Part I., p. 539. (Part 3)

previous patient first felt pain in shoulder ; in June, first appearance of tumor; carbol- ized catgut ligature used. 2 days before ligature of stibela- «ton, the right carotid had been obliterated by means of Dr. Speir's " constrictor." The carotid wound healed by first intention ; t?ie subdavian went on to suppuration ; 2d day, tumor decreased one-half in size ; 4th day, neuralgia ; 7tb, tumor increasing and looks red; 18th day, inflammation increas- ing, difficulty of deglutition ; 23d, intense pain through aneu- rism ; 25th, swelling spreading to right of sternum, with mark- ed '■''bruit ;^* 26th, nemorrhage from tumor; 27th, do. and pul- sation noticed first time in ra- dial ; 28th, 30th, 31st, and 32d days, hemorrhage from sac ; death. Autopsy: Displacement of right clavicle, erosion of manubrinm ; liver waxy ; left kidney do.; aneurism from transverse portion of arch ; neither innominate nor carotid involved ; carotid closed by eo- agula on both sides of constric- tion ; int^nal coat divided and turned in; subclavian tied on both sides of the ligature ; thrombus in right subclavian vein; sac full of clot. {Noteby author. — The "constrictor" of Dr. Speir seems to bid fair to prove a successful innovation in surgery, having been applied to all the large arteries with success, by the inventor.) Carotid tied simultaneously. Carotid tied same time; subcla- vian in 3d division ; 3 months after operation, patient was considered out of danger, and aneurism consolidated. Died 3 months after operation. See foot of page 100. 2 ligatures — Distal. This case is not considered in the sum- mary. Removed scapula and part of clavicle for disease after ampu- tation at shoulder. This case is not considered in the sum- mary. SUMMARY OF THE SURGICAL HISTORY OF THE INNOMINATE AND SUBCLAVIAN ARTERIES. SUMMARY OP THE OASES OP LIGATURE OP THE ARTERIA INNOMINATA. I HAVE accepted as reliable 16 cases of ligature of this vessel. The case of Peixoto was not a ligature proper, as the thread was only passed around the artery and was not tightened. I have no reason to doubt the two cases of Bujalski reported verbally to Vel- peau, but, as I have been unable to find anything definite concerning them in the literature of this subject, they are noted and not included in the table. Porter's was a case of acupressure of this vessel. Of the 16 cases all were males. All died except one, and he re- covered, temporarily cured of the aneurism, which returned and caused death ten years later (see Table). The ages given are 57, 36, 52, 31, 30, 52, 46, 27, 40, and 32. Of the causes necessitating the operation there were — Anearism of sabclaviaii — Traumatic 6 Idiopathic 3 Character of aneurism not stated 5 Hemorrhage* of the ligature of subclavian 1 Cause of operation not given I Total 16 Point of Ligature. — Location indicated in only 3 instances. Once "near the aorta." Once only \ inch below the bifurcation of the innominate. Once 1 inch from the aorta. I The case of Hutin. (221) 222 PRIZE ESSAY. Hemorrhage after Operation, Hemorrhage in 12 cases — On cardiac side of ligature in 3 On distal side of ligature in 5 Source not stated 3 Into lungs (A. B. Mott), rupture of sac ... 1 — 12 No hemorrhage in 3 cases — Death 8th day 1 " 2d " 1 " (date not given) 1 — 3 15 Not definitely stated (probably none) ; death 11 hours . . 1 Ligatures came away in only 4 cases, respectively on the 20th, 17th, 14th, 14th days. Recovery^ 1 case ; condition temporarily cured, with slight and probably temporary debility of right upper extremity. Causes of Death. Hemorrhage alone after operation 10 " with pericarditis . ,1 Exhaustion (with probably pyaemia) 1 ( " " ** uraemia) 1 from loss of blood before operation . . . , 1 Pyaemia (alone) 1 15 Complications with Ligature. Ligature of innominate and carotid simultaneously . 1 A. B. Mott. Ligature of innominate and carotid simultaneously, and vertebral on 54th day 1 Smyth. Ligature of subclavian (3d division), and innominate 9 days later 1 Hutin. Ligature of innominate alone 13 Total 16 In the cases of Lizars and Valentine Mott, an anomalous branch (probably the inferior thyroid) was from the innominate near the ligature. In 5 of 34 consecutive cases examined as to this feature, I found this anomaly ; 3 of these 5 were branches to the thyroid body (the thyroid branch from the axis being wanting in 2) and two were pericardiac branches. In the cases of Lizars and Mott, the hemorrhage was from the seat of ligature. (I do not doubt that these abnormal branches were partial causes of the non-closure of the innominate.) INNOMINATE AND SUBCLAVIAN ARTERIES. 223 Dates of Death after Operation. Days. 26, 67, 8, 5, 18, 22, 17, 34, 23, 6, 9, 2, 2J, i; not given 1. Total, 15. Condition of Vessel as shown by Autopsy. V. Mott. Innominate not occluded on cardiac side of ligature. Portion beyond ligature had disappeared by sloughing, but the ends of carotid and subcla- vian were open. Graefe. Cardiac end of artery occluded, distal end open. Bland. Cardiac end occluded, distal end open. Carotid was closed by clot, but subclavian was open. Lizars. Both ends open. Gore. Both ends of innominate open. The carotid was open, but subclavian was closed. Arendt. Died 8th day. Ligature still in situ. Hall. Died 5th day. Ligature still in situ, Bickersteth. Died 6th day. Ligature still in situ. Clot in subclavian, none in carotid. Mott, A. B. Aneurism burst into thorax. Ligature separated on 20th day. No hemorrhage at seat of ligature. C ONCLUSIONS. To arrive at a just conclusion as to the propriety of deligating the innominate artery, it will be instructive and necessary to com- pare with this operation other and more conservative methods of treatment. Of the 16 cases given in the history, 14 were for relief of sub- clavian aneurism. In 1 the cause of the operation is not given. In 1 other (Hutin's) the cause of operation was hemorrhage. In this last case, a punctured wound of the thoracic branch of the axillary artery was the cause of ligature of the subclavian^ and, hemorrhage again occurring, of the innominate. It seems that to have enlarged the original wound and secured the bleeding vessel should have been the first step, instead of liga- ture of the subclavian. . And after hemorrhage occurred again (as suggested by Dr. Otis in the Medical and Surgical History of the Rebellion), amputation at the shoulder would have been safer than ligature of the innominate. In 14 operations for subclavian aneurism we have 18 immediately faial^ and one ** temporarily cured," which proved fatal, from the original aneurism, which reformed in the reversed collateral circula- tion^ about ten years later. 224 PRIZE ESSAY. SYNOPSIS OP 22 CASES OF SUBCLAVIAN ANEURISM IN WHICH " NO treatment" was UNDERTAKEN. 18 deaths ; 4 spontaneous cures. (After Poland.) 18 fatal cases. Dates of death after turaor was noticed (and when surgical interference might have been undertaken). 1 case. Aneurism had existed for " some time." Died 12 weeks after admission to hospital. 1 case. Not known how long aneurism*had existed. 1 case. Lived " some months.'' Died of exhaustion and suppuration caused bj pressure of sac. 1 case. Died of rupture of sac 24 years after recognition of aneurism. 1 case. Died from asphyxia caused by pressure of sac, 8 years. 1 case. Died from external rupture of sac 2 years and 8 months after recognition of aneurism. 1 case. Died from exhaustion from pressure of sac, 2 years after recognition. 1 case. Died from dyspnoea from pressure of sac, 2 years after recognition. 1 case. Died from dyspnoea and exhaustion from pressure of sac IJ year after recognition. 1 case. Died from rupture of sac into lungs IJ year after recognition. 1 case. Died from rupture of sac into lungs 8J months after recognition. 1 case. Died from rupture of sac into tissues, becoming diffused, and causing death by pressure 5J months after recognition. 1 case. Died from rupture of sac, death by pressure 5 months after recognition. 1 case. Died suddenly (probably from cerebral clot) IJ year after recognition. 1 case. Died suddenly, cause not stated, not rupture of sac. 2 cases. Died from rupture of popliteal aneurisms. 1 case. Died from typhoid pneumonia 3 years after recognition. Of the 4 cures, 3 remained well ; 1 died about 4 years later from rupture of an aortic aneurism. Of these 18 fatal cases in which no treatment was undertaken, 8 died of other disease than the aneurism. Of the 13 cases in which the duration ot life is noted after the recognition of the aneurism, the sum total is 47 years and 9 months The sum of life in the 13 cases after deligation of the innominate is about 8 months, a difference in favor of non-interference (in an equal number of cases) of about 47 years of life. An examination of the cases on the next page will show that judicious treatment without ligature is a more successful method than either this latter or perfect non-interference. INNOMINATB AND SUBCLAVIAN ARTERIES. 225 SYNOPSIS OF li OASES TREATED BY "VALSALVA'S METHOD, (More or less modified.) 1 citBe. Ml ; B. Subclavian aneoriam. Size, ben's egg. VenEBeotion ; cold and lead lotion locally. Recovered. Two aud a, half yeare later waa work- ing as a carter in the city. lease. M. ; B. Snbciaviaii. Immense size. TeoesectioD. Cold and astriogentB locally. I'nnior reduced in size aod firmer ; lost sight of while iu pro- cess of care. 1 case. U. ; B. Subckviaa (Byphilitic). Talsalra's method and antisyphilitics. Cure complete. lease. M.; R. ; age 45. Subclavian (syphilitic). Yalsalva's method and anti- syphilitics. Cured and seen well 6 years later. 1 case. M. ; age 42. Subclavian. Venesection. Digitalis. Best. Marked im- provement, so that patient left hospital and waa tost sight of. 1 case. M. ; age 50. Subclavian. Waa treated for an intercurrent attack of rhea- matism by rest, strict diet, and an tiphi agist! cs. Cured. 1 case. M. ; age 3!). Subclavlo-axillary (Paocoost's case). Valsalva's method had been tried and considered a failure. Operation determined on. Carried into operating room. Patient fell into collapse and operatiou was post- poned. Recovered cured. (It is stated that a large dose of aconite bad been given by mistake just before the operation was to have taken place.) 1 case. M. ; age 3T. Subclavian. Yencsection. Talsalva's method and careful and persistent direct compression for l^ year. Cured. 1 case. M. ; age SI. Subclavio-axillary (by Pelletau). Valsalva's method. Cured. 5 cases treated by this method (in part) were fatal. Venesection was not practised except in one case. Only local and constitutional treatment All died within 1^ months of the recorded recognition of the disease; 1 from ^L nlceratioti into trachea, hemoptysis, and exhaustion; 2 from estemal ^P bursting of sac ; 2 from exhaustion and coma (with pressare on the ^ trachea in one case). Summary. — 14 cases. Cured 7 ; improved, and in process of cure when lost sight of, 2 ; died 5. No venesection in 4 of 5 futal cases. _ 1 successful case modified hj direct pressure. SYNOPSIS OF 6 CASES TREATED BY DIBKOT PBE3SUBE UPON THE SAC (modifications GIVKN). (All subclavian aneurism.) . ; 4G years ; B. Leather " cup" moulded over tumor and held io place by fignre-of-S straps around shoulders and axilla. Cured iu 14 mouths. Did light work during treatment, and had no other medication. Seue. M. ; 3d years; L. Enormous size. Treated by cold and pressure "in turns." Small cannon-ball suspended so as to press comfortably. Dis- charged relieved. Some months later violent infiammation (from fall), suppuration, rupture of sac, discharged two qnarts of pus aud blood. Cared. Debility of arm probably perniaueut. 16 i 226 PRIZE BSSAT. I case. M. ; 41 years. (13 months' duration.) Kept in bed, on back, ice locally, restricted diet. 3d day air cushion for 12 hours with intermissions amounting to 3 hours. Every half-hour interval of ice. Treatment for 7 days. Tumor began to subside and was cured in 12 months. 1 casiB. (T. Holmes.) (Lancet, Feb. 12,. 1876, p. 237.) Subclavian. Treated by direct pressure from rubber ball. Cured. 1 case. (Dupuytren.) Direct pressure. Resulted fatally. 1 case. (Porter.) Exposed axillary and passed needle under it. 35 days later exposed innominate and passed the "acupressure needle'' under it. Died from hemorrhage from innominate on 10th day. (In 1 case given in preceding table, direct pressure was practised with Valsalva's method.) Summary. — 5 cases of " direct pressure" (without operative pro- cedures). Cured 4 ; died 1. SYNOPSIS OF CASES OF MASSAGE OR KNEADING IN THE TREATMENT OF SUBCLAVIAN ANEURISM. Of this method there are 6 cases. 3 cured ; viz., by Fergusson, Little, and Porter. 3 died; viz., by Fergusson, Hilton, and Morgan. (See Guy's Hospital Reports, vol. xvi. p. 42 et seq.) In addition, Mr. Bryant, in his " Practice of Surgery," p. 190, gives a case by Dutoit, of Berne, in which a subclavian aneurism was cured by injection of ergotin around the sac under the skin, and digital compression. Poland cured one case by digital pressure on cardiac side. A third case was tried for 46 hours and abandoned on account of pain from pressure. The patient died from exhaustion. Paget tried mechanical pressure in a fourth case, but abandoned it as a hopeless undertaking. A fifth case by Yerneuil was improved, but lost sight of before a cure was effected. Conclusions. 1. That the circumstances justifying ligature of the arterta inno- minata, for the cure of subclavian aneurism, will occur so rarelv that practically the operation should be abolished. 2. That nature, unaided, is more successful than surgery which ligatures the innominate. 3. That judicious venesection, prersistent and perfect rest in bed, restricted diet, careful medication, combined with a determination, INNOMINATE AND SUBCLAVIAN ARTERIESi, 227 on the part of both patient and surgeon, to succeed, is safer and more certain of success than either nature or the ligature. 4. That direct pressure by means of any substance that will press equally upon the entire surface of the tumor (Holmes's elastic ball seems best adapted), applied gradually, in order to accustom the patient and the tumor to its presence, in connection with the last method above mentioned, is surest of success as compared with all known methods of treatment. 5. That, should all these means fail after a persistent trial, should the sac by ulceration open and threaten instantaneous death, or should the surgeon from the appearances judge that this accident was on the eve of occurring, then I should deem ligature of the innominate artery justifiable and imperative. As insisted upon in the ** operative surgery'' in connection with this vessel (which see), the artery should be twisted after being tied, the carotid treated in the same manner, and the subclavian tied near the innominate. It is most probable that this last vessel will be so involved in the disease that torsion would scarcely be safe. In all cases the vertebral, the thyroid axis (or its branches), the internal mammary, the intercostal, and the posterior scapular should be tied or twisted. 6. That "kneading, or massage," has an element of danger in the suddenness of its action, and is inferior to the above method. 7. That pressure on the cardiac side is scarcely practicable; while pressure on the distal side is dangerous and useless as compared with other methods. 8. That the introduction of wire, horsehair, acupressure, galvano- puncture, and injections into the cavity of the sac are not to be practised. 9. That in wounds of the innominate it should be tied and twisted (as heretofore given), and the carotid and subclavian treated as before. [In case the carotid were wounded within half an inch of the in- nominate, or the subclavian within the same distance, I would consider it safer to practise ligature of both carotid and subclavian, and then torsion of both "stumps" with the innominate — the distal ends of these two vessels to be treated as above. Especially would I insist upon this in wounds of the subclavian, since ligature of this artery in its first surgical division has invariably proved fatal. (See 19 cases in history.)] 228 PRIZE ESSAY. GENERAL SUMMARY OF CASES OF LIGATURE OF THE SUBCLAVIAN ARTERY. This collection of cases includes 283 instances of ligature of the subclavian artery (all in the third surgical division, excepting 32). The sex is given in 262 cases ; of this number 240 were males and only 22 females; an unmistakable indication that exposure and violence are causes of the lesions requiring so grave an operation. As to the side of body, mention is made in 222 cases ; of which 132 are on the right, and 90 on the left side. The ages of the patients were as follows (as far as noted): — 1 3 4 6 13 8 4 2 5 2 4 7 3 11 5 6 8 5 11 9 6 4 4 13 3 3 A risumi by decades shows that accidents leading to ligature of the subclavian are more apt to occur in the ** active periods" of life. Under 20 years there were only 9 cases. From 20 to 30 years there were 48 30 " 40 " " " 69 40 " 50 " " " 34 50 " 60 " " " 22 60 " 73 " " " 10 17 years of age 18 (( (( 19 (( (( 20 (( (( 21 (( (( 22 »( i( 23 u (( 24 (( << 25 u (( 26 n ti 27 ((