CASE OF ARTERIO-VENOUS ANEURISM OF THE 
AXILLARY ARTERY AND VEIN OF FOUR- 
TEEN YEARS’ DURATION. 
WILLIAM OSLER, M. D., 
PROFESSOR OF MEDICINE JOHNS HOPKINS UNIVERSITY, AND PHYSICIAN IN-CHIEF TO 
JOHNS HOPKINS HOSPITAL. 
THE following case is worth placing on record, partly on 
account of its rarity, but more particularly on account of 
the long duration without serious symptoms, and the 
admirable illustration which it affords of the propriety of non- 
intervention in certain instances of aneurismal varix. 
On December 28, 1888, I saw in Llamilton, Out., with Dr. 
Malloch, H. B. T.,aged twenty-five, who presented the following 
condition : He is a strong, healthy young man, with a fresh 
complexion, well developed muscles and a well-shaped thorax. 
Inspection.—The apex beat of the heart is in the fifth inter- 
space inside the nipple line. There is a slight fulness beneath 
the outer half of the left infra-clavicular space, and pulsation is 
seen in this region; there is also slight, but not nearly such 
marked, sub-clavicular impulse on the right side. The carotids 
do not throb visibly, but on the left side above the clavicle 
there is fullness in the lower cervical triangle, and a distinct im- 
pulse. The position and appearance of the left clavicle are nor- 
mal. It is not elevated. There is perhaps slight fulness in the 
first intercostal space, near the sternum ; there is no special 
prominence of the first rib, or of the manubrium sterni. 
Palpation.—The cardiac impulse at the apex has moderate 
force; there is no thrill. There is no impulse upon the sternum, 
or beneath the inner half of the left infra clavicular region. 
There is a very distinct impulse in the prominence above 
referred to in the outer half, upon the clavicle itself, and upon 
the sub-clavicular fulness. There is a continuous vibratory 
thrill communicated to the hand, which' is‘“‘Mrii.x^H;-he-whcile. 2 
WILLIAM OSLER. 
region of pulsation, and the entire left side of the root of the 
neck. It is not felt on the right side, nor over the sternum, nor 
on the praecordia. There is no definite tumor to be felt either 
below or above the clavicle ; the enlargements referred to are 
soft, and yield readily to pressure. High up in the axilla there 
is a fulness in the course of the artery. To the touch it does 
not give the sensation of a distinct tumor; there is a remarkable 
continuous thrill in this region which is obliterated here and in 
the subclavian region when the axillary artery is compressed. 
The left arm looks normal, the veins are not distended, the 
finger-nails are neither blue nor incurved, and the tips are not 
clubbed. The pulse in the left radial is not so strong as in the 
right; there is no perceptible retardation. 
Percussion.—The cardiac dullness is normal. Percussion 
over the manubrium and on the inner half of the infra-clavicular 
region is clear; the outer half is distinctly resonant. 
Auscultation.—The heart sounds are clear at apex and base. 
There is no special accentuation of the aortic second sound ; no 
murmur in the right carotid, or in the right sub-clavian arteries. 
Over the outer half of the left infra-clavicular area, on the corres- 
ponding portion of the clavicle, over the lower cervical triangle 
from the sterno-mastoid border to the attachment of the 
trapezius there is a loud continuous bruit. This murmur is also 
heard with great intensity in the axilla, down the inner surface of 
the arm, and on the front and back of the fore-arm. It is very 
loud and distinct in the palm of the hand and in the finger tips. 
In all of these regions the murmur resembles art intense bruit de 
diable, or a venous hum at the root of the neck. At one point 
only, just below the clavicle, there is a slight systolic intensifica- 
tion of the murmur. Posteriorly the bruit is heard in the sub- 
scapular space and feebly upon the scapula. Subsequently, when 
the patient came under my care in Philadelphia, he was seen by 
Professor Ashhurst, who noticed that pressure upon the axillary 
artery high up in the arm-pit caused complete disappearance of 
the thrill and the murmur in the clavicular region. The diag- 
nosis of arterio-venous aneurism was made. 
The history of the patient is as follows : When fifteen years 
of age in running down a sloping grass plot he fell and forced a 
lead pencil, which was in his watch-pocket, into his side high up A R TER JO- VENOUS ANEURISM. 
3 
in the axilla. When pulled out this was followed by a gush oi 
blood; which instantly ceased- Shortly after, the arm began to 
swell and was subsequently black and blue to the wrist. His 
physician kept him in bed for two day.' 3and in the house for 
ten days with his arm in a sling. He does not seem after this to 
have had any special trouble. He has been accustomed 
to take a great deal of athletic exercise; rows in the 
summer, and has worked hard in the gymnasium during the 
winter months. He consulted Dr. Malloch for occasional 
pain in the lower portion of the chest and sleeplessness, but 
all this time he was keeping up his athletic sports and the condi- 
tion above described was only discovered accidentally by Dr. 
Malloch, who stripped him to examine for the cause of the pain. 
He has had no serious interference with the use of the arm, but 
considered himself in perfect health. Since the discovery of the 
condition he has been somewhat nervous and uneasy and says 
that the pain has been aggravated. 
The most careful examination of the axilla fails to discover 
the point at which the lead pencil entered. The patient was 
shown at a meeting of the College of Physicians in Philadelphia, 
in January, 1889, and the general opinion of the surgeons present 
was that, as the condition had lasted for so many years, and had 
not seriously interfered with the use of the arm, nothing should 
be done. 
Unfortunately the friends of the patient became uneasy, and 
not satisfied with the opinions which had been given them, and 
he returned to the old country, and there sought advice in sev- 
eral quarters. In Dublin he very narrowly escaped operation, 
and even the day was set, but relying, as he said, on my strong 
statement, he, to use his own expression, escaped to London, 
where both Sir Joseph Lister and Sir Wm. Savory counselled 
non-interference, the former stating that life might not be curtailed 
at all by the affection, and that if at any time inconvenience arose, 
the artery might be tied above and below the orifice of com- 
munication. 
I have heard from this patient within the last six months, 
and he continues well. 
Arterio-venous aneurism of the axillary and sub-clavian 
vessels is rare. Bramann, in his exhaustive article, (Langen- 4 
WILLIAM OSLER. 
beck’s Archiv. Bd. 33) was able to collect only ten cases. In 
several of these the condition lasted for a long time ; in one five ; 
another seven; and n a third thirty-three years. In the latter, 
after persisting for al chis length of time without anything more 
than slight painful ? itions in the fingers, the left arm increased 
in volume, became eedematous, and the veins were distended, a 
condition which necessitated ligation of the sub-clavian artery. 
In this case the lead pencil, in all probability, perforated the 
artery and vein high up in the axilla, and it is evident that the 
opening is in the axillary artery, and not in the sub-clavian, 
for the thrill and pulsation above and below the clavicle disap- 
pear when this vessel is compressed high in the arm-pit. The 
remarkable thrill and fullness in the sub-clavian triangle and 
the sub-clavian space is associated probably with distension of 
the sub-clavian vein and its branches. An interesting point in 
the purring murmur was its intense transmission to the peri- 
pheral vessels, and it could be heard loudly even in the finger 
tips.