Part I., p. 539. (Part 4)

it 28 (( a 29 it a 30 u a 31 (( a 32 u a 33 u 4( 34 u (( 35 (( (( 36 (( (( 37 (( (( 38 (( u 39 (( (( 40 ti ti 41 (( a 42 n it ti 43 years of age 44. a n a 1 . 3 . 1 45 " ** " . 2 46 " " " . 1 47 " " " . 3 48 " " " . 3 49 ' ' ** . 2 50 ** " " . 8 51 " " " . 3 53 " " ** . 1 54 " " " 4 55 " " " . 3 56 " " " . 1 57 " " " . 1 59 " " " . 1 60 " " " . 3 61 " " " . 2 63 ** " " • . 2 65 " " " . 1 68 " " " . 1 •79 (( (( (( 1 Noted as old . . 1 " " child . 1 " " young ** " middle-ag •ed . • > < 2 . 15 a a it it a it a INNOMINATE AND SUBCLAVIAN ARTERIES. 229 Hemorrhage, Of 283 cases, hemorrhage is given as occurring after the opera- tion in 93. There is stated " no hemorrhage" in 37 cases. In the remainder this accident either did not occur, or it is not noted in the account if it did. It is evident that no exact conclusion can be reached as to the proportion of cases in which hemorrhage may occur. The source of the hemorrhage was as follows in the few cases in which it is specified : — At seat of the ligatare (side not stated) 10 cases. (from distal end of artery) ... 13 (from central end of artery) . . 6 (both central and distal end of artery) 3 At seat of lesion beyond ligature 31 {( « (C {( « (( u u u From the carotid artery From the internal jugular vein From rupture of sac on cardiac side of ligature (Brasdor- Wardrop) Total . • • • . • Ligature came away on — 7th day .... 1 22d day 9 ** 1 23 (( 10 " 2 24 « 11 " 6 26 (I 12 " 10 27 CI 13 " 8 29 u 14 " 3 31 ii 15 " 7 32 u 16 " 5 34 il 17 " 7 36 tt 18 " 8 43 t( 19 " 6 47 (t 20 " 4 85 It 21 " 4 96 u 2 1 5 71 u tl it il n tt tt 3 3 3 Hesult. Of 283 cases of ligature of the subclavian in its three surgical di- visions, 162, or 57 per cent., were fatal. The condition of the 121 recoveries will be found under the special summaries. 230 PRIZE ESSAY. Death occurred as follows : — In a " few minutes" in 1 case. In a " half-honr" in . 1 u In "6 hoars" in . . 2 u In a ** few boars" in . 1 u In 18 hours in . 1 u In 1 day in . . 3 n On 2d day in . 6 ki (( 3 u . 6 It u 4 tk • . 11 tt, ii 5 u . 7 it u 6 <6 . 10 u n 7 U . 4 it u 8 U . 5 li. K 9 U . 6 it ii 10 U . 3 it. i( 11 U . 6 it U 12 U . 7 it (4 13 H. . 4 (« (( 14 U . 3 it (. 15 u . 4 tt U 16 u . 3 it Causes of death as given — Hemorrbagi ^ al(»e in . • . 47 u and pleuritis V . 1 u bronchitis » . 1 li. and pyaemia • . 3 ic and pneumonia . 2 it and exhaustion . 13 (( and dyspnoea • . 2 « erysipelas, & pleuritis 1 (( exhaustion, and gan- grene . • . 1 (( exhaustion, and diar- rhcea . 1 Phlebitis • • • . 2 SufTocation • • • . 1 Shock • • • • . 2 Pleuritis • • • . 2 u pneumonia, emphysema . 1 (( pericarditis, pyaemia . 1 On 18th day in . 3< jasos. " 19 1 ** 20 2 a 21 2 " 22 " 4 ' 25 2 " 27 1 • 29 " 2 " 30 2 " 31 1 " 32 " 1 " 33 ** 1 " 35 1 " 36 1 a 37 a 1 u 4g 2 a 57 1 " 60 2 " 62 " 1 " 65 2 " 90 1 Pneumonia and pneumothorax . 1 Exhaustion (( 1 Cerebral anaemia • • • < 1 " symptom s * < 2 Exhaustion, pyaemia, gangrene . 2 Pneumonia . • • • 2 Pyaemia • • • < 9 Bronchitis and pulmonary con- gestion • • • . 1 Inflammation of sac, pleuritis, pen - carditis • • . 1 Exhaustion and pyaemia i . 1 Gangrene . • • , 1 " and pyaemia . 1 Exhaustion and gangrene . 3 Septicaemia . • • . 2 Exhaustion . • • ,28 Cause not given in .18 SUMMARY OF LIGATURE OF THE SUBCLAVIAN IN ITS FIRST SURGICAL DIVISION. I have been able to obtain positive results in 19 cases of the above operation. Death followed in each case. 13 were ligatures of the subclavian alone; 6 of the subclavian and carotid o^ the right side. INNOMINATE AND SUBCLAVIAN ARTERIES. 231 LIGATURE OF THE SUBCLAVIAN ALONE. (All on right side but one.) The cause of the operation was — Subclavian aneurism in 8 cases. Subclavio-axillary aneurism in 2 " Shot wound of subclavio-axillary region in . . . . 2 " Cause not given in 1 " Total • . .13 Hemorrhage occurred after the operation in 10 of these 13. No hemorrhage occurred in 2 cases (one of these dying on the 4th day ; the other in half an hour after operation). In one case no mention is made of hemorrhage. Death on 4th day. The autopsies showed that in the 10 cases in which hemorrhage occurred it was from beyond the ligature in 6, viz.: — From rupture of sac in . 1 case. '* distal end of artery at ligature in 5 ** (In these 5 cases a firm clot was found in central end of the vessel.) From rupture of the artery at seat of ligature . . . 2 " No autopsy made of hemorrhage in 2 " Total 10 Causes and dates of Death, Hemorrhage alone 1 4th day 1 18th " 1 24 hours. 1 13th day. 1 36th " 1 15th " 1 11th " 1 8th " " and pneumonia 1 22d " ' and bronchitis 1 12th " Pericarditis, pleuritis, and pyaemia 1 4th " Exhaustion 1 half an hour. Cause not given 1 4th day. Total 13 Hemorrhage had occurred previous to operation in 2 cases (Ayres and Ballen). 282 PRIZE ESSAY. LIGATURE OF SUBCLAVIAN IN ITS FIRST DIVISION AND THE COMMON CAROTID. (SIMULTANEOUSLY.) Causes of Operation. Subclavian aneurism in 2 Innominate " " 1 Aortic (supposed innominate aneurism) in 1 Bayonet wound in first intercostal space in 1 Vascular tumor of frontal region in 1 Total 6 Hemorrhage occurred after ligature in 4 of these 6. Of the 4 cases of hemorrhage 3 were from the distal end of the suhclavian^ one from the carotid. Dates and Causes of Death. Hemorrhage alone 1 13th day. 1 42d " 1 16th " 1 10th " Cerebral anaemia 1 6th " Cause not given 1 2d " Total 6 Operators — Liston, Rossi, Parker (vertebral tied same time), Ho- bart, Cuveillier, Kuhl {subclavian included by accident?). Comment is scarcely necessary upon the operation for ligature of this artery in its first division. 19 operations, 19 deaths. The ligature of the innominate gives a better result, 16 operations and 1 recovery and temporary cure. There can be little doubt that the cause of death to such an alarming extent is due to the uninterrupted currents of blood from the smaller vessels coming off from the main trunk in dangerous proximity to the point of ligature. In the majority of cases the vessel was closed by a safe clot on the cardiac side of the ligature. I am of the opinion that the impaction of the blood current has no little to do in -consolidating this cardiac clot, while the current which is inverse in the smaller arteries beyond the ligature retards the formation of a coagulum by exerting a suction force in the flow of the blood current toward the periphery. Conclusions as to the Propriety of Ligature of the Subclavian Artery in its 1st Surgical Division. 1. That for aneurism upon the cardiac side of the ligature (Bras- dor- Wardrop) this procedure is not justifiable, since death has INNOMINATE AND SUBCLAVIAN ARTERIES. 233 occurred in every instance. The vessel should be tied in its 3d division (Wardrop). 2. That for aneurism upon the distal side of the ligature, the operation is not safe. The same reasons given for opposing the ligature of the innominate are applicable here; as is the treatment for the existing aneurism. (See treatment of subclavian aneurism under summary of the innominate.) 3. That for injury to the subclavian in its 1st division requiring the ligature, it should be secured on both sides of the lesion. Every branch within three-quarters of an inch of each ligature should be also tied. Should the cardiac ligature necessarily be placed within one-half inch or less of the arteria innorninata^ then the carotid should be tied with a double ligature, divided between the two, the upper portion twisted, while the innominate with its two " stumps" should be twisted in the same manner. This may at first seem somewhat too "heroic," but since 19 deaths have occurred in succession, and since the autopsies have shown that hemorrhage is not so much to be dreaded on the cardiac as on the distal side, I am convinced that all these precautions are essential. SUMMARY OF LIGATURE OF THE SUBCLAVIAN IN ITS 2d SURGICAL DIVISION. (8 cases upon the left ; 5 upon the right side.) This vessel has been tied behind the scalenus in 13 cases; died 9, or 69 per cent.; recovered and cured 4. The carotid was secured in none of these operations. The causes of the ligature were — Axillary aneurism in 4 Subclavio-axillary aneurism in 5 Shot wound of axilla in 2 Medullary fungus (supposed aneurism) in I Punctured wound of axilla 1 Total 13 Hemorrhage followed the operation in 5 instances ; 2 recovered, 8 died. From seat of ligature (both ends of vessel open) .... 1 ' wound well beyond ligature 3 " a vein 1 Of the 4 recoveries all are reported as cured (one with amputation at shoulder-joint on account of gangrene). 234 PRIZE ESSAY. Causes and Dates of Death, Hemorrhage alone 1 14th day. 16 hours. 1 4th day. Pneumonia ** 16 Exhaustion " 1 15 " pyaemia, and gangrene 1 12 Pyaemia alone 19 Cerebral complications 1 2J Bronchitis and pulmonary congestion . . . .19 (Hemorrhage had occurred previous to the operation in 5 in- stances.) In one of the above fatal cases the ball had wounded the lung. In another the axillary had been previously tied, and after ligature of the subclavian the arm was amputated at the shoulder. A third fatal case was attempted removal of a malignant fungus. The ligature of the left subclavian in its second division is prac- tically as safe as that of the third division, since the comparative length of the first division has removed it further from the great trunk. The 4 cases of recovery, of the 13 instances of ligature at this point, were all on the left side. Conclusions. 1. In the left subclavian, the application of the ligature to its second division is subject to the same rules and is as safe as that of ligature in the third surgical division (which see). 2. Since the average length of the first portion of the right sub- clavian is 1.15 inch, it would seem that it should be safer to apply the ligature in the second than in the first part, yet in the five in- stances in which this operation has been performed it has proved as invariably fatal as that in the first division. As in the operation within the scalenus, every effort should be made to avoid the application of the ligature ; but when the ne- cessity still exists, the scalenus should be completely divided, and all the neighboring branches tied on either side of the two ligatures, between which the main trunk should be divided and each end twisted securely, when it is not involved in the disease to such an extent as to contra-indicate torsion. INNOMINATE AND SUBCLAVIAN ARTERIES. 235 SUMMARY OF LIGATURES OF THE SUBCLAVIAN ARTERY IN ITS THIRD SURGICAL DIVISION. (Between the outer border of the scalenus auticus muscle and the lower border of first rib.) I have found in the literature of this subject up to date (November, 1877), and have accepted as belonging properly to the third division of the subclavian artery, 251 cases of ligature. I have rejected more than 100 cases which have been considered and reported by some writers as cases of subclavian ligature, because, in a large number of these, the description of the method of operating and the point of ligature indicated clearly that the axillary was tied and not the subclavian. In other cases no result of the operation was given, which rendered its acceptance useless. Between 13 and 20 of my cases were tied helow the clavicle^ but from a detail of the pro- cedure and the character of the lesion I have taken these to be true cases of subclavian ligature. Of these 251 cases, 134 died, or 53+ per centum. Of the 117 recoveries, the great majority were cured. (The condition of re- covery will be given under each special summary.) SPECIAL SUMMARY. (Hemorrhage.) Ligature of the Subclavian in its third portion on account of Hemor- rhage from Gunshot Wounds. Under this heading there are 49 cases, of which only 8 recovered, a mortality of 83 -f per cent. All were cases in military practice with probably only two exceptions. A synopsis of the date, and cause of death, and complications of the operation is subjoin^. Fatal cases. Ligature after gunshot wounds. 9 cases (uncomplicated). Died of hemorrhage alone on 5th, 4th, 5th, 2d, 12lh, 21st, 13th, 9th, 9th days respectively. 4 cases (uncomplicated). Pyaemia alone. (Only one date given) 4th day. 2 cases (uncomplicated). Exhaustion alone. On the 29th and 19th days. 4 cases (uncomplicated). Exhaustion and hemorrhages. 16th, 9th days, 18 hours and 2 hours. 1 case (uncomplicated). Gangrene, 10th day. 1 case (uncomplicated). Gangrene, pyaemia, and exhaustion, 6th day. 1 case (uncomplicated). Pyaemia and hemorrhage, (?) 1 case (uncomplicated). Pleuritis, erysipelas, and hemorrhage, 8th day. 1 case (uncomplicated). Hemorrhage (before operation), exhaustion, 31st day. (?) 1 case (civil, uncomplicated). Hemorrhage, gangrene, exhaustion, 3d day. 1 case (uncomplicated). Pneumothorax, pneumonia, 2d day. 4 cases (uncomplicated). (?) (Only two dates given) 11th and 4th. 236 PRIZE ESSAY. 2 cases (with excision of humerus). Exhaustion, 6th and 9th days. lease (with excision of humerus). (?) 2d day. 1 case (exsection head of humerus). Hemorrhage, 3d day. 1 case (exsection head of humerus). Exhaustion, pneumothorax next day. 2 cases (amputation at shoulder). Exhaustion, 11th and 20th days. 1 case (amputation at shoulder). Gangrene and exhaustion, few hours. 1 case (amputation at shoulder). (?) 2d day. 1 case (amputation upper third humerus). Exhaustion, same day. 1 case (amputation upper third humerus). Pyaimia, 22d day. 41 Total. All of these except 1 were gunshot wounds, treated on the field, or in military hospitals. A second case was a civilian wounded by a pistol shot, but treated in an army hospital. Of the 8 recoveries only 1 was in civil practice. 1 case of shot wound of lung and subclavian artery. 1 case of amputation at shoulder (No. 182). 1 case of amputation, upper 3d (No. 185). 1 case of resection of humerus (No. 215). 1 case (civil) small shot wound, axilla (contraction of flexor muscles with fixa- tion of fingers). 3 cases. Nothing of interest given. 8 Total.' Lacerated Wounds (not gunshot). 1 case caused by fractured humerus. Died, pyaemia, 7th day. 1 case caused by dislocation of humerus (amputation at shoulder). Died of exhaustion next day 1 case caused by fall. Recovered, cured. Total 3 cases: Died 2 ; recovered, cured, 1. Wound (character not stated). Onfy 1 case. Recovered 1. Punctured Wounds. Fatal cases. Cause and date of death : — 1 case (scissors blade). (Innominate tied later, No. 99.) Died of hemorrhage 10th day. 2 cases. Hemorrhage, on 5th and 11th days. 1 case. Gangrene, on 8th day. 4 Total. ' Of 8 recoveries the side is stated in 5. Four of these 5 were on the left side. This would indicate that wounds of the left side are less dangerous, which, from the stand-point of surgical anatomy, I am inclined to believe. The condition of these 5 (given) recoveries is as follows: Paralysis of arm; total disability of arm; partial disability of arm ; amputation at shoulder ; amputation in upper 3d liume* rus; in 1 case respectively. All gunshot wounds were in males; 22 on right, 21 on left side, as far as given. INNOMINATE AND SUBCLAVIAN ARTERIES. 237 Cases of recovery : — 1 case (thrust with red-hot poker). 1