Part I., p. 539. (Part 5)

case (point of scythe blade). Amputation (No. 101). 7 cases (nothing specially interesting in character of injury). 9 Total. Of punctured wounds there are 13 cases, with 9 cures; 4 deaths. Ratio of mortality 31 per cent. Ligature of the Subclavian in its Zd Division onjiccount of Surgical Procedures. Synopsis of fatal cases. Cause and date of death : — 1 case. Wound of axillary in reduction of shoulder. Died of exhaustion and gangrene, 6th day. 1 case. After amputation. Prostration, 6th day. 1 case. After amputation. Prostration, ? 1 case. After ligature of axillary for shot wound, a few minutes. 1 case. After reduction of shoulder, 2 mouths. 1 case. After removal of head of humerus. Exhaustion, 25th day. 1 case. After excision of head of humerus. ? ? 1 case. After opening abscess of axilla. Pyaemia, 6th day. 1 case. After dividing cicatricial contractions of axilla. ? 1 case. After removal of sarcoma of axilla. Septicaemia, 20th day. 1 case. After sarcoma (supposed aneurism). Hemorrhage, 25th day. 1 case. After removal of mamma (sarcoma ?). Pleuritis, 3d day. 1 case. After removal of humerus. Carcinoma. Septicaemia, 5th day. 1 case. After removal of humerus. Carcinoma. Exhaustion, 3d day. 1 case. After removal of tumor in axilla. ? ? 1 case. After fungus, axilla (supposed aneurism). Exhaustion, ? 1 case. After malignant tumor of axilla. Phlebitis, 6th day. 17 Total. The 15 cases of recovery under the above heading are given below. Cases of recovery. Cause of operation, etc.:— 1 case. Amputation for encephaloid of humerus. 1 case. Bemoval of clavicle and scapula for osteo-sarcoma (No. 91). 1 case. Bemoval of head of humerus and scapula ; cancer. 1 case. Bemoval of sarcoma of axilla. 1 case. Bemoval of carcinoma of axilla. 1 case. Osteo-sarcoma. Supposed aneurism. Becovered, not cured. 2 cases. After ligature of brachial for aneurism. 2 cases. After opening abscess in axilla. 2 cases. Amputations for railroad crush. 1 case. After resection of humerus for fracture. 1 case. After excision of humerus for fracture. 1 case. Ulceration of amputated stump. 15 Total. 238 PRIZE ESSAY. Out of 32 cases coming under the above caption 17 were fatal, or 53 per ct. (It is worthy of note that of the 15 recoveries, 6 were in connection with malignant diseases.) ResumS of Gases of Ligature of the Subclavian in its Sd Division on account of Hemorrhage, Cases. Died. Recovered. Gunshot wounds 49 41 8 Lacerated wounds 3 2 1 Punctured wounds 13 4 9 ? wound 1 1 Hemorrhage after, or on account of, surgical procedures^ 29 15 14 Total ....... 95 62 33 Or a death-rate of 65 per cent. SUMMARY OF CASES OF LIGATURE OF THE SUBCLAVIAN ARTERY FOR ALL LESIONS EXCEPT ANEURISM AND GUNSHOT WOUNDS IN ITS FIRST, SECOND, AND THIRD SURGICAL DIVISIONS. Under this head there are 52 cases in the table, with 27 recoveries. The conditions are as follows : — Cured with no remaining lesion 20 Cured with amputation of scapula, clavicle, and humerus for osteo- sarcoma Cured with amputation at shoulder (punctured wound) Cured with amputation at upper third (railroad accident) Cured with amputation at shoulder Cured with resection of arm Case not cured (tumor still persisting) Reported as recovered, no mention made of condition Total 27 Ligature in the third Division on account of Aneurism. Under this head I have made a summary of the following sut> • divisions, viz.: — 1st. Subclavian aneurism.^ 2d. Subclavio-axillary. 3d. Axillary. * The 3 cases of "supposed aaeurism** are omitted in this r^sum^. 2 It is very probable that all of these cases were subclavio-axillary, as it would "bo diflBcult to tie the artery in its third division for aneurism involving this portion alone. INNOMINATE AND SUBCLAVIAN ARTERIES. 239 4th. Aneurism on distal side of ligature, situation not given. 5th. Aneurism on cardiac side of ligature. (Wardrop as sug- ested by Brasdor.) For Subclavian Aneurism. Total 5 cases; recovered, 2. Of the 3 fatal cases the cause of eath in — 1 was gangrene and exhaustion, on 5th day. 1 (probably injury of thoracic duct) on ? 1 cause not given. SuhclaviO' Axillary Aneurism. Total 29 cases. Died 13, or 45 per centum. The cause and date f death and cause of aneurism as far as given were in — 5th day, fall from horse. 1 case exhaustion . 1 case exhaustion . 1 case exhaustion . 1 case hemorrhage 1 case hemorrhage 1 case pleuritis, pneumonia, em- physema . 1 case hemorrhage 1 case hemorrhage 1 case hemorrhage 1 case hemorrhage and pyaemia 1 case pleuritis . . . 1 case phlebitis and coma 1 case pneumonia . 13 Total. 4th day. ? 7th day. ? 35th day, syphilis. 29th day, carrying weight on shoulder. 15lh day. ? 12th day, rheumatism. 65th day, rheumatism. ? day, shot wound. 14th day, punctured wound. 3d day. ? 22d day, fall. 22d day. ? Of the 16 recoveries, all were cured but one. In 8 cases no cause of disease is given. In 1 case the cause was " strain while drawing a cork !" In 1 case " barrel fell on shoulder." In 1 case " struck with rope." In 1 case shot wound (military). In 1 case (No. 147) after amputation. In 1 case " cask fell on shoulder.'* In 1 case shot wound (civil). In 1 case idiopathic. 'Axillary Aneurism, The ligature was applied iti the third division on account of axillary aneurism" in 75 cases, with 47 recoveries; the death-rate eing 37 per cent. As far as given the following is a synopsis of 3.e causes and dates of death and the cause of the aneurism in the 8 fatal cases. 240 PRIZB ESSAY. 1 case. Exhaustion 1 case. Cerebral symptoms 1 case. Hemorrhage 1 case. Hemorrhage 1 case. Hemorrhage 1 case. Hemorrhage 1 case. Hemorrhage 1 case. Hemorrhage 1 case. Hemorrhage 1 case. Hemorrhage 1 case. Hemorrhage 1 case. Hemorrhage 1 case. Hemorrhage 1 case. Hemorrhage 1 case. Exhaustion and hemorr. 1 case. Exhaustion 1 case. Exhaustion 1 case. Exhaustion 1 case. Exhaustion 1 case. Exhaustion 1 case. Exhaustion and dyspnoea 1 case. Shock 1 case. Cause unknown 1 case. Cause unknown 1 case. Cause unknown 1 case. Cause unknown 1 case. Cause unknown 1 case. Pyaemia . 5th day. ? 8th day, traumatic. 12th day, rheumatism. 6th day, punctured wound. 15th day, punctured wound. 37th day, " sack of beans fell on shoulder." 27th day. ? 46th day, shot wound. ? shot wound. 16th day. ? 62d day. ? 42d day, " rebound of cannon." 33d day, reduction of shoulder. 14th day, shot wound. 60th day. ? 30th day, fracture of humerus. 46th day, idiopathic (opened for abscess). 30th day. 2d day, shot wound. 12 th day, shot wound. 6 hours, shot wound. 4th day. 4th day, traumatic. ? pistol wound (civil). ? traumatic, several days ? ? thrust of pitchfork. 18th day. ? 28 Total. In the 47 recoveries, the causes of the aneurism as given were — 4 cases. Idiopathic. 7 cases. Punctured wounds. 4 cases. Shot wounds (2 civil and 2 military). 2 cases. " Fall." 2 cases. " Strain." 1 case. " Fall, with wound and dislocation of shoulder." 1 case. " Fall and catching by arm." 1 case. " Muscular exertion." 1 case. " Gored by cow." 1 case. " Lifting weight." 1 case. " Thrown from carriage." 1 case. ** Traumatic." 26 Total given. In addition to the foregoing there were 12 cases of aneurism be- yond the seat of ligature, the vessel involved in the lesion not being given. The majority (if not all) of these were no doubt aneurisms of the axillary ; 6 died and 6 recovered. INNOMINATB AND SUBCLAVIAN ARTERIES. 241 The cause and date of death, and cause of aneurism were — 1. Hemorrhage 1. Hemorrhage 1. Hemorrhage I. Exhaustion . 7lh day, shot wound (civil). 13lh day, traumatic. Several days, dislocation (subglenoid). 4th day. ? ? ? 1. ? 1. Inflammation of sac, pleuritis, and pericarditis . . 7th day. ? Causes of aneurism in the 6 cases of recovery : — 3 cases. Cause not given. 1 case. Punctured wound. 1 case. Pistol-shot wound (civil). 1 case. Dislocation or reduction of shoulder. SYNOPSIS OF CASES OF LIGATURE OF THE SUBCLAVIAN IN ITS 8d DIVISION, FOR ANEURISM BETWEEN THE LIGATURE AND THE HEART. (Wardrop's operation, after suggestion of Brasdor.) 1. Ligature of subclavian alone. 2. Ligature of subclavian and the right common carotid. Ligature of Subclavian alone, 1 case (No. 61. Wardrop). Recovered, temporarily relieved. 1 case (No. 227. Broca). 1 case (No. 237. Bryant) . ** permanent relief. Total 3 cases. (Wardrop's case died of tlie disease 2 years later. Broca's of ' pulmonary gangrene." Bryant's case was alive and doing well at last account.) The following cases were ligatures of the 3d portion, and of the carotid : — Operations SimuHaneous. Fatal cases: — No. Operator. 246. Durham. 247. Eliot. 248. Elisor. 257. Holmes. 260. Hodges. 279. Weir. 283. Maunder. Recoveries : — 284. Barwell, aortic, carotid, subclavian and innominate aneurism. Probable cure, 3 months later doing well. 276. Sands, aorta. Died 13 months later from the aneurism. ' Barwell's case died three months after operation. (See foot of page 100.) 16 Seat of Anearism. Innominate. .\orta and innominate. Date of Death. 6th day. 25 " 65 Caase. Shock. Hemorrhage. Innominate. 57 «( « n 11 <( 11 n 11 (( it ti Few days. ? 242 PRIZE ESSAY. 259. Heath, innominate. Died 4 years later from the aneurism. 261. Lane, innominate. No improvement. 270. Little, innominate or aoria. Marked improvement, one year after opera- tion doing well. Cases in which the carotid was tied at a previous operation. Fatal cases : — 242. Bickersteth, innominate an^ aorta. 2l8t day, suffocation. Carotid tied 7 weeks previously. 280. Wickham, innominate. Died 3 months. (?) Carotid tied about 3 months previously. 282. Speir, aortic. Died 32d day, hemorrhage. Carotid obliterated by " con striction" 2 days before. Recoveries : — 255. Fearn, innominate. Much improved. Carotid tied 2 years before. 265. A. B. Mott, innominate. Cured. Carotid tied by Doughty, of New York, 1 year previously. Total 17 cases ; 10 deaths ; 7 recoveries. [On a previous page I have given 6 other cases of the double operation (see Nos. 14 to 19 inclusive), all of which were fatal, making 22 cases, with a mortality of 16, or 73 per cent. Hemor- rhage was the cause of death in 10 of these 16 fatal cases; viz., from the sac in 5 instances; from the distal end of the subclavian in 3; the carotidin 1; and rupture of the internal jugular in 1 (Hodges). Hemorrhage occurred in one case which recovered temporarily (Prof. Sands).] A GENERAL SUMMARY OF CASES IN WHICH THE SUBCLAVIAN ARTERY WAS TIED IN ITS IST, 2d, AND 3d DIVISIONS ON ACCOUNT OF ANEURISM. Of the 283 cases of ligature of the subclavian given in the accom- panying " History," 167, or 59 per cent., were for the cure of aneu- risms. All of these aneurisms were beyond the ligature excepting 21, which were lesions of the aorta, innominate, or both. As to Sex. Of the 167 cases, the sex is stated in 153 ; of which 140 were males, and only IS females / We may expect (according to this ratio) to meet with 12 males with aneurisms, suggesting ligature of the subclavian, to 1 female. It is an interesting fact, that, in V6 females, suffering from aneurisms for which the above operation was performed, 6 {or one-half) were for aortic or innominate aneurism, the ratio in males being only 1 in 13 cases. INNOMINATE AND SUBCLAVIAN ARTBRIES. 243 Of the 21 cases of the distal operation, the sex is given in 17, of which 11 are males and Q females. All of the females recovered hut one^ while of the 11 males only three recovered. It is clear from this that the distal ligature is fuller of promise in females than in the opposite sex. I am of the opinion that this is due to the fact that women are more patient and obedient under treatment, and can be kept quieter than men. As to Side of Body, Theszc^e is designated in 145 instances: on i\iQ right in 89; on the left in 56. According to this aneurism will exist about IJ times on the rights to 1 on the left side. Of the entire 167 cases of aneurism, 85 recovered, a death-rate of 49 per cent. Of these 85 recoveries the side of body is given in 80, 37 on the right and 43 on the left. Since the artery was tied on the right side in 89 given cases, with only 37 recoveries, we have a death-ratio of 58.5 per centum on this side; while on the left side, out of 56 given cases there were 43 re- coveries, or a death-ratio of only 23.2 per cent., a difference of about 35 per cent, in favor of the ligature of the left subclavian artery. (This difference is doubtless in great measure due to: 1st, the *'Brasdor-Wardrop" operations being on the right side. 2d, the greater length and more favorable position of the left subclavian.) The condition after recovery on the right side is as follows : — Reported permanently and completely cured 24 With amputation at the shoulder, cured 1 With loss of use of hand by ulceration, cured 1 Aortic or innominate aneurism (distal), ** improved" ... 2 ** " " " improved" (died, 4 years, of aneu- rism) 1 Aortic or innominate aneurism, " improved" (died, 13 months, of aneurism) 1 Aortic or innominate aneurism, " no better" 1 " ** ** "improved," died, few months, of pulmonary gangrene 1 Aortic or innominate aneurism, " improved" (died in 3 months of pleuritis 1 Aortic or innominate aneurism, "temporary relief," died in 2 years of aneurism . 1 Contents of sac remained fluid for some time 1 Aneurism persisted 5 years after operation . . . . . 1 244 PRIZE ESSAY. *( i( Of the conditions on the left side^ in 43 cases: — Cured without any injury or lasting deformity with amputation at shoulder (gangrene) (fall) upper 3d (pistol shot) partial anchylosis of elbow (punctured wound) " (fall) disability of arm (shot wound) lost two fingers, gangrene (fall) . Small tumor persisted in . Noted as recoveries, cure not reported . (( « u n u II u il u 32 1 1 1 1 1 1 1 1 3 43 It will be seen that not only are the chances for recovery greater after ligature of the left subclavian for aneurism, but that the recovery is more apt to terminate in a complete cure than upon the right side. Conclusions as to Ligature of the Subclavian Artery in its third Su rgica I Division. 1. That in gunshot wounds of the axillary region, the ligature of the subclavian is fraught with danger from secondary hemorrhage after the establishment of the collateral circulation. That ligature in the seat of injury, upon both sides of every bleeding vessel (in this as in all other lesions) without regard to the extent of the in- cisions necessary, should be the practice. That wounds thus made in the track of the original wound should be left freely open for drainage. That in case the tumefaction or any accidental condition of the part injured should render the operation at the seat of lesioD impossible, then the subclavian should be tied in its third division, the posterior scapular sought for and tied (if present). Two ligatures should be placed upon the subclavian^ the vessel divided between them, and torsion practised with both ends. 2. That in all lesions causing dangerous hemorrhage, while tbe danger of death does not exist to such an alarming extent as in gunshot wounds, the same operative procedures should be practised as in the foregoing class of cases, subject to the same exceptions. 3. In aneurisms of the axillary region, the ligature (which is fatal in 40+ per cent.) should not be attempted until a persistent trial is made of the various metliods recommended under the head of ** Aneurisms of the First Surgical Division." Digital or mechanical pressure as the vessel crosses the first rib, in connection with Val- salva's method, rest on the back, gentle pressure directly upon the INNOMINATE AND SUBCLAVIAN ARTERIES. 245 tumor, if undertaken with a determination on the part of both sur- geon and patient to succeed, will (I believe) fail so rarely that ligature of the subclavian will not be necessary in the great majority of cases. Should however the necessity arise, the same rules are applicable as heretofore given. 4. Simultaneous ligature of the subclavian and carotid arteries for relief of aneurism on cardiac side of these ligatures (Brasdor- Wardrop) is of questionable propriety. I would advise that the conservative methods given (and illustrated in the successful cases) heretofore be courageously and persistently tried. Should these fail and deligation be determined upon, the carotid should be first tied, and, after an interval of some weeks, the subclavian, in its third division (subject to the rules laid down in the operative surgery, which see). The subclavian should not be tied first, since the danger of an embolus being carried into the cranial circulation would be thus increased. Bauga of origin of the right and left vertebral and luternal inaiQiiiBr/ arteries (deduced from 62 ooDEecntive dlsseotions). (Figure redaued from life-Biie drawing.) Ocoasioual abnoTmal positions of tlia branches or the sabolUTiaii arteries. (Keduced Trom life-size drawing.) Raugs of origin of the inferior thyroid, posterior softpnlar, aod saparior intercoBtal branchea of the right and left subolaviau arteriea. De- daoed from 52 consecutive diaaectiona. (Reduced from lire-siie drawings.) Ori«1qofRLghl3nb Arch ot tlie Aorta. — ReUUoDB at the great vessfis wbeii tho right snbclai derived from tlio desCFuding portinu of the aroli. (Reduced from a li drairing.)