SECTION 3. SUMMARY OP THE SURGICAL HISTORY OF THE INTERN'AL AND (Part 5)

and aorta athero- matous ; large clot in sac ; an- eurism needle had partially transfixed artery, accounting for hemorrhage. \ 166 PRIZE ESSAY. Ligature of the IV o. Name of operator. Source of information. PATIBIfT. QQ bo 9 Caase of operation. ^ 9 ■** tj © •»< c ^ bo • b ■^ »* (t 9 Ag c 7 Bland, 1832. 8 Lixars, 1837. Lancet, vol. i. p. 97, ' M. ' 31 et seq.; Gnj's Hosp. Reports (cit.). Norris Contrib.; Lancet, vol. ii. p. 445 Guy's Hosp. Keports (cit.). M. 30 Spontaneous an* .2 years, curism of sub- clavian, of about 2 years' dura- tion. Subclavian rism, fall right arm ; ture of left clav- icle. aneu- Some on months, frac- INNOMINATE AND SUBCLAVIAN ARTERIES. 167 Arteria Innominata — continued. No. Date of operation. 9 h C o ^ 5 ^ a VIM o o c« © • ft RBSULT Recovery. Condition. Cause of death, date after op. REMARKS. 8 March 26, 1832. May, 31, 1837. Oc- curred. 20 and 22 days. 17 18th day. Hem. haustion. ex- 22d day. Hemor- rhage ; exhaustion. Aneurism had existed for about 2 years. Operation, March 26, 1832. Soon after operation, ye- nesection 18 ounces ; 2d day, yenesection 10 ounces ; 3d day, patient easy, venesection 18 ounces, and purgatives, and on same day, venesection again 11 ounces ; 4th day, venesection 3 ounces ; 5th day, doing well, venesection 2>^ ouuces, and again 2 ounces ; 6th day, vene- section 8 ounces ; 7th, 9 ounces ; 8th, 12 ounces; 9th and 10th, doing well, and bled 5 ounces ; nth, 12th, and 13th, doing well ; 14th, bled 3 ounces ; Idth, some fever, and bled 14 ounces, re- lieved; 16th, not so well ; 17th day, hemorrhage from wound about 5 ounces, and in evening of the same day, venesection 6 ounces, and again of 14 ounces ; 18th day, hemarrhage repeated- ly, and death. Autupsy: No injury to neighboring parts by operation ; central end of in- nominate closed ; carotid closed completely ; sttbelavian open. (The patient was bled a total of about 8}/^ lbs. and lost about 1 lb. by accidental hemorrhage.) 4 months before operation, pa- tient fell on left shoulder, breaking clavicle. 15 months before operation he had fallen heavily upon right arm and el- bow. Tumor not observed until a few weeks before op., which occurred May 31, 1837. While clearing the innominate, the thyroidea ima^ or some anom- alous branch was found, as in the case of Mott. In Lizar's operation it was divided. Few hours after operation sense of suffocation and pain in chest ; 2d day, better and easy ; 3d, in- ability to pass water, catheter ; 4th day, pulsation returned in tumor; dth, 6th, 7th, and 8th, progressed favorably; 9th, 10th, 11th, doing well; 12th, 13th, 14th, not so well, vomited '■^hiU ioutf - looking " fluid; 16th, wound discharging pus; 17th, ligature loose; did well until 20th'day, when there was slight hemorrhage from wound ; vene- section 20 ounces, digitalis, hy- oscyamus ; 22d day, death from hemorrhage. Autopsy : hemor- rhage into pleura ; lung soften- ed ; central end of innominate not entirely closed ; the sub- clavian was pervious, and the hemorrhage was supposed to be from this and the vertebral. PRIZE E88AT. operator. ,.„„., r^T>.»T. ■5 ■5 1 ii SI -.5 1 i J •'"""■• 11 ^1 ^ Qors. Balh. Cooper, B. a . ISM.a.B Fran- do. 1860. PirogolT. HnUn (OrnB). H™ (irimB.7 Bewrorfc.lMB Ericb»K;aar>H<»p. Kepom (Oil.). Obt'b Hoap. Eepcprli (oil-). AllicBinelii ; Krieg'i Chlr.,1984',p,4,w; Bu^'b BoBp. Repolll Gny. Ho.p. Beporl. (Olt-). Ne« Orlotni Med. PKi...M»i 19B«; On^i Hoip. Reporu. Hole t.) »ntlior. U. M. jn b-l .1^ t Sm o" I'liboi dniUii (Irau- m.lio). llKBlnVo at >ub. itrelDbLng of Syo*™. 48 32 re.!.. Abonl (ieiD. INNOMINATE AND SUBCLAVIAN ARTERIES. 169 ^T'teria Innominata — continued. Date of operation. 9 u u o Vi i-3 at 4 RESULT. Condition. Recovery. Cause of death, days after op. REMARKS. 10 11 12 13 14 15 Bept. 24, 1856. 17th day. 1859. 1860. 1864. Aug. 13, 1868. None. Oc- cnrred. Not clearly stated. 14th day, 15, 16, 51. Oc- curred, Recovered. 20 17th day. Hemor- rhage. Cured. ? 9th day. Exhaus- tion (probably from uremia and pye- mia). .34th day? rhage. Hemor- 48 hours. Pyemia. 11 hours. Exhaus- tion from hemor- rhage before ope- ration. 23d day. Hemor- rhage in thorax. Operation, Sept. 24th, 1856. Did well until 5th day, when e-y- jsipelas ensued ; 11th day, phle- bitis ; 17th day, clot of blood escaped from wound during a fit of coughing, and was follow- ed by terrible hemorrhage and death in a few minutes. Autop- sy : Cardiac end of artery only partially closed ; both Kubcla- vians closed ; carotid of ri^ht side open ; purulent infiltration of tissues in neighborhood of wonnd. Sternal end of clavicle and up- per portion of sternum removed to facilitate operation ; ligature close to aorta ; did well for 5 days, then difficulty of breath- ing, retention of urine ; 9th day. death. Autopsy: Tuberculosis of right lung ; pus in right kid- ney. Operation same as above ; pa- tient did well for several weeks, when hemorrhage occurred re- peatedly ; pationt becoming dis- couraged Irom his hopeless con- dition, removed the compress, and died on 34th (?) day from hemorrhage. No autopsy. After operation, pain in right side, difficulty of breathing ; '2d day, paralysis of left side of face; death in 48 hours. Au- topsy: Purulent infiltration of pleura and mediastinum, oede- ma of lungs, and lobular pneu- monia. Patient received a punctured wound in a duel (thoracic branch of axillary was divid- ed) ; subclavian was tied ; 9 days later, to arrest hemor- rhage, the innominate was tied; died in 11 hours. Autopsy: Hem. from thoracic branch of axillary. Aneurism resulted from violent stretching of the arm ; 3 months later, innominate and carotid were tied simultaneously; did well until 14th day,' when hem- orrhage (16 ounces) occurred, which was controlled by com- press ; 15th and 16th days, con- tinued slight hemorrhage ; 17th day, wound was filled usith small shot; 51st day, terrible hemorrhage ; 54th day, verte bral tied ; 55th day, shot re- moved from wound ; patient continued to do well, and re- covered. (Note. — After finish- ing this essay, I learn from the New Orleans Med. and Surg. Journal for Ju'y, 1875, p. 27, that this patient died ten years later from hemorrhage from the original sac. Dr. Stone reports case.) The carotid was tied same tin^e ; sac was found to have burst into pleural cavity. FBIZS B8SAT. Ligature of ths ....Snbclkilmi Ligature of the Subclavian Artery Bdlnlinrgh Msd. b Norrt) Coolrih',, PbiU., 1873: iieh Klin. Cblt.. Bd. X. n»rien. B. T., O-Iteillj.'lS ;. SabcUiliiii uiaa INNOMINATE AND SUBCLAVIAN ARTERIES. 171 Arteria Innominata — continued. IX 0. Date of operation. Hemorrh'ge occurred after op. ® ^' Pi RESULT. REMARKS. Recovery. Condition. Cause of death, date after op. 16 Mays, 1868. 5th, 6th days. 6th day. Hem. A lead wire was first applied, bat this was removed on 2d day, and two silk ligatures ap- plied above and below the abrasion caused by the lead wire; 5 days after this last operation, hemorrhage, and on 6th day, 3 more hemorrhages occurred ; shot were poured into wound; death. Autopsy: Clot firm in innominate on cardiac side ; subclavian occluded ; ca- rotid open, whence hemorrhage. (Bujalski told Yelpeau that he had ttoice. tied the innominate with fatal results. The innom- inate has been exposed and not tied on account of diseased con- dition, by A. C. Post, Mr. Key, Porter of Dublin, and Doughty of New York. This last case recovered after ligature of the subclavian, by A. B. Mott, the carotid having been previously tied by Doughty. Peixoto ex- posed and passed a ligature around this vessel, bat did not tie it, and patient recovered.) in its First Surgical Division. Jo. Date of operation. o =3 si's « o at Pi o Vi © • Pi a o o ^ as 08 RESULT. Recovery. Condition. Cause of death, date after op. REMARKS. 1 i Oct. 10, ! 1811. 3 , Sept. 22, * , Sept. 1829. Sept. 16, 1835. April 16, 1836. 1841. Sept. 20, 1830. 1815. Oc- curred. do. do. do. do. None. Oc- curred. 13, 15 days. 4th day. Hem. 4th day. 18th day. Hem. 24 hours. Hem. 12th day. Hemor. rhage ; bronchitis. 13th day. Hem. 4th day. Pericardi- tis; pleuritis; pyae- mia. 36th day. Hem. 15th day. Hem. On account of subclavian being diseased, the ligature was placed in i inch of innominate; pleura was wounded ; ligature not tightened immediately. Autopsy : Ulceration of sub- clavian near ligature. Sac burst in attempt of patient to raise himself up in bed. Au- topsy: Sac full of stinking fluid ; 2d and 8d ribs carious ; pleuritic adhesions . Autopsy: At point of ligature artery had ruptured. Autopsy: No clot in distal or proximal side of artery. Autoppy: Central end of sub- clavian closed by clot ; periph- eral end not closed. Erysipelas on .Sd day. Autopsy : Proximal end of artery closed by clot ; distal end where ver- tebral was given off, open ; hem- orrhage from this point. PRIZE E3SAT. Ligature of the Subclavian Arb ,...., ,.!=„■:.. P.T,.«r. operation. I'i If ii ■5^ 1 1 1 I m AoTBrt, Oaj's Hotp. Hepopti, M. M. M rlsin (radnclion ry nnearlsui. ture^roUTiX ShQl WQOnd a»r do. do. do. " JuDe<l. Ligature of the Subclavian Artery in ils First Dioiii<», + •• LtstoD, 1838. Ou^-g Hd>p. ReporU, M, 3l R. Oil. Med.. 1M4, p. AS ; Arcb. Klla. ChlT., INNOMINATB AND SUBCLAVIAN ARTKRIBS. 173 FHrst Surgical Division — continued. te of Hemorrh'ge occarred after op. Lig. came away No. days aft. op. RESULT. REMABES. ration. Recovery. Condition. Cause of death, date after op. 9, 11. 13 and after. None. Occur'd repeat- edly. 11th day. Hem. 22d day. Hemor- rhage; pneumonia. Half hour. Exhaus- tion. 8th day. Hem. Autopsy : Proximal end clooed by clot; distal end open, whence hemorrhage ; pleura and lung involved in inflammation near wound ; pus. Doing well until 8th day ; pneu- monia ; 13th day, hemorrhage, and after do. Autopsy: Proxi- mal end of artery closed, distal open. BaU emerged at back of neck, near 3d cervical vertebra ; had fractured clavicle, first rib, and entered thorax; lung hepatized; bloodv serum in pleura. Ball fractured acromion, and c. 14, J64. ae .30, 864. passed beneath scapula. Au- topsy: Subclavian tied i from innominate, ligature had cut through ; clot on cardiac^ none on distal side. 3 Common Carotid (operations simultaneously). lyl8, ; 11,13. b38. S44. 2,1863 B39. 10,21, 35, 42. 16 24 14 13th day. Hem. 6th day. Cerebral ansemia. 42d day. Hem. 16th day. Hem. Carotid tied simultaneously ; eveninsr of operation, fainting and collapse ; 2d, vomiting ; 3d day, pain in chest, venesection 12 ounces ; 4th day, difliculty of breathing, venesection 8 oz. ; 5th day, cerebral symptoms : 12th day, hemorrhage from wound ; 13th day, hemorrhage and death. Autopsy: Pus in mediastinum ; pericarditis ; in- nominate closed firmly ; carotid closed ; subclavian open, as also vertebral and other imme- diatebranches ; from distal end of subclavian hem. hud come. At autopsy, the left carotid and right vertebral were obliter- ated. The only vessel going di- rect to brain was left verte- bral. This case is analogous to one by Dr. Hutchison of Brook- lyn, in which, after ligature of right carotid, the right verte- bral and left carotid were found obliterated (right carotid tied). The common carotid and verte- bral tied same time. Autopsy showed that the fatal hemor- rhage waH from the distal end of subclavian. This patient had progressed without an unfavorable symp- tom until 16th day, when in a fit of temper she jumped from her bod, and threw a pillow and some books at the nurse ; hem- orrha^'e from the carotid en- sued and death. Autopsy show- ed the subclavian closed ; the carotid patulous. Although the aorta was the seat of the disease and not th^ innomi- nate, the pulsation of tumor had disappeared b^orf death ^ and the process of cure had commenced. PRIZE ES3AT. Ligature of the Subclavian Artery in its Mrst DivitUm, Ho, .",:=.",' Sourcsor PiTIBHT. opersUon. li 1' 1= It s S 1 1 1 ^ K.„,,.», A h Kit CM ' « » B. BBjDUBt wound ■pare. ftoulll rsgion. ai mm. 1 tdl 1. Bd. s.;Gttj'»Ho.p, BepotW |cH.). F. •Ion. do. DupuTlroii, NDnHCiinirll!. (cU.ll M. 37 I,. !AKlllB.ry Bd. i.lLetonao Ligature of the Subclavian Artery in its Seemi •••V- EdlDbargh Kei. & INNOMINATE AND SUBCLAVIAN ARTERIES. 175 Common Carotid {operations simultaneously) — continued. B of Uemorrh'ge occurred after op. Lig. came away No. days aft. op. RESULT. BEMARKS. tion. Eecovery. Condition. Cause of death, date after op. . 25, 7, 8, 9, 10. None. 10th day. Hem. 2d day. (?) The carotid was closed, as "was i9. }6. proximal end of subclavian; distal end of subclavian open, whence hemorrhasre. It is stated that Kuhl intended to tie the carotid, and that the subclavian was included by mistake. Autopsy: Pulmonarr tuberculosis ; cause of death not known ; carotid tied same time. il Division (behind the Scalenus Anticus), Jh7, L9. None. t. U, 26. 16 13, 14. '. 27, None. 65. 34. 1.13, J64. il30, 7 23, 533. Be- fore the 15th. Recoyered. Cured. Profuse 21 Recovered. 14th day. Hem. Cured. 12th day. Exhaus. tion; pysemia; gan- grene. 15th day. Exhaus- tion. 6 hours. Hem. 68^ hours. Cerebral symptoms. 7 years previous patient received punctured wound in left shoul- der (from behind) ; hemorrhage; 2 months later aneurism appear- ed, which seven years later had reached the size of a child's head ; 3 years after ligature the aneurismal tumor was seat of abscess, which was opened, and recovery took place. Artery was first tied in 3d divi- sion, but it being involved in disease, a ligature was placed behind scalenus ; did well until hemorrhasre from wouad on 13th day, which occurred again fa- tally on the 14th. The vessel had given way near the exter- nal of the two ligatures, the in- nermost one having become loosened. Both proximal and distal ends of swclavian toere open. Ball entered thorax and wound- ed lung ; gangrene had resulted before the ligature was applied. Autopsy: Multiple abscesses in both lungs ; clot in subclavian. Patient had a fungous growth in left axilla ; attempt to remove it ; hemorrhage so profuse, it was thought to be an aneur- ism ; ligature behind scalenus ; death. Ball entered at insertion of del- toid, and lodged between cla- vicle and first rib ; patient did not rally ; ball cut out at ope- ration. Aneurism caused by strain of arm in catching from a fall ; on account of nearness of tumor, the outer fibres of the anterior scalenus were divided, and the ligature placed in the 2d divi- sion. On the day of operation, venesec- tion 10 oz. ; 2d day, vomited greenish fluid ; ordered 2 grs. of calomel every 2 hours ; died comatose. Autopsy: Serous ef- fusiou beneath arachnoid; brain slightly softened ; purulent in- filtration in region of wound. PRIZE E33AT. Ligature of the Subclavian Artery in its Secon operuicr. ..■,=r.. PA.,„T. CimsB of opentlon. ^i H 1? a? •s- 1 Hi = m U=Bp[Ul|. QuHrHmoa Annfes de Arrh, Kill,, fblr., do. LaiicBl, lB71,p, M2; d.^ «.,.., M. M. M. U. M. Mid'-H puDctureS T-Bd or Hiilla ind (fLlfand 'to'duc- ItonofBhouldorl. ',£:■"»•- Udiji. 41 dlj-s. do. 30 L. „ Ligature of the Subclavian Artery in its Third Surgical Division {belvtti M Rtmaden, 1909. Arcfa. E o rhlr M. ra Tt. linos. «,m. V- 1 11 rib Praet AnsorlJin do M Hospiwl H INNOMINATE AND SUBCLAVIAN ARTERIES. 177 Surgical Division (behind the Scalenus Anticus) — continued. No. Date of operation. o C »J »H O 9 SO*? -> O^ 9 O * RBSniiT. Condition. Recovery. Canse of death, date after op. BEMARKS. 27 28 Feb. 8, 1844. 29 SO 31 32 Nov. 5, 1862. Nov. 14, 1866. 21 44,46, 47,68 days. March 29, 1871. 13 19 Recovered. Recovered. Cared. 4th (or 5th?) day. Hemorrhage. Cured. 6th day. Pneumo- nia. 9th day. Pyemia. 9th day. Bronchitis; pulmonary conges- tion. A grocer in pursuit of a custo- mer who bad passed a counter- feit note it trade with him, was stabbed from behind through right scapula; hemorrhage im- mediate and frightful; for next few days, do. ;on 12th day, Koux tied the axillary; 2 days later, hemorrhage not being control- led, he tied subclavian behind scalenus; hemorrhage again on 4th day; amputation at shoul- der; death in 36 hours. Did well until 2lst day. when profuse venous hemorrhage oc- curred to amount of 1 pint; prensure; 22d day, pneumonia sapervened; pulse returned in radial artery on 36l8t day. Diffuse aneurism resultint; from rupture of circumflex artery in attempt at reduction of shoul- der; tumor size of man's head; 3d day after operation, partial unconsciousness ; 6th, pneumo- nia and death. 4 days after operation, fever and rigors, and on 9th day, death ; thrombus formed on either side of ligature. Autopsy: Adhe. sions between pleura and lung on right side, bloody serous ex- udation in left pleural sac. 43d day after operation, a bundle of nerves from brachial plexus sloughed away; 44th, frightful hemorrhage; pressure and per- salt of iron; 46th and 47th, also hemorrhage; 48th, gangrene of arm evident ; d.3d day, ligature of subsrapularie ; 6'Jth day, amputation of arm at upper third ; 68th day, hem. again ; 90th day, removal of humerus at shoulder-joint. There was no pulsation in the subclavian