Bruit force

Committee reports aren’t exactly famed for their entertainment value. But while leafing through the 1850 volume of the Transactions of the American Medical Association I found one that contained an unexpected gem:

Report of the standing committee on surgery

Buried deep within this lengthy document is a section about aneurysms – a disorder of the blood vessels in which a localised weakness causes the vessel to bulge outwards.

Of all the cases of aneurysm on record, probably one from St. Louis, about six years since, is the most remarkable, when to the peculiarity of location is added the success of the treatment. The patient, a laborious mechanic, 25 years of age, had been an occasional and intense sufferer in his head for five or six years, for which much had been done in the way of local applications and internal remedies.

The phrase ‘laborious mechanic’ means that he was an artisan whose work involved physical labour; the man was a blacksmith. The ‘suffering’ in his head was not mental, but physical, pain.

Upon examination, the right eye was found to be remarkably protruded from the socket, with pulsations which could not fail to arrest the notice of the observing surgeon at some distance from the patient.

This sounds an unnerving and unpleasant symptom – and certainly unlike anything I’ve ever seen.

The transverse suture at the outer corner of the eye was opened sufficiently to admit the end of the finger. A large portion of the os frontis, os temporis, and temporal plate of sphenoid bone, and a part of the parietal bone, were disjoined and elevated some lines above the proper level by an aneurysmal affection of the internal carotid.

A disturbing and (these days) extremely unusual affliction. The source of the patient’s distress was a large blood vessel inside his skull, the internal carotid artery. Humans have two of these arteries, one on each side of the head; their function is to supply the brain with blood. This patient’s right internal carotid had a large aneurysm: a weakness in the wall of the vessel had ballooned outwards. So large was the aneurysm that it had pushed the bones of his skull outwards, even opening up a large gap at the corner of his eye. It is pretty amazing that he was still alive. As it was, it had severely compromised his ability to function.

The eye and ear of that side ceased to perform their functions.

Which suggests that the aneurysm was also compressing nearby nerves. The doctors decided to treat him conservatively at first, using drugs (unspecified), diet and regular laxatives.

The patient was put upon the tri-weekly use of evacuants, selected with a view to the profuse, yet healthy action of all the secretory processes, while his diet was required to be light, of easy digestion, unexciting, fluid, and in most moderate quantities.

This was apparently successful.

After a few weeks passed in this preparatory course, with great amelioration of suffering, he was taken before the class, since an operation was deemed necessary, however remote the prospect of triumph.

They had a specific procedure in mind: the Hunterian operation for aneurysm. In the late eighteenth century the great London surgeon John Hunter started to treat aneurysms by tying cotton tape around the artery, preventing any further blood from entering the aneurysmal sac. This procedure was often effective: the sac would deflate, while any blood remaining inside it would first clot and then be absorbed by the body. Hunter only attempted it on the blood vessels of the arm and leg, however. By the 1840s only a few surgeons had tried to employ the procedure on a vessel as large as the internal carotid.

When the carotid artery was exposed, it was held for a short space of time between the thumb and finger, in order to witness the effects of checking the circulation on the brain and nervous system.

You might think that interrupting the blood flow to the brain in this way would have disastrous consequences, but that’s not necessarily the case. In the 1760s the French surgeon Jean-Louis Petit discovered that it was quite possible for a patient to live a normal life with one of their two carotid arteries entirely blocked. For most people, a single artery provides more than enough blood for the brain’s needs.

Immediate quiet in the corresponding side of the head, with cessation of pulse, ensued, and then without further delay the artery was tied.

The report has nothing to say about surgical technique, but we can reasonably make one or two assumptions. It seems certain that no anaesthetic was employed, since neither chloroform nor ether was widely used until a few years later. And as the internal carotid artery is tricky to get at – even with modern techniques – the surgeon presumably tied his ligature around the common carotid, a larger vessel which is easily reached through the superficial tissues of the neck.

Diagram of carotid artery
A – External carotid artery
B – Internal carotid artery
C – Common carotid artery

When the dressings were applied, the patient expressed himself as being relieved of a noise in his head, which had been an attendant throughout the history of the malady.

This noise was almost certainly caused by turbulence in blood flowing through the aneurysmal sac. In the sixteenth century the French surgeon Ambroise Paré noted that aneurysms often caused a ‘sensible hissing’ that was clearly audible to people other than the patient; this phenomenon is known today as bruit.

The great disturbance of the circulation of the brain, consequent to the application of the ligature, was attended four days after by a highly morbid state of the biliary secretions, accompanied with fever, which soon yielded to broken doses of tartar emetic and cathartics of calomel.

These symptoms may have been caused by mild infection rather than the change in circulation to the brain.

By the expiration of the second week from the operation, the tumor had receded so far that the disunited portions of the cranial bones had recovered their proper position, while the eye and ear were restored to their functions. Before the conclusion of the month, he left this place for St. Louis, where he resumed and now is engaged in prosecuting his occupation as a blacksmith.

And that is the last we know of the blacksmith, who was apparently cured. It’s a truly remarkable case history, since the aneurysm must have been pretty enormous – large enough to force the bones of the skull apart.

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