istopping the current of blood through one common carotid may told you, was of exceedingly rare occurrence, for even Mr.induce fatal disease of the brain, of which Mr. Guthrie cites Guthrie seems only to have witnessed one case of traumaticsome cases, Paralysis of the opposite side of the body has aneurism of the common carotid, and has alluded only tobeen an almost immediate result, attended with twitchings or another, the case treated by Delpech. The extreme rarity ofconvulsions of the same side on which the carotid had been such cases is to be accounted for by the fact that wounds oftied. Softening and abscess of the brain have also occurred as the common carotid are almost always fatal from the imme-more remote effects. In THE LANCET, of December 17th, 1853, diate loss of blood. This lecture, gentlemen, I will concludeMr. Solly, in a lecture on Carotid Aneurism, quotes the follow- when time shall have shown us the conclusion of the case.ing passage from a paper by Dr. Norman Chevers, published ____

in the thirty-sixth volume of the late Medical Gazette. Dr. [CONTINUATION OF LECTURE, MARCH 27TH, 1854.]Chevers says,

" I find fourteen cases in which obliteration of [CONTINUATION OF LECTURE, MARCH 2?TH, 1854. ]one of the carotid arteries was distinctly followed by great IT is now, gentlemen, ten weeks since I had the pleasure ofinterference with the circulation through the brain, which in meeting you in order to call your attention to a case of trau-eleven cases produced fatal results." Great congestion, or matic carotid aneurism. Since that period the case has pro-inflammation of the lungs, has also been found to result from ceeded, as you already know, most favourably, and I havedeligation of one common carotid, little else to do than communicate to you a continuation ofWith all these possible dangers attendant on an operation its history. In my last lecture I read to you my notes as far

for the cure of the aneurism under consideration, I preferred as the sixth day after the first venesection, at which time Iadopting the course advised by Mr. Guthrie in analogous cases, thought there was a slight diminution in the size of thei. e., in the wounds of arteries, for he has probably also givaza aneurismal tumour. Two days after this, on the 17th of Jan.,more profound thought to the subject than any other sm’geon ) there was a very marked prolongation of the tumour upwards.

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- i. e., in the direction of the blood’s current, the pressure ofwhich was probably greatest against the upper part of the sac,and, if so, from this cause its dimensions were increased inthis direction. It is true that the upper part of the sac mighthave been the least resisting, and therefore the first to yield,even though the impulse of the blood against it should nothave been greater than against the rest of the sac. This pro-longation of the aneurismal sac felt like a small nodule en-

grafted, as it were, on the general swelling. The pulse wasat this time 66, and small, and the patient did not thereforefor the present appear capable of bearing a further loss ofblood.On Jan. 22nd, thirteen days after the bleeding, the tumour

was decidedly smaller, and the pulsation, which had beenoccasionally seen in the external jugular, had ceased forsome days past.On Feb. 2nd, twenty-four days after the first bleeding, the

tumour was still on the decrease, and he was bled again totwelve ounces, which he bore well. On Feb. 6th, four weeks after the first bleeding, the tumour

was reduced to half its former size, the diminution being verygreat after the last bleeding. It had been gradually and veryperceptibly diminishing during the last fortnight. It felt quitesolid and much harder, but the bruit remained as loud, ornearly so. There had not been observed any pulsation in theexternal jugular during the last two or three weeks, but adistinct vibratory feel or purring had throughout been per-ceptible over and along the course of the internal jugular, from. the cicatrix to a.point as high as the angle of the jaw, or verynearly as far. His health and strength had not been impairedby the treatment, which had been steadily pursued from thefirst.On Feb. 22nd, six weeks and two days after the first bleed-

ing, and fifteen weeks after the receipt of the wound, thetumour was scarcely perceptible; and as his strength had notin the least suffered, he was again (the third time) bled to tenounces; and it is worth bearing in mind that the blood pre-served its former proportion of fibrin-viz., six ounces anda half of coagulum, to three ounces of serum.

Eight weeks after the first bleeding, the tumour was still,though scarcely, visible, and it felt beneath the skin like ahard and slightly enlarged lymphatic gland. During the wholeof this time, he had taken three times a day fifteen or twentyminims of the tincture of digitalis, and the same diet had beenstrictly adhered to. He was now allowed to sit up for the firsttime.Nine weeks after the first bleeding, and eighteen after the

receipt of the wound, the aneurismal tumour was no longervisible, but could still be felt beneath the skin. The bruit was.perhaps as loud as ever, continuous, sounding like the roar ofthe sea, but increased at each pulsation; the vibratory feelwas also the same.On March 20th, ten weeks after making the first cast of the

neck, I made a second, of which the right and left sides pre-sented no difference, except that on the left there was a raisedand puckered cicatrix. The same bruit still was heard asloud, and the same vibratory feel was still as distinct over thecourse of the internal jugular, all of which phenomena remainthe same up to this day, the end of the eleventh week afterthe first bleeding; but no vestige of the tumour can be feltbeneath the skin. For the last week, he has been allowed asmall mutton chop daily, in addition to the pound of breadand pint of milk. His health is good, and he feels much

stronger than he did a week ago. The persistence of the loud,’continuous bruit, and of the vibratory feel perceived over thecourse of the internal jugular, can, I conceive, only be ac-counted for by the supposition of a communication betweenthe currents of blood in this vessel and in the common carotid,both of which may have been penetrated by the wound.

P. S. -If a communication between the common carotid andinternal jugular exists-and I do not see how it can be other-wise, for both the bruit and the thrill can be perceived nearlyas high up as the angle of the jaw, and the thrill is not felt byplacing the finger on the carotid-then this case is one of,perhaps, unprecedented occurrence, for in it we find both atraumatic carotid aneurism, and also this abnormal communi-cation between the artery and vein. Firm pressure on thecommon carotid near its bifurcation causes a total cessation ofthe thrill, and diminishes greatly the loudness of the bruit.A przoai, I should have expected a contrary effect. Thetumour could not have been an aneurismal varix, a merevenous dilatation caused by the impulse of arterial blood, forsuch could hardly have occurred as a subcutaneous tumour ina vein so deeply placed, and so covered by muscles; and,

moreover, its contents would not have become solid beforedisappearing, nor is it likely that it would have disappearedat all.

It will be interesting hereafter to learn if violent muscularexertion can cause the upward current of blood from thecarotid so to impede the downward current in the internaljugular as to give rise to any cerebral disturbance such ascongestion might induce.A cast of the patient’s neck, made when the tumour was at

its largest, and another made ten weeks afterwards, when thetumour had entirely disappeared, I hope very shortly to beable to send to the museum of the Royal College of Surgeonsof England.

CLINICAL AND CRITICAL CONTRIBUTIONS TOOBSTETRIC SCIENCE AND PRACTICE.

BY ROBERT BARNES, M.D. Lond.,MEMBER OF THE ROYAL COLLEGE OF PHYSICIANS, PHYSICIAN-ACCOUCHEUR

TO THE WESTERN GENERAL DISPENSARY, PHYSICIAN TO THE METRO-POLITAN FREE HOSPITAL, LECTURER ON MIDWIFERY, ETC.

(Continued from p. 689, vol. i. 1854.)

II.-ON VASCULAR POLYPI.

THE tumours which take their rise from the bloodvesselsrunning under the mucous membrane are the true " vascular

polypi," a term which has not unfrequently been erroneouslyapplied to the fibro-cellular polypus. The vascular polypus isa form of teleangi retasis consisting in a dilatation or aneu-rismal growth of the vessels, resembling naevus or haemorrhoids.This form of polypus is rare. Examples have, however, beenrecorded.

III.-ON POLYPI SPRINGING FROM THE MUCOUSMEMBRANE.

The tumours which arise from the mucous membrane are oftwo kinds.

A. The fibro-cellular polypus, sometimes called the "gelati-nous," the "mucus," or the "vesicular" polypus. These

polypi most commonly spring from the cavity of the cervicalcanal; they are but rarely found in the cavity of the uterus;and perhaps this may be accounted for by the scarcity ofcellular tissue in the constitution of the mucous membrane inthis latter situation. The microscopical characters of thesepolypi assimilate to those of the fibro-cellular sub-mucous tissue.Mr. Paget has accurately described them as presenting " deli.cate fibro-cellular tissue, in fine, undulating, and interlacingbundles of filaments. In the interstial liquid, or half-liquidsubstance, nucleated cells appear imbedded in a clear or dimly-granular substance; and these cells may be spherical, or

elongated, or stellate, imitating all the forms of such as occurin the natural embryonic, fibro-cellular tissue; or the massmay be more completely formed of fibro-cellular tissue, inwhich, on adding acetic acid, abundant nuclei appear. Ingeneral, the firmer the polypus is, the more perfect, as well asthe more abundant, is the fibro-cellular tissue." To this itmay be added, that these polypi are covered by mucousmembrane, containing blood-vessels in greater or less abun-dance. The size of these polypi varies greatly. They seldom,however, attain the magnitude sometimes exhibited by themuscular polypi. The polypus I removed from the firstpatient answered exactly to this description.B. The follicular-epithelial polypus. I propose to give this

name to the tumour which has sometimes been less accuratelycalled the -" Nabothean" or the " glandular" polypus. Thisform is thus described by Dr. Lee :-

" A fourth variety of tumour of the uterus, to which theterm polypus has been applied, is produced by a morbidenlargement of the glandulae or ovulse Nabothi. One of thesebodies is sometimes converted into a cyst as large as a walnut,or even a hen’s egg, and hangs by a slender pedicle from thecervix or lips of the os uteri. It is smooth and vascular, and.contains, in some instances, a curdly matter, or yellow-coloured, viscid fluid....... Though unacquainted with thenature of the glandular tumour of the os uteri, Herbiniauxhas given a description of the appearances it most frequentlypresents: ’There is another species of polypus,’ he observes,‘ extremely soft, of which M. Levret has not made mention: itis a little excrescence, of the same form as the preceding, butwhich is always very small; it arises from a segment of theorifice of the uterus, and either remains within the orifice orhangs a few lines out of it. Often it is not larger than a pea,sometimes it is the size of a finger, but its stem is usually verylarge, considering the small size of the tumour, "