Aneurism of Common Carotid Artery. 97

always experienced in the treatment of some varieties of luxation-- one which has often become quite insuperable, and forced him to abandon the attempt at reduction as wholly iml)racticable , and condemn the sufferer to be a hopeless cripple for life.

ART. VII.--Case of Spontaneous Aneurism of Common Carotid Artery, left side--Ligature of Artery in •ower Stage of its Course--Cure of Aneurism. By CHRISTOPHER FLEMING, M.D., Ex-President Royal College of' Surgeons; Late Surgeon to the Richmond Hospital; Visiting Surgeon to Steevens' Hospital; Senior Member of the Court of Examiners, Royal College of Surgeons, Ireland, &c., &c.

SOME of the details of the following case, though it is of compara- tively distant date, possess points of practical interest which appear to me to entitle them to a special record. The notes taken during the progress of the case in hospital, of which the following may be considered as a brief summary, have lately t~allen under my observation.

A Welshman, aged forty years, an ostler by trade, was sent to me from North Wales, with a tumour on the left side of the neck, having many of the features of aneurism of the carotid artery. He was admitted into the Richmond Hospital in August, 1852. The tumour was about the size of a large orange, somewhat irregular in shape, and projected so much externally as to render the integu- ments covering it remarkably tense. It was imbedded behind the angle of the jaw, forcing the parotid gland upwards, and bulging into the fauces, where it, could be seen and fhlt, pushing forward the left arch of the palate, and encroaching beyond the mesial line behind the pharynx and the upper part of the larynx. Posteriorly, it passed beyond the tube of the ear into the occipital region, where it distended outwards, the upper attachment of the sterno-mastoid muscle, its anterior margin advanced on the body of the jaw, about midway to the symphysis, and interiorly it might be said to have been bounded by a line parallel with that of the lower edge of the crieold cartilage. Its transverse measurement along the base of the jaw was five inches, and was increased about half an inch in the act of degluti- tion. Its vertical measurement along its central portion was about three inches. There is a cast of these several outlines in the

98 Aneurism of Common Carotid .Artery.

museum of the Richmond Hospital, and also a drawing by Conolly, executed with his usual graphic accuracy, of which the accom- panying wood-cut is an accurate representation. The integuments covering the tumour were of a natural colour, and presented marks of leech bites and cicatrices from ulcers, the results of several local stimulating applications. A t the lower part of the neck numerous superficial and deep-seated veins of large size were traceable, and at the outer and back part of the tumour the external jugular vein was to be seen crossing obliquely, and bedded in its walls. Pulsation, in some points less evident than in others, was yet very manifest, both to the eye and touch, especially in the throat, and was controlled by compression on the main vessel. The expansile and contractile character of the tumour, though limited, was also seen and felt. On auscultation there was a systolic and diastolic bruit, and accom- panying the systolic, some ringing and musical murmurs were audible, which were much modified in their insensity by the amount of pressure made on the tumour. These several sounds were distinguishable by the naked ear. The man stated that twenty years previously he had an attack of what appeared, from his account, to have been acute tonsillitis; that for a month he was unable to open his mouth satisfactorily; that subsequent to this period a small tumour, about the size of a marble, made its appear- ance beneath the angle of the jaw ; that it progressively increased in size, but that only within the last four m o n t h s had it even approached its present magnitude, and this rather suddenly, whilst stooping at his ordinary stable work. He was now, for the first time, attacked with an uncomfortable feeling in the head, and with occasional difficulty in his respiration. The latter complaint recurred in some degree when he stooped, or exerted himself much in walk- ing ; otherwise, he suffered nothing worth noticing. He had no pain in the tumour, or i~ its immediate vicinity ; no fixed pain in the head ; no giddiness. He could lie indiscriminately on either side and in any position of the head, but was liable to sudden startings from sleep, with sensatlons of dyspncea and dysphagia. His voice was unaffected. He was a man in tolerably good bodily health, of medium stature and framework, and of a remarkably placid, though nervous tempera- ment. A t the time of his admission into hospital his respiration and his circulation were tranquil, his ordinary range of pulse was from 76 to 80, and his digestive functions were healthily performed. The only abnormal, vital, physical sign discernible, was a loud bruit following the cardiac systole, persistent and traceable from the apex

l'L.t'l'F, I.l]. Vol,. 1,V].] INr 20, p. D~.

DR, FI.E,mxa on Spontaneous Aneur i sm of Common Carotid Alter),.

By DR. FLEMING. 99

Of the heart, where it was very intense, along the tract of the aorta, towards its arch. No bruit of note could be detected along the thoracic or abdo~inal aorta; neither in the superficial arteries were there visible those indications of' cardiac valvular lesions described by Dr. (now Sir Domlnlck) Corrigan. The brachial artery and the arteries of the forearm were free fi'om these, so also were the femoral. There was no irregularity of the action of the heart or of the pulse, and there were not, nor had there been, any attacks of dyspncea beyond those already specified, and they appeared to be distinctly attributable to the local pressure of the tumour.

After much deliberation, all doubts respecting its aneurismal characters being removed, the ligature of the common carotid artery was decided upon. The operation was performed on the 18th Aug., in presence of my colleagues at the hospitM, and many other profes- sidnal friends. No chloroform was administered, and the artery was necessarily tied low down in the inferior stage of its course, below ~he omo-hyoid nmscle. Much caution was required in the first steps of the operation from the meshes of large, tortuous, and cross veins, particularly from the external jugular, which lay in the line of the incision, and much delay and embarrassment occurred in pass- ing the ligature around the artery, as well from the extreme depth at which it lay, as from the total absence of any pulsation in it, and the condensation of the surrounding structures fi'om previous thickening. Moreover, the man was so feeble and ~:Ant, that it was difficult to detect any pulse at the wrist. The internal jugular vein was full, and so distended as often to cover the artery, and to render the passing of the aneurism needle under it a matter of no small difficulty. Again and again I thought I had the needle around the artery, when, slipping away, it would roll fi'om the needle; ultimately I succeeded, and, inserting a ligature in it, secured it under the vessel, and removed the needle. The man, throughout the whole, and necessarily tedious steps of the operation, conducted himself with the greatest calmness and steadiness. He was now pallid and feeble, and it was deemed more prudent to wait fbr somewhat of reaction before the artery was tied. After a time this was established, and though the pulse was yet feeble, I took the opportunity, and tied the artery as near as possible to the lowest part of the wound, having first ascertained, by compressing the artery, that the pulsation in the aneurism was fully commanded. No appre- ciable effect was produced as regarded the sensations of the patient ; no uneasiness in the head; no fkintness; no cerebral derangement

100 Aneu~qsm of Common Carotid After!~.

of any kind ; on the contrary, the man gave directions himself as to the mode of removal to his bed in the most perfect composure. The effect of the deligation of the artery on the aneurism was most satisfactory; its pulsation was fully stayed, and its tension and size completely altered. The lips of the wound were bro ,ght together by strips of adhesive plaister, and the ligature adjusted in the usual way.

From the date of the application of the ligature until its separa- tion, on the 21st day after the operation, the progress of this case was most satisfactory. There was a return of pulsation in the tumour on the evening of the second day, but it subsided after forty-eight hours or so, and did not recur. With this exception, there was no other untoward symptom. From day to day a diminution in the size of the tumour took place, and its essential anenrismal elements wholly disappeared, a distinct surrounding induration alone remaining, which was traceable when the man left hospital, in tile first week of October.

In the following April I had occasion to visit Holyhead, and made it ray business to see him. His general health was much improved ; the cardiac sounds were decidedly improved ; the systolic bruit was much less rough and prolonged, and the cardiac action tranquil. There was a tumour in the neck, but occupying its middle region, the upper portion of the original tumour having completely disappeared. Not a trace of pulsation was discernible, but the peculiar diastolic murmur, accompanied with the whistle above noted, was communicated to the naked ear, and through the stethoscope. There was no tumour in the left palate ; it had completely subsided. There was ~ projection along the side of the pharynx, near the tonsil, but it gave no annoyance.

I should apologise for the length of this communication. My excuse is tile special interest and importance of its subject. Carotid aneurism is, comparatively, of rare occurrence; its diagnosis is often obscure and difficult; its cure is effected, almost necessarily, by ligature of the main artery; and the results of this operation, its casualties, and its contingencies, are too often very treacherous. In the present advanced and almost exhaustive state of the subject of aneurism at large, both in its clinical and in its pathological aspects, this class of aneurism has, doubtless, received due attention. The record of this case will, I hope, tend to confirm views, instruc- tive and encouraging to the physician and the surgeon, where doubts may be entertained as to treatment by operation.