ARTERIO-VENOUS ANEURISM 
OF THE 
COMMON CAROTID ARTERY AND INTERNAL 
JUGULAR VEIN, 
WITH A CASE. 
BY 
LEWIS A. STLMSON, M. D., 
SURGEON TO THE BELLEVUE AND PRESBYTERIAN HOSPITALS; AND PROFESSOR OF CLINICAL 
SURGERY IN THE UNIVERSITY OF THE CITY OF NEW YORK. 
FROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES. 
April, 1884. • Extracted from the 
American Journal of the Medical Sciences for April, 1884. 
ARTERIOVENOUS ANEURISM OF THE COMMON CAROTID ARTERY 
AND INTERNAL JUGULAR VEIN, WITH A CASE. 
By LEWIS A. STIMSON, M.D., 
Surgeon to the Bellevue and Presbyterian Hospitals ; and Professor of Clinical 
Surgery in the University of the City of New York. 
Piiit.ip McM., 25 years old, a butcher by occupation, was admitted 
into Bellevue Hospital,.in August, 1883, a rather small, but naturally mus- 
cular and robust man, with a markedly nervous and excitable tempera- 
ment, and plainly showing the effects of prolonged indulgence in alcoholic 
drinks. 
In February, 1882, he was stabbed in the neck on the left side with a 
penknife at a point now marked by a small scar half an inch behind the 
anterior margin of the sterno-cleido-mastoid, and on a level with the 
crico-thyroid space. Bleeding from the wound was profuse for about two 
hours, then ceased spontaneously, and the wound healed in a week with- 
out other treatment than that which he himself gave it. During this 
week the neck on the wounded side was much swollen, and there was at 
times much difficulty in breathing; the corresponding side of the face 
was cedematous. The swelling gradually diminished, and disappeared 
entirely, he thinks, in the course of two months. 
Early in the following June, after a spree, a lump as large as a hen’s 
egg formed at the seat of the wound, the cheek and neck again became 
swollen, and the difficulty in breathing recurred. lie then consulted a 
physician, who called his attention particularly to a whirring sensation felt 
in the neck, which he had himself noticed for some time, but had thought 
nothing of. The lump and the other symptoms, except the thrill, disap- 
peared, and in August he resumed work, but as the work caused the choking 
sensation, accompanied by dizziness, to return, he again abandoned it. 
To what extent the injury enforced idleness, or whether it was not simply 
an acceptable excuse for self-indulgence, cannot now be determined, but 
it appears that since that time he has done no work, and has at times, 
perhaps persistently, been drinking heavily. He alleges discouragement 
as an excuse for his conduct, saying that during the year he consulted 
many physicians, became thoroughly acquainted (too much so, he thinks) 
with the nature of his injury, and was uniformly advised to seek no ope- 
ration for its relief. 
On admission to Bellevue Hospital, eighteen months after the infliction 
of the wound, he was tremulous and distinctly alcoholic, and complained 2 
of nausea and gastric distress, of occasional choking, vertigo, some 
dimness of vision in the left eye, and dulness of hearing in the left ear. 
The last two symptoms were not confirmed by appropriate tests, and the 
first were thought to be due to alcoholism. The statements concerning 
the choking and vertigo probably shared the exaggeration that marked 
his account of other symptoms. 
On the left side of his neck, in the position above described, is a non- 
adherent linear scar half an inch long. A very distinct thrill could be 
felt on the left antero-lateral region of the neck between the clavicle and 
the ear, with a loud buzzing sound strongly reinforced during the systole 
of the heart. The thrill was recognizable by the slightest touch, and 
could be arrested by firm pressure at the scar or on the line of the caro- 
tid below it. Pulsation was barely perceptible in the left facial artery, 
easily recognized in the left temporal artery, and was of the usual force 
in the corresponding arteries on the right side. No recognizable dilata- 
tion of the veins. Pupils equal and normally responsive. There seemed 
to be a slight deep swelling or thickening in front of the great vessels 
near the scar. 
The symptoms and history clearly indicated the existence of a trauma- 
tic communication between a large artery and vein, and, together with 
the position of the scar, left no doubt in my mind that the artery was the 
common carotid, and the vein the internal jugular; and, as the vein over- 
lies the artery completely on this side, I think the point of the knife must 
have passed completely through the vein, perforating it at two points, and 
punctured the adjoining wall of the artery. As there was no recognizable 
tumour, I inferred that there was no aneurismal sac intermediate between 
the vessels, but that their walls were in contact, and that the blood passed 
directly from the artery into the vein. The absence of recognizable dila- 
tation of the veins and of symptoms indicating obstruction to the venous 
flow is to be explained by the ease with which the blood passes from the 
internal jugular to the heart, and perhaps also indicates that the opening 
in the artery was small. The history of a previous tumour and swelling 
indicates that the blood must at one time have escaped quite freely into 
the surrounding tissue. 
After having kept the man under observation for more than a month, 
and having sought and received the counsel of several colleagues, I deter- 
mined to operate. The controlling reasons for this decision were the 
man’s alleged inability to work, about which some doubt might be felt, and 
his moral decadence, about which there was none. As to the first, he 
persisted in his assertions, after having been warned of their importance 
in determining the question of interference; and while it is probable that 
a man of stronger will and steadier nerves would, under similar circum- 
stances, be able to regulate his life accordingly and earn a livelihood in 
spite of the infirmity, I think corroboration of this patient’s sincerity is 
found in his persistent search for relief in the face of all the advice to the 
contrary which he had received. 3 
As to the second reason, it may be claimed that his moral regeneration 
was a task belonging rather to the professional teacher of morals than to 
the surgeon, but it seemed to me that the latter might fairly deem himself 
under a professional obligation to remove an apparent obstacle that stood 
in the way. And while a successful result is by no means always a justi- 
fication of the propriety of the interference which led to it, it carries the 
advantage of allowing that propriety to be called in question without excit- 
ing those painful regrets which arise from a conciousness of harm done 
through an error in judgment. 
A decision as to the details of the operation was also reached with some 
difficulty, partly because of doubt as to the extent to which the tissues 
about the seat of injury had undergone change. The point of communi- 
cation between the two vessels appeared to be not more than three-fourths 
of an inch below the bifurcation of the artery, and perhaps not more than 
half an inch, and therefore the application of a ligature to the common 
trunk on the distal side of the opening, in addition to the necessary one 
on the proximal side, seemed too hazardous to be undertaken. The 
alternative of placing the second ligature upon the internal carotid, with 
or without a third upon the external carotid, was also rejected, and I 
determined to tie the artery at one point only, and that as near to the 
opening on the proximal side as possible, hoping either that the distal 
clot would extend far enough to close the opening, or that the reverse 
current through the internal and external carotid would prove too slight 
to cause inconvenience. 
The operation was done October 8th. The vessel was approached 
above the omo-hyoid, but as the tissues immediately overlying it were found 
thickened and condensed, the incision was extended downward, and the 
artery tied below the muscle. It was necessary to divide one of the in- 
ferior thyroid veins between two ligatures in order to expose the artery. 
The ligature was of stout catgut (E violin string), prepared by soaking in 
oil of juniper and keeping in alcohol. The wound was frequently irrigated 
during the operation with a solution of salicylic and boracic acid, 1 and 6 
parts respectively in 500 of water, and at the last was washed with carbolic 
acid, 1 in 20. A rather short drainage tube was inserted, and the inci- 
sion closed with catgut sutures. Carbolized gauze dressings were applied 
so as to fill the normal depressions and make snug pressure. 
The left side of the face was cool and pale during the afternoon, but 
had recovered its colour and temperature the next morning, and except 
for some nausea the man was then comfortable and his condition natural. 
During the first six days the temperature did not rise above 99|°. The 
dressing was changed for the first time on the 14th day, and the wound 
was then found perfectly dry and healed throughout, even over the drain- 
age-tube which had slipped in. Two stitches were cut, and the edges of 
the wound separated for about an inch to remove the tube. On the 7th 
day, the temperature rose in the afternoon to fell the next morn- 
ing to and after rising again the following afternoon to 
remained below 99°. Oct. 17th there remained only a small dry scab at 
the seat of the drainage tube, and the dressing was discontinued. 4 
The thrill ceased entirely when the ligature was tied, but at the first 
change of dressing, on the 4th day, it was again present, though with 
greatly diminished force and recognizable only on deep pressure with the 
finger over a small area about the opening; it increased somewhat in area 
and force during the next few days. On the evening of the 10th day the 
patient was awakened by an attack of dyspnoea with precordial distress 
and pain, and wras much frightened ; he received some morphine subcu- 
taneously, soon wTent quietly to sleep, and awoke the next day free from 
all the unpleasant symptoms. I suspected the cause of this attack to be 
a pulmonary embolus, either a portion of the distal arterial clot broken 
oft'and washed through the opening into the vein, or a portion formed in 
the vein by growth through the opening. But as the patient was quite 
hysterical during the following fortnight, and made frequent complaint of 
pain behind the low'er part of the sternum and in the epigastrium, the 
diagnosis remains in doubt. There can be little doubt about a second 
accident which occurred on the 15th day, when he noticed in the morning 
a little dizziness and a slight loss of power in the right hand ; the pupils 
were equal and normal, and there were no other paralyses. The symptoms, 
which were probably due to a small cerebral embolus, disappeared within 
an hour or two, and have not recurred. 
The thrill is now', seven weeks after the operation, recognizable only over 
the seat of the opening, and can be arrested by moderately firm pressure 
at that point, or by deep pressure behind the angle of the jaw ; it is 
steady and continuous. The portion of the anterior temporal artery 
visible on the side of the forehead is notably enlarged, and pulsates 
strongly; its pulsation is arrested by distal pressure. 
I have found nine similar cases recorded or mentioned, together with 
three of traumatic communication betw'een the internal carotid and inter- 
nal jugular, and six between the external carotid and a vein in the neck. 
I. Common carotid and internal jugular. 
1. Reported by Marx in Mim de VAcad, de M6d., 1833, vol. iii. p. 233. A 
man forty-thrde years old who, twenty years before, had received in a duel a 
sabre-wound in the right side of the neck just above the inner end of the clavicle. 
The wound was half an inch long, and bled profusely ; he arrested the bleeding 
by pressure with his handkerchief, and went alone and on foot to the hospital, a 
distance of two miles. In five days the wound was healed, and he left the hos- 
pital. He suffered no further inconvenience from it. At the time of the report, 
twenty years later, there was still a thrill with peculiar bruit, arrested by pres- 
sure on the line of the carotid 1 £ inches above the scar. 
2. Mentioned briefly by Lefort in Diet. Encyclnptdique, Art. Carotide/p. 644. 
A soldier received a sabre-cut in a duel; the bleeding was arrested by pressure. 
A large tumour formed with a peculiar thrill perceptible between the clavicle and 
ear, and with a bellows-murmur. He left the hospital on the 45th day, the 
tumour having shrunk to the size of a small nut. The scantiness of the details 
leaves some doubt as to the exact nature of this injury. 
3. Larrey, Clinique Chirurg., vol. iii., 1829, p. 149. A soldier, forty-one years 
old, received a sabre-cut on the right side of the ndek just above the sterno-clavi- 
cular joint. The hemorrhage was so free that it placed the man’s life in immedi- 
ate peril; it was arrested by bandaging, and the patient was brought to the hospital. 
There was a large tumour under the wound, and pulsation in, and dilatation of, the 
external jugular vein ; thrill. The wound was half an inch long, and divided 
the inner portion of the sterno-cleido-mastoid muscle. The tumour disappeared 
entirely about the 60th day ; the thrill and bruit persisted. The man returned 
to duty. Larrey thought the artery was wounded near its origin, and that both 
sides of the vein were perforated. 5 
4. Larrey, Inc. cit., p. 154. A soldier, thirty-seven years old, was wounded in 
the lower right side of the neck while fencing with a comrade. The wound was 
small, and the bleeding slight; there was an ovoid aneurismal tumour under the 
wound with thrill and bruit. Dismissed cured in two months, the thrill persisting. 
Iioth these eases were treated by the continuous application of iee. 
5. Allge.meine vied. Zeituny, April, 1833 ; abstract in Arch. Gin. de Mid., 
1834, 2d ser. vol. iv. p. 135. A student was wounded in a duel in March, 1833, the 
narrow blade of ,the sword penetrating to a distance of three inches downwards 
and inwards; the external wound was one inch below (?) the middle of the right 
clavicle, or a little nearer its sternal end. Only a few drops of blood escaped. 
A large tumour immediately formed above the clavicle ; the patient fainted, and 
had tetanic convulsions and dyspnoea, which were relieved by free venesection. 
The next day the tumour pulsated with “a peculiar sound like that of a liquid 
escaping through a narrow orifice;” three weeks later the tumour was reduced to 
the size of a hen’s egg, pulsation and bruit persisting. Eight months afterwards 
the bruit could be heard only over the point of communication between the 
vessels, and the tumour could be entirely reduced by a full inspiration. The 
patient considered himself entirely well, and was leading a very gay life. 
6. Pennsylvania Ilnsp. Reports, vol. i p. 195, and Norris in Amer. Journ. 
Med. Sci., 1847, vol. xl. p. 13. A coloured seaman, 59 years old, admitted 
April, 183G, with a “traumatic varicose aneurism” on the right side, for which 
the carotid was tied by Randolph a month later. He died, comatose, the next 
day. (The record on the Hospital books, for a copy of which I am indebted to 
the kindness of Mr. Cadbury, the steward, is even more brief, and speaks of it 
as “aneurism of the carotid.”) 
7. Dr. David Prince, U. S. Sanitary Com. Sury. Mem., vol. i. p. 147. 
Soldier ; 20 years old ; pistol shot in left side of neck, one inch from median 
line at the level of the larynx ; not much bleeding. Eighth day, swelling less, 
very distinct thrill, perceptible to touch, and loud whizzing murmur heard 
through stethoscope ; slight bleeding occurred in the evening. Ninth day, 
common carotid tied ; patient remained stupid and drowsy most of the time for 
nearly five days, and then died. On the third day symptoms of partial paralysis 
of sensation and motions in the right extremities were observed, and twelve 
hours before death “ a sweat came upon the right half of the body and not upon 
the left.” The autopsy showed that the bullet had notched the artery on its 
outer side at the bifurcation, and had perforated the internal juglar vein. There 
was no distinct aneurismal sac, no clot in the distal portion of the carotid. The 
corpus callosum and optic thalamus seemed softer on the left than on the right 
side. “ Nothing abnormal was found elsewhere.” 
8. Yerneuil, Bull, tie la Soc. de Chiruryie, second series, 1870, vol. x. p. 
487. A man, 40 years old, received a pistol-shot wound in the right side of the 
neck, two centimeters below the bifurcation of the carotid, and midway the 
width of the sterno-cleido-mastoid. Bleeding was slight. The next day the 
neck was slightly and uniformly swollen, with intense thrill and very loud double 
bellows murmur or spinning-wheel sound, perceptible over an area two inches 
wide, and extending from the mastoid process to the clavicle, but with their 
maximum at the seat of the wound. Pulsation equal in the temporal arteries; 
continuous application of ice. On the ninth day the wound was almost entirely 
healed, the swelling had subsided ; the thrill and murmur persisted with the same 
intensity, but had not been noticed by the patient. 
9. Maclean,1 in Perrin’s Journ. of Med., Detroit, 1875, xi. p. 261. 
“ Pistol-shot wound from above, penetrating neck on leftside. Healed. Dis- 
tinct buzzing sound continued over seat of wound. Health good. No aneuris- 
mal sac at seat of injury. Arterial pulsation synchronous with beat of heart. 
Diagnosis : Arterio-venous aneurism of common carotid and internal jugular, or 
one of th*! inferior thyroid veins.” 
10. The one above reported. 
1 For this abstract and four of the following (Mazzoni, Queirel, Duval, and 
Desparanclies) 1 am indebted to the kindness of Dr. J. S. Billings, of the Library of 
the Surgeon-General’s Ollice, Washington. 6 
To this series may be added a case, apparently unique, of supposed 
non-traumatic communication between the common carotid and the in- 
ternal jugular, reported in the London Med. Gazette, 1842, vol. xxxi. p. 
107. 
A woman, 66 years old, with a large, pulsating tumour on the right side of the 
neck, extending from left sterno-clavicular joint to middle of right clavicle, and 
up to the right ear. The body of the tumour is firm and somewhat lobulated. 
There is a projecting portion as large as a hen’s egg near the ear, which is “ soft, 
movable, easily emptied, and has a strong vibratory motion. To the outside 
of this projection the integuments have a very distinct vibratory motion, as if a 
small bird or insect were fluttering strongly under them. . . Pulsation and 
bellows murmur throughout the whole tumour, but over the projection and portion 
of integument just alluded to the sound is very loud, whizzing, and like that of 
an old-fashioned spinning-wheel.” The carotid artery and a very large vein, 
thought to be the internal jugular, could be distinctly traced along the upper 
half of the outer side of the tumour. Pressure on the side of the tumour or on this 
vein arrested or diminished the thrill and sound. The patient said the tumour had 
begun thirty years before at the lower part of the neck, and had gradually en- 
larged. The soft portion appeared six years before this examination, after 
vomiting and coughing. [Nine years afterwards the patient was alive and the 
tumour unchanged.] 
II. Internal carotid and jugular vein. 
1. Duval, Arch, de Mid. Nav., Paris, 1864, i. p. 413. “Stab-wound be- 
hind left ear. Frightful hemorrhage ; general tumefaction with thrill and indis- 
tinct sounds. Under treatment, tumour diminished and wound healed completely. 
Diagnosis : Arterio-venous aneurism of the internal carotid and jugular. A year 
later the wound reopenedj hemorrhage returned, characteristic sound slowly 
diminished.” 
2. Joret, Gaz. Mid. de Paris, 1840, 2d ser., vol. viii. p. 457. A man, 35 
years old, wounded in a duel, the ball entering on the right side of the face, 
traversing the nostrils and upper part of the pharynx, and penetrating again 
behind the left tonsil. Free hemorrhage. The patient was apparently well 
after a month, with the exception of much headache and strabismus. Four 
months after the injury an attack of aphasia, from which he recovered ; during 
the following two years his mind weakened, he had epileptiform attacks, and 
died about thirty months after the injury. The ball was found lodged in the 
left internal jugular behind the angle of the jaw. At the upper portion 
of the internal carotid was an aneurism as large as a pigeon’s egg, communi- 
cating also with the internal jugular. The portion of this vein between the 
ball and the heart was normal ; the wall of its distal portion was so thickened 
that it could hardly be distinguished from the artery. Two foci of softening in 
the brain, and two small cerebral veins distended to form pouches one-third of an 
inch in diameter, and filled with clots. • 
During the latter part of the patient’s life there was a pulsating swelling be- 
hind the ramus of the left jaw, with the “ murmur pathognomonic of varicose 
aneurism there was also projection of the left eye. 
3. Giraldes, Bull, de la Soc. Anal., 1854, vol. xxix. p. 298. A man, wounded 
by a single bird-shot in the right side of the neck, just below the angle of the 
jaw. This was immediately followed by diffuse swelling of the right side of the 
neck, with characteristic thrill and double murmur. A month after the accident 
the swelling and ecchymosis had disappeared, leaving a small pulsating tumour. 
An operation was proposed and declined, and the patient left the hospital. He 
returned shortly afterwards with malignant anthrax, and died. 
The autopsy showed an aneurismal sac as large as the end of the little finger, 
lying between and communicating with the internal carotid and jugular, and 
containing the small shot. The opening into the carotid was a short distance 
above the bifurcation, and was as large as a crow’s quill; the opening into the 
vein was a little smaller. 7 
III. External carotid and external jugular. 
In some of the following cases doubt must be felt as to the identity of 
the vessels involved. 
1 Desparanches, Jnurn. Gin. de Mid. Chir. et Pharm., Paris, 1819, vol. lxvii. 
p. 202. “ Stab in neck. Arterio-venous aneurism of left external carotid and 
jugular vein. Usual sound as above described. Slight symptoms of paralysis of 
the corresponding arm. Eight months later man seen in same condition. 
2. Queircl, Marx. Mid., 1872, vol. ix. p. 354. “Sailor, 40 years of age, 
large tumour over external jugular vein, slightly pulsating. Auscultation 
souffle d double courant. No serious inconvenience.” 
3. Ilolston, Western Lancet, April, 185G, p. 199. The patient was a man 50 
years old, who, fifteen or twenty years before, had received a charge of bird-shot 
in his neck, followed by the formation of a small pulsating tumour which caused 
no trouble except “throbbing, which extended to his brain, and often confused 
his mind.” Within two years the tumour had become much larger. “The 
vein [which ?] also increased in size, and the thrilling sensation extended down- 
ward to the breast, as well as upward to the head. The eye on that side [appa- 
rently the right side] inflamed, and its sight became impaired, the hearing was 
also nearly lost on that side. Memory was much weakened, and he laboured 
under constant and considerable confusion of mind.” The aneurismal tumour 
was on a level with the larynx, as large as a hulled walnut, and pulsated ; the 
facial vein formed a bunch as large as an egg at the angle of the jaw ; the exter- 
nal jugular was tortuous and as thick as the forefinger. The carotid was tied 
below the omo-hyoid ; the patient was comatose the next morning, and died fifty- 
five hours after operation. 
4. Mazzoni, Clin. Chir., Rome, 1876, iii. p. 138. “Woman, 24 years of age. 
A month previous had received a cut in the neck ; wound slight; healed rapidly. 
A continued bellows-sound producing great discomfort brought her to the clinic. 
Cicatrix three centimeters long. Placing hand on tumour a thrill and pulsation 
corresponding to beat of heart was observed, with loud bellows-sound. On pres- 
sure of carotid pulsation in tumour ceased. Diagnosis: Arterio-venous aneurism 
of external carotid and jugular. Compression made constantly three days and 
nights unsuccessfully. Tumour was laid bare, and common carotid tied. On 
tenth day after operation hemorrhage commenced, and continued during two or 
three days ; it was thought to come from the superior thyroid, which was tied. 
Transfusion of blood. Died on twelfth day, exsanguinated.” 
5. Rufz, Bull, de l'Acad, de Mid., Paris, 1838-9, vol. iii. p. 278. A man, 38 
years old, who, fourteen years before, had been struck on the left side of the head 
with a bottle; a fine linear cicatrix in front of the ear. Several tumours, evi- 
dently formed by the dilatation of vi/ins, occupy the left side of the cheek and 
head ; the largest and lowest extends from the tragus to the angle of the jaw, 
and forward to the anterior border of the masseter; they are soft, subcutaneous, 
evidently filled with liquid ; the overlying skin shows no change in colour, but is 
much distended. An aneurismal thrill is easily recognized, by ear and finger, in 
eachtumour, and is most marked in the largest. Pressure on the carotid arrests 
the thrill and the tumours shrink. The left eye is prominent, and the veins of 
its conjunctiva varicose. 
6. Parkman, Am. Journ. Med. Sci., April, 1853, p. 370. A man, 35 years 
of age, who, at the age of 11, was struck within the right ear with a small chisel. 
Profuse bleeding. The external jugular vein is enlarged throughout its whole 
length to diameter of two inches; some slight enlargement of the veins of the 
temple. In front of the ear there is very strong pulsation with loud, purring 
thrill. There had been no change in the condition for many years, and the 
patient did not desire treatment. 
Of the nineteen patients, eighteen were males, one a woman; a dispro- 
portion which is readily explained by the traumatic character of the 
cause. In ten cases the cause was a stab-wound (five with a sword, four 8 
with a knife, one with a small chisel), in four a pistol-shot wound, in two 
a wound by bird-shot, in one a blow with a hottle, in two unknown. 
Excluding for the moment from consideration those cases in which the 
external jugular vein or its immediate branches were directly involved, 
the attention is arrested by the absence of those changes which are so pro- 
minent a feature when a similar communication between an arter}randavein 
occurs in other regions of the body, and which cause so much discomfort and 
even disability. These changes, as is well known, are a marked and often 
irregular dilatation of the veins, not only near the point of communica- 
tion, but also in the distant branches on the distal side, interference with 
the distal flow, and the usual formation of an aneurismal sac with the 
usual tendency to increase in size. 
The cause of these changes is the increase of the pressure within the 
veins, produced by the passage into them of the arterial blood. Normally 
the pressure of the blood in the distal veins of the extremities is slight, 
seldom exceeding that of a column of mercury half an inch high, and the 
venous flow in them is carried on by a vis a tergo communicated through 
the capillaries, aided by such other influences as the pressure of the con- 
tracting muscles, the changing position of the limbs, and the suction 
exerted by the thorax during inspiration. The numerous valves placed 
along the course of the veins preserve each advance as it is gained, and 
protect the underlying branches from the extension to them of accidental 
temporary increase of pressure in the trunks above. 
When arterial blood passes directly from an artery into a corresponding 
vein, it does so under a pressure that is far in excess of that previously 
existing in the vein ; it cannot escape toward the heart without lilting 
and rapidly pushing before it the venous column on the proximal side, 
without, in other words, exerting a pressure much in excess of the normal 
venous pressure, and this pressure must of course be equally exerted in an 
opposite, distal, direction, and laterally upon the wall of the vein. Under 
this increased pressure the wall yields, and the lumen of the vein enlarges ; 
so long as the distal valves remain sufficient this pressure is not trans- 
mitted to the veins beyond them, but the passage of the blood through 
the latter is obstructed by the obstacle thus placed before it; when, how- 
ever, the valves yield under the pressure or become insufficient by the 
enlargement of the vein, the pressure is transmitted from above to the 
segments thus deprived of protection, and the same changes occur in turn 
in them. The extent of the change depends upon the size of the opening 
in the artery and the relative amount of the blood which escapes from it; 
when that opening is large, as, for example, when the artery is cut com- 
pletely across, all or nearly all of the arterial blood makes its way into the 
vein, and may even reverse the current in the distal segment of the latter, 
and make its way back to the heart with difficulty through the branches 
and their anastomoses. 9 
The essential cause, therefore, of the changes which make the injury 
so serious is the pressure of confined blood within organs incapable of 
resisting it, the tension of a quantity of blood which is pressed upon 
strongly from behind by the arterial column, and escapes with difficulty 
through the vein. The amount of pressure varies directly with the insuf 
ficiency of the means of escape, and the changes in the walls of the veins 
vary with this pressure. 
But when the communication is between the common carotid and the 
internal jugular, the conditions are very different. Here the venous cur- 
rent is habitually aided, not opposed, by gravity, and instead of being 
pushed forward by a vis a tercjo it is drawn along by a vis a fronte, the 
strong suction of the chest during each inspiration, and the feebler one of 
the elastic return of the lung upon itself during expiration. Instead of 
being distended the wall of the vein is habitually flaccid, and the pressure 
within it is nil or even negative. In addition, its lumen is very large 
and it communicates within a short distance with other trunks as large 
and even larger than itself, in which also the pressure is negative and 
into which, therefore, any temporary excess of blood will readily escape. 
If the opening from one vessel into the other is not direct, if, in other 
words, there is an intermediate aneurismal sac, this sac is not large and 
does not grow larger as a similar one does which communicates with an 
artery alone. In the latter case the sac pulsates and enlarges because the 
pressure in it corresponds to that within the artery, rising and falling with 
it through a range on either side of the mean arterial pressure; and the 
constant action of this pressure gradually distends the wall of the sac. 
But when the sac communicates also with the vein, the average pres- 
sure is less, and the same maximum is never reached, because the incom- 
ing blood is no longer confined, but escapes into the vein as readily as it 
enters from the artery, and is thus prevented from exerting a distending 
pressure upon the wall of the sac. The change, therefore, when once 
fairly established has no tendency to increase. 
When, however, the external jugular vein is directly involved the con- 
ditions more nearly resemble those found in other parts of the body. The 
escape of the blood through the vein to the heart is not entirely free, and 
hence the distal flow is obstructed. The effects of this obstruction are 
shown very clearly in Rufz’s case (III. 5), where a series of tumours de- 
creasing in size from below upward formed along the veins of the cheek, 
forehead, and scalp, tumours formed by dilatation of the veins. In the 
other cases of the same group the aneurismal tumour was large, or the 
external jugular notably dilated. In two of them, Ilolston’s and Mazzo- 
ni’s, the discomforts thus produced were so great that an operation was 
undertaken. 
In one of the three cases in which the internal carotid was the artery 
injured (Joret’s, II. 2), in which the opening was above the angle of the 10 
jaw, and in which the flow through the internal jugular was obstructed by 
a pistol-ball lodged in the vein on the proximal side of the opening, 
changes due to the obstruction took place in the veins within the cranium, 
and death followed two years after the injury in consequence of these 
changes and apparently also of cerebral emboli originating in the associ- 
ated aneurismal sac. The presence of an aneurismal sac in this case sup- 
ports the explanation above given of its absence in the others, because in 
this one the conservative condition of free venous flow toward the heart 
did not exist. 
Another feature of much interest is the facility with which hemorrhage 
was arrested and the external wound healed. In the absence of other 
statistics showing how frequently men have perished by primary hemor- 
rhage after a wound of both these vessels, it would be improper to infer 
that recovery is the rule or even frequent. It is well known, however, 
that death by hemorrhage is common after wound of the artery alone, and 
it may, I think, be plausibly maintained that the additional wound of the 
vein is a favourable condition, and diminishes the risks arising from the 
wound of the artery. And this, for the same reason that makes the later 
changes less serious, the free escape of the effused blood into the vein and 
thence back to the heart. When the artery alone is wounded, the blood, 
if its immediate escape through the external wound is prevented by the 
shifting of the latter’s walls or by dressings, infiltrates and presses back 
the surrounding tissues until it forms a collection the tension of which is 
approximately equal to that of the blood within the artery ; and under the 
influence of this tension, the external wound reopens and the hemorrhage 
recurs. When, on the other hand, there is also an opening into the vein, 
the effused blood is drawn into it by the thoracic suction and forced in by 
its own pressure, and thus the collection is kept small and its tension too 
low to force the edges of the external wound apart. At each beat of the 
heart as much blood comes from the artery as if it alone wei’e divided, but 
the patient does not lose it, it is simply turned back again to the heart; a 
portion of the stream is withdrawn for a moment from the vessels and 
then returned to them, auto-refit si on. And as regards the distal circula- 
tion in the corresponding territory there is no more change than, indeed 
not so much as, if a ligature had been placed upon the artery. 
The course of the affection in the principal group of cases, after it had 
become established, was eminently benign; that in the group in which 
the external jugular was involved less so, and it was complicated also by 
the presence of venous tumours immediately under the skin which threat- 
ened by their liability to injury. 
Of the ten cases of the common carotid and the three of the internal 
carotid, one (Joret’s) died two years after the injury, and apparently of 
cerebral lesions arising from it; one (Prince’s) was operated upon on the 
ninth day, and died of the operation; one (Giraldes’s) died of an intercur- 11 
rent disease shortly after recovery from the wound; of one (Randolph’s) 
no details are known, except that an operation was considered necessary, 
and he died in consequence. The others, nine in number, recovered 
easily from the injury, and, with the single exception of mine, appear to 
have suffered no inconvenience from the persisting lesion ; the history of 
one of them covers a period of twenty years subsequent to the injury, that 
of the others varying periods counted only by months. 
Of the six cases in which the external jugular vein was involved, in 
one (Desparanches’s) details are lacking; in another (Mazzoni’s) so much 
discomfort was caused by the throbbing that the patient sought relief by 
operation one month after the injury, and died. In one (IIo ston’s) oc- 
casional mental confusion was caused during fifteen or twenty years, then 
the tumour grew larger and the symptoms more marked; relief by operation 
was sought, and the patient died. In two (Rufz’sand Parkman’s), cover- 
ing periods of fourteen and twenty-four years respectively, the patients 
suffered no inco venience, and declined operation. In the remaining one 
(Queirel’s) there was “ no serious inconvenience.” 
The mortality, four deaths in five operations, is vastly in excess of 
that of the same operation, ligature of the common carotid, under other 
circumstances. One of the deaths was due to a cause, secondary hemor- 
rhage, which is always liable to occur, and which excites no comment except 
upon its rarity. The causes in the other cases are obscure or unknown ; 
one of the patients died within twenty-four hours after the operation, 
another in fifty-five hours, the third on the fifth day. Concerning the 
first there are no details except that the patient died comatose, and 
Norris, in his table of operations upon the arteries prepared more than 
ten years afterwards, gives “ congestion of the brain” as the cause. The 
second patient (Ilolston’s) became comatose during the night following 
the operation, and remained so until death, partial hemiplegia on the 
opposite side occurring meanwhile. In the third case (Prince’s) the 
patient remained stupid and drowsy until death on the fifth day, and in 
him also symptoms of paralysis on the opposite side promptly appeared ; 
the patient was operated upon on the ninth day after the receipt of the 
injury, no clot was found in the distal portion of the artery, and the sur- 
geon attributed death to acute anaemia of the brain. Concerning the 
previous history of the first of these three nothing is known ; the second, 
after many years of comparative immunity, presented before the operation 
cerebral symptoms which may have had another cause, and which were 
rapidly increasing in severity. There is a free field for speculation as to 
the probable periods of survival if the operations had not been done, but 
it cannot be doubted that the operations were the immediate cause of 
death. 
No other treatment seems to have been employed in any case except 
Mazzoni’s, in which compression was tried for three days before resort 12 
was had to operation. In my case the patient could hardly bear momen- 
tary pressure sufficiently firm to arrest the thrill. 
Finally, if a case should again arise in which an operation might he 
deemed necessary, what should the operation be? The experience gained 
in operations for the relief of arterio-venous aneurisms in other parts of 
the body cannot be wholly relied upon to guide us in a choice, because 
of the differences in the conditions present and in the objects to be at- 
tained. 
The anatomical conditions peremptorily exclude all those operative 
methods in which the sac is opened ; and equally of course no one would 
think of tying both the artery and vein above and below the point of 
communication. There remains, then, only ligation of the artery on one 
or on both sides of the opening. (In recent cases pressure, if it could be 
borne, and if the proximity of the pneumogastric nerve did not prevent, 
might work a cure as it has done elsewhere.) 
A guide in making the choice is to be found in the object to be attained. 
This object is not, as it is so frequently elsewhere, to secure the oblitera- 
tion of an aneurismal sac which disables by its size and threatens by its 
steady growth, and into which it is unwise to allow any arterial blood to 
continue to enter, but it is merely to diminish the amount of the blood 
which escapes from the artery, to reduce it to that which can be readily 
carried away by the vein. This is an end with which the surgeon may 
well be content, even while recognizing that there is a superior one ; for 
while it falls short of completeness, its shortcoming will probably cause 
no disability, no weakness, its lack of perfection does not make itself ob- 
trusively manifest, and, if need be, the second step that leads to a com- 
plete shutting off of the stream can be subsequently taken without addi- 
tional difficulty or danger. 
Judged by the standard so neatly formulated by Verneuil, “ Vejficacite, 
la benignite, la facilite” proximal ligation of the artery seems to deserve 
the choice. It may be less efficacious, but it is also less dangerous and 
easier of execution than double ligation, and it offers the chance not only 
of reducing the evil to a degree at which it can be well borne, but even 
of curing it entirely by the growth of the distal clot within the artery. 
This clot may be fairly expected to extend to the opening, which takes 
the place of the first collateral branch so much insisted upon in operations 
upon vessels, and it is quite within the range of possibility that it should 
overlap or plug it. 
A second ligature upon the distal side of the common trunk, or upon 
the internal carotid if there should not be sufficient room upon the other, 
doubles some of the risks by doubling the operation, and increases the 
probability of the occurrence of cerebral embolism or of a thrombus ex- 
tending into the cerebral arteries. On the other hand, it is to be said in 
its favour that by preventing a recurrent stream through the internal caro- 13 
tid it prevents the withdrawal, before distribution, of a portion of the 
blood carried to the brain by the arteries of the other side, and thus di- 
minishes the chance of the occurrence of dangerous acute cerebral anaemia. 
This chance must exist, though to a less degree, in all ligations of the 
common carotid, the blood passing down the internal to be distributed 
through the external carotid ; but, judged at least by the operations of the 
last ten or fifteen years, it is not a very serious one, and it might be made 
still less by pressure on the internal carotid for a few hours after the oper- 
ation. 
When the communication is between the external carotid or one of its 
branches and the external jugular the conditions are less simple, and so 
varied that the choice of an operation must vary with them. These cases 
have more in common with arterio-venous aneurism of the extremities, 
and the general principles of treatment are more nearly the same. So far 
as they can be formulated for the latter, they suggest the ligature of all 
vessels entering or leaving the sac so far as this can be done without 
opening it, but such a plan should certainly not be carried out in its 
entirety if the external jugular is dilated throughout its course to the ex- 
tent noted in some of the cases here mentioned. As the diameter of the 
external carotid artery is comparatively small, it is more likely that the 
vessel will be completely divided in the original injury, and this is still more 
true of its branches ; and the well-established tendency of the distal por- 
tion to become occluded under such circumstances would, I think, justify 
the surgeon in limiting his operation to the placing of a single ligature on 
the proximal side, and of course on the wounded artery, if practicable, 
rather than on the common carotid. The number, size, and free inoscu- 
lations of the veins of the region are such that an attempt to secure all the 
afferent ones would be bloody, dangerous, and probably unsuccessful. 
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