318

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

UNIVERSITY COLLEGE HOSPITAL.ANEURISM OF LEFT AXILLARY ARTERY ; LIGATION OF

SUBCLAVIAN TRUNK IN THE THIRD PART WITH CAR-BOLISED SILK CUT SHORT ; CURE WITH RETENTION OFLIGATURE ; RECOVERY.

(Under the care of Mr. BERKELEY HILL.)

Nulla autem est alia pro certo noseendivia, nisi quamplurimas et morborum Iet dissectionum historias, tum aliorum tum proprias collectas habere, etinter se comparaj’e.—MozaAaNi De Sed. et Caus. MQ’I’b., lib. iv. Prooemium.

T. Wiz, a labourer, aged forty-four, who worked usuallyat heavy lifting, was sent to the hospital by Dr. Gramshaw,of Gravesend. There was no history of rheumatism, syphilis,or of alcoholism. About eighteen months before admissionhe had felt a tingling from the left elbow to the tips of hisfingers. Rather more than a fortnight before his admissionhe noticed a swelling in his left armpit. This grew in size

rapidly, and the pain of the forearm increased, though itnever prevented him from working, nor was felt above theelbow.On admission, on March 9th, 1882, in the left axilla a

swelling occupied the whole hollow, pulsating forcibly withthe arterial pulse. There was also fulness of the infra-clavicular region, where pulsation was also distinct. Thoughthe pulsation of the left subclavian artery was more distinctthan that of the right, no swelling could be felt along itscourse. The left external jugular vein was distended,though it did not fill from below. The left arm could beplaced close to the side. The left radial pulse was as full,if not fuller, as the right pulse. Compression of the sub-clavian quite arrested the pulsation of the tumour. At the

heart’s apex was a soft blowing murmur. There were nosigns of aneurism in the thorax or elsewhere other than inthe left axilla. During the patient’s stay in hospital the painin the left forearm ascended to the shoulder, became almostconstant, and greatly interfered with sleep.On March 15th Mr. Berkeley Hill tied the left subelavian

artery in the third part, using for the ligature a piece ofChinese silk twist soaked in carbolic water for twenty-fourhours. The ends of the thread were cut off short, and thewound, except for a short drainage-tube at the outer end,was closed with sutures. Until the vessel was tied, theantiseptic spray was not used. During the dressing of thewound the spray was turned on, and the wound well washedwith carbolic water. Lister’s gauze dressing was applied,and the instruments, operator’s hands, &c., well washed incarbolic water before the operation. The pulsation in theaneurism ceased at once on the application of the ligature.The patient complained of his old pain in the forearm

during the night after the operation. The left hand remainedwarm. On the third day the patient was fairly comfortable ;his temperature had not risen ; there was no pulse in theradial artery. The pain in the shoulder was felt everynight with varying severity. On the 19th the dressingswere changed. The wound appeared to have healed by firstintention, except where the tube lay. Slight pulsation ofthe tumour could be detected in the armpit. On the 19th,20th, 21st, and 22nd the temperature rose to 100° or 101°,the highest being 101 ’8° on the evening of March 21st. Itfell to the normal range on the 23rd, and never exceeded thatstandard afterwards. On the 22nd the dressings were changed,the skin over the infra-clavicular region was red and

slightly cedematous, and the drainage-tube was found to beblocked; on gentle pressure three or four drachms of puswelled out. The drainage-tube was replaced a little moredeeply, and the dressings again applied. The pulsation inthe aneurism was, as before, just perceptible. On the 25ththe wound was dressed again. The swelling had much sub-sided, and the discharge was scanty. The tumour had ceasedto pulsate, and there was no pulse in the radial. On the29th the inflammatory swelling had quite disappeared; thewound was nearly closed; the aneurism was a firm solidmass; there was a very weak radial pulse.

The wound was thenceforth slow to heal. A few drops ofpus could be squeezed from the wound at each dressing tillApril 12th, four weeks after the operation. On the 28ththe wound was healed except for a bunch of granulations,the size of a pea, at the angle of the wound. The tumourcould be easily made out beneath the pectoral muscles,occupying and filling the infra-clavicular fossa, and lyingclose against the thoracic wall. Nothing has been seen ofthe ligature. There is no pulsation in the brachial norradial arteries.On May 3rd the patient was discharged at his own urgent

request, that he might go to work.’ On Jan. 31st, 1883, Dr. Gramshaw (of Gravesend) reportedthat the patient was very well then ; the tumour was stillto be felt, without the least pulsation, but not much smallerthan in May last and not very hard. The ligature had notcome away nor the wound opened since it healed.

LIVERPOOL ROYAL INFIRMARY.WOUND OF NECK; SECONDARY HÆMORRHAGE ; LIGATURE

OF COMMON AND EXTERNAL CAROTID ARTERIES ;RECOVERY; REMARKS.

(Under the care of Mr. REGINALD HARRISON.)LOUISA B-, aged fifteen, was admitted on October 5th,

1882, suffering from an extensive incised wound of the neckextending downwards for nearly four inches from the angleof the right jaw. The injury had been occasioned the daypreviously by the patient having fallen violently on a brokenplate she was carrying. The wound had been plugged withlint steeped in perchloride of iron.On admission, Mr. Harrison had the patient placed under

ether, and having removed the plug carefully examined thewound with the view of ascertaining the amount of damagethat had been inflicted. Though the carotid artery wasbared no wound either in it or in any of the branches of theexternal carotid could be discovered. A few veins andsmall vessels were ligatured, and the sides of the woundwere then brought together by silver sutures.Twelve days afterwards, when the wound had almost

entirely healed, free arterial haemorrhage was observed totake place. Mr. Harrison was summoned, and on openingthe wound, and recognising that probably one of the carotidshad given way, he requested the assistance and advice of hiscolleague, Mr. Banks. As the haemorrhage was so free onremoving pressure from the bottom of the wound, and theparts were so matted together and obscured by the previoussuppuration, it was resolved to tie the common carotid.This was accordingly done with a catgut ligature. Thisto some extent controlled the bleeding, but it was clear thatthe haemorrhage was above that point. The external carotidwas then traced up, when a distinct hole could be seen in itabout half an inch above the bifurcation. A catgut ligaturewas placed above and below this opening, when the htmor-rhage entirely ceased, and the patient made a good recoverywithout any further recurrence of bleeding. - As she wasgoing to America in a steamer in which her passage hadbeen booked, she had to leave before the wound had com-pletely closed, but as five weeks had elapsed since thearteries had been tied, no great risk was anticipated.Remarks.-Mr. Harrison observed that the case was one

of considerable interest; it appeared to him that the arteryhad been opened into by ulceration. The operation was oneof considerable difficulty and danger, as the neck was small,the patient enfeebled by the loss of blood, and there was thefurther disadvantage of having to operate by artificial lightin the middle of the night. It was felt that no chanceshould be thrown away bv searching about to determine theprecise seat of the haemorrhage ; it was quite clear that oneof the largest vessels in the neck was involved. It wastherefore determined to place a ligature on the commoncarotid, as this would permit of breathing time and give abetter opportunity for further search. The wisdom of thiscourse was fully sustained by the subsequent proceedings;the haemorhage was abated and traced to the externalcarotid, which was easily ligatured. The completeness ofthe collateral circulation in the head and neck was wellshown in this case; for though the hemorrhage was distinctlychecked when the common carotid was secured, yet it wasstill sufficient to have caused death in a very few minutes ifthe opening in the external carotid had not been occluded by