Journal : Photographic review of medicine & surgery ; vol. 2., no. 5.
Philadelphia : J. B. Lippincott & Co., 1871-72.
Description : pp. 38-40,  pl. ; ill.: 1 photo. ; 24 cm.
Photograph : mounted albumen.
Subject : Carotid artery — Traumatic aneurism.
EARLY in July, 1868, I was consulted by a colored woman, twenty-five years of age, on account of a tumor, of the size of a double fist, which occupied the right side of her neck and face. Nine months previously she was accidentally shot, one pistol-ball having penetrated just below and behind the angle of the jaw, the second having entered opposite the upper border of the thyroid cartilage, and ranged downwards towards the subclavian triangle, where it still remained. The former missile was removed from the ear. There was profuse venous hemorrhage from the lower wound, which was supposed by her attending physician to proceed from the internal jugular vein. This was checked by firm compression, under which the orifice made by the ball closed in one week. Six months subsequently, a small, pulsating swelling was observed just above the division of the primitive carotid artery, which rapidly increased until, at the time of her visit, it measured eight inches in its transverse and five inches in its vertical diameter, forming an extensive tumor, which was larger posteriorly than anteriorly, elevated the lobule of the ear, rested on the mastoid process, and extended over to the face nearly as high as the zygoma, and as far forwards as to within an inch and a half of the mental symphysis. It was quite soft at some points, particularly at its anterior limit, where it would apparently soon have given way ; elastic ; distinctly lobulated ; and the seat of tremulous pulsation and a blowing sound, both synchronous with the contraction of the left ventricle, and annulled by compression of the primitive carotid. The woman was advanced four months in pregnancy, and suffered from severe and constant pain, which she referred to the shoulder-joint, and, to some extent, to the tumor itself, the latter being relieved by arresting the flow of blood through the sac. The larynx and trachea were displaced to the left side ; the right sterno-cleido-mastoid muscle was pushed outwards and backwards, and was much wasted, thereby indirectly giving rise to torticollis.
The process of formation of the aneurism appears to have been in this wise. The pistol-ball grazed and contused the external carotid artery, but, on account of the natural resiliency of the vessel, the missile bounded off. Inflammation of the coats of the artery set in, followed by a small slough, and extravasation of blood into the surrounding tissues, which became condensed and thickened, forming, finally, a circumscribed sac, which limited the effused blood, and was lined by strata of fibrin.
With the twofold object of preventing the tumor from bursting, as it seemed likely to do, and of enabling the patient to complete her pregnancy in safety, I determined to ligate the primitive carotid artery, in preference to performing the more hazardous old procedure of laying open the sac and securing both ends of the injured vessel; and I felt the more inclined to practice the Hunterian operation, since its results are as favorable in cases of consecutive aneurism as in instances of true aneurism. On the 6th of July, with the assistance of Dr. Page and Dr. Maury, I cast a ligature around the primitive carotid at the omo-mastoid angle, or the point at which the omo-hyoid muscle emerges from beneath the sterno-cleido-mastoid, with the effect of arresting the pulsation and bruit. Forty-eight hours subsequently, slight pulsation again appeared in the tumor, which led some of the gentlemen who had seen the case with me to predict a failure. But I was not at all alarmed on this score, since after deligation of the carotid the anastomoses are so free and direct that temporary return of pulsation is not an uncommon occurrence. The pulsations continued for five days, for the first two of which they were feeble, but on the third day they were very marked, and the patient complained of a return of pain at the shoulder. After that time they began to diminish until the sixth day, when they disappeared entirely and the suffering ceased. During this time laminated clot formed to a very considerable extent, through which the tumor had acquired a firm, solid feel. The ligature dropped off on the sixteenth day.
At the expiration of two months the swelling had diminished two-thirds, and at the expiration of one year not a trace of it remained. The photograph shows its volume six weeks after the operation. Unfortunately, the picture taken before the operation has been mislaid, but the present one conveys an idea of the original size of the tumor.
Aneurism of the external carotid, whether of spontaneous or traumatic origin, is extremely uncommon, the only additional instance of consecutive arterial aneurism of which I have any knowledge being that of Professor Lisco, in which the operation of Antyllus was successfully performed. Rufz, of Martinique, and Gabe, of Masarellos, have each described an example of arterio-venous aneurism of this vessel. In the latter case, the tumor, which was of the size of a nut, and caused by the thrust of a sabre, was cured by Stromeyer by the old operation, compression and ligation of the common carotid having previously failed in the hands of Chelius.