A Case of Extirpation of a Large Non-Pulsating Aneurysm Involving the Common, Internal, and External Carotid Arteries of the Right Side of the Neck with Remarks on Non-Pulsation in Aneurysms and the Treatment of Aneurysms by Extirpation

W. J. Walsham
1899 Medico-chirurgical transactions  
six years ago he first noticed a little lump in the right side of the neck, which had growni slowly and without pain until four months ago, since which time it had begun to increase rapidly. At first it was hard, painless, not tender on pressure, and felt to Mr. Johnson like an enlarged gland. Some of the teeth on the right side were discovered to be carions, and two were extracted, but without influencing the swelling. The patient, a stoutish, florid, short-necked, and healthylooking man, had
more » ... hylooking man, had hitherto enjoyed excellent health, and his family history was good. There existed on the right side of the neck, extending from below the right ear and angle of the jaw almost down to the clavicle, a swelling the size of a cricket ball. It reached nearly to the middle line in front, and behind passed deeply beneath the sterno-mastoid muscle. It was roughly globular in shape with a somewhat irregular surface, and was generally hard in consistency, but soft and semi-fluctuating in places. The skin over it moved freely, and although it clearly had deep connections it was not fixed to bone, nor to the larynx, which moved independently both vertically and laterally. No pulsation was present, and nothing in the form of a primary growth was discoverable either in the mouth, pharynx, or larynx. Breathing and swallowing were quite natural; the pupils were equal; and nothing was noticed abnormal in the pulse; in short, the only trouble complained of was the inconvenience in moving the neck, due to the large size of the swelling, and a shooting pain, like earache, in the right ear at night-time. A medium-sized exploring syringe was passed 224 at University of Leeds on June 5, 2016 jrs.sagepub.com Downloaded from NON-PULSATING ANEURtYSM deeply into the tumour at one of the soft spots, but only a little glairy fluid was obtained, the piston being suckled back when released from pressure. I came to the conclusion that the swelling was primarily glandular, and that its recent increase mnade it probable that it was now malignant in nature. The patient was placed on medium doses of liquor arsenicalis, and in November, 1895, he was shown at our weekly consultations, when those of my colleagues who were present considered the tumour was now probably malignant. There appeared some doubt, however, whether it might not be merely inflammatory, and the majority advised that an exploratory incision should be made. All agreed that if the growth were found malignant the incision should be closed, as it was felt, considering the size of the growth and its evident deep connections, that its extirpation under these circumstances could only be accomplished with extreme difficulty and risk. The state of the case having been fully placed before the patient, he decided, after consultation with Mr. Johnson, to have an exploratory incision made. On December 5th, 1895, with the assistance of Mr. Berry, our then surgical registrar, I proceeded to explore the growth. Having placed the patient under chloroform I made an inicision about three inches in length over the tumour alongf the anterior border of the sterno-mastoid. The tumour when first exposed appeared to be well encapsuled though slightly adherent to the neighbouring parts. When cut into it was of a greyish colour and firm consistency. Seeing that the growth was well encapsuled and wavs now obviously not malignant, I determined, with the concurrence of Mr. Berry, to attempt its removal. Mr. Berry at this stage of the operation was of the opinion that we were probably dealing with an old thyroid cyst. Whilst, howevei, cautiously continuing the enucleation, a sudden gush of darkish blood took place from the exploratory incision previously made in the tumour, but was controlled by the fingers, sponges, 225 at University of Leeds on June 5, 2016 jrs.sagepub.com Downloaded from EXTIRPATION OF A LARGE and gauze. For the first time it dawned upon us that we were dealing with an aneurysm; we felt, however, at this stage of the proceedings there was nothing left but to complete its extirpation. Accordingly, whilst Mr. Berry controlled the hwmorrhage, I cautiously dissected downwards towards the clavicle till the common carotid was discovered entering the lower and outer part of the sac. Two stout silk
doi:10.1177/095952879908200112 fatcat:62egz5dlhzcmxoxoynshxcsvbm