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Full text of "The Science and art of surgery v.1"

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611 



THK 



SCIENCE AND ART 



SURaERY. 



A TREATISE ON SURGICAL INJURIES, DISEASES, 
AND OPERATIONS. 



BY 

JOHN ERIC ERICHSEN, F.R.S., LL.D., F.R.C.S., 

triSXOX KXTRAOKOIIiAXr to bFx MlJBBtT TBI QDBBH; XX-PI1E8IDBRT OF THK KOTAL COLLBSl 

or scMiKosB OP laai-AnD akd or thx rotal vkdical and cHiRUBatcAL bociktt; 
KM rritcs rRorusoR or scRacRT aud or clikical anRflSRr in UHiTiBSiTr 

CVLLKOB ; COKBDLTIRO SrHeKOH TO DHITBnsITr COLLROK ■OSriTAI., 
ARtl TO MARy OTBRR MRDICAL CHARITIES. 

EIGHTH EDITION. 

REVISKD AND EDITED BY 

MARCUS BECK, M.S. and M.B. Lond., F.E.C.S., 

»riiKKO!i TO iRivauiTT COLLEGE bospital; and propessor or clinical suroert in 

CSITRRtITT COLLESE, LONDON. 

H'/rW .V/.V£ UVSDRED ASD EIGHTY-FOUR ESGRAVINOS ON WOOD. 

VOL n. 




PHILADELP m A: 

LEA BROTHERS & CO. 

1885. 



"^They be the best ChintrgeoQS tchtck being leametl incline to the tradition* of 
experience, or beinif empiriea indine to the methodx of learning" 

Bacor vn Ltarni-ng. 



rHII,ADKI.PHIA: 
WH. J. DOHNA!), FXIMTRa, 

H28-«34 Fnb«rt St. 






CONTENTS OF THE SECOND VOLUME. 



DIVISION THIRD. 
SURGICAL DISEASES. 

(COKTINDKD.) 

Chapter XXXVII. — Suboical Diseases of the Skin and its 

Appendaoes. 

PAflB 

DisEAKO or THX Appehdaoes or the Skin — Diseases of the K'ails — Onychia — 

Simple — Srphilitic — Ingrowing of theN^ail — Hypertrophy of Toe-nail , 88-86 

Di-EA»» or THE Skim — Lupiu — Varieties — Lupus Erythematosus — Lupus Yul- 
Z^Ti*. or Lupus — Causea — Prognosis — Diagnosis — Treatment — Rodent Ulcer — 
Symptoms— Diagaoa is — Pathology — Treatment — Cancer of the Skin — Primary 
Cancer — Secondary Cancer — Sarcomata of the Skin — Alveolar Sarcoimi — 
Simple Tumore of the Skin — Fibroma — Keloid — False Keloid— Oateomata 
— Aden^ima — Moles — Papillomata, or Warts— Corns — Perforating Ulcer of 
Foot 8&-48 

Chapter XXXVIII. — Diseases of the Nervous System. 

NrtRiTi! — Symptoms — Treatment 48 

>.-i tTii A — Symptoms — Dia^nn^is — Treatment — Acupuncture — Stretching the Sci- 

al:o Nerve 48-50 

Nk' rvlgia — Symptoms — Situation a— Causes — Diagnosis — Treatment — Stretching 

>■'. tlu- AtTvcted Nenc — Secli.m of the Affected Xerve— Facial Neuralgia 50-56 

Mr-Mi.\KTic — Clonic Torticollis -t? 

Tkai matic Paraltsis — Kheumatic Paralysis, or Paralysis from Exposure to 

(-'■■IJ — Treatment 57— '>S 

Ni.<H<>u* — Structtire — Traumatic Neuroma — Treatment .... 68-60 
TcT \M> — Causes — Period of Occurrence — Forms— Symptoms — State of Ner^-es — 

S..»i of Injurj- — Patholi>gical Conditions in Spinal Cord — Treatment 60-68 

Chapter XXXIX — Diseases of the Lymphatic System. 

Im i.-iMVATioj; Of THE Ltmpuati'' Vesselh — Lymphangitis, or Angeiolcucitis — 

C.'aU'^-* — Morbid Anatomy — Symptoms — Results — Diagnosis — Treatment fi8-T0 
VAai\ i.r THE Lymphatic Vehsklm — Occurrence — Treatment .70 

Kui.rii 4>TiA»is OF TBE Leos A>'T» ScROTCM — TroHtmcnt .... 70-72 

Li UPIIAI'KMTIM, OR IJIPLAMMATION OK LvMrilATIC Gl.AM>S Pllth"lr>i.'icBl 

AnHt-iiiy — Sympt'>ms — Tremmcnt 7"2-76 

Li Mi-iiAi'EXoUA — KetnovQl 71 



33203 



Tl CONTENTS. 



Chapter XL. — Diseases of Veins. 

PASK 

Vkmoub THEOMBOflis—Cauaea— Process of— Fate of the Thrombuft— Effect*— 

Symptoms — Treatment . 77-88 

Pblebitib— Causes— Pathological Anatomy — Symptoms — Treatment . . 88-86 
Yabicobk Vkim8, oe Vaeix — Definition — Causes — Locality — Morbid Anatomy — 
Appearances and Symptoms — Progress and Effects— Treatment — Obliteration 
of Varicose Veins 86-91 



Chapter XLI. — Aneurism by Anastomobis, and Njevub — 
Hemorrhagic Diathesis. 

AVKUBIKM BY AXA8T0H0BIS — Nature — Diagnosis — Treatment .... 92-93 

Nmyvb — Capillary — Venous or Cavernous — Prognosis — Treatment — Operations — 

Obliteration — Nitric Acid — Galvanic Cautery — Galvano-puncture — Ligature 

— N.«Ti IN Special Situatiosb — Scalp — Fontanell<i — Face — Eyelids — Nose 

— Cheeks — Lips — Tongue— Penis — Vulva — Extremities, Neck, and Trunk — 

Nicvoid Lipoma 98-106 

Heuosbuagic Diathesis, or H.cmofhilia — Causes — Pathology — Treat- 
ment 105-108 



Chapter XLII. — Diseases of Arteries. 

Abtieitis — Acute — TraumaUc — Arteritis by Extension — Embolic — Acute Endar- 
teritis — Arteritis Deformans, or Atheroma — Nature and Causes of— Effects — 
Arteritis Obliterans — Endarteritis Proliferans — Periarteritis 108-1 1« 

pRilfABT Degenkrations Of Artkbies — Fatty DegeneraUon — Calcification — 
Ossification — E Sects of Disease — Ulceration — Spontaneous Rupture — Con- 
traction and Occlusion 116-1*21 



Chapter XLIII. — Aneurism. 

Akeubism defined— Caufes — Classification — Fusiform or Tubular Aneurism — Sac- 
culated Aneurism — True — False — Dissecting Aneurism — Formation of an 
Aneurism — Structure — Pressure-effects — Number — Duration — Symptoms of 
External Circumscribed Aneurism; of Diffuse Aneurism — Diagnosis — Termi- 
nations — Spontaneous Cure — Causes of Death fk>m Aneurism — Constitutional 
or Medical' Treatment — Local Treatment 122-141 

SuROicAL Tbeatment ot Aneurihh. — LioATUBE — Situation — Ligature on both 
Sides of Sac — Ligature on Cardiac side of Aneurism — Distal Ligature— I ndi- 
catiuna and Contra- indications of Ligature — Accidents after Ligature — Secon- 
dary Hemorrhage — Continuance or Kctum of Pulsation — Secondary Aneurism 
— Treatment of Recurrent FuUation — Suppuration and Sloughing of Sac — 
Gangrene — Causes — Treatment. — Comtrkssiox by iNoTBUHENTa — Principle 
— Circumstances influencing Success — Application of Compressor — Effects — 
Durution of Treatment^ A jiplicabi lit j' — Digital Compression — Esmarcfa's 
E lustic Bandage — Flex ion — Acu pressure — Man i pulation — Gal vano-puncturo 
— Injei'tion with Perchloride i)f Inm — lIy(KK!erniic Injection of Ergotin — 
Introduction of Foreign Bodies — Acupuncture 141-171 

Artkrio-vknous Ankurihm 172 



CONTKNTS. Til 



Chapter XLIV. — ANEmusus op the Thorax, Head and 
Neck, and Upper Extbehitt. 

PAOI 

Tboeacic Aorta — Symptoma — Auscultatory Signs — Pressure-effects — Pulsation 

And Tumor— Tre&tmeat 178-160 

IvxoMUiATK AbtsRT — Symptoms — Piesaure-effecU — Prognosis — Diagnosis — 
TreAttnent — Ligmture of Subclavian only — Of Carotid only — Of Subclavian 
and Carotid — General Bemarks on the Operation .... lBO-188 
Cakotid Astkbt — Aneurismsl Varix of Carotid Artery and Jugular Vein — 
Spontaneous Aneurism of Carotid — Symptoms — Diagnosis — Treatment — 
Digital Compression — Ligature of Carotid — Effects on Brain — Table of Cases 
of Ligature of both Carotids — Effects on Lungs — Ligature of Carotid on 
Di*tAl Side— Table 188-200 

I5TEKXAL Carotid Abtirt — Extracranial Aneurism — Treatment . 200-201 

IrrKACKAXiAL Akeubihh — Causes Pathology — Pressure-effects — Symptoms — ■ 
Causes of Death— Treatment 201-206 

IxTAAORBiTAL AsxiTBUM — Erroneoiu Opinion regarding — Causes — Symptoms — 
Prognosis — Patholc^y— Diagnosis — Treatment 206-210 

SrBTLATiA!* Abtcrt — Symptoms — Diagnosis — Results — Treatment — Ligature of 
Uie Bntcfaio-cephalic Artery — Table of Cases — Ligature of Subclavian on 
Tracheal Side — Table— Compression of Artery on Distal Side — Distal Liga- 
ture of SubclavUn beyond the Scaleni — Amputation at Shoulder-joint, and 
Distal Ligature— Ligature of Vertebral Artery 210-221 

IziLLART Artkbt — Symptoms — Diagnosis — Treatment — Ligature of the Sub- 
clavian in Third Part of Course — Accidents during Ligature of the Third 
Part of the Subclavian — Ligature behind the Scalenus Anticus — Results of 
Ligature of the Subclavian — Suppuration of the Sac — Secondary' Hemorrhage 
— Gangrene of Hand and Arm — Treatment of Inflamed Axillary Aneurism 
thieatening Suppuration — Ligature of AxilUiy Artery 221-237 

Arm, Forearh. and Ha»i> — Rarity of Spontaneous Aneurism — Treatment — 
Litrature of the Brachial Artery — Ligature of Radial and Ulnar Arteries 287-241 

Chapter XLV. — Aneurisms of the Abdomen and Lower 
Extremities. 

Aiit-'KiNAL Aorta and its Branches — Symptoms — Diagnosis — Treatment — 
(.'•■nipre^sion of Abdominal Aorta 241-244 

l5t;t i>AL Akkurism — Symptom»^Diagnoais — Tr^tment — Ligature of External 
liiac Artery — Abemethy's Modified Operation — Cooper's Method — Results — 
Lieaiureuf Common Iliac — Results — The Old Operation — Treatment by Com- 
pre^ion — Ligature of Aorta — Aneurism of the Internal Iliac and its Branches 
— Gluu^l and Sciatic Aneurisms — Lig&ture of Intemnl Iliac 244— S'li) 

Femoral and Popliteal Akehrisuh — Aneurism of Deep Femoral Artery — 
Aneurism of the Superficial Femoral and Pupliteal Arteries — Symptoms — 
Iti*L-nijsif — Treatment — Compression — Flexion — Ligature of Common Femoral 
— <»f Superficial Femoral — Results — Accidents attending; Operation — Wound 
^'f Fcm'-ml Vein — .Secondar>- Hemorrhage — Gangrene — Return of Pulsation 
in ."^c — Secondary Aneurism — Ligature of Femoral Artery in the Middle of 
th^ Thiiih — Ligature of Kxtemal Iliac in Poplitenl Aneurism — Double Pop- 
litml Aneurism — Ififfused Popliteal Aneurism — Amputation fur Diffused 
P<-ptite«l Aneurism 256-2ii8 



VIU CONTENTS. 

Aneubisu or THX Tibial Artkries — Ligature of Popliteal Art«ry — Of Poste- 
rior Tibial— Of Anterior Tibial — Of Arteria DorsaliB Pedia — Of Peroneal 
Artery 2t>8-2TI 

Chapter XLVI. — Inflammation op Bone and rra Effects. 

OsvKRAL pATHOLOQT OF iKri^MMATORT ArFBCTiONs OF BoNC — Inflammatory 
Proceuee in the Periosteum — Affecting Compact Ttisue — In the Medulla of 

Long Bones— In the Cancellous Tissue 272-28S 

PiBiOBTiTis — Symptoms — Treatment 268-2S4 

Cbkohic Osteitis and Periobtitis — Symptoms — Treatment — Linear Osteo- 
tomy 284-286 

Osteitis DxroRUAtra — Microscopic Examination 285-286 

Obbokic Abscess of Bone — Causes — Symptoms — Treatment . 28G-289 

DiFrosK Bkftjc Ostiomyelitis — Symptoms — Treatment 28d-2dl 

Acute Nkckosib — Symptoms — Pathology — Results — Diagnosis — Prognosis — 

Treatment 292-294 

Gabies — Definition — Causes— OenemI Appeannces — Situation — Symptoms — 

Treatment — Operations on Carious Bone 294-300 

Kecbosis — Nature — Causes— Characten — Peripheral and Central — Sequestrum — 
Symptoms — Separation of the Dead Bone — Exfoliation — Reparative Process 
— Treatment — Removal of the Sequestrum — Instruments — Amputation — 
Resection— Necrosis of the Sternum, Scapula, or Pelvis— Cranial Bones — 
Patella— Kibs 800-31 1 

Chapter XL VII. — Steuctural Changes in Bone and 
Tumors of Bone. 

Htpbbtbopht — True Hypertrophy — Inflammatory Hypertrophy — Increased 

Length. — Atbopht — Arrested tirowth 812-818 

Rickets — Causes — Symptoms — Prt^jess and Prognosis — Pathology — Treatment 

818-317 

Mollities Ossidu : Osteomalacia- Nature — Cause — Seat of the Disease — State 

of Urine — Symptoms — Diagnosis — Treatment 817-819 

TuuoKS OF Bone — Exostosis — Varieties — Symptoms — Treatment — Enchondro- 
mata or Cartilaginous Tumors — Fibroma— Cystic Tumore — Structure — Treat- 
ment — Hydatids. — Sarcouata of Bone. — Priuabt Malignant Disease — 
Central — Peripheral — Situations — Symptoms — Diagnosis — Treatment. — S«c- 
ONDABT Sabcouata. — Trde Canckb OR Cabcinoua — Epithelioma, — Put- 
SATiNO Tumors — Situation — Symptoms — Treatment .... 819-881 

Chapter XLVIII. — Diseases of Joints. 

Synovitis — Cause* — Pathology — Symptoms — Acute Synovitis — Chronic Synovitis 

— Hydrarthrosis — Terminations — Treatment 382-886 

AcTTK Artiiritii? — SituftiioHfl — Symptoms — Suppuration — Diagnosis — Pathology 
— Niituni of Changes in Cartilage — Destniclion of Cartilage from Synovial 
Discusi' — >'niiii Disease of Bone — Causes and Varieties — Repair — Treatment 

386-848 

Chronic STKUMors Artiiriti:*, or WhitiSwki.i.ino — Synipti'ms — Pathological 

Change* — Treatment 848-868 



CONTENTS. tX 

PAflM 

Chromic RHRinu.Tic Abthritib — Nature — Symptoms — Causes — Treatment — 
Chronic Rheumatoid Arthritis of Hip — Pathologfcal Changes — Diagnosis — 
Chronic Rheumatoid Arthritii of Lover Jaw — Of Shoulder 358-358 

AxKTLOsis OB STirr Joint — Incomplete or Fibrous Ankylosis — Complete or 
Osseous Ankylosis — Treatment 858-861 

LoosR UASTII.AOZB IN JotNTs — Waity Condition of Synovial Membrane — Loose 
Cartilages — Characters — Symptoms — Diagnosis — Treatment . S6 1-364 

yKCRALQiA OP JoisTs — Sj^mptoms — Causes — Treatment .... 864-866 

Chapter XLIX. — Excision of Jointb. 

HisTORT — Indications for Excision — Conditions of Success — Repair after Ex- 
cision — Instruments — Operation 866-878 

SzcnioKa in tbc Upper Extbsuitt. — Shodldrr-joint — For Disease — Partial 
Excision — Complete Excision — Result — Fur Compound and Comminuted 
Fracture. — Scapui^ — Entire — Partial — Operation — Result. — Claticle. — 
Elbow-joikt — For Strumous Diseases-^For Ankylosis — For Compound 
Fracture or Dislocation — Operation — Results. — TJlna or Radius — Ole- 
cranon. — Wrist — Lister's Operation. — Hand — Excision of Fingers and 
Metacarpal Bones 878-398 

COICSKBTATITI SdbOBRT 07 THE LOWRB ExTRBllITT. — HiP-JOTMT. — £kEE — 

Operation — Selection of Cases for Excision — Resulte. — Bonks or the Leo. — 
Foot — Progress of Conservative Surgery — Conditions demanding Excision — 
Tarsal Bones — Os Calcis — Operation — Subperiosteal Excision — History and 
Results — Astragalus — Cuboid Bone — Scaphoid — Cuneiform Bones — Several 
Tarsal Bones— U all eoli—MeUtarsal Bones— Toes .... 398-414 
Ahpctation in Joint Diseasks — Circumstances influencing Mortality . 414-416 

Chapter L. — Diseases of the Spine. 

Spina BiriDA — Characters — Prognosis — Treatment .... 416-419 

Caries of xar Spine. — Angular Curvature. — Pott's Dihease — Pathology 
— Symptoms — Paraplegia — Pleuritic Attacks — Abscess — Diagnosis — Prog- 
nosis— Treatment 419-485 

Disease op the Certical Spink — Diseases of the Atlas, Axis, and Occiput — 

Treatment 43r)-436 

Other Diseases of the Spine — Qummata — Rheumatoid Arthritis — Tumors . 487 

Chapter LT. — Diseases of the Sacro-iliac Joist. 

ijACRO-iLiAC Disease — Nature — Pathology — Symptoms — Pain — Swelling — 
Lameness — Alteration in Limb — Abscess — Prognosis — Diagnosis — Treat- 
menl 437-442 

Chapter LH. — Diseases of the Hip-joint, 

Hip-joint Dihease — Characters — Forms of the Disease — General Phenomena — 
Pain — Attitude — Limitation of Movement — Suppuration— Sinuses — Disloca- 
tion — Ankylosis — Pathology and Symptoms of the Various Forms.— 
Arthritic Coxaloia — Symptoms — Results. — Chronic Strumous Arth- 
ritis. — White Swbllino. — Femoral Coxaloia — Symptoms — Pathology 
— Acetarular Coxaloia — Symptoms — Prognosis of Hip-joint Disease — 
Life — Utility of the Limb — Diagnosis of Coxalgia — Treatment 442-461 



X CONTENTS. 

PAOK 

Excision or the Head of the Thiob-boke and ov the Hip-joimt — Ui«tiirj 
— Cases requiring Operation — In Arthritic Cozalgia — In Femoral CoxBlt;ia^ 
In Acetabular Cosalgia — Removal nf the Diteaaed Acetabulum and I'clvic 
Bones — Methods or Uperatini; — Results. — Diheabe of the Great Tho- 

CRANTEB. — AMPnTATION IN DiSEABE OF THE HlP-JOINT . 461-471 

Ankylosis of IIip-joint — Operation for Oueous Angular Ankylosis — Ctom or 
Scissor- legged Deformity 471-47& 

Chapter LIII. — Dibeabes of Synovial Membranes, and of Muscles. 

Diseases or Bxjbsm — Situations in which Biirsie exist — Morbid AUerHtionn. — 
DlBEASES op THE BuRSA pATKLLiS — InQammation — Suppuration — Diiieau 
of the Patella — Sloughing of the Bursa Patella — Enlargements — HouseniHid'a 
Knee — Treatment — Chronic Enlargement — Solid Tumors — Treatment — Dib- 
eabes OF otbeb Bvjiba. — BcNiON — Treatment .... 4Tr>-48S 

Diseases op Sbeathb or Tendons — Ganglion — Simple Ganglion — Treatment — 

Tenosynovitis — Treatment — Compound Ganglion — Treatment . . 483-tS» 

Dibeabes of Muscles — Fatty Degeneration — OssiBcation — Inflammatory Affec- 
tions—Syphilitic Diaeasfr— Tumors— Treatment 48i>-488 

CHArTEB LIV. — Defoemities. 

Latebal Cortatube or the Spihe — Nature — Mechanism — Kyphosis and Lor- 
doiis — Caufef — Signs of Lateral Curvature — Treatment of Lateral Curva- 
ture — Recumbent Position — Mechanical Contrivances — Treatment of P(»- 
terior Escurvatton — Of Posterior Incurvation 489-49>'V 

Deforuitieb op the Neck and Lihbs — Causes — Treatment — Tenotomy — 
Repair in Divided Tendons 496-499 

Deformities Apfectino the Face and Neck — Wry-neck — Nature — Causes 
—Treatment 490-.J01 

Deformities or the Arm and Hani>— Contraction of the Arm — Straight 
Ankylosis — Acquired Contraction of Muscles of Forearm — Paralysis of Er- 
tensors and Supinators — Club-hand — Arthritis Deformans of Hand — Con- 
traction of the Fingers — Pathology — Treatment — Congenital Deformities of 
Fingers and Hand 50l-o08 

Deformities of the Leo and Foot — Knock-knee — Treatment — Antiseptic Os- 
teotomy — Contraction of the Knee-joint — Varieties — Causes — Contraction 
from Nervous Irritation — Treatment — Contraction from Inflammation of 
Knee — Chronic Contraction — Contraction from Ligamentous Consolidation 
— Treatment — Contraction of Hamstrings — Division of Hamstring Tendons 
— Contraction with Lateral Displacement — Treatment — Osseous Ankylosis 
of Knee — Deformities of the Bones of lower Limb fr^m Rickets — Clul>>foot — 
Varieties — Pathulogicnl Changes — Talipes Equinus — Treatment — Talipes 
Calcaneus — Treatment — Talipes Varus — Treatment — Talipes Valgus — Treat- 
ment — Spurious Talipes Valgus — Hollow Club-foot — Contraction of the 
Plantar Fascia — Contraction of One Toe — SupernumerHry and Webbed 
Toes— Congenital Hypertrophy of Toes and Fool — Weak Ankles :i08-629 

CnAITEK LV. — D[ftEA8E8 OF THE HeAD AND NeCK. 

ScAi.p AND Skull— Pachydermatous Tumor of Scalp — Fungus of the Dura 
Maler — Nature — Symptomii — Treatment — Fungus of the Skull — Congenital 
lli^rnia of the Membranes of the Brain — Tapping the Head . LiS0-&S2 



XU CONTENTS. 

Langenbeck's and Ollier's Modifications — Fistulous Openings through Nasal 
Bones — CTperation for I>epresBed Nose r>9S-60i 

Plastic Sdboebt or tbk Lifb — Harelip — Single and Double — Median Fissure- 
Age for Operation — Objects of Operation — Operation for Bingle Harelip^ 
Operation for Double Harelip — Treatment by Simple Suture— Congeaital 
Transveree Fissures of Cheeks — Cbeiloplasty — Buchanan's Operation for Re- 
storing Lower Lip 604-614 

Plastic Sdrqekt of the Palate — Age for Operation — Suphyloraphy — Fergus- 
son's Operation — Pollock's Operation — Uranoplasty — Perforation of the Hard 
Palate 614-CI9 

Chapter LVIII. — Diseases op the Mouth asd Throat. 

TosocE — Tongue-tie — Hypertrophy and Prolapsus — Glossitis — Abecees — Chronic 
Superficial Qlossitis — Psoriasis, Leucoplakia — Prognosis — Treatment — Apbthse 
— Simple Ulceration — Tuberoular Ulcer — Syphilitic Oummata — Tumors- 
Nevus and Aneurism by Anastomosis — Cancer of Tongue— Nature — Diagno- 
sis — Treatment — Division of Gustatory Nerve — Ligature of Lingual Artery^ 
Operations on the Tongue — Excision of a Small Fart — Strangulation by Liga- 
ture — Excision of Whole or Lai^e Portion — Application of £craseur — Sub- 
mental Operation — Excision after Division of Lower Jaw — Hemorrhage 
During Excision — After-treatment — Accidents after Operalion — Comparison 
of Methods of Operating — Results — Effect of Removal of Tongue on Speech — 
CysU in Floor of Mouth— Salivary Calculi 619-641 

Palate, Uvula, and Tonsiib — Hard Palate — Soft Palate — Elongation of the 
Uvula — Tonsillitis or Quinsy — Treatment — Enlargement of the Tonsils — Treat- 
ment — Excision of Tonsils — Malignant Tumors 641-646 

Diseases op the Phaktnx — Byphiliiic Affections — Erj'sipelatous Pharyngitis — 
Abscess— Treatment — Tumors 646-647 

Stricture or tue (Ebophaqus — Conditions producing Dysphagia without Stric- 
ture—Forms of Stricture — Hysterical or Spasmodic — Fibrous — Cancerous — 
Treatment — Gastrostomy 647-654 

Dihearks or the Larynx — The Laryngoscope — Laryngitis — Varieties — Acuta 
Catnrrfaal Laryngitis — Symptoms — Treatment — Acute (Edematous Laryngitis 
— Symptoms — Diagnosis — Treatment — Chronic Laryngitis — Varieties— Simple 
— Chronic — Treatment — LochI Medication of Larynx — Syphilitic Laryngitis 
— Diagnosis — Troiitment — Tubercular Laryngitis — Diagnosis — Treatment — 
Complications of Chronic Laryugitis — Nervous Affections of Larynx — In 
Children — In Adults — Paralysis of the Larynx — Tumors of Larynx — Thy- 
rotomy — Malignant Tumors— Extirpation of Larynx .... 664-668 

Chapter LIX. — Operations on the Air-tube and on the Chest. 

Lartnootomt AM) Traciieotomt — Conditions requiring Operation — Opening 
the "Windpipe in Membranous Laryngitis — In other Forms of Laryngeal Ob- 
htniction — Necessity fur Promptitude— Operations — Conditions requiring Ope- 
ratiiin — Laryngolomy — Tracheotomy — DilHcultics — Ex|>09ing the Trachea — 
Heiii'irrtiiige — Opening the Tnichoii — Intn.>dMetii'n of Tube — Trachea-tubes — 
TrftcliRototiiy In Children — Com|>Brison of Liirynijotomy and Tracheotomy — 
After-treatment of Laryngotomy and Trite lii'otoniy .... 669--668 

Sdroic.vi. Oi'KRATioNs ON TUE Chkst — Tttjiping the Pleural Ciivity — Surgical 

Tn-HtTiicnt of Enipyenm 683-689 

Tappino !'ri,M0NART Cavities — Operation — Tnp]iini; the Pericardium . 689-691 



CONTBNTd. xiii 

Chapter LX. — Diseases op the Breast. 

PAfll 

DuxAsas or tbk Bbeast — Ages at which they occur 692 

AiroMALiBB or DxTELoricXKT — Absence of Breast — Supemumerary Breasts and 

Xipplea 6B2-«98 

Xeuraloia — Symptoms — Diagnosis — Treatment 698 

HTPSRTKOFHT^^imple — Treatment 698-694 

ABNOufAL CoMDiTiom OT^TBi Lactzal Sscbstioh— Absence — Excessive FIot 

— Lacteal Tumor— Treatment 694-69& 

Implammatiom or the Bbkast — ^Varieties — Of Nipple and Areola — Treatment — 
Eczema of Nipple— Abscess of Areola — Milk-abrcesi — Inflammation and 
Abscess in Subcutaneous Areolar Tissue — Inflammation of Mammary Oland 
— Inflammation in AreolarTi»ue between the Uamma and Pectoral Muscle — 
Treatment — Chronic Inflammation— Chronic Inierstitial Masiitis — Chronic 
Abscesf — Diffused — Treatment — Encysted — Diagnoei»— Treatment— Tubercle 

— Syphilitic Disease of Mamma 69O-701 

TcruoRB or thk Bbzabt 701 

SoK-UALioKAMT TuMOBS — Retention — Serous — Hydatid Cysts — Lipoma — 
Fibroma — Chondroma and Osteoma — Adeno>fibroma — Adeno-sarcoma — 
Painful Mammary Tumor — Treatment of Adeno>flbroma and Adeno-sar- 
coma — Cysto-iarcoma — Sarcomata — Diagnosis — Treatment — Sanguineous 

Cysts — Tumors containing Fcetal Remains 701-712 

Cajtceb or THE Ubbast — Varieties — Scirrhus — Symptoms — Implication of Skin 
— Pain — Retraction nf Nipple — Implication of Axillary Glands and Ytscera 
— Constitutional Cachexy — Duration of Disease — Structure of Scirrhus — 
Encepbaloid — Colloid — Duct-cancer — Causes of Cancer of Breast — Sex — 
Age — Injuries — Inflammation — Eczema of Nipple — Diagnoeis— Treatment^ 
Compression — Caustics — Operation — Question of Relapse — Prolongation of 
Life by Operation — Cases UnBt for Operation — Doubtful Cases — Cases Favor- 
able for Operation — Return of Cancer after Operation — Amputation of the 
Breast — Mortality after — Axil lo- mammary Cancer .... 712-732 

D19EA8E8 OF THK Male Brbast — Scirrhous Cancer 732-738 

AxiLLABT TuuoKs — StrumouB Disease of Axillary Glands — Simple Tumors — 

Lympbadenoma of Axillary Glands — Fibromata — SarcomaUi . . 733-784 



Chapter LXI. — Diseases op the Abdomen. 

Iktroddct-ort Remarks — Operative Treatment of Diseases of the Abdominal 
and Pelvic Viscera — Septic Peritonitis and Septicatmia — Shock after Opera- 
tions — Hemorrhage . ■ 78 5- 739 

Hkbkia defined — Structure — Sac — Neck — Body — Contents — Enterocele — Epi- 
plucele — Entero-epiplocele — Adhesions — Fluid — Hydrocele of Hernial Sac — 
Loose Foreign Bodies in Sac — Signs of Hernia — Intestinal Hernia — Omental 
Hernia — C«cal Hernia — Hernia of Bladder, or Cyslocele — Exciting Causes — 
Predisposing Causes — Sex — Age — Occupation — Other Causes — Conditions 
presented by Hernia 739-744 

RiDDCiBLE Hernia — Definition — Application of Truss — Radical Cure of Ilernia 
— "Wutzer's 0[>eration — "Wood's Operation 744-7J1 

Irreducible Hkbmia — Causes of Irreducibitity — Symptoms — Treatment — In- 
flamed Irreducible Hernia — Treatment — Incarcerated Hernia — Treutuient 

701-753 



XIV 



CONTBNTS. 



StaakoolatKU Drskia— Otflntlion— UeclianUtn of StrangulftUon— 8«mt uf 
BirkUire — L<m.-«I KffecU of Strang uluiit>a — InAamuftli'ti) i>r Uut sfler raliuf 
of SmnguliLioii — Symptunij — Loeul Slgiu — Clonitltutinnvl Sytnptonf — 
MudtllcntloiiR of S^mptonif — l>iAgtiotit — TrtMiiaMiit — TxkU — Auxiliary 
MaMurva— PentatOnce t>f Sj'nt|>luiui KfUr Rctluctioti^Trcalmont ''ilV-7aS 

Opmiutiox rox •Stnakuvlatku IfiCRMt^ — Uporniiou in wbich lb* Sac it opsned 
— Kspoture of ihe H»c — Opening iho :^c— Uviiivn «f llie Sulviun — R«duc- 
Uoa— TrMtswDt of thv Sue — TmBtotont of tho Wound — Aftvr-UMtoMnI — 
AoeldenU and Hodiflcation* of the Uperallon — PftriiAnltIt— AouU Catarrhal 
Inflaminalian — Managtinont ofCongoUd IntMtine— Of Ti^htljr CuntLriuied 
IdImUiiv — Of Oaii(;Teu<fu>IiilMlJne— Uf AdliaiunB-~Of Uiii«Dtum— Woutuli 
of line iDtwiin*— Wowmli of Art«ri9* — ^lougbing of tli« S»c — Artillclal Aim* 
■nd Focal Fblulu — TreatineRi — Operailoa witlii>ui Opiinlnit tb« Sac — R«lu&- 
tioa in Maat — Cau*«i — Symptomi — Traalmonl — £Iydrucal> of ibe Bernial 

H*o ;aa-7U 



CaATTiiU LXII. — Sr&ciAL Hbbnia 

IffOU JV aL HKKHia — Varktin — Oblique — Co««riDgi — B«lalioikt — Dlj«el-> 
COTeringt — Botatioiu — lacumpli'iv or lotvntkuil — t>oubl« — In Fvraalei, 
Signt — THagBftri? — ^Treatmeni— Ojieration — Seat uf Strlctur«i— llBrnla con- 
talning Cikuiii, Sigmoid Flexure of Colon, or Urinary Bladdor— Ilernla io 
TllliloaTaginiilii, ur Oon^iiilal llernia — Stgiu and Diagnoait—CuRi plica* 
tlon witb UndiMoand«d T««lii — Traatnivot — Enojrtlvd Uenua la Timi«B 
Taslnalh, or lafimUle Hernia 7U-79S 

FnioiuL Hbbmu — Courw — Balalioiu — Cootenu — Sigat — Diacnoali — Tmsi- 
ment — Operalioa 708-1 

UMaiLifALlIicHai*— lu Children — In Adulti — Trcattnenl — Operation . 

VKKTitAi. lIcKMtA— Trealuicnt 802- 

pHLTir IltaKtx — Obturator — ijyniptorai — Trsatment — Perineal- -Va|ina] — Po. 
dendai — ^luUi: 

Duu-BkAflUATlc Ukrnia — CoDgeniul Uefeot of Uiaphragtn— Traumatic Dis> 
phrajpiiaiio Hornia 8(U-807 



CuAVTER LXIIL— Intebtktal Ojmtbuctiox. 

AocTB OnrrnoCTtov — Cau«ei — Syioplonu — Cusoxio OumDcriOK — Symptoraa 
— InliiwuKepUon — STmptumi — IhagnoKiiofCaufMofUbatrucUan — Previous 
Uiitorjr — Mode of Invailon-^iieneral Concitlon uf Patient — Character of 
Pain— Vomiting — Duration and Uegree uf Conktipatiun — Phyiical Kxaiui> 
nation of Beily, of Reutuin — (Janotlty of Urine — Trkatuext— Acute UU- 
itruflioD — Inr«r*ionof Patient — Puncture of IniMtmc — Operation — TnM- 
meat of Inttiuuu'eiition — Operation — Trsatment uf Chronic ObstrueUon — 
Gaitructomy— Colotumy — Litlre's Operation — Atnuaiat'a Operation —Ooai> 
|iftri«>n of Litlre'* and AmuMat'a Ujieration« B07- 



CtlAKTEIt LXIV. — TAPI'l.'iO TOK AUDOMKN. — OrSKAllUNS ON TKU 

Auik^minai. VidCKKA. — Tiuoa-* or tui: Groin. 



TAPrmn THB Aii»»i»K . . . . 
Rkmuval or PoRTioKa or rat Iktbtisb 
Kxciaiox or tbk Ptlobcs 



Kiism 



CONTENTS. XT 

PASK 

Ofuatio!ts as the Liteb — Abscess — HyditJds — Diseases of the Gall- 
biadder 829-881 

KxTiKrATion or tdb Spleen ■ 881 

[tUEASB or THE UvBiLiCDS — UlcenttioD — W&rt; growth — Epithelioma — Um- 
bilical Fistube 882 

Trvi^Bs or tbb Oboiit — Varieties — Diagnosis — Pulsating — Kon-pulsating — 
Kcducible — Irreducible — Fluid Tumors—Solid Tumors — Treatment— Re- 
moval of Cystic or Solid Tumors 88S--S84 



Chapter LXV. — Diseases of the Large Intestine and Anus. 

Cii^OD-iTAL MALTOBHATioini — Narrowing and Partial Closure of Anus — 
Completa Closure of Anus — Occlusion of Rectum above Anus by Mem- 
bmnous Septum — Complete Absence of Anus — Treatment — Closure of Anus 
vith Absence of Rectum — Treatment — Perineal Incision — Iliac Incision — 
—Lumbar Incision — Abeence of Anus : Opening of Rectum into other 
Canmli 83^^-837 

Stiktukb : SiupLE, Stphilitio, aso Maliohant — Simple or Fibrous — Symp* 
tomi — Prepress — Treatment— Syphilitic Stricture of Large Intestine — Cancer 
ud Malignant Stricture — Symptoms — Treatment — Cancer of Anus — Sarco- 
maU of Rectum — PapiUomau — Polypi 887-840 

BiCTAL Fistclj: — Recto-vesical Fistula — Treatment — Entero- vaginal Fistula — 
Kecto-TBgioal Fistula— Treatment— Entero- vesical Fistula 846-849 

Ultkb axd FustjKK or the Ahus— Symptoms — Causes — Treatment — Spasmodic 
Contraction of Sphincter Ani — Treatment — Atony of Rectum — Treatment 

849-851 

Akchb axd Fistula — Acute Iscfaio-rectal Abscess — Chronic Abscess — Treat- 
ment — Anal Abscess — Fistula in A no — Extent — Yarietiee — Complete — In- 
complete or Blind — Operation for Fistula in Ano .... 851-857 

HuoKSHoiDS OK P1LB8 — Tarieties — Predisposing Causes — Exciting Causes — 
StTuctur»— External Ilemorrhoida — Symptoms — Internal Piles — Longitudi- 
nal or Fleshy — Globular — Symptoms — Hemorrhage — Complications — Ter- 
minatioDS — Subsidence — Coagulation — Suppuration — Sphacelus — Diagnosis 
—Of Uemurrhoidal Tumors — Of Hemorrhoidal Flux — Treatment — Consti- 
tDtional — Local — Operation — Excision — Ligature — Smith's Operation — Gal- 
tanic ^raseur — Crushing — Causticc — Dangers attending Operations for 
Pile* — Uoist Condition of Slcin around Anus — Pruritus Ani . . 857-870 
PioLAFScs Aki — Causes — Diagnosis — Treatmeni — Palliative — Curative — Liga- 
ture— Prolapsut of the Rectum — Causes — Treatment — Protrusion of an 
OvariM Cvet 870-874 



CiiAPTEB LXVI. — Secondary Diseases of the Urinary Organs 

ARISING FROM SURGICAl. CAUSES. — Py.EMIA AKD SEPTICEMIA IN 

UttiNAKY Diseases. 

V ibid Conditions of the Bladder — Diseased CundilionB of the Ureters and Pelvis 
..f the Kidney — Morbid Conditions of the Kidneys — Results of Pressure — 
Acute Diffueo Interstitial Inflammation — Acute Interstitial Nephritis with 
Scattered Abscesses — Eflects of Former Attacks from which the Patient has 
Rccuvercd — Causes of Interstitial I ntlammatiun— Tension — Keflex IrriU lion 
of Kidney — Septic Matter in Pelvis of Kidney — Symptoms of Kidney 



OONTBMTS. 



DiMftw In Stirgkftl Affactiont Df GttDito-uriniry OrgKU — UnHbnil Ftvar 
QT Uniinic Porer— Pit>gno«i*^Tr«atni«nU-Pya!Riiii mini 8«)ilicMniia in I>i«- 
cM«i of lh« ITrinary Orgsiif BT&-S8B 



Cbaptek LXVII. — Surgical Opeiutioss ok the Kidmey. 

Stosbisthe Kidsit— Symptom*— TrvnimfDl—C»lc«ln«« PyellUf — TubofcuUr 
or SororuloM Kidn«.v — Syrnptonii — l'vone[jl)ri>«ii — Uydrun«|rhr<Mi»— Trcal' 
in«nt — Tuino»— Otrcinomii and Sumima — DiagDutiii ur lUiial Tumon^ 
TmtDient of CarclDomn or Sarcoma — FiaiDloiji Communtcationi — ytoatioi; 
Kidney 

OfKHATiojfs OH TllK CiDNKT — Exploration — Aipintion — naphro-lilholontjr — 

Kephrolomy— NephKctomy — Abdominal Xephreetomy — ItMolU . e9fi»8WS 



CnAPTER LXVni.— UttI.VA.aT CALCt'Ltm and LmiOTOMT. 

Vrisart DspoeiTS axd Calvdu — Uric or LUIiic Acid I>epo«iu — Catcall— 
Tr«aun*nl— ItepMiu of OxalnU of Lime — Calculi— Treatmsnt—Phoipballc 
DepoiiU — Varietiea of I'hMphatM — Calculi — Trealm«nl— Cyiline — Xanlhinv 
or Xanthic Uxid»~('«rbdijal« uf Lime— ^bemical Eiaminalion 
IthxrVK tx TUK BLiUiDKii — ^titicturo of Calculi — Urifiii) — Number — Sponlaneoua 
Fracture— Pbyiloal Cbarmaiert— Siae— W«lgkt— Baidnew — Sbapo— Potttion 
— Caiaes— A{« — flex — Geographical l>islribulion — SymptotM— Pain — In. 
crMued PrequAnoy nf Mii-turltion — Stoppa;;* of Flow ■>f I'rinc— ^tone in 
Eldarly M«o — Stone in Childron — Enc3>lm] Calculut — Pfay^ical Uingntjaia of 
Ston 9— Sounding Bladder — Erruis in Sounding— Rxami nation by Manipu- 
lation — Slone IB Womon — Palholugicutl CbaDgTC induced by Calctilua OOo-l 

LiTBOTouy — IriiiruBiitnt« — PrcjiarBlioD of PattenL^LATiKAi. Opkkatio]*^ 
Stage* — Portion of Knift^-Incbion of Protiaie— Gxtrscilon of 8u>ne — 
LithotoiB* for L«l«r»l Litbutotny— Afloralrdatmeiit ff Lithotomy — Lateral 
Lithotomy in iloy' — DifBotillioi diirioK Lithotomy — In Findini; S(on»— In 
£iitiinns Bladder— In Svisiiig and £Ktmcti»g Sume — From Foeltioo of 
Stone — From Fixtura of Sion* — From Fibroid Tumon in Pr«i«t»— From 
RioktU of Pelvii: Boaet — From Sbapa and Slu nf Stone— R«moral of Lmrgn 
Stone— Inciiion of Kif^hl Side of Proiiate — Criuhing Oalculuf in Bladdei^^ 
DittcuUy tram Fneiura uf Hton»— AccidenU during Litltotomy— Hemor- 
rhage — Wound of Bulb — Miuintc tli« L^ntbra — Wognd of Kwtum— Wound 
of P«M«rlor Part of Bladder— OiOlcultle* In Cbildrvn— Suutcai of Dangtr 
and canMt of l>ft«ll) after Litliotomy — .^utiitioof Moruiity— ladaenoAof 
Ag»— of Shock — Stal# of Kidneyi — Prolonged Operation— Homorrh age — 
Cyiliti* — UltftiM IndammAtivn of Areolar Tiuue uf Polvi*^Frum Cutting 
beyond Pruatate— From UruUing and Ov«t-disteritiui^~PeriUiailie— Sktagb- 
Ing — Pyictnia and Scpticxmia — Oihvr Metbodi of Performing Lltbolomf . — 
Mbdun LiTHoToyv—Qlilory— Operation— OoupariMn botwesn Uedtao 
and Lateral Oporationi — (jeneral Kaw and Simplicity — Oemorrhag^— Wound 
of Bulb— W^oond uf Rectum — Trealmonl of Pmntiiitt— Manipulalioo of 
Fon;«i«i and Exiradion of Htone — Indication* for Median Operation. — 
BiLATKIUL LiTUOrUMT. — UKblO-nil^iaiUL OrKKATIUK. — Ubcto-vxucal 
LlTUvTOUT. — QlOUOR'SDnUrUDlC UrXKATtuN .... 9UU'B&& 



CONTENTS. XVU 

Chapter LXIX. — Urinaey Calculus (wntimted). 

rAam 

LiTBOTRiTT — IIi«u>rj- — Ltthotrit; m PnmtiBed before 1878 — InstrumenU — Prepa- 
ntion of Patient — Annatbetio — Openition — IntroductioD of Lithotrite — 
Seizure of Slune — Braaking Ston»— Litbotrity subsequently to 1878 — Bif(e- 
low'i Opention — Accidents in Lithrotity — Impaction of Angular Fragments 
in Urethra — Chronic Enlargement of Prostate — Dangers in Litbotrity — 
Cystitis — Atony of Bladder — Disease of Kidneys — Constitutional Disturb- 
■nc* — Perineal Litbotrity — Results — Applicability .... 95&-97& 

CoMr^Eisox BETWKKX LtTHOTouT A.SD LiTHOTBiTT — SutUtics — Circumstances 
determining Selection — Age — Size and Character of Stone — Conditions of 
Vrinary Ot^ns — Choice of Operation of Lithotom}' — Result of Operations 
fur Stone — Recurrence of Calculus after Operation — Treatment . 97&-988 

tuTBKAL Caixulc« — Symptoms — Treatment — Impaction of Calculus in 
Urethrm of Boys 988-985 

Pio»T4Tic Calcclcs — Characters — Symptoms — Treatment . . 985-986 

CiUTLCK in TBK Female — Statiatici — Symptoms — Removal — Lithectasy — Sim- 
ple Dilacatiun — Dilatation with Incision— Lithotomy — Suprapubic — Urethral 
-Vaginal— Litbotrity in the Female 986-990 

Chapter LXX. — Diseases op the Bladder. 

CoieixiTAL Malfoematiok— Extroversion— Treatment— Ay re's Operation — 

Wood's Operation 990-998 

Cmms — AcuU — Termination — Treatment — Chronic Cystitis— Pathological 
Changes — Symptoms — Trvatment — Irritable Bladder— Cauces — Diagnosis — 
Trcmtment — Cystotomy — Irritable Bladder in Boys — In Women 998-1001 
Atojct or THE Bladder — Retention of Urine — Symptoms — Diagnosis — Results 
—Treatment — Incontinence of Urine — Passive — Distention of Bladder with 
'h-erflow — Active Incontinence^Treatment — Hysterical Retention and Incon- 
tinence — Painful Conditions of the Bladder 1001-1007 

TcBtECLE or THE Bladder 1007 

$JC>:uLi »r TiiE Bladder 1007-1008 

TcMORS fr THE Bladder — Villous Tumor or Papilloma — Mucous Polypi in 
CLiidren — Sarcoma — Symptoms — Diagnosis — Treatment — Cancer — Treat- 

Bifct 1008-1011 

Hahati RiA — SitiRCs — Kidneys — Bladder — Prostate — Urethra — Treatment 

1011-1013 

Chapter LXXI. — Diseases op the Prostate. 

Pa<»T*riTl>-^Symptoiiw — Treatment — Prostatic Abscess — Kitcntion of Urine — 
<. l.ri'nii' InflainniBtii'u of the Prostate — Diagnusia — Treatment — Deep-seated 
».vi vvrj' Lhr-.nic AU^-efcs 1013-1016 

Caa '^n- Enlaroemextok the Prohtatb — Chametets — Simple Pn>static Tumors 
— Min hanical Effects on Urinarj- Organs- Moral Elfects of £nlurged Prostate 
— >_vni[.Hims— CuNiplete Kelention of Urine— Diagnosis- Treatment— Pnistatic 
t a'.ti'-ttr — Treatment iif Complete Retention — Puncture of Bladder above 
I'.l'-— Punciure tlin>ui;h Reel urn- Forcible (.'atheterism or Tunnelling the 
I*^-tate 1016-1026 

ToL. It. — H 



XVIU 



0ONTBKT8. 



Otbbr DiKKASxa or tub Pkobtatk — Atrophy— ('xneor— Tubercle— Crite or 
CBTitiM .... ... ' 1026-1037 



CUAPTBB LXXII. — DiSKASte OF TUB UOKTHRA. 

UBnaairdi— SympUHw— TrwiliMiii . . .... \<t27-lOQS 

GonoHRuau — Cmim — Cbusoter— Symptom*— Incut«lJviiStKg«— Acuta or Influn- 
niKtorjr Stag«— Chruiic ^^ugo- GI«ot— Tn>«tm«nl i>f Oonorriiow— TrvatfiKntuf 
OlMt— (.'ura|iluHtUHM— Influumalion of Lvinpliutict of Pniik— UbordM — 
AcuUi snd Clironlc Prnatntitu— InflaminKtion <if ?ir<(;k of Kladdor— t\*liti»— 
Pftilttis BiiJ Sepbriiis— Helen lion of Vrine— UcimirrbuKe front I'retlirB— 
DroUinl or rvriurvtlirol AImccm— Soqueneecuf GuiuirrlurA— AVnrU-iftrk-tiini 
— liidui»Ui<n and Tbickeniug- Oonotrhcml Ept<]idymUi»— ConJuaitiTitts- 
TinUincnl — Sclcf-jtHi*— 'IVcftlittcnt— Indunmntion of Nom) — Oonorrbom iif 
BfictuRi— HheumAtism— PyaemiM— <.!iitMieoui Kniptiont- GonorrtaiM In Itn^ 
Fanftlo— Dbgnocb—Trattmiriil 1038-1043 

STKiOTOBioFTUxtTMCTiiRA — VarMtlec— S|MnnodieStrictut« — Ckusei— Sjrmptona 
— Trofttmenl — Congatti vc Stricture— C«iiM»—Symplom»—Tn»tmPB I — Orgsithi 
Stricture— Ap«—S«il—l*ntliolop«J App«*rancet— Amount of t'«mirictioD— 
Ihlataliun of ITrrlbni behind St Hctiin*— Chronic Cjr*liti* in Illaddur— DiUtA- 
tioD of Vrvterc — 8yin)tt[init — Loral Si|;u<— Kiamiiiation of J'alienL for Strtc^ 
tura— TraiUnum -(tniduul >i«>chiinicnl 0!Uuitfo»— Introduction of Cnthno* 
—Gum-elastic and Molal Jnitrumoou— lt««ulUof Introduriionof InBtnmienu 
— Accidenta ■tt«adlng Cfttltet^H&m— N(-r%-ons Symptom*, Kigor»,tind Urrtliml 
Fever— TrutinaDt-^upprGMioiiof Urine— UemoiTl)«g«—lnllararo»lion—KKlM 
fftmgB*— Uoulinuou* DilalMlinn— Cauitin- Furviblu Expaii«K>n or Kupturv 
^SUdins Tubes— Kxp«nfion by Screw Mechwiism- By Wed|;e— Dimion of 
Stricture— Internal Urvtbrotumy— K(«ulu— Exlornil Uretbrolomy- Op«r>tion 
for Pennuble Stricture — Perineal auction— Result — tk.mp*rison of Method* of 
TrrmUnnn I— Stricture of Unttfaral Orillc — li[ipi>rtneiibli>Slnctiin>— t)permtions 
for lmi*nneaW* Stricture — Opt-rvtion from Ilebind — Openiliou fn»m Frwit— 
Gfincm) Retulu of Treatment of Striolura lOia-lOTO 

C0UFLU-ATIDN8 AVD Rsei'LTB OP Strictcrb — Rctetillufl of Urine — TteBtment— 
Foreibk CethetoriMn— Upenine Urrtbrx bebind und through KtHeium— Puncw 
ture of BUdder tbMU^;h Uectum — Puncture Mbnvn Pub^o — Employment of 
Atpintor — 4*i>nditi<>n<i rrquiring Puncture of DIaddor — Extraviuuition of ITnne 
— L>K«1 Xfl'ectt— Onsiitutional DUliirUnoe— Tmlmeot— Periamt AbiecH — 
Chenutors — TrrjituK'ut — tTrinary FijilulH — Tnatmont — UrvlfaroplHrty — Strio- 
lurcof Female Uretbm tOTO-IOdl 

UbO'Akt Va<i1.sal Fi.vriTL.K — Vurietiet — Vrethr^>-v«)piiAl--Vi»ico>v«eine)— lb«- 

nilu — Treatment — Simi't and lloECman'a l)|i«r»liuiit 10BI-10M 

TuHOM i)C TUE UtimiRi. — Polypt^d Tumor — Trvalment — Kidn'm — Ligature 
— Cnmike— 0«uiery . 10M-10M 



CHAPTRIt LXXltl.— DDtRARIV OF THB PBKIB AND StmOTUM. 

DnXAan or tuk 1'km»— Complete Aneat of l>evelo|imonl of Male.^iiial (lre»Ra 
— CuBgvniliil .MAir<>nn»tii<n — Adhoaiun of Penii to .Scrotum— tlyp»tjudhi 
Timtiutuil — Kpiipadtu — PhuiiniU—Ctin|^ull«I —Aoqu ired —Treatment 
ntioiu— Uilalatlonor Phimotit— tilitting-up Prepuce — Ulrcumeiiioti furCoA- 



CONTENTS. Jtix 

PAflB 

geniul Phimosis in Infanta— In Boyi or Adults— Paraphimosis — Treatment 
—Balanitis and Posthitis — Treatmant — Horpos of Qlans and Prepuce — Byper- 
tii>[Ay of the Prepuce — Warts — Uorny Excrescences — Persistent Priapism — 
Wart» — Gangrene of Penis — Fibrous Tumor of Penis — Cancer of Penis — 
—Squamous Epithelioma — Causes — Diagnosis — Treatment — Amputation of 

Peni* — Nkvus and other Tumors 1086-1097 

Dut4ses or toe Scrotum — Inflammatory (Edema — Treatment — Hypertrophy or 
Elephantiasis — Treatment— Epilhclioma — Treatment 1097-1099 



Chapter LXXIV. — Diseases op the Testis and Cord. 

HtLrwiTinx or THK Tkstib — Treatment 1099-1100 

Nicuuii. OF THE TssTiti — Causes — Treatment 1100-1101 

bruMMATios or thk Testih — Orehttis and Epididymitis— Acute Inflammation 
—;*e»t— Symptoms — Atrophy of Testis — Subacute Orchitis — Treatment — Of 
Acutely Inflamed Testicle — Of Subacute Orchitis — Strapping the Testis — 
Absceu — Inflammation of Testis in Inguinal Canal — Inflammation and 

AbMeu of Cord— Chronic Orchitis 1101-1104 

Htdiocilb and H.KKATOCKLK — Hydrocele of Tunica Vaginalis — Congenital 
ByCrucele — Symptoms — ^Treatment — Tapping — Injection of Iodine — Seton — 
AntiKptic Method — Acupuncture — Encysted Hydrocele — Hydrocele of Coid 
—Diffused Hydrocele of Spermatic Cord — Unmatocele — Characteia — Symp- 
toms — Diagnosis — Treatment — Hiematocele of Spermatic Cord — Diagnosis- - 

Treatment 1105-1116 

ViucocKLE — Cauaea — Symptoms — Diagnosis — ^Treatment— Radical Cure 1116-1119 
Solid EsfLAsaxuEKTS or Testis — Simple Sareocele — Structure— Treatment — 
Tubercular Testicle, Scrofulous Testicle, or Tubercular Sareocele — Symptoms 
— Structure — Progaoaia — Treatment — Syphilitic Orchitis or Syphilitic Sareo- 
cele— Simple Inflammatory Form — Structure — Gummatous Form — Structure 
-Prognosis — Treatment— Diagnosis of Simple, Tubercular, and Syphilitic 
San.ix-tle — Cystic Disease or Cystic Sarcoma of Testis, or Cystic Sareocele — 
Diuru'jfis — Sarcoma of the Testicle — ^Enchondroma of Testicle — Cysts con- 
tainini; Colored Matters— Cancer of the Testicle, or Malignant Sarcocele — 
Cbaraclen — Symptoms — Treatment — Structural Disease in Undescended 

T^m . ' U19-1129 

Opeeitiun of Castration 1129-1131 

Ge>kkal DlaONOais of Scrotal Tduors — Ueducible Tumors— Irreducible 

Tum.irt 1131-1133 

SrcKMAToaKlKKA AND IiiFOTENTE- Sexual Melancholia- Tnie Spermatorrhcea 
Diagiiiwi*— Treatment— Spasmodic Sperma torrhoea-Treatnienl— Impotence 
—A»c«-rmB— Sterility 1133-1137 



CiiAiTKR LXXV. — Diseases of thk Female Genital Organs. 

iKTrn'-Di'iTioN or Immtrcmests- Speculum Vaginse— Female Catheter 1137-1138 
HirEAKO or TOE External Oroash and Vaoina— Hypertrophy of Laliia — 
i'ondylomata or Vei Tuc» — Cystic Tumors— Imperforate Vagina — Imperforate 
Hymen— Absence <)f Uterus and Osaries- Hyp^'rtrophy of Clitoriii- Removal 
of Clii'Tis — Vaginal Tumors- Vaginal llemorrhoidn- Prolapsus of Vagina— 
lUftocfle— Cyi-tiiele — Vaginal Discharges— Treatment . 1138-1142 



XX CONTENTS. 

TuMOBS OF TBI TTtckus — Subperitoneal, Intrftinural, and Submucous Orowths 
— Polypi — Malignant Affection! : Glandular Carcinoma — Epitbeltoma 
(Cauliflower Kicresoence) — Sarcoma 1142-1144 

TuuoBS or THK Otabt — Diagnosia— Treatment — Medical Means — Tapping — 
Inciaion and Drainage — Other Means — Ovariotomy— Statistics — Preparation 
of Patient^Operation— After-treatment. — Hkrnia or the Otaby 1144-llfift 



APPENDIX. 

COBROSIVE SUBLIMATE A9 AN ANTISEPTIC . . Iliw-IIST 

INDEX TO VOLUME II 1169 



LIST OF ILLUSTRATIONS IN VOL. II. 



415 STphiliUc Onvchift 

41fi ilvpertrophy of Toe-nail . 

4i: lUent Ulc«r of Back of Hand . 

418 Rodent Ulcer, Perforatin); Skull 

419 Kodrnt Ulcer, SecUon of 

(Warren) .... 
43) CiDceroui Ulcer of Leg . 
421 N'eururoa, with nerve-fllament 
ipread over it . . . 

421 Wnt Indian Elephantiacis 
4^ Ljmnbaiienoma at Root of Neck 
m Utrelip Pins applied to yariooce 

Vein* 

^ ^irin^ for Injecting Neviu 
4^ Lipture of a Nbvui : mode of 
uiing needles .... 
^ IKigram of Nnvus tied 
439 Diignm of Ligature of Flat 

anil Elongated Nsvui 
IS Diaeram o( Plat and Elongated 
Nievus tied .... 
4)0 Narua of Lower Lip: Front 

Tiew 

<tl Nvvut of Lower Lip: Side 

Tiew 

4Jl' L«ree X^vua of Upper Lip: 
>'runt view .... 
tW LaTK« S»Tu» of Upper Lip : 
.Side view .... 
*H N»vu» of Tongue 
435 Aiberomatous Material under 
Mtcro#co[>e .... 
43>{ .\the^■^)a of Aorta: Section 
4-17 Annular Calcification of Artery 
ti" Tutiular Calcification of Artery 
4-I1' Thronibo«ii of Two Large 
Branches of Abdominal Aorta 
Ua Kmb-dium of Axillary Artery 
with Secondary Thrumbosis . 
441 Large Fusiform Aneurism of 
Ascending Aorta, bursting 
into Pericardium 
44^ Sarrulated .\neurism of Ascend- 
ing .\<irla . . . . 

443 Aiirta laid iijien, thowinf; Mouth 

"f Sacculated Aneurism 

444 I>M-««lini; Aneiiriim of Aorta . 

445 Larjfe Atieuri<m of Ascending 

.\rTta, Prtijocting against 
nb. 

V.>L. M. — K* 



PABB 

84 
86 
40 
40 

42 
44 

&9 
71 

77 j 

I 
91 

Ml 

98i 
98 

99; 

99 
102 
102 
102 I 

102 I 

103 I 

1121 
112 
117 
117 

120 

120' 



126 

12c 
1-J8 



130 



no. PAflB 

446 PoslcriurTibialNerveFUttened 

by Pressure of Aneurism . 181 

447 Aneurism of Calf Undergoing 

Spontaneous Cure . . . 186 

448 Aortic Aneurism opening Into 

(Esophagus . .189 

449 Stellate BuptureofAorticAneu- 

rism into Pericardium . . 189 

460 Diagram of Anel's Operation . 142 

461 Diagram of Hunter's Operation 142 

462 Diagram of the DisUl Operation 142 

463 Femoral Artery tied for Aneu- 

rism ; laid open from Seat of 
Ligature to Sac 146 

464 Popliteal Aneurism Compressing 

Vein: Oangrene of Limb . 154 

466 Sac laid open : Cured by Com- 

pression 156 

456 Sacof Tubular Aneurism, Cured 

by Compression . . 167 

467 Carte's Compressor for Middle 

of Tbigb ■ ... 168 

458 Carte's Compressor for Groin . 158 

469 Two Compressors Applied 158 

460 P. II. WaUon's Weight Com- 

pressor 159 

461 Tuffnell's Compressor . . I6O 

462 Tuffnell's Compressor Applied . 160 

463 Erosion of Intervertebral Sub- 

stance by a Small Aneurism . 1T4 

464 Aneurism of Descending Aorta, 

Eroding, and Traversing Ver- 
tebra? 174 

465 Aneurism of Arch of Aorta, 

bursting into Left Bronchus . 175 

46ii Aneurism of Innominate, 
Siretchine Recurrent Laryn- 
geal and Displacing Trachea . 182 

467 Diagram of 'Treatment of In- 
nominate Aneurism by Liga- 
ture of Subclavian 184 

408 Diagram of Treatment of In- 
nominate Aneurism by Liga- 
ture of Carotid 184 

4C9 Diagram of Treatment of In- 
nominate Aneurism by Liga- 
ture of Subclavian and Carotid 184 

470 Aneurism of Arch of Aorta, 

Simulating Carotid Aneurism 189 

471 Incision for Ligature of Carotid 193 



xxu 



LtST OF ILLDSTKATIONS. 



47'i Anatomy of Right Ckrotid «t 

Seal uf Lif[«iiire 
-ITS Fueiforiii Aritiumni of Biuitu- . 
474 Anourittn of Lell Internal 

CftrotitI buriilD)t Into Ltttera] 

Ventricio .... 
4Tfi Anvurumnf L«flIut«rn«1Csro< 

tid, f««n fritiii hol»w . 
in Ugature of Vim Part of 6ub- 

clariBo 

4T7 Uciture gf Subi-Uviaii dii<J 

Ciir»itd fnr Siibi-litvlun Aiieu> 

ri«m 

478 Ug»iur« of Tbird Part of &ah- 

clarlan 

470 Anatotny of Tliinl Part of Sub. 

clavlan ..... 

480 Anatomy of Thin] Part of Sub- 

vlaviati 

481 Anatomy nt Fl»t Part of Axil- 

lary . . , , . 

MS Anatomy of Third Partof Axi - 

lary 

468 InciiioD fnr LiKalurcof Braclital 

at Middle or Arm . 
4M Anatufny of Brachial at Mtddio 

of Ann ..... 
4H& Anatumj "f Ulnar at VfHn . 

486 Ini'tfliriii fitr l,|)|;aiiirfl of [tra- 

cliial nt ltwn>l (if RIbovr, und 
lUdial and Ulbar al Middle 
of Portarm and al Wrlil 

487 AnaUicny of Radial at Middla 

of Foreartp .... 

488 Li^Utr« ■'•f Kxi«rnal Iliac ; 

Alx-rn(ttliv'» Ontrraliou . 
480 FiMii'iral V«in Ob1ilcnt«d by 
Inguinal Anfuirium 

490 FuIh) AnvuriBin of Pvrfonititig 

Artery 

491 Uk*'"'* oI SuparScial F«ino 

nl 

493 Anatomy of Siifiorftflal Femoral 

in ix'tr^'a'* Tnanglc 
4dft Anatony of Fvm'jral in Hun- 

ur*! Canal . . . . 
4M Anatomy of P<>pltt«»l Artorjir 
4V& Anatomy of Putvrior Tib' 

Artaf^y 

496 DilTuH) 0*(vom>«llti« of llo- 

m<>rui 

497 CaritHi* Bone from Scrofulous 

Otlellis of Skull . 

iSS Scro(\ilMU Vomica in Head of 
TiUa 

48U rtiront? Rararartlva OvtoitU of 
Cancellous Tiatue of Ilead of 
TlUa 

fiOO Ah«^«i In amd of Tibia . 

COl Bnn« Trvphino .... 

fiOS 3«olion of Tibia: (.nironlc Oa- 
teltlj anil Clrcum«cribed Ab- 
M-iiiwa 

003 Sayre'» Verlebmied Probo 

004 Mar«hall'i 0M«otrlt4 



881 



Central Ncoroiu : Xew Bona, 

Cloucie, asd Included S«(|u«*- 

trum 

Reproduciioa of Ijowar Jaw 

■Aer Phaapboru»-nocr>i*i* 
Actito yacroiii of Tibia : Dcfl- 

ct«Qt Formation ot New Buna 
Ouitinji; Flier* fur Kemoving 

Nwn»ed Bona 
Catting Pli«r> for R«ino«fng Ne> 

crowd Bone .... 
Cutting Plkn for RcnKrvIng 

N«cro»cd Bono 
Cvuffo F'<r\-r|M , 
Straight Saw 

Nacrnwia Forcc|» , , , 

Bono Forcepi . . . • 
Celk from Hpindle-c^Iled SftN 

contaof glca|>t>la 
Ouitytng Spinfll(s«l!^ Sar- 

CORiH 'if S<'a|iiiU ; K<-(;linn 
Cftlh from Svcoiid R«curr«nc« 

of al>r>ve .... 

Uyeloid Colli fVnm Tumor of 

Low«>r End of Femur 
Fu*if(>rm ni'd Oat-ntiati^ Cetta 

fWim Myeloid Tunn.r 
Secondary Noduk of Calcified 

Sarcoma in Liinr: Svciion . 
" Expaniinn " of Lpwct End of 

Femur by Sarcoma 
Myeloid Tumor of Law«r Jaw 

Invading Bona: SrctiuB . 
PoripliDrnl Splndtc-roUiMl Sar- 
coma of Hhiitl of Fomur 
Pcriphfml Spindlt^ci^lM Har- 

comaof Shnn of Fotnur: Am- 
putation at lIip»iKC-«<*«fiil 
Maliitnant Growth of Head of 

lliimftrui .... 

M icriaoopic Hoctioa through 

abovD growth 
Aneurism by Anutomotia of 

Pariftnl Bona 
Interior •.•f Knt-e daalroyed by 

Aputf Pvirmic Arlhiitit 
Carict of Qmd of Tibia , . 
Rheumatoid Arthriiu of Hip: 

PutiRDt 

Secliou of Hip affvcled by 

Khcumatold Artlirilii 
OMaoui AnkyloiU of Dip 
Dutcbar'' Saw .... 
Kxciiion of Shoulder: Longita- 

dinnl Incision 
SlK-uldor Stump, iifti>r Amputa- 
tion by Speoce'a Meihud 
Kxeiiion ofSboaldcr: Klllptical 

Inriaton .... 

KEt-iiiun of Klbow: flawing 

Low«r End of Uumarns 
Esdalon of Elbow : T-*bap«d 

Incltioii ..... 
Excision of Elbow: T-thaped 

Indsioa : Bones Kipoaed 



804 
804 
806 
807 
807 

80? 

WT 
B07 

ao7 
«• 

a23 

«a 

sas 

tat 



tH 

SM 
ta 



S26 

836 

8«0 

841 
848 

sse 

8A7 

871 
876 
876 
870 
881 
804 
8M 



LIST or ILLUSTBATIONS. 



XXlll 



n«- 

640 Eicition of Elbow : Longitu- 

diiul Incuion 
541 Arm after Excition of Elbow . 
0-42 Arm after Removat of lU- 

diui 

atZ Radius Removed 

544 Diaermm of Bonea of Wriit 

^Luter) 

Mi) Diuram of Tendons ibout 

Wriit (Liaier) 
544 Lifter'* Splint for Excision of 

Wrist 

647 Hand after Excision of Wrist 

fixed on Litter's Splint . 

548 Thomas's Knee-splint 

549 Tbonia»'s Knee-splint Applied . 
650 EjLcifion of Knee by Elliptical 

Incision 

»S1 Application of Butcher's Saw 

to Head of Tibia . 
552 Portions of Femur and Tibia 

removed in Excision of Knee 
65S Pi-rtioDS of Femur and Tibia 

remoTcd in Excision of Knee 
554 LJmb with Kecroais of Fibula 
&>>5 Limb after Removal of Fibula . 

556 Diagram of Synovial Mem- 

branes of Foot 

557 Foot with Diieve of Os Calcis, 

Cuboid, and Calcaneo-Cuboid 
Joint 

558 Exci»toD of Ob Calcis 

559 I>i»ease of Ob Calcis : Foot be- 

fore and after Operation 
5>W Disease of Astragalus 
S41 Limb after Excbion of Ankle- 

jcint 

562 ExciMon of Astragalus: Foot 

l^fore and after Operation 
rvijZ Diiea^e of Cuneif(>nn Bonea 
■VA L>rt:<; Spina Bifida . 
>-5 Angular Curvature of Dorsal 

S|ine 

-»i C»ri<-* of Lumbar Spine: no re* 

r»>' 

>;T Diagrams of Natural Curves of 
Spine 

» Cbangeof Curve in Early Angu- 
lar Curvature 

->:i" Change of Curve in Advanced 
Angular Curvature 

^70 Ai'.itude uf Child in Advanced 
Angular Curvature 

'.~l S'ap[-jrt in Spinal Cariea . 

'~- T«yl' Ti Spinal Suf'port 

'■T-; Application of Sayre's Platter 
Jacket 

-"4 Sayre's Jacket Applied 

'•'.'j Satrf'i Jat.'ket with Jury- 
n:a*t ..... 

■'•>. Early Sacru-iliac Disease — Sac- 
rum ..... 

'TT Karh Sacrn-iliac Disease — Ilium 
■T- Advanced Sacro-iliac Disease 




8891582 

389 588 

891 1 684 
686 
891 '686 
894' 
894 : 687 

897 j 588 

898 I 689 

398 

690 
898 : 691 
408; 
408 692 

405 598 

«7|694 
408| 

1695 
4081 
410 

I 596 
411 

412 ' 697 
413. 
41" 698 

422 699 
42-2 600 

423 601 

4:i3 602 

423 I (103 
1604 
425 I 606 
432' 

432 60C 

433 ■ 607 
433 608 

609 
434 

610 
438 61 1 
438 612 
438 613 



Position assumed by fLimb on 
forcibly dislending Hip with 
Fluid (Barker) .444 

Bonea from Acute Disease of 
Hip-joint in Adult 

Patient with Chronic Hip Dis- 
ease and Sinuses 451 

Head of Femur after Excision, 
from above case . 451 

Apparatus for Extension by 
Weight in Hip Disease . 468 

Thomas's Hip-splint . . 459 

Thomas's Hip-splint applied 469 

Sayre's Extending Apparatus 
for Hip-joint Disease 460 

Acetabulum perforated in Hip 
Disease 464 

Head of Femur Carious : from 
same care .... 464 

Patient, Three years after Exoi- 
sion of Head of Femur and 
much of Hip-hone. 466 

Excision in femoral Coxatgia 465 

Gowan's Osteotome applied to 
Femur 467 

Splint for use after Excision of 
Hip 468 

Incision Exposing Great Tro- 
chanter for Removal of Dis- 
eased Bone .... 470 

Patient with Rectangular Anky- 
lusii of Hip: Spine straight . 472 

Same Patient: showing Curve 
of Spine allowing toes to toueh 
ground 472 

Lines of Section of Femur in 
Sayre's Operation for Anky- 
losis of Hip . . 478 

Application of Chain-saw in 
Sayre's Operation . 474 

Saw used in Adams's Operation 
for ;\nkyl(ifis of Hip , . 474 

Application of Adams's Saw to 
Neck of Femur , 474 

Crofs-legged Deformity (Lucas's 
case) 475 

Enlarged Bursa over Olecra- 
non 477 

Toes Distorted by Pressure: 
Bunion 488 

AppBrHtii.<> for above Deformity 488 

Fibr< '-sarcoma of Sartorius 486 

BackView of and Section through 
above Tumor .... 487 

Back View of and Section 
through above Tumor 487 

Malignant Tumor in Sole . 488 

Section through above Tumor . 488 

Lateral Curv»ture and Kotation 
of Spine .... 489 

Outline of Double Lateral Curve 489 

Outline of Quadruple Curve , 489 

Outline of Kyphosis . . . 490 

Outline of Ijuniosis . . . 490 



XXIV 



LIST or ILLUSTRATIONS. 



I'Bliciii with Lai«ral Cnrva- 

tur« 

34[i|>un for Laicrnl Curvnture . 
Sapjioit for PiMUrlor Eiciirv*- 

««m 

417 Support for Poilorlor Iiicurv»- 

Uon 

618 T«iMU>iny-knlfe 

4110 TcDotwntj'knlfc 

C'JO Tenotomy -knife 

Ctil Ui|5g'« Anjianilu* for Wry-n»«k 

632 Cuniraction of Suplnktort Kn<l 

Kxt«nM>r( ftt n&nd 
028 Conlniotlon of I'lexun and Fn>- 

DuUtn of Uanil 
Wit Tluptivtren'i Ci'iilrtctloni Dli* 

leetioii (AtlNmii) 
625 Su]i«rnumGrary Tbumb 
Km Appcn^nt Kiiitnn at Iwo H«ndt 
627 Arrwt of I>vv«l<.>prii<int of Fin- 

^n: l^li Mktia 
A28 Arr«tt of DevrUipmant (if Pin- 

K«n: Kli;lii IlHnd . 
A29 I>iKtrrflmii*howlngOp«r«iiun fur 

C80 Dliii:r>in*i)iowlriij; Opomilon fur 

Apiianltu fur Kn'iok-kn«o 

D4>n» la Kn<)ck>kno«: LIna of 
MiKwvren'B And Ogston'a Ope- 
nttucu 

M«oeweti'« CliiwI 

CohtfBclion of Knee: Dlcplaocs- 
■ittTut BackwKrda of Hewl uf 
Tibia 

Kriuivjoint dlraighl/>ned; Bcftd 
I'f Tibin ThrowD Backwardi . 

ApDiratui to rcnied}' above Dis- 
■ilikccuicnt .... 
087 Drill for Auk,Tl.«e(l Kne« . 
696 Drill for Ankj-loacd Joint . 

639 Talipes Eqiiinui. 

MO Tali|>M KijiiiiiiH. Bene* in 

oil Ap)MratU4 for wic after divuioB 
of Tcndo AchilUt for Panljrlic 
KqutDu* 

042 Tatipu Calcftooui 

«V43 TallpM Varu» . 

M4 THlipw ^'arut: Bone* I u . 

«16 Kdation of Tondona divided in 
Kqiliiio-vann . . . , 

640 AfflfltiB'* Taliven 

647 Talifrtii Vnlgu* . . . . 

MM lli.llotr (lH».f.tL>t 

A49 Appamlufc fur tnainUining Kx- 

(f^iuiun of Toci alter Divbion 

■if Tendoo* . . . . 
6aO (-'■.npjiilt*! HTTpertrophy of To« 

aiMl Foot: I'lnntiir Ajpcnt 
C£l Cutie^fittal Svp«rtrjph}' '.'f To«i 

and Foot : t*ur<»l .\iipect 
SfiZ I'achytlonnaloiuTumur of Scalp 
<68 Mpoina •'T Svu* Wfon Opof»- 

tion 

KM Snnw Xum afW Oporation 



081 
082 



6I« 
684 



flSu 
68S 



4irj 6M) 

4M 057 

491, 
411.'. imO 

im flfii 

4»8 
4Uil flA2 

fiC)t 

<t«8 
SOU 

664 
f.02 

(Hn) 

r«r> 

MM 000 
WW 

IM7 
tiOC 



,070 
507 671 
/rflB (172 
078 



MO 

&09 



879 



614 6R0 
6l7'«f*l 
M7 

620 OSS 

I CM 

621 ' 

&3) \e»t> 

&22i 
«2-^ OM 

&£8,68; 
«34' 

&37 

OVO 
AM Ot»l 

.01)2 
62&I 
680 098 

!g94 
fins 09r> 
68B- 



Xaanl S|wciilutii. . . . 
NaJinl Sjimtlum (Priuisal'*) . 6W 
B<.'11>«.>)'* Sotinii . . . . M4 
DiiL^nm uf I'lug^ng Noatrll by 

mpMiiii iif Hclloci]'* i^iund 644 

NtuK>-<jH)iul Tumor . . . M» 
Section of j^llhnlloraa of Faea . 568 
Bit«iMiv« Wartj Bnithcliuma of 

Up 864 

Llnet of IncUlon for nrnoring 

V-«li«pcd Pirn of Up . . CM 
£piUi«liun)nef Lowvr Lip: LInca 

of IncUlon .... fiM 
Lip al\«r Rvnioval of Epilli^ 

lioma fiM 

Rstoiulv^ Rplth^^lioma of Lip: 

Lintv i>f iMciniun . . 6(>6 

£p)tht-lioiua uf Lvwer Lip Ib- 

volTtns Jaw (IlMth) . 5SA 

Tiini'fT "f Parotid, loo d«op1; 

ncnfd fur romoval . . (UM 

SimiiloTumornf Parutid: Prunt 

Vm'w 687 

Simple Tumor of Parotid: Back 

View 667 

S«x>u* Crrt of tbo Tbyrold . 698 
Epulia of Lower Jaw . 669 

^uliftiif f^ppcr Jaw 600 

Wood'' Cam of Pfao«pbora*<ne- 

oiwli of entire Lower Jaw 67S 

Anlrxitii-|>erforatur 674 

Antnini-i'orfomtor 674 

Aninim-pcrforator . . 674 

Oyitie Tumur of Antrum . 676 

Malignant I>U«ue of Malar 

Bone 678 

UalijEQaiit Tuniorof Uppn Jaw, 

larolTlnp all Bona of Face . 679 
Jaw Mw, with luovablo back 680 

Li»«* of Inciiion (Lialun'i) fur 

Kxcislon of tapper Jaw . 680 

Trcad«lenbiii^'aTniclwa>Unipoa 6631 
ExcttioD of Upper Jaw (LlftonV 

Mothod) 688 

Line of Indflion In Eicfajon of 



L'p|ter Jaw by External Flap . 
KiciJiun of l»wer Jaw: Boft 

part* rabed .... 
EsoiMtw of Lower Jnw : DImt^ 

tioulalion of Condyle 
Lirrn of IncLiion in IJurow'a 

Op«ra(lon .... 
Opcmii'in for R«p«ir of Eve* 

lid If) UlidiOK. (A] Twiattno 

Method 

Lower Eyelid deformed br 

Scar 

Lnw«*r Eyfilid after OpenlJoa . 

l>cl)rie»cy of Ala 

Diafjram of Flap fmiB Fowband 

in '''■' ' :■.- 

Dcj.: . . . . 

Now .'..... .irn after OparatioB . 

Pati«>iii Iwforc RbinupUstie Ope> 

ralloti : MoM Oeatruyed . 



684 
690 
601 

687 



6»7 

CM 
608 

tan 

000 

001 

oot 

OQS 



MST OF ILLU8THATI0NS. 



XXV 



ris- 
CM 

69T 
TUO 

:oi 

T02 
TliS 

TM 

7(V-, 

TC>6 

to: 
:ii 

'V2 

713 
714 
71". 



:-.'i 



ri-4 



7:> 



Satne Pnticnt tmiie months aft^r 

Ofxratirtn .... 
t>p»-nine 'o*o Antfriur NHrvs: 

Cl-«ed by Operation 
Op^ninj! into Anlorior Naref. 

Clns«^ by Openttioii 
Single Uarvlip .... 
I>i»uble H>Tvhp: Front View 
IV'uble Harelip: Side View 
Bonesoont^^medin UoubleUHrp- 

lip mnd Clefl Palate 
Elaftic Comprewor on Coronary 

Artery of Lip 
ApplioHtioD of Twisted Suture . 
Appliration of Pins and Sutuira 

in Harelip 
Harelip: Spring Cheek Com- 

(.rw*tir 

NeUton's Operation fur Partial 

Harvlip: TwoStagra 
Freshening Edge in Double 

Harelip 

l><iiible Harelip; Intemiaxiliary 

IHirtion fixed to Nuee: Side 

View ... 
I)<>uMe llarvlip; Intermaiillnr}- 

iMirtion fixed to Nose: Front 

View 

Cfaopart's Of<eration of Cheilo- 

plasty; Linen of Incision: 

Part* appn)xiniated by Sutures 
Chi'part's Operation of Cheilo- 

t>>a^ty; Linea of Incision: 
*an» approximated by futures 
Buchanan* Operation for Re- 
storation of Lower Lip . 
Buchanan's Operation for Re- 

»t-ir«tioR of Lower Lip . 
B'ichanan'a Operation for Re- 

^t• ration of Li>wer Lip . 
S_\ ni(- 1 <.i|ier^tion for Restoration 

' f I^iwcr Lip: Lines of In- 

ci>i"n ..... 
Sy:iif"»Operatifinfor Restoration 

• ■f Lower Lip: Operation Coin- 

[■>tfd 

B-'ne^ in Fissure of Hard and 

<"{t I'alaie .... 
W.nKi's MudiScation of Smith's 

(JaiT ..... 

S^-dill.i* Operation of Staphy- 

Krniphy . . " . 

S^-dill'fi Operation of Staphy- 

loraj.hy 

S-'-dill.^is Operation of StMphy- 

I'^r^phy 

IIvjMTtr phy and Prolajieus of 

"T-.m;'!!' ..... 

N:»'Vti- lif Tonjiue 

Licturv rif Liniiual Artorv 

Aj'l-liciiti.'ncif Scn-w-iTHir.C'htt^k- 
Ptnicior, tind Whipcord in 
'>["-nili'ins I'll Ti>ii;iic 

KT^iu—'n- (jii:; 

\Vhit.-L<-»d - i;*:; 



TAOE 


PIO. 




729 


602 


730 


G04 


731 


004 


782 


t»5 




CO.'. 


783 


605 


734 


606 


736 


608 


736 


608 






737 


608 


738 




789 


609 


740 




741 


609 


742 




743 


610 






744 




746 


611 






740 


611 


747 




748 




749 


612 






750 




751 


612 


752 




7.')8 


61^ 


7.>4 




765 


013 


766 




767 


613 


7:"* 




7-VJ 




700 


014 






701 




702 


614 


763 




764 


014 


765 


015 


76 


Cl- 


707 


ou 


768 


017 


709 


020 


770 


024 




628 


771 


02fl 


772 


t;2fl 


773 


030 





PASB 

Cork screw- needle . . , 680 
Application of Ligature to Cancer 

of Anterior part of Tongue . 681 
Two Erraeeiirs applied to Cancer 

of Tongue .... 682 
'Wire-fcraseur for removal of 

Tongue 688 

Galvanic Ecraseur . , . 688 
Lines of Incision in Regnoli'a 

Operation .... C84 
Tongue drawn out below Jaw in 

Operation .... 684 
Removal of Tongue by division 

of Jaw 686 

Raniila: Introduction of Seton . 640 

Vulsellum- scissors . . 642 

Forceps- scissors .... 642 

Tonsil-guillntine applied . 644 

Tonsil-};ui]lotinc shut . 644 

Tonsil-guil lotine, anoiher pattern 644 
Removal oT Right Tonsil with 

LeA Hand .646 

Pharyngotome .... 647 
Epithelioma of Phar\'QX and 

Q^ophagus causing Stricture . 661 
Modeof usin^ the Laryngoscope 

with Reflector . 656 

ThroBt-mirror .... 656 

(Edema of the Glottis . . 669 
Pmbang for applying Nitrate of 

Silver lo the Larynx . 660 

Laryngeal Syrinire . . 661 

Endo-larjngeal Forceps , 665 

Endii-laryngeal Forceps . 666 

Endii-l»ryngeal Forceps . 666 

Epithelioma in Larynx . 667 

Operation of Tracheotomy 674 

Parker's Automatic Retractor . 676 

Trachea-hook director . 077 

Cutting Trachea-h(K)k 677 

Riv»Jve TrHchca-tubo, closed 678 
Bivalve Trachca-tubc with Can- 

ulrt intn>diiced . . . 078 
Tmchon-dilator - .678 
Traciiea-tuhe: Side View . . 079 
Trachca-tubn: Front View 079 
LHryTisri'al-tuhc .... 679 
Baker's India-rubber Trachea- 
lube 080 

Tapping the Chest by the Bottle 

ui^pirator 684 

Pii^ton -trocar for Tapping tlio 

Chest . "; .684 
Tapping the Chest bv Siphon- 
trocar ...".. 686 
Trocar for Tupping Pulmonar^- 

Cavities . . ~ . . '. COO 
Simple Hypertrophy of Breast in 

a girl flflecn years old 694 
Breast laid open, showing deep- 
ly sealed Cysls, mistaken tor 

Scirrhus 704 

Cvslo-sarcoma of Breast 709 
Ulcenited Cystic TumorofIJroa»l, 

of twenty vears' dunition 710 



XXVi 



LIST OF ILLUSTRATIONS. 



774 UWrBl"d<'y«ii:Tiimitrwriir»'niH, 
six monvli Itilcr, with Kiinj^- 
inij Samimnliiui (jniwlli . 710 

776 Ulnnilini; Svirrbtit v( BrLtict 713 
770 PtMition or t'litit^iit ftJT Ampiiu- 

tM.li ..f Bnwt .... 728 

777 ItK.'iii';riiin><)iiitT>d Tur I bo roughly 

ClMirltii; AwiU . .789 

778 Surrhii* -f M.ilx llruatt . 7fl2 
770 Fil>rr<u4 'I'timor in Azilte of 

Womnn ..... 7Hi 
jm Pil>roua Tumor in Aitll* of 

Wuinan, rroitt vi«w . 734 

781 Lan;c H«rGonift \a Axilla of « 

tUn 784 

7ft! Larni SHrcouM in Axillii of a 

Mun 784 

788 Diag^min of nvdmwlnnf llirmial 

8»c. .741 

7W WuUw'i Ap{wnlu« for Rutiml 

Cuiv of lli^mia . .747 

nh Snc laid nptn : StrirUirv in Nock 734 
780 OtMrnti'in fi>r litTniia: Uivmon 

ofilw9kin . .704 

787 Oponilkm for licrnin: Incision 

iirStitwermii .\miliii Tiwiii? . 764 

788 Biuml utid Narruw UnrnU-dl- 

ni'iiir ■ . . , . 765 

780 Hnrnin-knifv . . 76fi 
7W> Mtxieof uiiuc: B«miii-kni(b 780 

781 Itii/*unf, OwigKnou* from 

htrnn}!;iilrttion .... 770 
793 ]>uf)uytrun'K EnUmtotne . 777 

708 DujiuviKtn'* Knt«rob>me An- 

l.ii.n.! 777 

7M DiiMcLiuii of I>(>tibk' Direct In- 

ruinal tlitnita . 786 

7M nrncUon of Obliiuvund Dinct 

Ui-mlw on <Ntii« itd« 785 

790 Congniiitiil Hernia (diagratn) . 71M] 

797 Infniiiilu llvniiB(dtaj(niiii) . 798 

798 DUjortlon ^bowing KclatloM of 

Kpin'>rsil Unmia 

799 IHtMviii'ii "f Fumorul Hvriiitt 

turnlnr upvrunl* over ft-o- 
(larl'i l.i;u;ar(i>'nt 

800 Ui>lHti'>ii>i of Kciiiunil Ucmin: 

(Ibtiirator riaing f^m Kpigai- 

tric 

Mii I' -ii3(lc llnniitl of Coitin 

W^ . iil.iiniftii'n fnim In- 

liriiiil lli-riiia .... 
tOCt Intliioii I'l-r Ltiiiib«r Coloionijr 

andU«n'latt>>nio l.tni<vir(.^Uiti 
MM tncjii^n iti I>-fl L>>iiil>nr ICcgtun 

III AniUkwii'x upt-mtUm . 
006 Colon '>)ir(ii>d and ktiU'faid totikln 
8H B«ctiim riiln; r .... 
807 Can< < ■ )Min of Kn^urn : 

V' • iiirtng Ailmiiiia- 

Unr. '. I ''■inn . . . 842 it' ' 

800 PiOi|n i:.. iiirii. with Tall- KAH Kf. 

cU in.ioi iiiriJ, twrvn jr*>ni>ld 84& fjAI Sci 
006 Kaked-«Y« Sn-tioo Uirou^b pi»- &&6 An 

cadkng Mi> i'.. 



794 



7M 



ria. PM 

itIU Anal Uiinlt^r . ... MM 
Bll SMculuin Ani . . .819 

81'i l*robi>nolnlMl ititlHory for Ki^ 

tutH 88ft 

818 Opnvllnn far Pblula in A«o . 865 
1*14 RiniC-fon-op- . . . . W7 

815 Dmhi-'« Nwiik' fur Applying 
Lii;atur« to rili-4 . * . 887 

816 Kinilir* Catit"rv-(.'lainp . 080 

817 Allirmliiim'' Ciamp . . 986 

818 ^?]H-culllm Ani 889 
810 Oilt Ulip ..... 8A0 
8^ FrolnjuuK Ani . .871 
821 AoiiU: InlcMltlnl Nc|>hr(tU: 

Bi^atlvm) A Iwmaea. M icio- 
■CMpiti :4«K'lioii . B80 

8SS Acute IntontJtlnl »pbrttb: 
Condition tif I'^pitbi.'liunt. Ui- 
ctTi*iMpic::i«ctian . 881 

BSS A. Ornupnf AlMc-eaMWonSurfaro 
of Xiuney. u. Vuiiical Sve- 
tion nf Mnio. Nnkt-d njra . 881 

R-J4 (Trio Acid Cr^Mab ... 900 

826 Umi« of Ammonia and Anor- 
phiHiK U ntt4» .... 900 

828 One Acid C'kIcuUm ... SOI 

827 Cr)>ult of OiaUlQ of Llin« . 908 
838 Very Itnii;*)! OiftlaU of LIniO 

Calculus .... 909 

S20 Crv»uU of Ammonio-mi^uaabui 

l>bii>pbNli> .... DOS 
H«0 CrvHUl. of t,>«tin« ... 904 
K81 Section of an AlumaUng Cal- 

ouliu 906 

K32 S^iHion of UxalH(« of Lima Cal* 

culun Incriutcd with Umtc* . 905 
ess Urio A^-id CalcMli inatl«4 to. 

(nllier 997 

KS4 Calculi with Fatvti ... 907 
HK't Exterior of BUdd<v caiit*iiilng 

an Encviud CahHilui . SOS 

8»t Interior of llladdrr: Showing 

SniKll llrin<-0 ..r Oral . 900 

837 Sound fir rxatninine Btad(l«r . 912 
KM Sounding for .Stone behind Pna- 

tnie - . . 912 

889 Koondinic for Stono abore Pabo 918 

40 l[olI<.M'.S..iind . . .Bit 

841 Sotiiiding lor Rmr<r*lt>d Stone . 914 

842 Lithoioinv Scalpel .917 
M.I i'rol>o-pointnl Liib.>(*>mv>knire, 917 
8-14 0(«n.blH(l«l I -' i« fll7 
M<y~^:^. l-ninii'i 'U- 

olotiiy Ki.iii [!•. I 1.1 .nl I ..r- 
CV|M. Sc<>i>{. In llMidU;, Scoop, 
.Sun; tv«r<'Upr . 918 

861 LithnlottiT Pmilton: LimioflB- 
eulon in lliv Lateral Onvni- 
Uoa 919 

H63 TjatArat Iiilbiriotnv? FingMwnail 



:iU Hlld 



brrp 






LIST OF ILLUSTRATIONS. 



XXVU 



86« 

«7 

808 

R5» 
S<0 

Wl 

863 

»«■) 
846 

867 

848 

WJ 
870 

>71 

872 

878 

8 
87s 

879 
8»> 

>^I 

lift! 

8M 

8*»*i 
Ri"7 

«*5 
«W 



Pt*iUi>n of Hand »nd Knife 

(Frriftut'OD) . . . . 
Pt»iti<>n i)f Hand And Knife 

(LiFton) 

PMition of Ilaud and Knife 

(Author) . . . . 
Ini-irii'n in Prostate . 
Line of Traction in Extracting 

a Stone 

Exinction of 8tone by Finger 

and Scoop .... 
Smith't Lithotomy Staff and 

Conductor .... 
Smith's Gorget .... 
Tumor of Proetato, Removed 

during Lithotomy . 
Cru'her and Drill fur Ijargc Cal- 
culi in Lithotomy . * . 
Sledian Operation with Rectang- 
ular Staff . . . . 
Line of Incision in Bilateml 

Lithotomy (Dupuytren) 
Dupuytren't Lithoiome Cach^, 

opened ..... 
Bilateral Section of the Prostate 
Line of Incision in Prostate in 

Bilateral Lithotomy ; relations 

of cut 

"Woode Bilateral Gorget . 
Lithometer Sound (for meaaur- 

ing Sione) .... 
\f eiu's old Thumb-screw Litbo- 

trite for breaking Stone . 

'77 Stfctionsof Lithotrile-blades 
Ciriale's Lithotrite for Crushing 

Fragments .... 
Thompffon's Improved Lilhotrite 
Intn>duction of the Lithotrite . 
Bri'dte'f Mode of Seizing the 

Su>ne 

Clviale'fi Mode of Seizing the 

."^tone behind the ProetMtc 
P-«iti--n of Lithotrite in Crush- 

int; the Stone .... 
Pi«)tion of Hand in using Cifi- 

al<;'R Lilhotrite 
P-«itioQ of Hands in using 

Thumb-screw Lithotrite 
Liihntrily Catheter: Eyes at Ei- 

Iremiiy ..... 
Lith"lriiy Catheter : Eye in 

Concavity .... 
Litholrity Catheters i Eye in 

C'lnveiity .... 
Clover'* Lilhotrity Injeclion- 

afinaratus' .... 
Handle of Higelow'^ Lithnrite : 

fhul 

Handle of nii;cluw's Lithotrite : 

'>[*n 

Ja*« "f Bigc-low's Lithotrite: 

fhui 

J»w* of Kigdow'B Lithotrite : 

"F-n 

Bicelfiw't Evacttator in use 



PAflB 


rie. 




895 


922 


896 




897 


922 


898 




899 


928 




924 


900 




901 


926 


902 


926 


903 


928 


904 


928 


906 




906 


931 






907 


934 




945 


908 


960 


909 


951 


910 


9ol 






911 




912 


961 




962 


913 


966 


914 


956 


915 


957 


916 


967 




968 


917 


96t) 






918 


960 


919 


961 


920 


962 


921 




922 


962 






923 


902 


924 




925 


968 






926 


963 


927 




928 


963 






929 


964 


930 




931 


966 






932 


9GC 


!(33 


9C0 


•JM 




93'i 


•ifi« 


ya« 


'MM 





Bigeluw's Cuthetor : Straight . 

Bigelow's Calheter: Curv«l . 

Otis'a Evacuator 

Thompson's Early Evacuator . 

Thompson's Improved Evac- 
uator 

Urethral Lithotrite . 

Urethral Forceps 

Urethral Forceps with Alltga- 
tor-jaw action 

Periiieal Lilhotrity: Introduc- 
tion of Dilator (Dolbeau) 

Extra-urethral Calculus . 

Pro>tai]c Calculus . 

Crusher for large Calculus in 
Female Bladder 

"Wood's 0|>eration for Extro- 
verted Bladder. Outline of 
Incision .... 

Wood's Operation : Flaps ap- 
plied 

Wood's Operation by Lateral 
Revereea Flaps 

"Wood's Operation by Lateral 
Reversed Flaps 

SaccuUis in wall of Bladder 

Cells found in Urine in Catarrh 
of Bhidder .... 

Bladder laid open, showing En- 
largement of Prostatic Urethra 

Urinary Organs in case of En- 
largei] Prostate 

Elbowed Catheter 

Enlarged Middle Lobe of Pros- 
tate arresting progress of 
Catheter .... 

Puncture of Bladder above 
I'ubes and thn>ugh Rectum . 

Teevan'a Urethral Injector 

Guyon's Injector for nitrate of 
silver 

Stricture from Consolidation of 
Corpus Spongiosum 

Bridle Stricture 

Stricture of Anterior Part of 
Urethra .... 

Conk'ul-hcadcd Sound 

Olive-headed Sound 

Olis's Urelhronicter, open and 
cl(«e<l 

Conical bulbous Bougie . 

Conicnl bulbous Ciitheler 

Catgut Bougie bent to Shape of 
Stricture .... 

Thompson's Stricture Expander 

Holfs Dilator .... 

Liincettrd Stylet for Division of 
Stricture .... 

Otis's Dilator and Urcthrometer 

Berkeley Hill's Diliiior and 
I'reibnilome 

Civiiile's Urethrotome 

Syinc'.'iStiiflTor IVnn'nil Section 

Civiale's Uri-tliroicinic for Strict- 
ure of tiio Orifice nioditied . 



PAOB 

967 
967 
968 
969 

969 
970 
970 

970 

974 
984 
980 

989 



992 

992 

992 

992 
995 

995 

1018 

1019 
1022 

1028 

1026 
1084 

1034 

1047 
1047 

1047 
1050 
1050 

10.50 
1052 
1052 

1052 
105!) 
1059 



1060 
1061 

1062 
1063 
I0'>4 

]0fi6 



XXVlll 



LIST OF ILLUSTRATIONS. 



1080 

1080 
1082 
1088 
1088 
1083 
1083 

1064 

1084 
1086 

1090 

1090 



na. I'Anis ' via. 

986a. Another Form of Bistoiirie 963 

Citchde 1066 

987 Seat of Puncture through U&v- 964 

turn in case of Stricture 1072 965 

988 UrethroplHstjr : N^lutou's First 

Method .... 1080:966 

989 Urethroplaijty : N^latun's Sec 

ond Method .... 1080 

940 Urethroplasty : Clark's Opera 

tion: First Slai^o . 

941 Urethroplasty: Clark's Opera 

tion : Second Stage 

942 Duck-billed Speculum . 

943 Angiilnrly Curved Knife 

944 Angularly Curved Knife 
946 Hollow Suture Needle . 

946 Sims's Catheter 

947 Bozeraan's Button Suture: Ap- 

plicution of Plate 

948 Bozeman's Button Suture: Ap- 

plication of Split 3hot . 

949 IrriUted Congenital Phimosis 

960 Clover's Circumcision Tourni 

quet; Open . 

961 Clover's Circumcision Tourni 

quet: Shut . 

962 Instrumentforholding thePre 

puce in Circumcision 

968 Circumcision in the Adult 

964 Sloughing of Prepuce and Pro- 
trusion of Olans . 1091 

966 Reduction of Paraphimosis . 1092 

966 Incision in Operation for Para' 

W>himoais .... 1092 
arts onOlansand Inner Sur 
faoe of Prepuce . . . 1098 

958 Fibroid Tumor of Penis . . 1094 

959 EpiiheliomH of Penis . 1094 

960 Elephantiasis of the Scrotum , 1098 

961 Double Hydrocele constricted 

oppoMte oxtemal abdominal 
nng, and thus eimuluting in- 
guinal hernia 1105 

962 Hydrocele of Tunica Vaginalis, 

laid open .... 1107 



967 
968 
969 
970 

971 



972 
973 



974 
975 



1090 
1090 1 976 



977 
978 
979 



980 

981 
962 
988 
964 



DiiisoL'tion of a Hydrocele, to 
show coverings . 1107 

Tapping in Hydrocele 1108 

SperuiutoKa from Encyted Hy- 
drotelo U12 

Haimatocele with thickened Tu- 
nica Vaginalis and adherent 
Fibrin 1114 

Iron pin for Treatment of Vari- 
cocele 1117 

Needle threaded with Silver 
Wire for Varicocele . 1118 

Vidal 's Operation forVaricocele, 
Needle and Wire applied . 1118 

Vidal's Operation for Varico- 
cele: Wire twisted; and 
Veins rolled up . . 1118 

Vidal's Operation: appearance 
of needle and wire when re* 
moved 1118 

Hernia testis (Benign Fungus) 1120 

Tubercular Testicle : naked-eye 
section through Epididymis 
and Body .... 1121 

Tubercular Testis: Microscopic 
Structure 1123 

Syphilitic Testicle (Gumma- 
tous): naked-eye section . 1126 

Syphilitic Testicle: Microscopic 
Structure .... 1125 

Cystic Sarcoma of the Testicle 1127 

DivisionoftheCordinCastration 1180 

Encephaloid Testicle, with Hy- 
droceles of Tunica Vaginalis 
and Cord .1181 

Syringe- Catheter for applying 
Cuustio to Urethra 1136 

Cylindrical Vaginal Speculum 1188 

Branched Vaginal Speculum . 1188 

Bivalve Vaginal Speculum , 1186 

Incisions for: Ligature of Ex- 
ternal Iliac (Abemethy's and 
Cooper's); Abdominal Ne- 
phrectomy ; Ovariatomy ; 
Gastrostomy .... 1 160 



SCIENCE AND ART OF SURGERY. 

DIVISION FOURTH. 
DISEASES OF TISSUES. 



CHAPTER XXXVri. 

SURGICAL DISEASES OF THE SKIN AND ITS APPENDAGES. 

The rarious specific cutaneous affections, such as eczema, scabies, impetigo, 
acne, lepra, psoriasis, etc., probably fall within the province of the Surgeon, 
and are commonlT treated by him in practice; but, as the consideration of 
theae diseases would necetearily lead into the whole subject of Dermatology, 
the limits uf this work would not allow me to discuss so extensive and special 
a branch of Surgery; and I must therefore content myself with the con- 
sideration of some of thoee affections of the skin, which, requiring manual 
awi«taiice, may perhaps be more properly looked upon as within the scope of 
the present Treatise. These diseases may be considered under the several 
headji of Diseases of the Skin itself, including the various forms of uon- 
malienaut ulceration, and the malignant ulcers and tumors, and Diseases of 
the Appendages of the Skin, as the nails. We have already in Chapter VI. 
<*■ n.-iilt?reti the ordinary non-malignant ulcers of the skin, and in Chapter 
XXXIV. some of the simple tumor?) that occur in coimectinn with the tissues; 
Mf- f hal I here, therefore, c<)n9ider only the Diseases of the Ap{)endages of the 
Skin and the Malignant Ulcers and Tumors. 

mSEASEJ' OF THE APPESDACJKS OF THE SKIN. 

DisEASii* OF THE Naiij". — The nails may become diseased, asthe result 
■•{ m*-<-hanical injury, or as a part of some general cutaneous aflection; they 
may 'Utft-r from inflammation of the matrix, or may grow into the soft tissue 
■ ■i ibf iiiej, 

A vi'ilent blow or pinch oflen partly loosens the nail and causes an extrav* 
UA:i<iii of bliNwl beneath it. It then becomes black in color and slowly 
•rjiarati-i". Xo treatment is required beyond protecting the injured part by 
-jCDe ctiuvenienl covering. 

Id w>me broken states of health, and especiallv in persons suffering from 
■^[iiamous lUfezee of the skin, the nails occasionally become blackish or dark- 
bniwn in c>>l<>r, are ru^ed. dry, and cracked, scaling ofl', as it were, without 
tay apparent affection of the matrix. This condition, of which I have seen 
•rveral in«tADce«, id best cured by a course of alteratives or tonics, the dis- 
*»« yiflrling aa the general health Iwcomes improved. Arsenic will often 
> f-^uoil of great servicei either atone or with mercury. 
v.jL II —a 



HI 



SUROICAL l/ISKASSS OF TBB SKIN. 



Onychia h odiiwtawof the nailtt ilependent ott inflflnmialioD of tlie r 
it oceurc under two foriiiH, the »itnp{e and the epecljic, 

lu Simple Onychia llierc ar« redness, heat, uiid enelline. ii»u»lly do one 
eidc of iht' iiiiil, itud in the Hu^\e ul'tho tii>«uf> in wLich it is iui[iliiuu-d : there 
ie dinchargc ot' pus, and the usil gmdually looseus, becuiiiai ilark-ctilortxl, 
somewhat ehrivdlcd. and may Qvcntuslly bv tiirown off, a new tiail making 
iu appearance betuw, which vituniouly Heauiues a samewliat thickeood and 
rugircd shape. This disease ueualiy reujJig fruii) iligfat de^refs uf violeaoc, 
an tTie running of thorns and epliuteni into the fingera. 

The treatment cnnHiHts In cutting away any part uf the nail thai becnraes 
lorae, (to that no dischargw may nri'uniiilute buneath it. Tht> inAaraniatiun 
may be Buhduet] by hot moist appliralions. In >H)ine eaant ii lotion conipfjfled 
of li<]. plumb, snlmcetnlin jw, reiTCified apiril ,^j, and wiLlcr to one pint, will 
be ffiiind nioHl pffit-aoious. 

Syphilitic Onychia is a more serioui) affection, and is often dependent oo 
injiirii^ iiillictcd on the fin^r during cntii'titutitinal «y|ihili9. In it a iloKky- 
reil or livid in tin munition tnkpj plncf at the Rides or mot. of the nail ; ulcera- 
tion is set up. ncrunipfliiieil by the diiifharffe of tanioofl and very Ji-iid pus; 
nnd large lcx>w gmnulaiiong spring up at its r(»ot and «do«, m ihm the end 
of the toe or finger that is affectM (and this is mn#t cunmionly either the 
erewt Ikk-, the thumb, or the index finger) Wcomea greiitlv enliirged and 
bulhuus in »hnpe. The nail then shrivels, becomes brown or Idack, and peels 
off in atrijw ( Fig. 415} ; after its separation, thick epidermic mnme«, forming 

abortive attempt* al the production of a new 

^^^^^ nail, may dewlop al the bn«« and vidva. In 

^^^^^^ ■. I the TttainxKni, both local and cutt»tituti>Hial 

^^^B 1^ \ means are n-tiuired. The fi/st and moel 

^^^^m ^DflB^^ esaeutial )H)iut is to Ttwmt the naii, either in 

^^^9 ^^S^^B whole or purl, fur it acts as a fon-ign body, 

jF W ^^^^V and prevents the healing ai the surface from 

nbicli it springs: the ulcvr may then be 
trcutinJ niih ioiluform or well rubh^l with 
the nitrate iif eilver.nnd dreewd with black 
wash. Coltes reconimenils fumigaliug it with a mercurial candle, maile hy 
melting a drachm of cinnabar and two ouoom of white wax t^igelher. The 
coustitulwnaf treatment is that of syphilis. Sir A. Cooper recommends onlo 
mel and opium, but t havi! generally found bichluride of mercury, irilh 
earsBpnrilla or rinchona. the most useful reme<ly. 

Ingrowing of the Hail is an extremely painful and troublesome aflection, 
principally iK-ciirring in the great toe, nnd brought about hy wearing pointed 
shoes, hy which the siden oi' the soft 'part of the toe arc preaeed u|^Hin, and 
made to overlap the edge of the nail. An ulcer here fornm, the liability to 
which is greatly increased by the nail being cut B<)uare, so that the tlesh 
preaaca ofainst a sharp and pMJocting corner •*{ it; thiri ulcer «ecrelca a fotid 
aanioua discharge, ami large granulations are thrown up by It. The caiiae> 
r|uen(w is innhllity to walk or even stand with omfort. 

TVcfilmrtil. — Id thu very early stage« before ulceration has taken plaoe. 
further (rouble may often l>e prevented by vcrnping the nail ilown along ita 
middle with a piece of l>rok<'i] giam or a knife, till it is atraut as thin as a snevt 
of note paper. At the enme lime, its free end should be cut short id the 
middle, and ita coriien^ altoned to gn>w well beyond the matrix, ao that tbt 
nalurni edge of the nail, and not a sharp angle, ahall be in contact with tin 
9ofl parts. W'h«n thv tofi parts begin to overlap the nail rarions plana hftva 
been deviar^l with a view of raising the edge of the nail, and prcauitt uicte 
the aofl stnioturea. I have never, however, seen much pemuiuent Iteoefil 



Fif. 416.— Sypbililitt Onjrohia 




LUPUS — VABIBTIKS. 35 

muU from an^r of these means ; and the only method that is, I think, really 
servicvable to the patient, is the removal of the whole naii. As this opera- 
tiiia u an excessively painfut one, the patient should be ansesthetized with 
oitroQS oxide, or the matrix should be rendered insensitive by the ether- 
sprmy. The Surgeon holds the diseased toe in bis lett hand, ana then, run- 
ning one blade of a strong, sharp-pointed pair of scissors 
uoder the nail up to its very root, he cuts through its whole 
length, and, removing the scissors, seizes first one half and 
then the other with a pair of dissecting forceps, and twists 
tbem away frum their attachments. The surface left is still 
covered by the deeper layer of the epithelium, and becomes 
covered with a dry layer of cuticle in a few days. The 
back of the sciflBors usually wounds the matrix in the mid- 
dle line, and here granulations may form. The new nail 
f-ows straight and oeatttiy. In sonae rar« cases, however, 
have seen a fwulty direction assumed by it. If this should 
happen the nail must be again removed, and the matrix Fig- 4ifl.~-Hjper- 
diasected awmy. Avulsion of the toe-nail is usually unat^ trophy ^nd De- 
tended by danger. I was, however, once called upon to rortnuj or To*- 
amputate a foot for gangrene, which had followed the oper- >>ftil. 
atiatii performed on an elderly person. 

Htpertbophy of ToE-NAiL.^Occaeionally from neglect the toe-nail 
mar become enormously hypertrophied and twisted, looking more like a 
bom than a nail, as iu the accompanyiog drawing (Fig. 416), taken from a 
pstieDt in whom the nail had been allowed to grow uucut for twenty years, 
pffTtducing complete lameness. I removed the nail whole by avulsion, and a 
soand and useful foot resulted. 

DIBEABES OF THE SKIN. 

Ll'PUB- — Under the terra fupiu various affectioDB of the skin were formerly 
included, having but little in common with each other beyond running a 
cbrvoic course and leading to destruction of the cutaneous tissues, with or 
without ulceration. It is now limited to two diseases which, although in- 
rludtd under the common name, are iu reality quite distinct. These two 
auctions are distinguished aa Lupus Erythematosus and Lupus Vulgaris. 
When the terra lupus is used alone it is applied only to the latter disease. 

Lnpns Erythematosnt. — This disease was originally described as a disease 
of the sebaceuua follicles. Hebra, in 1845, gave it the name of Seborrbcea 
CitDgestiva. It is now generally known by the name of Lupus Erythema- 
Daiid. It consists essentially in a chronic infiammation, affecting chiefly the 
H-baceous follicles and the tissues immediately surrouudtng them. There ie 
ID increased secretion of sebaceous matter from the follicle by which the 
arini of the gland become dilated and the duct widened. The parts imme- 
diately surrounding the follicle show the ordinary signs of chronic inflam- 
mation, the capillaries being dilated and the tissues infiltrated with small 
piuod celts. The disease terminates iu destruction of the follicles, and the 
rbp>nic inflammatory pnxlucts partly degenerate and are absorbed, and 
partly become developed into cicatricial tissue. 

Tb« dii>ease commences as a sharply defined red patch, the color of which 
didppMirs almost entirely on pressure. The redness is most marked round 
the orifices of the follicles. The spots may be isolated or in groups, and vary 
in ftiw from a pin's head to a split-pea. The patch soon becomes covered by 
an ailberent scale, which is greasy to the touch. If this be removed, it is 
f'^und to be continuous with the plugs of altered sebaceous matter filling the 



M 



SCBOICAL DI8BASK8 OF THE SKIt(. 



dilati^ dui-lK nf tlif. fiAWcl^. Tbe patches itch eJightly, but are not nctualljr 
pniaful. Aft ih« diecssc Bilvnnvcs the 8poi« slowly iacrrase in size m tb* 
cireuiDfereucf, while the cciUrnI tmrte l>u»roe paler, fligbtlr depresieO, aod 
ciratricial — the ihio »PBr-(ucue W-ing drv like piircJiiiMDt and oUen scmly. 
Tticru it uu icDdcncy to iuppuratixii or iilcpmtion. Another and leaa oon- 
num varietv oi the iliHcafc is descrilK-d.in «hii'b it ixnamences as numennia 
dincrctir siiots, and tprcads hy the apm-arauce of frvsh patchw, rothor than 
by extenmon fmiii a single ccuirr. Lupus cn*lhpmnii«u8 it m<«t eomnion 
no the elit-ekfi. It may iiccur ntsu on the van, lips, sralp, am) ihp Imclu of 
the hands. The dtaraae rnns an exirvuifly chrDoic Limrae, ofi<-o lai^iing 
inaDy years, and raiisiog great disfigure men t. It has a gn>ai tcndi-ncy to 
relapse after amtan^nt cure. Attarks uf errsipelas are ont UDroinmon during 
its iirncn^m. The cause is unknown. S'o diatiuct connection has been 
traced uelweim it and MTnirula or xyphilis, and it is not brn^diinry nor ctm- 
laffions. It comnienccs wually in youny adult l)f« af^r lh<> rightrcnlb 
yenr. and is nio>tL ntmnion in wonjfD. 

TWntinf^il. — 'Sn drup f itertJi aur ipwlfie itiflurnce on the disease, and iho 
eomatilutional treatment consistit therefore merely in atteudini^ to iho ^'eneral 
health on ordinary principles. Locally, Kaposi states that be has fimiid Lbe 
attplienti'in of Kmplastniin Hrdrarfjyri the mn»t efficient mode of treatment. 
The iurfacu mnv l)e cleaned bci'orc it^ n])plicaiion bv being tnieare<1 with oil 
and well washed with soil soap. The plosler should be spread ihiekly on 
thin linen, and changed dally. Strong caiiatica are not to be reconimcuded, 
and the results oinnined br the application of sajx'rticial e«i'harolirs have nut 
been very encourn^inj;. t*iiinting with iiMiiuc als(> has been recomnieuded. 
It excitet> a certnin dcf^rei? of intlitmniation atU-r u tew applications, in cun- 
se<^iien(-e of whivb the »i;bu('t-<)iia plug» in the ducts itf the fullicleM si>eiu to 
bet-onie softenwl iin>l discliiirgc*l, thus caiisinf; tenifmrHry ini|ir<ivemeiit. 

Ltqini Vulgaris or Lupni: Pathological Appearances, — TIuh diMease 
criiiiinem>^ in llip deep lavor ul" tin' Liilij' vera. In its carlicat nta^e circular 
accumulntimtsnf tnmll n*und cells are seen displacing the bundles of Hbroiis 
tUeue. The surrounding vessels ore dilnti>d, and neir capiliariia exbl 
auiungst the cells, nnd ttins the mtdule resembles in stnicturo ordiuarr 
grauulation-linuc. Tlicoe circular mn>«c« of cells gradually incr^nio iu Bite, 
and by their preaenre destroy the lisstiv of the trne skin and thus approitrh 
tbe surface, until at Inst the papillary layer is impltcnted and the new gruwtli 
is covered merely by the epithelium. Utiring this pntccw ncigbburiug 
groups of cells cidesce, nnd prucewes of eel! infiltration extend along the 
vesMTls and surround the hair bulbs and fulliolM, so that in ita fully dcvelowHl 
itagc a lu|>t>id tubercle cmsisu of an inSltrntion, nnd more nr 1c» complete 
d^^trurlton. of the ntirnml tissue of tbe akin from the papilla.' lo the sub- 
cuuinf.>iis fat. On exaniiuing a Bwlti»n of n folly developed patch, non- 
vascular uodulrs c«rop<wed of a giant c«ll,eurn>unded by Inrger "epithelioid" 
cells, and "gni" hy cnliunr)- lymph<iirl or BniHli round cells, will alwa^'s be 
met with. These me identical iu np|>enrniut with tbe n'Klule? of gray grann- 
Iatian.H, a fuel wtiicli has Id some jmlhologiKis to regard lupus os a toral 
tnbcfculoais of the akin ; hut (bio virtr if; not generellT accepted. 

After a. poteh of ti)pi>& has n.'ach«H) its full devetopnipnt, retrogresalT* 
chmiyi-s take place. These may be of two kinds. In the fiwt, some of tl»« 
icelU mnv become cloudy frjm fatty dcKcnrration, brnik up, and be ahsorbMl, 
while a development of cicatricial fibrous vame takes place from the re< 
maindrr. Thus, tbe prucen comes to an enil without ulceration, nnd a)thou)ch 
the rpithelial <-«iveniig has been lhntui;hout ininct. a scar rraalu rimilar m 
aPiNrarnoce ti> ilial caused by a superficial burn. When the diaeaae lakra 
curse. It is described as non-u/ceraft'iK tupu*, Ivput non-errdnu, or iujntt 



LUPUS — STHFTOUS AND CAUSES. S7 

fxj-jliaticui (Kaposi). In the second form the futtr degeneration afTects the 
whole v( the cellular maaa, which then softens, the cuticle coveriog it U 
thrown off, and the disintegrated caseous mass is discharged, leaving an ulcer 
whiL-h may slowly extend. The disease is then known as uieerattve lupus, 
lupus exedens, or lupus exuleerans. These two forms are therefore mere modi- 
ficatioDB of one process; the fat« of the new growth, whether it is absorbed 
without ulceratiou or whether it soflens and is discharged, being due to acci- 
deDUi, local, or constitutioosl conditions, the nature of which cannot in all 
CMies be deterniioed. 

SfjRpioms. — Lupus cuinmences iu the form of tubercles, buried iti the skin. 
Tb«r are separate fn>m each other, and arranged in groups, or sometimes in 
invjrular circles. At first they form red or reddish-brown patches, from a 
Hoc to a quarter of an inch in diameter, which are not raised above the sur- 
face. The tubercles continue slowly to develop, till after some weeks they 
become slightly elevated, and covered by a fine branny epidermic desquama- 
tioa. Several patches may coalesce, forming larger tubercles, and at the 
tame time new patclies appear, so that all stages of development may he 
obaerred at once in the same case. At this point the two forms of the (liaease 
diver^^ In Lupus nov-exeden$, the tubercle becomes paler in color and 
trraduallv shrinks and disappears. The integument which has been atfected 
by the disease may he in one of two states ; it may either continue red, irri- 
uble. and branny, having the appearance of a thin cicatricial tissue, and in 
this way the greater part of the whole of the face may be affected ; or it 
may leave a firm, white, smooth, and depressed cicatrix, exactly resembling 
that produced by a burn, along the margin of which the disease slowly 
spreads, in the f4irm of an elevated ridge composed of soft bluish-wbite or 
rcwldtsh tubercles. 

Id lupu« exedens, instead of disappearing, the tubercles become pale in 
Color and softened ; the epithelial covering separates, and the disintegrated 
rbecsy mass mixed with some pus is discharged, and drying on the surface 
t'-frms a scab. This process may be accompanied by considerable intlamraa- 
tioD of the skin surrounding the lupoid patches, with heat, swelling, and 
TKtio. When the scab separates, an ulcer is seen beneath. It is sharply de- 
rl:ie<l. with slightly niiseil edges, and usually a smooth red surface which 
i>U-e<ls readily. This sore may gradually extend both superficially and in 
.ir[«ih. and when seated on the nose often leads to destruction of the alje and 
miumna. Lupus vulgaris seldom, however, spresuls very deeply, although 
iirz-! art-as of skin may be affected, and the most fiightful delurmity result. 

.<iUi'itlan. — Lupus may occur on any part of the body, but it is far more 
.•..-omMnly met with iu the lace than elsewhere. The nose and cheeks are 
tiiv pttrt.- of the face usually attacked. It miiy commence un mucous mem- 
l<ntii««. hut most commonly reaches them by extension from the skin. It is, 
liowcver. c.K'cn!iiiinally met with as a primary disease in the pharynx and 
larviix. It then usually assumes the ulcerative form, and may lead to ex- 
itii.-iv** dt^trurtion of the mucous membrane. 

SrjT -iii'l Aiju. — Lupus vulgaris occurs altnost with equal frequency in the 
tK') itxe*. It Ix-gins m(«t commonly in early life, " rarely before the third 
vf^r and slni'<st never af\er puberty" (Kaposi). 

i •iMftlieatioM'. — Bevoud the deformity caused by the contracti<m of the 
tt-nrf. the di««ase itself causes no serious cunsetpiences. ^Vs a rule, it in no 
" IV atf<-cts the general health. Erysipelas not unoomiiionty attacks the <Us- 
tiiMfil ourface, and cases have been recorderl in which epithelioma has arisen 
fr-m the scan'. 

CauM. — Until recently it was universally assumed that lupus owed its 
-rijcin t<> a scrofulous taint in the constitution, and possibly sometimes to 



88 



BCBOIOAT^ niBIASKS OF THE 9EIK. 



)uhi'rilv<l syphilw; but at the preKtit tira« moat autliuntiei «re uf^Tt-c-d lliat 
ahlidugl) Will these views may bu irue uf siinie CMes, vvl in the great ma- 
jorily iir) eviilenre ie forthciimiDg tu justify them. Tbc (liseoBe a not bemli- 
tAry nutl is nut coiiimunicnhle. 

FrognosiB. — Lupus is cbaraclemed by its alow ctxiree, ami ito t«ii(l«)rr 
Lu relH|iw after appnrcut arreet ; it is, however, never directly ratal. 

Diagnoiit. — Tlie dingnoek ie not always easy, the cHmi^bbc lieitig especially 
apt to be euiifouDde<] with etnue fornis of Inipetigo, with Icrtiarv ^vphilitlo 
ult'eralioDs, with nident ulcer, and with oaiu'er. From itnprlitjo it tnnv ba 
distio^idied br the nbAence of puetulr^, an<i of the iLirk gummy crtivtii 
charaeteriMic of that aflecti'^n, as well an by the le«s cxtctil dC «urfin."p im- 
plicated, from trrtmiy «t/phiUtic ulrfmtionJ>, r^ptf'mWy from <in)^fnin(; cula- 
neous guninmla, it i^ uAeu very difficult to distififjuiith it. The hintury of 
th« disease, the age of the pMt'ient at th«> tlmo of inviuioii, nod the more 
rapid progress of the flvphifttic aflectiou will usually ettnbli; ihu l^ur^von to 
make a correct diaf^nosU. From uptamotu epilhe/ioma, it \« UMially ilititiR- 
gu*nhed with «a»e ; io lupus the tuherclec are nunien>uH, and there are luooy 
centrcv of ulcersttott, Lhe glandc are Kldom enlarged, and the disease cooi- 
mencM in early life; iu cancer the primary dtwaae is single, the glands ar« 
early aSected, the discaw commeuece after middle life. Id lupus the uleer 
is flat, with sharply cut ed>Ee« ; in cancer it is rugged and irregular, nith 
hard, elevated, and everted edges. Tbe diiguuna from rodent difrrr nill be 
^iveii with thai disease. 

Trmtmeat. — The evm/iiutimuii trfatmtnt of lupus waa formerly considered 

of much inipiirtADce. Cud-liver oil, the iodides of potnpj^ium, mercury, um) 

Offcnic, either alouL' ur combined wilh various other uru};e. have bevii cn'diUfl 

with a curative, or at tvu^i n beneGcial influence on the diseniae. At the 

present lime when, hy more extended clinical ol>ecrvatiuu, simple scnifuluun 

itvf and tertiary Kvphiliiic ulcerations have lieen clearly rii»!iiuguiithed from 

lopuc, ihe efficary of dru;js in the treatment of the iliaciisi* ha» been 

found to b4- mnrh let-s than whs once supposed. Kapi«i slater that no drue 

exi-rL« any deBnitr itprcjfic influence un the progress of Uie disaisc. H(ill, 

IjM lupii» frtt|u<'4itly oecurs in patients who are in feeble lieolih, nnnniic or 

[^roful'tus, constitutionnt trrHtmeut must on Do aecuuut Iw neglected ; fur, 

»lth<HiKh <\rugB mayoxerl no 9[)eeifiu influcDce, il is evident tliut by improv- 

[tiiu the geuenil hcnlih th<^y will promote the henling of the ulcent and so 

I lend to diminish (he iirvfrttv of the disea-ii--. Tht- dii-t should hf carrfully 

F regulated and nulritiriufi,iiDd general hygienic eondiiiimfl must be atti-iulfd |o. 

It is on thi- f'-riil tTtttlmenl that we have chiefly to rely, and |hr ouiy 

f^ftlcifnt III :ii(iM> by whirb the morbiil groivth in 4»ntpli-tely dcytniyen. 

'In the mi '. mm-tdivrative liipun, or Jupuit notfexeilciis, mii iittemtit 

niftv however In* nimh' I" iirrt^l the diwane without ki'IuhI di>iilrurti.<t) of tue 

vrontli. Ykt this iMifjKiMe mercurial pln^ler, |)«iiiling ivilh tincture of iiidiiie, 

bor with a stTvog 9olutii>u of nitmlc of viilvtr, xnd tlie applienliou nf xinc or 

.rt......!.. ..r I. ■.! ojiiiineut Imve been sometime* fouml etheactuuv. Ixitions 

'ii> an,' caiwciiilly useful at they prevent the surface fnmi 
>■• »»'l narsli. If the di«caec be situatetl on the fave, care must 
III aruid exposure toculd winds. dust. etc. Volkinann recommends 
pun.Miixrn •I'ariflcation by means of an instrument coiuihvc*) of several 
snaJI bladts set cl<»>t<ly l4»gclher. The object of this trv^tmeut is to obliterate 
Uw tfols and thus nrreat thegronlh and promote ahsurniion of thr morbid 
pmllwUk Mhould thr^e methods fail, the only h<i|>e of arrest ciuijiistii iu 
' « dlfiisetl ii.H>^ii{>, If it be liuiiteil in exti-iit, the ]uiieb nmy be 
4 anfrfqueuily the cicatrix becomes proniiiicul and irregular 




RODENT ULCER. S9 

from a fibruid growth reaembliag keloid. In lupus exedens destruction of 
the growth is the only treatment which holds out any prospect of success. 
In <k»ng this the means adopted must be eflScient. Feeble caustics only 
irritate the parts and i^ravate thedisease. The growth may be completely 
removed by excision, by scrapiog, by caustics, and by the actual cautery. 

£xcinon is applicable only to small isolated patches, and is seldom prac- 
ticable. Scraping has lately been found of great service. It is done by 
meansof "sharp spoons " (Fig. 95, p. 258, vol. i.). The brittle tissue of the 
growth is easily removed, and the sensation given by the denser healthy 
timues beneath shows when the operation has been carried far enough. The 
bleeding it very free, but is easily arrested by pressure with dry cotton-wool. 
It is wiser to apply some caustic to the scraped surface to insure the com- 
plete destruction of the growth. The caustics that have been used are 
various ; solid nitrate of silver, chloride of zinc, acid nitrate of mercury, and 
filming nitric acid have all been recommended, and are equally efficient. 
The actual cautery is easily controlled, and can often be used when other 
cmostics are inapplicable. In most cases Faquelin's thermo-cautery is the 
best, but in deep cavities, as the mouth or nose, the galvanic cautery ia more 
eanly applied. 

If when the case comes under observation there is considerable intlamma- 
tion round the patch, it is better to subdue this by warm moist applications 
belure adopting any of the above modes of treatment. 

After the growth has been destroyed healthy grauulationa spring up, and 
iht sore must be treated on ordinary principles. Vaseline and iodoform 
oiDtment often seems to promote the healthy healing of the raw surface. 

However successful the treatment may appear at first, relapses are very 
common, but in a large number of cases as life advances the disease seems to 
become less acute, and finally ceases to reappear. The cicatrix that forms 
after lupus is healed is thin, and readily breaks down, giving way on ex- 
posure to cold, or on the occurrence of constitutional derangement. The 
pUteot should therefore, for some length of time after recoverv, be careful 
not to expose himself to any such influences. The scars often lead to great 
deformity, drawing down the eyelids, distorting the mouth, and sometimes 
c]<«ing the nostrils. Various plastic operations are sometimes required to 
remedy these defects. 

RoDEST 1'l<-er, Xou-me-tangere, or Cancroid, was formerly included 
under lupus exedens. It is one of those remarkable afiections that stand 
midway between simple and malignant diseases; being, so far as constitu- 
tional causes or secondary complications are concerned, apparently of a 
simple nature, while, to a certain extent, in regard to structural condition 
and entirely in respect to local effects, it is of a malignant character. The 
diMaae consists essentially of a malignant growth of very feeble vitality and 
slight activity of development. This invades the surrounding structures and 
deMroTs them, and in its turn breaks down, disintegrates, and is thrown off, 
thur oaui'ing a pnigressive destruction of tissue. The disease is especially 
characterizes] by lie stow ]>rogress, by its eroding nature, and by the impossi- 
bility uf healing it by all ordinary methods nf treatment. It ia esseutlally a 
dtaea.-^ of advanced age, seldom beginning before 45 or 50. Its duration is 
Ld any given case indefinite ; seldom less than five or six years, occasionally 
est*-ndiD>; to twenty or thirty. It affects individuals uf either sex iudiscrimi- 
naiely ; and usually occurs in persons who are otherwise perfectly healthy. 
The b*»Uh also ia not influenced materially, if at all, by its long duration. 
I have seen persoos, who have been victims to it for more tl\pn twenty years, 
lo apparently rubiist health. But it is eventually and inevitably fatal, uuless 
rnuoved by operation. 



« 



SXTKOICJLL PISCASX8 OP TBK SXIK. 



U»m4- An|i«uilo&, 



It lU-avB rrimmMM>M in ih* »kiB. oauttlly on henJlhy iDtcgunitfiit ; liat 
occutoitallr it primsrilTBiivctaa fmrt wbidiit tht^amtof •omoell^lnic^hilD|re 

o(" rtnirtur*, lu « moJr, a wiirt. or n »cnr. It 
iTUir»fliK4 MivfMirlAf the hra<l, faci', or ttx- 
IrvmtltM. Tiirr f«c« » tt« iVAt of plmion, 
nprctally in the upper fnrtA, itiich *» thr 
fin-hraif, tW oidi- of tlif^ nn«e, tkft ittD«r 
•n^tv iif tbr v\f, .>r lh<» U»mple. ft iipr<Mdi 
•imftlr hr nHiliiniitr uf IlMue. ttt'vet hy 
(|i.'wmin>tv<t I1H.11I or by i«m>itdarr ilffwrnla. 
It n<«r Hiradt! uH tiw>ii««; th*" fik>ti pri- 
tiiarily. the cartiittuv of tl)« «Mr. the Iklan 
»ti<l erptom of liiv at*v, lh« p«riti<) t;l«ad. 
t)if- ciiajiinrtivii, anri Ihr' t^rlmll. K ill 
njHTinllr ilcetntctire tn brmr whru rnii'^ it 
Mliack« it. It cTixlra sa<i phLs iiwiiv tlie 
b'lne, mtlinul rmrits or ncrrwi*. It mar 
pmrtmtc tii lite durm mater, aod iovadc 
th« hmia. It prorresws, howevrr. bjr pre* 
fi-rporr 5ti[K>rtirtnny, not in drplb ; faeoea 
it 15 wlHoni mtuQiled ity bfrnorrhnfitr i-veo 
in the more advanced etopv. Tlic Dci^b- 
liorin;: lymplinlic ^tandtt dn n>a b«<»«ia 
iniplirutfd. nml Fivondary %-i«(vral depoaila 
arfr ntvrr met witli. A» th<- ulri'ratiiMi ex- 
tenrip, thpr«> 18 i)fti<n a iL*o<Ittiry to iraper- 
fibrt rimtriuiioti im one margin. «rhili*t tbc diwaae b making' pntgrew at ibe 
' nibiT. 

Ssrmptoma. — In wbutiver ••itimtion it Iw^iim, tt« fir^t apppantuoi! Ih in the 
eliHpr 'if a mbrnrk' or hard pimpln of u brown iph-ntl rulor. This mtK-ri'le 
utn;mt<r« kIokIv; and then tJbi' [ti:^4!iLS« rxti.-ndi'. Monre, to whom viv are 
indi^biAJ fur a toii^l lucid BL-tiiUDt of this terrible Rffr^ixD, Inya c^peeial 
amw oD ita eoiunifiicf luent in a bnnj wart, and its <xiutiuu«d ^xtntBioii by a 
hard niargiu. Tbi« ulo^rated tubercle becuiiii* (Vivpred Iwaacab; but^ aa 
tliD pntccn of dmructive uleemtiou progn»tM. tb« futn b<>cotiic« too larj^ u> 
be eovntd Id tbla way, and an nlcvr is left. Tbin ulcer. whiL'h >.>oti«Utute» * 

the di«ca«e. nod is the true " Luptu, or " Noli- 
ttf lunger*" of ibr oWer authors, prairnta 
the fuliuwiD^ L'barAfttira. It iit always «in|il«, 
iind spread* solely by couiinuity uf ii»*>w. 
Il ii doprt««ed «lit;litly beiutv ibe «url'fl4-v, W 
of a palo pink calur, witb a Ibmiwed 
tban a ]>ranulaliot; *urfaM>, rMuahtli^ 
iCi furrowed amootbneu an irre({ular lBy«r 
of pink wax.and ia UBualW (>ainlcaa,ez<«pi 
wbrre ricntricing. Itx eijgea are aligbtly 
mined, the de);rce varying iu diHerenl macs 
and ilcficndine 00 Hie eli>«cD«w nilh wliiRh 
the ■Wtriirtiuu of the new growth IoIIoms 
i\» devfloputent. In »om« i-aww the two 
follow eacli (ttlier »o closely that the ulcer 
aiifirnr* to In> a dimple Iom of tiMiic, »oarrcly 
anv ihickeninp of | lie v*\\^ boio); ri't-f^'Jii- 
alile. luijicrfwt uttcmpis at i-ii-atriiuitiua 
IJbrni II jiv<Hiliiir fcRtori' of the iiKt-r. At unc pari of ita rtinrutii it ctraMW to 
IirKail, and a liiin bloc line >d' L-pitiiclluiii ht'giiia to uleud ov«r the raw 



V 



}, 



\ 



uf M«Umi<1 Ci|io*uf**[ Dan M«t«r. 



PATHOLOGY OF RODENT ULCEK. 41 

Mirfac«. It DCTer, however, idvances far; before loog the spreading re- 
oomnwnces at the edge of the apparently unaltered skin, and the thin layer 
of epitheliura speedily disappears. This attempted cicatrization is never 
accompanied by any contraction of the Bore. The want of contraction is a 
very peculiar feature of the disease. If half an eyelid is destroyed, the 
remaioiDg half retains its normal position unaltered. Consequently signs 
of contraction may be taken during treatment to indicate that the growth 
has been succesafully destroyed in part at least. - 

The courae of the disease is always progressive ; more rapid in the skin, 
more slow in the bones and leas vascular tissues, as those of a cartilaginous 
and fibroid character — the pinna of the ear, the sclerotic, and the septum of 
the ti««e, for instance. When it attacks bones, it penetrates them, and sinks 
deeply into their softer parts. Moore has noticed that the morbid growth iu 
front of the advancing disease is always most clearly marked in cancellated 
bone — in the diploe, for instance. The soft parts immediately contiguous to 
the disease are perfectly healthy and uninfiltrated ; and there is never, even 
after many years^jf progress, any sign of secondary affection of the lymphatic 
glaoda. Unless the progress of this ulcer be arrested by treatment, it is 
never interrupted, but will terminate in the death of the patient. This fatal 
tennination may, however, be long delayed. The accompanying Fig. 418 is 
from a patient of mine who had suffered from the disease for nearly thirty 
yeare, but who was to alt appearance in perfect health, although the skull was 
perforated, the dura mater exposed, and the pulsations of the brain distinctly 
visible. 

Sugnosis. — The diagnosis has to be made from Epithelioma, Syphilis, and 
Lupu?. The distinction from ordinanr epithelioma is oilen at first difficult; 
but in the later stages the absence of glandular affection, the small amount of 
growth compared to the ulceration, and the prolonged course of the case, 
render the diagnosis easy. From faWtary typhilis it is clearly distiuguished 
by the duration of the case ; in syphilitic ulceration " the rate of destruction 
is n>easured by weeks ; in rodent cancer, by years." There is also an absence 
of all other signs of constitutional syphilis. From ordinary lupvs it is die- 
tinguishei] by the age and healthy constitutional state of the patient, by the 
^inglenes^ of the ulcer, and the absence of the pink, scaly, or cerlematous skin 
fn-a^iitrutly found around lupus. Lupus may cicatrize and cease at any time; 
raleiit ulcer never does. Lupus rarely causes death; rodent ulcer is always 
eventually latal. if unrelieved by treatment. 

Pathology. — The micn>ecopic characters of the solid infiltrating substance 
havf been examined by Moore, Hulke, and C Warren, all of whom have 
f lund some parts which presented appearances identical with ppilhelioma. 
MiK-n: found this in the diploe of the frontal hone, and Hulke in a part of 
the ::I'ibe tif theeye implicated in the disease. The greater part of the growth 
presents rliaraclers diBering but little from those of ordinary granulation- 
tivut-. M<»ore was of opinion that the growth commenced in all cnECS in a 

ftimple identical in structure with epithelioma, hut that this chanicter was 
i»t a.- the growth extended, hut could be readily assumed again iu "certain 
»ituati--n»' or in coui'enient textures." 

Thv nmctusions at which Dr. Collins Wnrren arrives as the result of his 

f»>w«rehw. are. that rodent ulcer is a form of epithelial cancer; and that it 

differs friim the more ordinary forms of epithelioma in the small size of the 

cc-lU. The arrangement of these epithelial cells mav be tubular and alveolar 

Fiji. 4iy^. 

l^tiT obeervations by T. C. Fox, Thin, and others, have generally con- 
firmed the observations of Moore, Hulke, and Warren ; but these observers 



TBBATXEHT OF RODENT ULCER. 48 

Imoi; covered with a piece of water-drening udUI the grayish slough that 

has been prodaced haa separated, when the caustic may oe reapplied as often 

M D e e ea sary. Berides the chloride of ziuc, various other caustics may be 

had recouree to, each of which poaaeMes Bome peculiar advantages. Nitric 

acid is asefiil, if the action required is not to be very deep ; for, as it hardens 

and coagulates the tissues to which it is applied, it does not extend so far as 

the chloride. The acid nitrate of mercury presents the same advantage as 

the nitric acid, and other fiuid cau8tic» — that it can be applied into the 

teures and hollows of the part into which the more solid caustics do not 

penetrate. The potassa fiisa and Vienna paste are useful, so far as their 

dcMfuctive properties are concerned, but are somewhat uocoDtrollable, and 

tpt to spread. The most convenient mode of applying them le to cut in a 

ptwe of plaster a hole of the exact size and shape oi the ulcer, to apply this 

uoand its borders, then to cover the sore with a layer of potassa cum calce, 

ODe lioe in thickness, and over this to lay on another piece of plaster. In 

Aw vty a considerable amount of caustic action may be induced, which will 

bt limiied exactly to the surface to which it haa been applied. Of all these 

ochtrutics, the preference is to be given to the chloride of zinc; its action 

ii more continuous and more controllable, and it appears to give a healthy 

ttimoliis to the subjacent structures. 

2. Excision of the whole of the ulcer may often be very advantageously 

Eised, especially when it is situated on the cheek, eyelid, eye, or fore- 
; sod the gap left may be filled in by some of those plastic processes 
1^ wilt be descrined when we come to epeek of the Plastic Surgery of the 
Fite. 

3. When the ulcer has attained a large size, when it is complicated in its 
ootlioe, and irregular in its depth, the Question arises whether surgery offers 
uy resource, or whether the patient should be left slowly and miserably 
to die. 

In these extreme cases, even, something may be done to prolong life and 
lo relieve suffering, even if no cure be ultimately expected. Moore proved 
thMt, unless the brain be implicated, or some large vessel involved, something 
eso usually be done at least to arrest the rapidity of the growth. The 
■ethod which he adopted was a combined use of the knife and of chloride of 
tine. By these means he removed in some cases the whole of the affected 
parts, leaving a huge chasra in the face, and even in one case exposing the 
dnra matrr for a considerable extent over the roof of the orbit. The opera- 
tions were done on no regular plan, the incisions being directed solely by the 
shsfM- of the growth, and no attempt being made to repair the deformity left. 
Hie results of these operations were, on the whole, favorable. Out of six 
caws three recovered, and three others received decided benefit, but were not 
permanently cured. In all the cases in which the chloride of zinc came 
mtu actual contact with the dura mater, epileptiform fits occurred, but only 
of a temporary character. 

When the disease is situated in an extremity, and the caucellous end of a 
bftoe esperially is involved, as when it dips into and erodes the head of the 
tibia or the lower end of the radius, amputation would be the proper and 
ooIt advantageous procedure. 

When the disease is so extensive, or so situated, that absolutely nothing in 
MO •>perative way can be done, the Surgeon must content himself by covering 
op tiie raw surface with lint snaked in glycerine and water, and protected by 
mted ftilk. Iodoform, either dusted on or applied as an ointment, composed 
of one drachm of the powder to an ounce of vaseline to which a small 
quantity of eucalvplus oil may be added, will usually be found the best 
applicmtion. 



44 



SCKOICAL DISEASRS OP THE SKIN. 



/:33, 




ftf. UV.— CMW*niM UlMc nf Ika Lt%, 



Cx'scr-R OF niK Skp* id«t be either priiiinry or eecomliirv. Primaiy 
Cancer, il" wo nclutic the K<xirot Ulcer, nlwnvs nwuiui-s the iorni »( iiin 

Si]iinni')U^ Epilhelioiiii). Thf struriun' 

iiiiH liiMory .if iJiis Imve uln-miy Ikvo 

described. Ii i« tuuulty MAict] nlxiut 

ihc lipe. fnoe, anil scrotum, aud ai the 

oriflds of the raaoitus caimU. Il lomr 

lu rare casta arise frmii itinli|;ii9tic 

Irauflforinitliiin of nu atb«rrinmti>U9 cytt 

1 p. 034, Viil. i. >. Kpitheliut iiiutTr may 

■irijtltititv alw) iu nti nlil D<^^ir )>r tikM!r. 

In lhi« wxy il mtir ■>(;i-iir ugiou nlitioat 

WMv |>itr1 oTtlie ivtfly ; I liiiveeci'tl it on 

thi* tifti>k, lirrff ■ hntiil, ihi^h, tiuil wiU- of the f">t. It ihni ("(•mis a 

luui uli-rr, (111- ." liirh i» j;riiy or^tUHi^hy.ntiil ttneti oivi-roti with large 

wnrty itrntiulati.nt- nti'l pnHulwraiil mnww*. Thi* Imi»«-' i» iiidiinilfd. the 

f\\p.v rniwtl iiii'l I'vi-nnl, Kiiil idlru {xiitillnrv iu sLructurv t Ki^r- -I'Ju i. Thr 

di»i'hHrgr is thiu aud toaittv. aail udWm the sors is treated by atitue|itiD 

nrndirAiiitiiK i( lHHt)iiii« burribly alT)>u«i\*r. 

BecoDdiU7 Cancer of Um Skin rtiny artH^ Trom direct extetuiion from a 
[iriiiiiirv tintwih >ir tritii a n>cniHlnr>- };laadular tunmr. Tb« inmt marked 
cxi>ni)if<L« an oiattiumW um with in cancer i>f tht> bfintat. Iu thla dtsMue, 
nfliT ihr priaiNry (umur haf rcarhtsl the surface, nunii'roii* Hm<xith, rlcvai^d 
tulKTi-lca iif a duitky rwl .ir bnmni.-ih iidor. niav a)»iN'ttr ilntied in the akin 
fitr iiinuy iuohca <tr.tiiitil tiw [uri fir^i im|)Iii-nt<-iV Kiu:h nf these i» a amftll 
snirrhou^ cnutvr idfiili'-nl in ^tructurt* with the jiritnary growth in the mam* 
mary ^land. 

In Ktbfr ciUM. fitrtuunlrlr rare, ibe akio corering the tide of the chest ia 
wiifrlv iiilillr:tti-^l hv tlic iiinlijnmni in^'Wlh. It ltccnnu'9smifnth,or a hroiriK 
iiih-ml i-.iliii, niid liatti and riaid, like a piece of leather, from which it baa 
rci-i-ivril thi> tiiiiiir •>(' lhi> canci>n)ua futrasa. 

Sarcomata of the Skin. — \'nriiuis f^irms of rarcoma are met with in the 
•kit). .Sm-.r. .vV/fW and vvui'l rrlirti mtrcimn are seen here a» in all 
othfr tiltfxu* mrMcUin*. Tw ftirms, hnwrver. »how a ^terisl pmlilection 
f<»r tho #kia— tb« mftanolic, and ihr akeolar, Mrlannlie tnrrt^ma oftvo com- 
tti9Ucc« in •••mo ptjiiicnlol sihiLfuch as a mnlr. It fi<rni* a ntun<leH limxir. 
■mimtb t>n the •urt'ac*'. and dnrk bnmn or hUck in v*Avr. It is iDlcowty 
IK '<■■•. atiil h-i«VT«r carl; it roar hv remove*!, it is v^rr ant to return 
I V and in ialcmal fincatia. If not removed, it grndimlly iucroam 

lud ai ',A*i itli'cratf-*. I> ' ihli takca place it nftca reaches a o^naider* 

ibic iiti-. 1 havi> lurt v^ .uataooaaof late of th'ta dbeaae, ona iia tha 

ftiot, tho oilier on th« baud, oi Indies both abot'e ecvcnty yean of an 
fianw time ntWr n-moral in both oaaea. browoi»h-black palclics looklof; like 
atainn «iih Indian Ink appeared oa the tkin in the neiKhburlHitHt of tbt* 

Iettmirix. TI>i-»« eradually daTalo|Md into new tumora. In one euebun- 
An^U ikf ilo^o f.>rii>i<d up tbe kg, varrioK in iiae frum a pen to a filbert. 
Tl>.'>' .L.-ii •:! . ' .inl ami lift viaa dca(roy«l, probably hy aecondary growth 
11 A t>cniid of about four yean from the priuiary mauifea- 

Alvi^'>l*c Suoama *4 thf »kin is rare. In tiiructurc and fpuenU cbarac- 
Irt ^ nMtv •t>'wrib«tl ( p. 966, vol. i ). It it pruhablv this tunurj 

lk b^ '-'•TtriM as the "M?irrhoiu wan." as from its hardnt 

L pHtrtal mati|[naQcy It usually manifests, it dusely rc*ein< 

I if a malijciMUit tumor uf the akin, whether a cancer or 



SIMPLE TUMORS. 45 

ttrtroma, consists in its ezcistoo or m amputation of the limb affected. Its 
mnoval by excision should be effected as soon as its true characters have 
declared themselves; provided it be of such a size, and bo situated, that it 
cmo be freelv removed with a sufficient stratum of subjacent healthy parts, 
and a wide border of surrounding skin. Should it be so situated that its 
excision through surrouoding healthy tissue is not practicable, tbe limb must 
be ampuuted, as was done in the case depicted iu Fig. 420. In such cir- 
cumstances the limb may be removed at no great distance above the dis- 
ease ; it not beiug necessary, as in cases of cancer of the extremities in 
whicb tbe bones are affected, to allow a joint to intervene between the seat 
of opermtion and the malignant growth. 

Simple Tcmobs of the Skin. — 

Fitoomft. — Circumscribed fibrous tumors are occaBionally met with in the 
skin, but are not cummon. 

Keloid is a fibroid growth not encapsuled, but fusing with the healthy skin 
at its edges. It forms a flat tumor, raised about a line above the surruund- 
ing healthy skin. It is oval, rounded, or irregular, and branching or radiat- 
ing in form. The surface is smooth, and white or pink in tint. It is firm 
■Oil elastic iu cuoustence. It arises without known cause and roost fre< 
qoeotly upon the trunk or extremities in persons otherwise healthy. It is 
seldom painful, but may give rise tu itching and burning sensations. It ex- 
tend)' slowly, and although covering a wider area sometimes seems to have 
uDilerguoe a process of contraction like a scar, the surrounding skin being 
ilnwn in and wrinkled ur puckered. After reaching a certain size it ceases 
In gn>w. It has no tendency to ulcerate or to degenerative changes. The 
Trmtment is merely to allay uneasy sensations by sedative applications. If 
excised, it almost certainly returns in the scar. 

Closely allied to true keloid are those fibroid growths that have a ten- 
dency tospmut up io scars, constituting Palse Keloid. It was described 
als«« by :^ir Cxmt Hawkins under Warty Tumors of CloatriMs. 

This morbid condition appears to be simply an abnormal increase in the 
activity of the development of the cicatricial tissue, which spriugs up with 
grvat luxuriance. They are wpecially apt to follow the irregular eicatriza- 
ii- n "t' l»um,s more particularly iu children. I have, however, seen them in 
ihf a.iuk. occacioned both io this way and by the irritation of a blister. The 
warty cicatricial tissue develo[» chiefly on the chest and neck, and 13 com- 
mxnly attended by much itching and tingling, ofYen of a most distressing 
ehameler. It is very vascular, blee<ling freely when incised. The Treat- 
iHtiii lit' th«^ prowihg is not satisfactory. As a rule, they may safely be let 
sl-m**. if thoy cause any aiiuoyance, the only treatment is to remove them 
by thf knife it' they are so situated as tu make this possible, but most com- 
monly the new scar assumes the same unhealthy condition. 

The disease known as Kolltucam Fibrosom, in which enormous pendu- 
louH tumor? coniixned of hypertrophied skin and subcutaneous tissue, has 
«lr«idy been <iescribed ( n. 944, vol. i.). 

Otteomata of the Skin have been described. They are always atheroma- 
t>>u' ry>t^, the walls of which have undergone calcificatioo.aud occasionally 
true ■**iti(.-atinn in [Mirts (p. 933, vol. i.). 

Adenoma of the Skin, arising both from the sweat-glands and sebaceous 
f .iiu-U*. have Imwo occasionally met with. They are, however, very rare, 
\\ iitii uriain^ in cimnecti<m with the sebaceous follicles, they form lobulated 
Qia.-**-* <.f wmie size, which alter i^rowing for many years may ulcerate and 
rv— -mi.ie e(»iiheli<mia in apiK-arance. Oo microscopic exarainiition, they are 
fxutKi iM be L'DmpijHed of a structure resembling a number of greatly en- 
largM follicles bound together by a vascular connective tissue. 



46 



SPKOICAL DISKASE5 OP TBE SKIX. 



i 



Atheroiutow and other CytCi bare alradjr bem dcKribBd (p. dSl, 

L^. and VsTt mil be dt»crib«d in ■ nbanjusDl «fa«pt«r mtli INmmi oC lb« 
Blood vow Is. 

HoIm are pigmcDted patcbca of variable iise ta thm ikia, and alwaya of 
coogcfiiial cfigia- Th«v are nAcn raind abi>ve Uie larfiwa of Un awTMsd* 
ia^ iktn and curered wiib hair. loiDfdiutv luug and eoana. Tbejr caawit. 
Im pry)\tt:r\y rlaaed ai tumon, as tbey ehuw oo trndeaer la gnm oat uf pro- 
portiim Uj llie rot of tbe body. In later life, buwvver, a mole out iuib«- 
qaeotly farru the ctftrtiag-puiut of a lunior. It mar gradually iacreaw 
in uae. becoming coore and more pnitnioent, and auaetinm peduaciilamd. 
It ma; tbu» form a tumor, usually loliiibiled or papUlarr, and nnira or Imi 
darkly pi^nt^ntrd. Finally, fn)ni tbe frininn uf tbe cloOica it nay uleerale 
and lievufue vary truublewmie. A mole alio iioi uoooaiinoatr fonaa iks 
of origin of a aarcuma, or more rarely of a equamuus epilbdioma. A 
requires nu ireaimeot unleaa it become affected by ooe uf tbfe eomplieatl 
•bora maatioued, wben it must be at once exri»ed. The ^r|^D la 

oananlled as lo the pnatihilitv of removing a divticuriDf; uoie tri>m tbe 

There u no metbod by wbinh ibis ran be ikwe inlbout Ifnrinif a sear in Itl 
place, but if the patient prefer this to the pigmented palrb.the uole may be 
deatrored by caustics. Nitric acid and potaaga fuM are the two tiu«t efficient 
apptieatioos, but they shouM nnt he applied in tuclt quantity as lo deatroy 
the wbrile »kin, othrrrise a puckered and rijitid ciealrix will reanlL 

FapUlomaU of the Skin, or Waits, con<>ie« j>f elonnted papill«. corered 
by strata, of thickened ao'l hardened cuticle, u^uaiiv situated ab<)ot the 
bands and face, and chiefly affectio); youn^ peiiple ; tbey appear in many 
case* U> be simple overfrruwtbs uf tbe cutaneous structures, cuming aud f^>tng 
withciui xny evident cAu»e. lo other cases they are m^jre permanonti becum* 
tug harde4ied and dark to color, and continuing perhaps thruuifh life. 

riie Trrahnrnt •jfwartsis osuaJly sufficieullr simple. Tlicy way bcnmdily 
destroyed! by the application of caustics ur a»(rioL'«nu : aniuU); Lhi< moat use* 
ful of these 1 hnw fuund tbe concentrated acvtic acid aod tbe tincture of 
lh« ■eaqulobluriile of iron. Bnidie rvciimmeods a solution of a dracbm nf 
ttrseaious acid ia half an ounca of nitric acid. In some casta they may be 
ligatured or snipped off* with advantage. 

Ooms consist of thickened iiMBSa of epitbelium accniuulaied on tboso 
poiolB on which undue prmeure or friction has been ejtervieed. Tbey reeolt 
from an overgrowth of the epiibelium. cuoaN|uent upon tht abnoraui ctimu- 
lalion to which tbe part is exposed. This is accompanied by some ealaree- 
ment of the |wpilla*. The man of epithelium ts hard, dry, and ecaly. In 
the central parts it may lead to snme atrophy of the papillae fnim preaanre, 
aad 00Bee()uently the homy manaasump^ a conical furm. with itsapex down- 
wanls, preaung on the anuitive cuib beneath, ami thus eauung coDsiderBfale 
pain. Wlien tbe com is situnled in places where the seoretioiis nf the skia 
accumulule and keep it moist, a» between the toe^i. (hf excefeiv'^ '' ' ira 
fornix a •«»l\ pulpy maaa which is easily removed, nod the enlarg> . : he 

papilla! is then very evident. 

Under fill and ven- thickened corns, it is stntnl by Brodie that a small 
burva ii> occasionally fuund; this bursa may Buppurate, aod beoone very 
|iainftil. ComH are at all times euflicieotly painful, but become espiKnally 
so if inftammntioo or suppuration take place beneath them ; tbe ncciimula- 
latlun of It umall drop of pus under the thickened cuticle, which prevt-nttf its 
Mcape. giving riao to very intense agony, and causing o^ema and redneos 
extending from tbe toe to tbe foot, and sometimes up tbe !«);. There ia a 
•pecial form of warty corn that I have seen only in tbe sole of the foot, and 
which may become tbe source of tbe grentcai jrassible pain and inomvenienoe 



PEBFOBATING ULCER OF THE FOOT. 47 

to the pstient, preventiDg his walking, and in l»ct completely crippling him. 
This Cum is usually of small size and circular iu shape, the Deighboriog 
cuticle being always greatly thickened and hardened. It is extremely sen- 
Htive ti> the touch, the patient shrinking when it is pressed upon, as if an 
cxpoeed nerve had been injured. On slicing it down with a scalpel, it will 
be found to be cumpoeed of soft, tough, and white epidermis, arranged in 
tufts or small columns, in the centre of each of which a minute black dot is 
perceptible. Each tuft appears to be an elongated and thickened papilla, 
and the black speck is a small point of coagulated hlood which has been 
effused into iL Around the depression in which each of these corns is seated, 
the bmrdeDed cuticle forms a kind of wall. 

The Treatment of ordinary corns consists in shaving or rasping them down 
to as to prevent the deep layers of cuticle, retained by the indurated super- 
ficial ones, from giving rise to pain by pressure on the papillae of the cutis. 
rbe ciiticle may be previously softened by dressing the toe with wet lint 
corered with gutta-percha tissue. Relief may he afforded also by removing 
■Jl presure from baring upon the com, by attention to the shape of the shoe, 
and by wearing a piece of soft leather or of amadou, having a hole cut in 
the centre into which the com projects. A soft corn between the toes is best 
treated by the application of tincture of belladonna after clearing away the 
sodden epithelium with soap and water. It is well to avoid the application 
of caustics to ordinary corns; injurious consequences being often produced 
by these agents, especially in elderly people, in whom fatal gangrenous in- 
flammation may be excited by their action. 

The painful papillated com of the sole of the foot is the only form to 
which an escbarotic can be applied, and in this no other treatment is of any 
oae. I have found the application of either fuming nitric acid or potaesa 
fnsa, so as to destroy it thoroughly, to be the best and speediest remedy ; and 
a* this com always occurs in young people no danger attends their use. 

If a com suppurate, it must be softened by water dressing and shaved 
down, and the drop of pus let out by puncture with a lancet, when immediate 
relief from pain will result. If the pus is not thus let out, it is unable to 
point through the indurated cuticle, and may burrow beneath the skin for 
some distance before finding an exit. In such case a troublesome sinus is 
left which can sometimes be closed by the injection of stimulating lotions, or 
bv passing a dctoo of two silk threads through it, but more often laying it 
open is the only efficient treatment. 

PEitFORATiso Ulcer of the Foot. — This, though not in reality a 
dbeaee of the skin, is perhaps most conveniently considered here. The 
disease seems usually to commence by a corn situated on the sole of the foot 
opposite the head of one of the metatarsal bones, usually the first. Thi^, in 
some cai>ee apparently as the result of some injury, becomes inflamed and 
suppurates, and a sinus is left opening through the thickened cuticle. If a 
pn>he be fKU»ed into this, it will be found to lead to dry and bare bone on 
one of the phalangeal or metatarsal bones. The discharge is scanty and 
•carcely purulent. The ulceration may extend, forming a sore an inch or 
m-tre in diameter. This is covered by feeble or unhealthy granulations. 
The disease in painless, and on further examination the foot will be found to 
be mnre or low widely anaesthetic. The anKsthesia may extend up the leg, 
but it is never associated with motor paralysis. The tendency of the disease 
i* sltfwly to pxtend, causing further destruction of the bouea and possibly 
c.>inplcifly perfi)rating the foot. The foot is cold, and in most cases is prone 
to e«eat pnifusely, the perspiration being very offensive. Both feet may be 
afl«ct«d. and ■ similar disease has been seen in the hand. 

Michaud, .Sonnenburg, Duplay, and more lately Savory and Butlin, have 



48 



DISXASKS Oy TUB NERVOUS STSTKU. 



piiintetl (HI I (liH* tlie ()neiu« Is lUBociatL'd iu many cases with tbickeiiiagof tfae 
-eutloiieuriutii mid aLn)|)liy of ihc Hlirt'f) of the nrrveo lending tn the aflectod 
BtKiU Biiviiry Htitl Hiitlii) liBVi' hnm^lit t'lirM-nnl evidence ti> show nl»<> that 
lliip seimory libri.ii am cliii'fly, if uti( tiijIpIy.iiffVcte*!. .Similar ulwratiMns bm 
met ttidi in Home oi.-^-e "f liK-titiKilrtr iilaxy. It mar therefore he conclntitd 
ihut ihu i>riniHry caum; of the diseiisp is iiiipnirment of Dulritioo coobctjueiit 
upoo degeiienilive chiitif^ taking nlnre either iti the nerves lefldlDg to the 
ftUbotei) narts or in that portiou ut' the wiisory oolunina of tho cord that u in 
^oommiiniPAtioD with the fmt. Iu some reepcdfi it rcseioblei the discan 
known M, aiiieslhetic leprosy. 

The IVojImenl consists in nmputati'm of the aflectcd parL In order that 
thisoperntion may be effective, it ihonld be done above toe area of aiiBithaHa 
in the fout or log. 



OUAPTEK XXXVIII. 

lilSKASES OF TIIK NERVOl'S STSTZSf. 

InfiammaiioD of tbe Nerre^ or rather of the Xeurilcmma, la not of very 
iinfrv|iii'rit llccll^rt-nl^t■, being i»tially the n»ult of rhc-umalism, of wunoda, 
or of utmimi. When Xeuritti is rheumatic, it aifcctA prioeipally the uerv«8 
of the fat-c «nil the lower extremity, 

ftvMPTOMt*. — ThMO c»in»i*i of iPiidemeM on preaiure along the coarse of 
thf nerve, und severe eonttQuooft puios running down it* trunk ond ruriiify- 
ing along ittt limnehe<\ with o(.'ea9iunal rioleoi exncerbatioiip, esjiecially on 
moving or touching the part, and at night. In very rare cases the ditfeavo 
luav aiHimv an acute form, with tome sH-ctlirig ali.>ag th^courveof the nerve, 
and slight pyrvxia. Ordinarilv the aftectiuu is chronic. It is one of the 
caUK* of neuralgia. On examiniitioD aAer deiith in Hcute caset th* sbwUl 
of the nerve wilt bo found iujeete<l and swollea from inBammat^nr oxoda- 
tiun. In chrtjiiiu cuss tbe netirilemma may be fonnd iodaratcd and iocr«aMd 
ID ([uanlity, the nerve fibre* boiDg more or leas txtnipnaed by the new libroid 
tlMue. Traumatic neuritii has mqo alraflr fully deacribed (vol. i. {>. 477). 

T^tattNrnt.—iu acut* casea this oouaista in the empiovmcnt of antiphlogistic 
means : cupuing or the applicutiuu of leedMi, aoourdine to the fiiuniion. and 
poppy ur beiladoana tumi'ntations. In diruatc casea blisleriug or the ajipli- 
caiiuu of mustard phulcn altrng the lioe of the nerve usually gives rdiof. 
Tbe part in which the a&ewl iterv«> \» tituatcd muit, if poniblc, bo kept at 
peHbct rc»t. When cbeaAiKitkm ii rheumutie. ulioylatooftodaisftvqaeiitly 
of great use : in some eases the acetous extract of eulcbicura is the best rtmcdy ; 
when it is morv cbrxmic, ami the pain ii chiefly nueitirual, iodide ut potasaiun 
a*lvantageuusly h« givro. 



iCUTlCA. 



The ehanelefiBtio feature of aolalica it> pain of a nenralfpe characlrf Is 
the ctuine of the great •cislic nerve. Tht^ all'eetiun is b«Uaved Id ibe grval 
majurily vf caaoa to be due to chronic rbrumatia intUmskalion of tbe tbeatb 



NKUBITIS — DIAGNOSIS AND TBEATUENT. 49 

of tbe Derve, and some thickening of the neurilemma has been recognized 
afk«r death in a few cases. In other cases pain of a similar character may 
be the result of pressure on the nerve by tumors in the pelvis or gluteal 
region, or oocaeionally firoro affection of the cord or disease of the spine in 
the lower lumbar or sacral region. Sciatica is most common in young adults, 
and frequently arises from exposure to cold or damp. 

The liymptoms of sciaUca are pain in the buttock, back of the thigh, and 
the leg below the knee. The pain may amount merely to uneasinras, or be 
iotense and paroxysmal. It is usually aggravated by movement, often to 
Mich an extent as to render locomotion impossible. When the pain extends 
to the foot it is fett chiefly on the outer side, the inner being supplied by the 
toDg sapheouus nerve from the lumbar plexus. By pressing with the point 
of the tinger. t«ndemes8 will be found m the course of the nerve. This is 
most marked in the hollow between the trochanter and the tuberosity of the 
ischium, and down the back of the thigh. The external popliteal nerve is 
alao sumetinies acutely tender where it winds round the upper end of the 
fibula. When the patient is lying on his back, if the limn be raised with 
the knee extended, acute pain is felt in the buttock as soon as the sciatic 
oerve becomes tense. If now the knee be flexed so as to relax the nerve, 
flexion \){ the hip can be carried considerably further without pain. Numb- 
Dees in st>nie of the jwrts supplied by the nerve is not uncommou, especially 
on the outer side of the toot. Motor paralysis never results from simple 
sciatica, but there may be some weakness or even wasting of the limb from 
want of use. The affection is very chronic, uflen lasting many weeks or 
even months. 

The DittgHosis of sciatica is made by attention to the above symptoms. It 
is motfl fretjueotly confounded with strumous disease or chronic rheumatic 
arthritis uf the hip. The distinction is in muet cases easily made by observ- 
log that tlie movements of the hip-joint are free and unaccompanied by 

Ein, nolens flexion is carried to such an extent as to render the nerve tense. 
rheumatoid arthritis the grating telt in the joint on movement will usually 
indicate the nature of the disease; with the "lightning pains" of locomotor 
ataxy it must not be confounded. In all cases of sciatica n careful exami- 
nation ot the buttock must l>e made for a tumor in that region ; the lower 
part of ihe spine must be examined for signs of caries, and the tiuger might 
be passed into the rectum to feel for a pelvic tumor, as in these conditions 
local treatment directed to the course of the nerve could be of but little use. 

Trratmeut. — The constitutional treatment already described for rheumatic 
neuriti)! m\in be adopted. The limb must be wrapped in flannel. Counter- 
irritation along the line of the nerve in the early stages by mustard-plasters, 
and lattT on by liiislere, is most useful. Hot baths usually give considerable 
relief. Stimulating applications, as the ammonia or compound camphor 
linimout, may be of use ; and sedatives, as the opium or belladonna liniment, 
aiay ea?e the pain, but they do little to cure. Hypodermic injections of 
morphia should be resorted to only when the patient is suffering from want 
(^ »lt:\{> due to tlie pain. They exert no curative influence. 

If the conslitutiunaj treatment and external applications fail, as lliey' very 
frpqut-nily iln, two modes of treatment may be adopted — acupuncture and 
■<rre-ffi ret oh iiig, 

Aeapimctiire is thus performed. The patient is laid on his face, and the 
trader [Miinb* nf the nerve found by pressure. Long fine needles are then 
thrust ill *•> as. if possible, to puncture the nerve. When the needle touches 
the n«Tve, the paiient complains of a sudden pain down the thigh. The 
nombc-r mI thf iitHlles used should not exceed eix. They nmy be leJt in for 
' *** niiniiie*. This treatment sometimes gives permanent reliel'. 



DISEASES or THE KCBTOUS SYSTKIC. 



Our last rcBoaroc is, hoire vcr, Stretching tlie Sciatic Verre. This open- 
ttnu hn» been more eiiccfsaful in Mi-iuLicft than in uttr otbi^r painful alTrctiiHi 
for which it haft brcn uuderluken. Nnrht hsa collvcletl 34 caavi : of thece 
16 wi'n* quiclilv, A chiwly, relieved, in 'i the operation fnile^l, and 1 ilied, 
Marvhall Guds ihtt itf 9c8see which ocvurreH in University College Htxpital, 
4 were lievidetlly iniurove<l. 4 parlintiv cured, and I faileo. 

The oiwmtinii is tiuiA perfurnie<l. The pstient is laid upon bit face, anil 
n vertical incisiou, nhout three iuchw in length, m nnide n liUte above the 
middle <*( the back of (he thigh. Tlie deep faecin is opened, aod the ooa- 
tiguuua borders of the t«nii-t«ndiQoeu8 and biccpf an* Mparaied with the 
tiuger. The wound being now held open by copper apatulie, (he Bciatio 
nervo txtmes into view nnd is railed out of the wound by piu<$ing the finger 
buDfiBth it. the knee beJn^ Sexed to relieve it from tension. It is then pulTol 
forcibly in both directions. Murshall has denionstrau'd that any furoo 
which can be applied while holding the nervo between the finger and thumb 
niav Mifely bo used. The Bxpcrimenls of Johntun, Trombetia, CVeuhorvUit 
and others, have shown thac the breaking strain of a healthy nerve is uever 
under eighty pounds. The wound after the operation must bo carefuUj 
drained and dreeeed by some antiacpda niotbod, and it is better to apply an 
anterior splint for a week or ten days. 

Borne i^urgeom prefer exposing the nerve at a higher poiot, below the 
lower border of the gluteus niaximua. If tbo opcraiiou be performed ac tbia 
point, the whole of the hamslring museled muil be drawn together to the 
inner Aide of the wound, and (he nerve Miujiht for external tu th«m. If 
aec«e«ary, the lower fibres of the gluteus may be divided. Tliere U do mi^ 
tieular advantage in thij mode of operating, and the rtMilting wouDd ta 
deeper and more difficult to treat, owing to iiH situation. 

Trombetia and Uillroth bav« ■UBgettte^l fitrei<.'hiii^ (he nerve by lueaus of 
forcible flexion of the hip with the Knee extended and the fout tlexeil. That 
A very great itrain can be put upon the nerve in thia way io wideot, 
the ntt'thod might very well be tried before proceeding to' the mom « 
o|>em(ii>n just u«ecribed. It is beat done by ffexing the thigh fully 
the abdomen with the knee bent, and then, while the thigh u hxetl, cxteod- 



OQ 



lug the leg. 
Tl 



he ino<Je of action of nenre-stretching in Kiatioa u uncerlaiu. The coo- 
iluclivity of the eciatic nerve ia not affected at all, or only tu a very alight 
degree-, by the force used in the operation. It ha« been sui/^ratt^l that it acta 
by breaking down adhesion* either imiongct the fibrea or lieiivten the nbenth 
and ■ummnding slruuturea. Manhall believee it acts by tttrutobing or even 
rupturing the emiiiU uervi tiervurum ramifying: in the ueurileniiim luid in Uie 
epiueuriuiii, uhicb must be more or lese implicnleil and pressed u|H>n by : 
inflammatory growth or exudation iu chronic neuritis. 



Henralgia frrnueutly occurs in surgical practice, either oamplirating nt 

tl'w**e*. or on a diHttnct affcetion simulating cloaety variona organic MnoU, 
more p»ppcially of joint* and bimee. 

BvMi-roMit.'-Tht.- pain in neuralgia is the eaaentia) synipUim. It mar be 
of two kindi< : either f<dlowing analomically the eoarve of a acrve utui the 
dEaiributlon of its (ilam*-nt« ; or uffbcting a cimsidemble p^iriinn of th« 
sarflic* with(»ul referwnci' lii any cfiecial nerve. It b nf all di'gr<T« of 
aeverity. sonictinit^ moderate, niinK'timi« unbearable, cvm by tiuMe 
posHw* the grcateiti fortitude; when severe, it usually come* itn »uiU 

a kind of abock, and continuea of a sharp, darting, or bearing ohsiV 



_E J 



NEUBALGIA — SITUATIONS AND CAUSES. 51 

acter, couning along the trunk or rami6catioDB of the affected nerve, the 
(li»tributioD of vhion may ofleu be diatiuctly iudicuted by the direction the 
fiaiii takes. It a often accompanied by other aeneatione, auch as a tickling, 
Mtmrting, or creeping feeling on the aflected surface ; it is in some iustaooes 
relieved by pressure, in others increased by the slightest touch or movement 
••f tlie (tart Occasionally there is spasm in the muscles supplied by the 
atftvted nerve ; in other cases, there are heat and redness of the aurface, with 
increase«t secretion from the neighboring organs, as a flow of saliva or tears 
«heii the nervea of the jaw or eye are implicated. The duration of an at- 
tack may vary irom a tew moments to many days or months. The pain is 
imist commonly intermittent or remittent; it is often irregularly so, but in 
some iustaiices the periodicity is well D)arke<l. 

SiTUATioxa. — This disease may affect almost any part of the body; it is 
tatnn commonly seated distinctly in tbe trunk and branches of a nerve. The 
(liviMooa of the fifth pair are the most frequent seat of neuralgia; the pain 
oiay extend to the whole of the branches of this nerve on one side of the 
bead and lace, but more commonly it is confined to one of its principal divi- 
»iuf», Buch as the infraorbital, which is especially liable to be affected ; in 
maur instances it is seated in the temporal and dental nervea. Not unfre- 
quently aome uf the termiual twigs aloue of one of these nerves become the 
seat of intense pain ; thus occasionally the afiectiou is found limited to a 
patch on the cheek, brow, or temple, from which it scarcely ever ehifts. The 
pusierior branches of the dorsal spinal nerves, and the intercostals, are also 
very commonly affected, though not to the same extent as the fifth pair. In 
otbt^r cases the whole of an organ, or part, becomes the seat of neuralgia, 
though no uue nerve may appear to be distinctly implicated ; thus the testes, 
tbc breast, the uterine organs, or one of the larger joints, as the hip or knee, 
are oocasioDally the seats of severe suffering of this kind. Extreme cuta- 
neuus senaibUity is a marked feature in some cases ; the patient wincing and 
Buffering severely whenever the skin is pinched or touched, however lightly. 

CaL'SEs. — The causes of this painful affection are very various ; they may 
he cunatitutiooal or local. It seldom occurs in strong and healthy individuals, 
)»ut is almtjst invariably associated with want of power, unless it be occa- 
-iun<^l by some local mechanical cause. Depretting influences of all kinds 
are t^pecially apt to produce it ; thus, debilitating diseases, mental depression, 
and particularly ex[)oeure to malaria, are common occasioning causes ; those 
t'i'rni* of the disease that arise from malarial infiueuces, or from exposure to 
"iniplt: cold and wet, usually assume a very intermitting or periodical char- 
it-icr. and are commonly seated in the nerves of the head. The hysterical 
••mj^rnment very frequently disposes to the spinal and articular tornis of 
nt- uraturia. There is no constitutional condition with which neuralgia is more 
irtr-|Utrntly a»iociated than with antcmia; hence its frequency in females. Aa 
K-imlHTg somewhat poetically says, " Neuralgia is the prayer of the nerve 
i'..r tit-alihy bl(K)d." Various sources of peripheral irritation,aB loaded bowels, 
;b« irritation uf worms, carious teeth, uterine diseases, and calculus, may be 
rt^>i;rDize«l aa pnxlucing some of the more olwcure varieties of the disease. 

Neuralgia may arise also from any compression exercised upon the trunk 
<il a uervc ; and in this way, indeed, some of the more intractable forms of 
ih*r BtfW'tion have their ongin. Thus, thickening of the ueurilemma, the 
prtwure of a tumor of any kintl, or of a piece of dead bone, may give rise 
VI tbe moot intense pain in the part supplied by the irritated nerve ; and it 
IS not improbable that, in many of the cases of neuralgia in the branches of the 
fifth nerve, pain may be owing to periosteal intlanuuatiun, or to some other 
di«ea^ of the oMeous canals through which the divisions of the nerve pasti. 



I118KA8IN Of TBI KIBTOPi STSTIM. 



. —Tti- dinffn'M of BenrmlEpa, ikuugb ummII^ i tbttt A «>llwct 
^'iSieah*, » io «'«« *■"" » "•''« einl-rrm-uig. t» ik* tarn Mf «>» 
"T -l-^t«ti. tlist of nrptuic ducjw of ioHadidisuub of lb» |«rt. FhMi 
-*-' I^ Jiim^e of Ihff i-fflrt i^i"' » l^i^ «*•* "*" »«*"!«• ■■*^ ■• '^ *^ •^ 
r^rTfc. ifMia or the brwut. (h« dieew* iii«¥ wtnJIjr b« i fa i n aiAw l by 
S^J^kMoc '.f iKicfiu'ft**! cutwieoM •MuabUUr, Um oiMnw of tW 

''J^ir -i-:J o( Biniclure io ihe fMUl RfleciwJ. Fmoi n^nailiM IW 
*!*^? ji gpually wffictrnilj e«y. by ftuendiug u» tbe iDti m ill M l afaar- 
^?!/ihe o«Jrtl)?ip pain, lo 'it« inxurrtiiM in hjrattrif 1 Ueape wiif i, — d 
*^^**.^^ ^,f the fowltiuliotial avniptonu of ta fl a ai m align. Bat •«>- 
*^ i*^jLn local iiiflan""«>'iry imuuoa in conjoioed with the 
*^^V' • j, diffleull. Here the praienM «il ctiiaaeoUB hyi 

J i^jlllRrf of Uie pain liy fir™ prwaarc will inriicau Detmlgia; w 
^y ^Sa a there if no l«ndenia» of Mirface, hot the snllbring ii HC*' 

«*■■ %^^^ —TbK rr«atm*nt of aearalgia mn« hare reference le its cao»f. 

T*^ i!L iseceaftil or aol nwnrdioK a« thia may be more or las readity 

** *"i n„ 1^,, ID (be coo*litiuB9 ihat primarily occuKion tbe diaeMe Mb- 

«^*P~'^ ji lik^lr to roniiauf, aoJ it' iheae conHitJoiw be incflDorabfe, 

•^■^•^ _l^ l.^.kul iii"'i>it»DeceBMirilv iururahle, thougli til' " 5 
^*fT^i]^«ittr*i bv »|)pn'iirin(e moun. U'ht-n it artsn from ; .^1 

•■T ^Jfcctjc" i^f"* "''^y ^ '*■'" "^ ^'"^ ultimate occurrence of UWam 

■ *^^g/lvpc, mcb n* cpilepiy. insanity, etc. 

k Mcnn' ** ^^'^ viro«^)U*nc< of aijinuia, or in the hyaterical tem- 
.L- ..iminiMratiMD of the more (tinmlBline an 



^* 



'ih« adminiRtratiMn of the more ^tiniulBlmg and Mntnger prrpara* 
.Tina ■0'^*' ■* '*** »itil|>h«tt or the ptrt-hloridp, or lh«" mi*iun» frrri 
I'itL^Mttr slofie or in curiihiiialion with (|uitiin«, with Btt«^i!nii 1 i!i* 
'jr^!# bnw«U uu'i of ihe uterine function*, and a neneraJ 1 

^T ^^-wihted t«> br%w mi'l improve tbo general health, »iifh a««r^ i.^, 

^•^v"rjj^t or LNiId »pt>njfiug. will tw of ewcnita) Krvice. In »nnt «f 
**JT^ tbe c«»mhinauoii« of zinc, eepedally the valoriaDale, with the 
^^ "^ ^1 remove llie disease when iron dow mn influeocc il much. 
^^t^Z^ timt, ih'" applicntioii of bflladoutiH or aoonite plasterB, or lfa« 
Al l**.^~J 1^^^ liDiiiifutH limy bf of scrric*. When the ovuralffia » dta- 



'^"iT'lLirio'Wl**- quiiii'tg i" full doM*. or Ihe lit|uor aneoi*.'nll», *iill uwially 
•■*? '"Jl^tan?. Wli€U it i» rbvumalic. wcurring in dchititaiod eub- 
<•■* *v^|^<d bv itiatinct nocturnal ejtiici*rbiiliDn» of paiu, 110 rcowdy 
-^*' ""^ It an uitprweioii opou it a« ihv iixlide of potaaiiiim, i^prcially 

^___ " in cjinhiotttion wilii quiniiit. In the mort- severe and 
'^m^af llw diwase. ri'licr iiiny Iw ocoasi-mally oblaiiifti by at- 
"^ ifcr <*** ^^ *'"^ "*'*'" "'"^ tliywlivc orgaus, by a counw; of aonie 
* ^ ^ por^'v*-* tiiioeral niitcD-, and by the ovL-uHooaJ adniiotMration 
^ -^ AiJFo**^! by tonif reHiL-diw. 

V' TrrpphealiiJiii' "f n (*dative kind, such aa cblorofurni, WlladnnQm. 
j^\,p,mn. i-lc.are oAeu uwful Bdjuncls to conatitutional Lreatmeni. Bv 

l^f,-;, 'ie of atliirdiug rvlit-f liicftlly is the hyp<idermic injectioo. 

'^^n I 4in«-tiiKlh to a quarter of a grain of morjibia should at 

ibsuK^l nt -'V itiiie, aut) the nrlioii uf ihi»Hn;a)l dowisouen Terypowvr- 

)|>-r^ than this, it is iitiKafe to lM>^in with : but the quantity may be atmr- 

<-d. 1 hare had a pntifiil who, to relieve the {wina Httending 

. • >-tum and atiu-n. rt 'jinrfil no Imi than aix gmina to bo itiJL-<-tr>d 

irellili hour, for M-verai mouth%. In w>me cuK* a Finglr iigtction has 

Ktinilgia which had resjateil nil oilier means, iteru^f may nl'wn b« 

' bv ta« use of oleclricity iu the form of the continuous current. Th» 



NEURALGIA — OPERATIVE TREATMENT. 53 

pocitive tpoage must be applied to soine conTenteot place near the eeat of 
paiD. while t^ oeurslgic spot is gentljr rubbed with the negative until the 
skin is reddened. Id exceptional cases the relief is permanent. 

In tomaj cases all these means, however, are unfortunately unavailing, and 
the i^aflerer is doomed to an existence of almost constant pain, except at times 
when the disease appears to cease of itself, or has its intensity blunted by the 
admiotstration of the more powerful sedatives, such as morphia hypoder- 
mically, or veratria, aconite, or atropine externally. In these distressing 
cases Che sufferer is ready to grasp at any means of relief that is held out to 
him ; and atntduu; of the ueeted nerVe is now frequently undertakeu in 
the hope of relieving, if not completely removing the afftHstion. This opera- 
tion has already been deiicribed (p. 477, vol. i.). It was there pointed out 
that the effect produced difTera considerably, according to the size of the nerve 
operated on. In small nerves, such as those of the face, the conductivity of 
the nerve is abolished as completely as if it had been divided, but as its con- 
tinuity is not interrupted, repair always takes place, and after a time its 
function is restored. In the larger nerves, even when considerable force is 
osed, the otnductivity is not completely abolished, although it may be modi- 
fied for a time. It is only when great force is used that the breaklDg up of 
the medullary sheath observed by Leuterman and Horsley takes place. We 
have seen that in sciatica, in which the disease is seated in the actual trunk 
of the nerve, great benefit is usually derived from nerve^t retching, and 
probably the same result may be hoped for when a similar condition exists 
in other nerves. In the majority of cases of neuralgia, however, the cause 
is either some peripheral irritation of the terminal branches or some central 
diseaie, and in these but little is to be expected from the operation. In the 
former case there might be temporary relief until repair of the nerve was 
accomplished ; and in the latter, although experience has shown that there is 
sometimes some improvement, this is onlv of the most temporary character. 

When stretching has fiiiled, section of ue affected nerve is not unfrequently 
recommended as a last chance of the removal of the disease. Simple section 
of the smaller nerves is now replaced by stretching, which, sb has just been 
stated, temporarily abolishes their conductivity. Division is undertaken with 
th« intention of permanently destroyiug the continuity of the nerve, and to 
insure this about a third or half an inch of the trunk must be cut away. As 
with stretching, however, it is clear that the operation, though wcasionally 
productive of temporary relief, cannot in most cases be expected to benefit 
the patient permanently; fur by It the cause of the neuralgia Is not removed, 
and it can consequently be uf service only when the pain is peripheral, occa- 
Hoot^l by some local irritation existing between the part cut and the terminal 
branches of the nerve. If the neuralgia depend on any central cause, or 
OD Itical irritation existing higher up than the point divided, the operation 
mu6t trveuttially be useless. Thus, if the source of irritati<m exist in the 
lermiosl branches of the infraorbital nerve, the division of this trunk might 
be useful; but if the pain be occasioned by any pressure to which this nerve 
may be subjected in its passage through its canal by a carious state of the 
bifD««. or by disease of the periosteum, it would be unavailing; though it is 
a remarkable fact, that it not unfrequently happens that there is after thf^se 
uptraiions a temporary cessation of pain fur u few weeks or months. In 
Bi>m*- of these cases, however, the pain shifU its seat from the branch operated 
■•u u* another division of the same trunk ; thus, if the infraorbital have been 
dividnl. the inferior dental or submental nerve Itecomes the scat of pain. Or 
thi- may ascend, as it were, to the point at which the nerve was divide<i; thus, 
after amputaiion for neuralgia of the knee, the pain may return in the stump, 
and again when this is removed a second or even a third time. 



I>ISEA9ES or THE KERTOUS STSTBK. 



DiAiJKiH^iA. — The diiif^oeiB of neurnlf2:ia, though usualty eflTvclod without 
nuy HitKcully, ig in Mime CRses a little i-iiiliArrnmiiig, »t the iiaia nwj oc>cft- 
Btotiiilly Miiiiiilflt^ thftt of organic diM'tiiio or inttaminHlifii) nt (he pnrt. From 
or^nie tlisetisf nf tho part itiai i» tlio seat of HtiflrriDg, sitch iih the hip, the 
kne«, th« ivfttis, or the breut, this tli»ea»« iiin^- usually be dtalinguifhed b^ 
the covxisteDce of heightened tutnoeoui M-uoibiltty, the existcDce of lfa« 
hyrterical tcni[MTHmOi)t, and ihn absonce of lite other Btgn* that would Kc- 
oorupanv k-sitm of structure in the part iiHWctefi. I'rmii i' " "ri ibfl 

diignniiiii ia Dsually BuUicietillv ener, br attemlitig to llie ii:: i ehar- 

acter Iff thu neuralgic paia, to ilB occurrence iu hysterical ti-miM-fanRUt^, Bod 
to the absence of the coustitulioaal evniptomn of iu flam mat ion. But ucca- 
gionully, when local ioflHrnmntory irritation is conjnioed with the neomlgia. 
the iliiignniits ta difficult. Here the pmeoce mI cutaneous bvpemlheaift 
MDd the relief of the pain by 6rm pre»iure will inrlicaie neuralgu ; irfaerou, 
in inHammation, there is do teaderaeas of surfaoe, but the eulTeriilg U aggra- 
rated br deep pre»ure. 

Tkeatuettt. — The treatment of neuralgia tnnet have reference to its cauae, 
and will be aucceeaful or not necordine aa this may be more or Ins readily 
removed. So lone ns the couditiona that prininrily oeca^ion the diaeue aub- 
»\tt, the pain is likely to eontiDue; and if ihem condition! be irremovable, 
the iliM-B^ may be lt>i>kcd upon as neceHUirilr incurable, though the duUerliw 
may bi- alleviated by appropriate meaiiB. \Vhtn ii arises fmni nny «^^itlnd 
nervous ufTeclion, lliere mny be fear of tho ultimate occurrence of dtsentc 
of ft more nerious type, wich aa epilepsy, insanity, ete. 

When it occurs aa the coD«e<]ueoc« of anvmia, or in the hyiitericjil tern- 
I)«ram*-iit, the adininifttraiion of the more ctimulating and titninger prf|uro- 
liona of iron, aueh aa the sulphate or the perehloriiltf, ur the mi-ilura ferri 
compwnla, either atone or iu cotubitiation with quinine, with attention tir th« 
Plate "f the boweU and of the uterine fuoetiooa, and a geuerat liuiie rr^ri* 
men calculated to hrace and improve the general health, audi aaaen-hathing, 
the cold douche or cold spongiog. will be of eawnlial »er«'ice. In tiymv of 
these CMCS the eombinacioits of zinc, especially the valerianate, with the 
fetid gums, will remove the dii>ease when iron does not influence it much. 
At the vittue time, the application of belladonua or aconite plailers, or the 
inuoeti'iu \jf thmt.- linimcntx mar be of service. When the neuralgia is ijb- 
linctly ]ierio<lical, ijuiuine in lull doaes, or the liquor an>eni<-ali», Mill uaually 
effect a spui'dy cure. When it i« rheumatic, occurring in debililaird mb- 
jeclB. anil attondeil by di»lioet nocturnal exacerbations of paiu, nu remedy 
rxer^isei' mi great nii impris^ion ii|niu it m the iixlide of jiotasiiim, eaprdally 
when admininlcrrd in romhinaliuu wiih quiniut;. In the nmrc scvi^re and 
pr*itrai'[ed forms id' the iliwa^f, ri'licf may be nccasinnally obinincd by at- 
tention to the Btate nf the liver aud digestive orgati^, hy n t^Hirse of atme 
of the niort- pur>^tive mlaeral waters, and by the occasional ndminisiration 
of aluelicM. fitllowed by titnir remediea. 

Local applications of a sedative kind, such at rhlomfbrm, bnltadotins, 
aconite, npium, et<^., are nften uacful adjuncts toconsiilntioital treatment. By 
far the readleat mode of afibrding relief locally is the hypodermic injection. 
Not more than fn>m oDe-aizih to a i|uarler of a grain of morphia ahould at 
fiist be Med at one time, and the action of thb small done io often very )i»M'cr< 
All. More than ihiit, it is unaafe tii begin with ; but the quantity may he ctior- 
mouety increaiie<l. I have had a patient whn, to n-lievc the patM aUendiun 
cancor of the rectum and aiiua, required no le» than nts graitts to be ioject<4 
iwerr twelUh hour, for several innntliH. In home caaea a Mngle iujection I; 
onreu neuralcta which has re«iste>l nil other meant. Relief may ulWa 
obtained by the uvc of elect ricity iu the form of the conUnuous current. 



I 



^^ 



HXURALaiA — OPEBATIVE TBEATUENT. 53 

poeitive Bponge muat be applied to sonie coovenient place near the seat of 
paia, while the neuralgic spot 18 gently rubbed with the negative until the 
skin is reddened. Id exceptional caaee the relief is peroianent 

In many cases all these means, however, are unfortunately unavailing, and 
the cofferer is doomed to an existence of almost coDstant pain, except at timefl 
when the disease appears to cease of itself, or baa its intensity blunted by the 
admin istrmtion of the more powerful sedatives, such as morphia bypoder- 
mically, or veratria, acooite, or atropine externally. In these distressing 
eases tne sufferer is ready to grasp at any means of relief that is held out to 
bim ; and itntdung of the aSbeted neire is now frequently undertaken in 
the hope of relieving, if not completely removing the affection. This opera- 
tioo haa already been dewribed (p. 477, vol. L). It was there pointed out 
Uiat the effect produced differs considerably, according to the size of the nerve 
operated on. In small nerves, such as those of the face, the conductivity of 
ibe nerve is abolished as completely as if it had been divided, but as its con- 
tiouitv is not interrupted, repair always takes place, and after a time its 
Aioetioo is restored. Id the larger nerves, even when considerable force is 
Dsed. the Oi>nductivity is not completely abolished, although it may be modi- 
fied for a time. It is only when great force is used that the breaking up of 
the medullary iheath observed by Leuterman and Horsley takes place. We 
have seen that in sciatica, in which the disease is seated in the actual trunk 
of the nerve, great ben^t is usually derived from nerve-stretching, and 
probably the same result may be hoped for when a similar condition exists 
m other nerves. In the majority of cases of neuralgia, however, the cause 
11 either some peripheral irritatioo of the terminal branches or some central 
diseaae, and in these but little is to be expected from the operation. In the 
former case there might be temporary relief until repair of the nerve was 
accomplished ; and in the latter, although experience has shown that there is 
sometimes some improvement, this is only of the most temporary character. 

When stretching has &iled, aaetion of the affected nerre is not unfrequently 
recomoteoded as a last chance of the removal of the disease. Simple section 
of the smaller nerves is now replaced by stretching, which, as has just been 
sutcd, temporarily abolishes their conductivity. Division is undertaken with 
tb« inlentiuu of permanently destroyiug the continuity of the nerve, and to 
insure this about a third or half au inch of the trunk must be cut away. As 
with stretching, however, it is clear that the operation, though occasionally 
pnMJuctive of temporary relief, cannot in most cases be expected to benefit 
thv patient permanently; for by it the cause of the neuralgia is not removed, 
«D<t it (."an consequently be of service only when the pain is peripheral, occa- 
Hooetl by some local irritation existing between the part cut and the terminal 
braucbes of the nerve. If the neuralgia depend on any central cause, or 
on local irritation existing higher up than the point divided, the operation 
must eventually be useless. Thus, if the source of irritation exist in the 
terminal hninches of the infraorbital nerve, the divisinn of this trunk might 
be useful; but if the pain be occasioned by any pressure to which this nerve 
nay be subjected in its passHge through its canal by a carious state of the 
bones, or by disease of the periosteum, it would be unavailing; though it is 
a remarkable fact, that it not unfrequently happens that there is after ihcae 
upfraliont a temporary cessation of paiu fur ii few weeks or months. In 
sum*- of these cases, however, the pain shifU its seat from the branch operated 
••u Ut another division of the same trunk ; thus, if the infraorbital have been 
Hirided, the inferior dental or submental uerve becomes the seat of pain. Or 
thL- iiisy ascend, as it were, to the point at which the nerve was diviile<l ; thut>, 
liter aniputalicin for neuralgia of the knee, the pain may return in the stump, 
and again when this is removed a second or even a third time. 



I>ISRA3BS OF THE NERVOUS SY»TCX. 

Facial Heonilgia in the nioet <v)nintnn form of thp diACfiAe. It nifty afT-rt 
any one of ihn braiioheii of tlip fifth, or in e«iremc caw* almoKt every iinrt al 
thf RBme time. The VArinun Hivisinns of l.hi» nerv# Imve, therefonr. Iieen 
mmt frcnucntly stn-lohed or iiivirl.>il for rieiimlRta.And it is necoMarr hrwfly 
t«i ^ItH'crilM' the o|KTAliv«^ nnx-f-iliire rfiininx) in tho CM»tt of each ner»*. 

Pint or Ophthalmic Dtrision of the Fifth.— It w evident thnt ilir frontal 
hrancji of llii<t xifrvf in iIk^ only pari ilmi can In* eitln.T i»ln>tclirtl or diviilwJ. 
Tho frontAl fliviil<^ til»niil tUe. middle of I he orbit inlo the eiifiralmidiliar »nd 
StipmnrbilN) hrftn<-he«. TIte Rii|tnitroeh)i>iir is ttxi erniill, and, ua n rule. Uni 
much bnilcen u|i into lirauolie« to Iw iMt|Kie<l nnil atrelchvd. The iitj|>ni- 
orl>ilill,oa (he other hnnd, leavc« the orbit nKiiiilly n» a single trunk, and I'lin 
be imilnted without itiflieuky. The iHntitiQii of lite nerve ie n-eojiitiixeil br 
fpfling for the Bupraorbila! noteh. through whieh il jiasM-s. The ucr^e may 
be atrelcbei) eiibetitHneoiiely by itiaking » email puncture with n tenotome 
alvDut D (juarlerof un iiieli ou iiiie side of ibe nnteh. A blunt hook is inserted 
through this aod forciblv Mraned along (he bono until its point hae pniweil 
the line of iha nerve. The ekin of the foruhirud niunl be nulleil upMarda ao 
ae to make it tenae, and there will then be un diffieully in aii(TrtAiniD|> bj 
the sen^ nf resialance whether the uer\'e haa been honked nr nuU If it be 
fell npiin the hook, the akin of ibo furcheod being pulle«l fnrcibly upwnnls. 
the nerve may be firmly Blreu-hetl. 

Hectiun of the supralnK'hlear and auprnorbilal brunehes can be ihrne pnb- 
cutaneoiiely by inserting a tenotome about half an inrh external lo the line 
of the latter nerve, and ptiRsing il inwiinlx nearly In the root nf the nose. Id 
withdrawing it a firm ineifinn niuM l»e made along ihe margin of thr> orbit, 
keeping slightly to the fronlul ^ide in order In avoid wounding the polpehral 
ligamont. whirn might he followeri by cnofiiderable extravneation of blood 
into the l<Hi^ tlwue of the nrbit. 

To expose the fupraorbitat nerve the akin of the foreheod must be drown 
Qp and the evelid driwn, and a rnrved inri^tinn niMint three quarters of an 
inch in length mitst be made parallel lo ihe crehrow nod a little hclow it, 
the centre of the wound being npiMioile the noleh. The fihren of ihe orbicti- 
lariit )>alpebrarum may then he *enarnte>) bv a bliinl in»lruni«Dt. and the 
nerve expn»e<l k» il learea the orbit lying e)n»ely upon iho bone. It mar 
then be siretehed. or a piece cut out na do.«!red. Cnre must l»e taken not t>) 
wound the |Hiii>t'bm) l>i;aiiient, olherwiM; blond may be exIravtiMiled into the 
orbit and cupouratioM follow. 

Th« SacQU or Superior Maxillary Branch of the Fifth. — Thi» nerre, 
after cmwiog the Bi'hrno-niaxillnry i''i»wi, loit-rB n cinial in ihe fl'xir of the 
orbit, and appears on the fm-e thntuyb ihf iufniorbitui foramen. The nerve 
haa bei'n divided a* il Imves the fominen, in llu- camd, aud in the fphenn- 
maxillarr f-xwfl. The situation of the infnmrbtlnl lornnien i» f'<iind bv 
drawii:g'ii line fr-uii the supraorbilnl noteb lo Ihe inlerrsil Iwlwevti (he two 
bieu8t>ld teeth nf the lower jnw. This line er'ifc'e* the infraorbital foramen, 
and, if pnilonged. will show the |>tM<>it>on al»c> <>f (be nienlal f-ramen. The 
infranrbital fommrn ia eitunlet] ittmut half an inch WInw the lower ninrgtn 
of the orbit. The nerve lie« rather deeply, but ean beatretehed xnbciitane- 
ottaly in the mnu< way as the supraurtntal, by punelnring (he rktii with a 
tenntnme and gmj>pliiig f<>r the nerve with a binnt hook, the (Miiiit of which 
il made lo »em[>e alimg (he bone l>elow the furanien. When stretehing it, 
the upper lip and cheek niutit lie drawn forcibly downwnntH. Hubeutaneoita 
aection can lie done in the same situation with a lenotonie. To expter the 
orrvr a rurvc^l inrirton, arranged m> as to fall into the lines of the fnvr. and 
ihoul one inch in length, ahituhl be made with its mid-point over the font- 
■ten. After dividing the akin the levator labii superioria must be cut 



NKURALGIA — OPBKATIVK THBATHKNT. 6S 

tkroaph, mud the aerve then comes into view, and when the bleeding hiu 
been Brrested, can be exposed clearly and stretched or a piece cut out. This 
operation, however, can be of little use when the teeth are the seat of the 
Bcurmlgic paaa, as the anterior dental nerve is not affected by it. To divide 
this, it is recommended by Maleaigne to make the incision parallel to the 
margin of the orbit and immediately below it. A few fibres of the orbicu- 
laris palpebrarum are cut through, the origin of the levator labii superioris 
turned down, and the nerve thus exposed at the foramen. The palpebral 
ligament is then separated from the margin of the orbit, and pushed upwards 
wtth the fiit and tlte eyeball su as to expose the floor of the orbit. The nerve 
is next cut through as it lies in the canal in the floor of the orbit, with a 
■troDK tenotome, which is made to penetrate the antrum, and the terminal 
branch being seized in a pair of forceps at the infraorbital foramen, it is 
forciblv draped out of the canal by which the anterior deutal branches are 
raptured. The free part is then cut off. This operation is apt to be followed 
by suppuration in the antrum and orbit. liiDgenbeck and HQter have 
rccomnaeDded that instead of opening up the orbit, the nerve should be 
divided subcutaneously just before it enters the canal. To do this a punc- 
tare is made in the skin immediately below the outer commissure of the lids, 
and a blunt tenotome is pushed backwards and downwards till its point is 
felt to be in the spheun- maxillary fissure. The nerve is then pulled forcibly 
where it has been exposed at the infraorbital foramen, while the tenotome is 
nade to shave along the maxillary border of the fissure. As soon as the 
traok is divided, it will pull out of the canal. 

Lastly, Bruns, Liicke, Loasen, and others, have exposed and divided the 
Dcrve in the spheno-maxillary fossa. In order to do this, an incision is 
commeDced just behind the middle of the outer margin of the orbit, and car* 
ried dnwDwards to a point opposite the last uppec molar. From the upper 
end of this another is carried backwards to the root of the zygoma. The 
malar bone and zygoma are cut through, and the arch turned down with the 
manor trr attached. The fat beneath is then pushed back, and, if necessary, 
some of the fibres of the temporal muscle which are inserted into the pos* 
terior part of the coronoid process of the jaw are divided. The posterior 
part m the superior maxilla is then rec(^nized and followed upwards and 
ttackwanls to the spheno-maxillary fossa. The nerve is then raised with a 
blunt h(»ok and divided, as large a piece as possible being removed. As the 
interna! maxillary artery and a plexus of veins which He in the fat may 
cause trouble»>me hemorrhage, the dissection should be carried out with a 
blunt instrument. After the operation the malar bune is replaced and secured 
by sutures. In some of the cases in which the operation has been performed 
considerable stiffness of the jaw has been lefl. 

Other methods, also, including partial resection and replacement of the 
upper jaw. have been recommended. 

Third or Inferior ICaxillary SiTision of the Fifth. — The three chief 
division.' of this nerve, the lingual, inferior dental, and auriciilo-temporal, 
have all been submitted to operative treatment in neuralgia. The lingtutl is 
earily reached from within the mouth. It runs obliquely forwards to the 
#ide of the t4>ngue from a point immediately internal to the last molar tooth. 
It v cDvered cmly by the mucous membrane, and forms a distinct ridge if 
the t'^ngue be pulled forcibly outwards and to the opposite aide. In this 
sitoation, the nerve can readily be seized and stretched by means of a blunt 
Ivtok forced through the mucjus membrane, the tongue being forcibly drawn 
to the- oppiisite side while the nerve is being pulled upon. Section can be 
made by putting the nerve on the stretch, and passing a curved bistoury to 
the inner side of it opposite the last molar tooth, and then cutting towards 



fiA 



DlBEASCa OP THE KKKVOCS &T8TKM. 



itteJAW. Ta ivmove a pit>ce, a lontfitudioal inctnoo tbonld be made ihnw^ 
tbe muoou> merobreQe in the liue of the DerT«, wbidi may tbcii be dravD out 
with a blunt book. 

The menlai bmndt ef tkt titfmoT denial m awlj reaclied, a* it enutrgd 

\from the dental caott]. Thu forameii is tituated diradlf below tbe luterral 
betweeo tbe bicuspid leetb. The oervc can be streiebcd HibcutaociHialjr hy 
ntakwg a poucture io tbe skin oppccitc tbe fint bieuspid al aucb a lenl at 
not to penetrate tb« mouth. A Muot book it inserted thruuirfa this, and 
forciblr scra|ied alnnc ibf luine acmn tha line of the ttrrvr. Th* ]ip and 
diin naH bu poIM bwards white tbe nerv« b ctretcbed. Tbe ocrre way 

|klM> be expoaed.aiKl a piece cut out ifderired bjr a anall ineiunn in the i 

Tbe MOM tnmk a^ (Ac taflerwr dmUat »enm baa. in eomc oun of in >■■■ ■■ , 
and penteieot neuralgia, bcoi dirided by djaeeieling up a flap over tbe nwi^^^l 
of toe lower jaw, applyine a trephine to (be booe ao expeaed. and cultii^lH 
I oat a piirtinn of it over that part where tbe oerre MHoa the dental eaiHu^ 
which iM thns laid bare ; when a portion of the mtv* any be eseieed, bjr 
beta? raised on a director, and •nipped avar with tciaaon. 

The Auriehlo'Umponl S'trM ran be rpachinl oolj where fl irota the rwel 
of ibe rrframa after emerging from ab>)ve the parotid gbad. It liea immfr- 
diateW SwiAd tbe temporal arterr. In ibiii nioation it can be expoeed bf 
a tmall indiMe parallel to iucaur»e,an<limmediatelT in fmni o^tbetngna. 
t*n being taken to avoid ihf artery. fNibcntaikeoaa •trcicbiog had beucr 
faoc be attempted! for fear f<f injuring tbe temponl Bftm-. 

The value of tlieM> uperatiuoa t» Milt •umewhat doublfal. Mnay caMi of 

perutaufol curv have beeu rerorded. sod temporary relief latttag fiir weeka 

t^r mootba vary ooomunly rceulta, Ko bawiatioo need ibcrefor* be bit itt 

[iwdcnakini; the leaa aerioui prucwediast, eoeb aa MibontaBooiia ilnubing cr 

[•xpcaure and divtsioo of tbe lermiual bcancbea. Tb« mora «XttMiTe oo«c»> 

lioo«.«ucl> at expoatu^ tbe (uperiMf nuudllary in t^ MbciKHMUtiUary MMft, 

or tlic inferior dt^nial iti the oanal.ahould bareacrvad Ibr very extraow caaea 

in which all miid^r pruceediog* ktr* fiuletL Woodf of Xcw York, baeano- 

[•MifBUy dirided tbe luperior marillary aarrw atar tba fimnoi mmdaiB. 

ooe caM uf lii> wbieb 1 bare aac*. a cwnplMa care waa tftalaJ ; tba 

, a haaltky mao. beinf catirdy frea frnai the Deiuwigta ooe yaar and 

half after tha opetaliuB. 

Tbvre ia eoe forai of Mttfalgta of the dcatal acrfai that it to wrare and 
pent w ent ia iia gencrai duratiaa. aw) to |«iuiji— I in iu attadu. that 
aoneiitalMatnie Ko. Thit iWMilfia may aftal tttWr jaw. I haTe BMat 
r net with it in iha hnrtr. aad aotw eoniiiMty m wowif thaa ia 
ocenn in people who ban hat taalh : aad tha paia, wUeh a aaaaa 
ively acnia aad paimjaaal. aeiBBWBM ia aad dana ana lha oeairBdcd 
IreoU and the coofltBted and iadanUod gam aovtring ihaai. It aniean to 
! owiaB ta tbe aMaptMita of tha Mfaaaal hnaehta of ihn dntaf aartM 
the aoatradiaa apoa tiMn of tha ipty ahaalL TWac thia via* of 
paiholocy of ihia iatB of aaaialgia, I aaw tnalad it bj ua rcMoval of 
prwii<ui ofUM iadaialed alvwolar bnrdcr and gam. Boia Tcan ^o 1 did 
%tt io m paiimi of Dnan't. reiMreias a V-^haped pieee of the Mae by lara at 
Hey* taw; aad mon reeeatn, I Imtc ia additioa cfippad away the 
■Hv br lacaa* of eoOiiw pGaiL iMnm. who baa fifceied anoatiuA i^ thit 

'.<rara^in. wa ue pUen ooly far tha t— nral of lha aftcted 
I :<«■ it u aeocHtfy io cat iafiB, faai ae& Ato^h, tha body of tbe 

t£it> indakm. the denial obmI bw he opeaad ia the body ct the 
tlte narrt dfatroyed by aeana of'^ihe fuvaaie caaucy. 



TBAUHATIC PABALTSIS. 57 



HUBCDLAR TIC. 

MuBcular tic of the &ce or "hUtriouic spasm" coDsists of almoet constaot 
tvitcfaJDg nf the muscles of the face, sometimes so severe as to interfere with 
sleep, aod always causing most serious annoyaoce and discomfort to the 
patient. During the last few years, the facial nerve has been stretched for 
relief of this affection in several cases. Godlee has collected thirteen, inctud- 
iog two of hia own. Of the 13 cases, 6 were unrelieved, the spasm returning 
asfoon as the paralysis caused by the operation passed off: and in 5 the 
■pMmfl returned, but with less severity ; in one only, under the care of 
Sootham, was the cure permanent One patient was lost sight of. The 
opermtioQ is performed by making a slightly curved incision immediately 
behind the ear, reaching from the root of the mastoid process to nearly 
the level of the angle of the jaw. The anterior border of the process 
and the edge of the tendon of insertion of the stern o-mastoid are carefully 
deaned. and the parotid turned forwards. The upper border of the digastric 
i* next found, crossing the wound nearly transversely. The nerve is parallel 
to this, and according to Godlee it will be found emerging from under the 
middle of that part of the mastoid process which is exposed in the wound. 
After the digastric is exposed, the dissection must be carried out with a 
director and forceps as the deep parts of the wound approach the internal 
JQgular vein. When the nerve is found and cleaned, it must be firmly 
■tretcbed with two blunt hooks. Complete paralysis of the face should re- 
mit if sufficient force is used. 

In elonie torticoUii the spinal accessory nerve has been divided in one 
(a«e by Tilleaux, and stretched by Nicoladoni, at its entrance into the steroo- 
nastoid. The division gave some relief, but the stretching only exa^erated 
the spasms. 

TRAUMATIC PARALYSIS. 

Traumatic paralysis is referable to three distinct sets of causes. First, it 
niay arise from Injury to, or Cbmpremon of the Brain giving rise to localized 
paralysii when the cortical motor centres are injured, or to hemiplegia or 
toon general paralysis when the deep centres are implicated, or pressure is 
exerteil on the braiu-eubstance generally. These conditions have already 
been fully describe*! in the chapter on the Injuries of the Head i pp. 683 
and 72^1. vol, i,/. Secondly, it may arise from Injury of the Spitifil Cbrd, 

Cng rise primarily or secondarily to lesion of the substance, either by 
ration, compression, or ultimate disintegration. The effects produced 
will vary with the extent and seat of the injury from complete [>araplegia, 
wiih l<"ir«i of sensation in the paralyze*! parts, to irregular impairment of 
wneati'iD and motion. (See Wounds of the Spinal Cord, p. 763, and Secon- 
dary KlTecl* of Omcussion of the Cord, p. 750, vol. i.). Thirdly. Injury to 
Ike .V*Trf^ at any part of their couree, from the roots to the terminal 8ul>- 
divisions of their trunks, may occasion paralysis of the pnrts supplied by 
them. The effect produced may be immediate, as from Section of a Nerve 
<«* p. 471. vol, i,> ; or more gradual, from Pressure (sec p. 470, vul. i.) ; or 
it may iK-cur hd the result of Chronic Neuritis following a strain, or other 
injury »ee p. 47S, vol. i.). 

ThfTS'- conditions having been already fully described, it remains to notice 
here only a form of paralysis that is occasionally confounded with the 
traumatic varieties; viz., that arising from exposure to cold, or rheumatic 
paralytic. 



58 



niSKASBS OF THK V8BT0US STSTEH. 



BlieQiDBtic Paralysis. orPftralysis from Expoiore to Cold i Dui-licuoc), 
is R I'ltriu uf .Hsea^u rin>rc frcqaitDtly spoken about than mtt with — that k to 
say, if wtf apply the t«nn paral}'8» to Ium of ncrvoui power itnlepcnilently 
of iaabilitr t« use tbe limb from iniucular wcakneMS, rigidity, nr (Miin, or 
from eimifnr ccmiiiliooA c^nncotcd with the joints. Ofnuiiio rheumatic 
paraln.t« from affectinn n( the n«rve« ilors, however, exbt Durhcnne nuUoi 
that l^e has met with it in mcwt of the nerve* of the limbs, and it b far from 
uneotnmon In the fneinl nerve, [i most oTDmnnly ariwa from exp-rtiire uf 
the atfeeteH juirt to a draught nr proloof^l chilt while the body tf> «weating. 
It Uk dilfiriili to Hjisii^n A dUlinct pnthol'^nical ("auno fur it : ihitt it ixlui- Lu an 
actual inflaniniAlion of the iicrve.n neuritis, may beaf«uni««l Trotn ibe ayotp- 
lorai, «ud the )i9irA)Yi>i» lo prithably the result <>f oompremioii nf the Ht>r«a of 
the Dorve frum e(1Vif)ion into it«i>beatl). Tbe parAlysis inHynrite in twu w»iyiu 
In the firat varietr there \» pruIooK«d evideuce of neuriti* tvefun: ibr |i>« of 
power appeatK. The fimt tiympt'imH when a cutnpoiiud nerve ix atfttcted is 
pain along iu course, ^ntduitlly increausg in Kverify, ttahbiug or violently 
aching in character. With tlui there may be variuui oiodiijoatioiu uf md- 
satinu to t))c parU eupplie*! by tb« nerre. as aambncH, tui{[liii^, or hypenBB< 
theeta. These symptumK are iocreaaed by movameoL AiVer lantini; eaoie 
time, ovea for wcclcs ur luiiDtlis. tbe pains oeaae, mad the muftcla aupuiied by 
the nerve t>ocamc paralvicd, and after a time waste, aod tbcn electrical 
irritability bcoumes impaired. 

In theM>con<i variety the preliminary «ympfaHiuofoeurilis arc wau(iu);,ib« 
paratysi.-! n|t|>'Hrin^ immedi»ti-Iy al\er cxpaeura to culd. Tbie tA t-oninKmly 
observed in lhi< farinj nLTW. or in tbe museolo^piml and uveaaioually in 
other nerrcfi. Dur-lnMinu has collected orer. 100 caaes of ttuddta paralyxuof 
the latter oerve twrurrinjraAer exposurs to oold, uaoally fmm »le<^ping with 
the nrm.'i expnned In n dmujchL The aymptoma of paralysia of the musoulo- 
apirai have already breu ()e«crtbet1 (p. 56.5, vol. i.). Durbenoe iital«s that 
ID paralysis fn>m expneure to cold tbe whole of the part» Mipplieil hy the 
norre io the forearm arc paralried, whereas in wrUt-'lmp fmm lead-palay 
tbe floptnalnr loa^o« ««capes. la paraJyw* nocurrinK in lhi« »udden way 
from pnld the rlertricat trritability of the muscles n^maing nurinal, tbe facial 
|»ef^-e «lone forniiDi; an exreption tii this rule. Ttm i» explained hy sup- 
p<«iin-; that thi» nrrre U expand to more severe preHUr* when it •wells, Itl 
«OR«eqiienee of its c<>ur«p hetoe through a lung caJaal. 

It i* important Uy difttiDi;ut»b these formi nf paralysis from that arimng 
from other cMUsni — more i«afticoIarly from ihf Iraumalie foniw. This may 
tnoally be d<Mio by ulteniline to tbe pn*liniiii»ry hislitrr of neuriUa iu the 
6nt f'^rm, ill which then.- i# nliui frt-iiiti-utly n cotfti^trot or aiUecedeflt rfaen* 
mxlic stfeotion of tbe joints or inu»cte«, aod in the sccimd form by the main- 
teuanee <>f the aonBal irritnhility of the muiKrles, remembering, howerer, 
that fneial paralyms fVom odd form* %n exception to the rule. 

The TVfttm^nt in the curly »ta)f«s ti> that of aeuritts. free cmoter^irritaUoD 
aad PBsL wtlb the ad mi nt«t ration nf saticyltc add if there are any eeoerml 
li§,m of rheumstism. ^Iien paralysb ■■ clearly derelopfd, faradixation 
must be Mnptoycd to pnveot waattag of th« moadca. By tbeae mcaM a cure 
b always eAeted. altoough the Pworsr y is oA«a vary uom. 



I 



MKraoxiu 

By Vanroaa is arant a lumor eooneeted with a Derre. Tha 
neuroma i> a dbroma spriapng A«n tha nettrilmaaB. idee, aba. p 
ruL I) It is computed of dove white Abnas tataa^ aad as a rvU tha 



TRAUMATIC NE0BOUA. 



59 



t>f the nerve are stretched over it or pass aloDg one side, seldom being 
involved in the mass. 

This tumor may vary from the size of a roillet-seed to that of a melon ; it 
i> itfually solid, but when it attains a large bulk, a cavity may form in it, 
containiog a yellowish or brownish serous-looking fluid, apparently owing to 
tiie dtsiDtcfrration of the central portions of the mass. In shape it is usually 
ovml or oblong, the long axis correfipnuding to the course of the nerve (Fig. 
421) : it grows slowly, and is movable transversely, but not in the direction 
vi the nervous trunk on which it is seated ; it has do 
Appearance of maUgnancy, and, however lai^ it be- 
cornea, it never contracts adhesions to the iategument 
nor iDTolves its stractnre. Neuroma ooramonly affects 
only the nerves of the cerebro-spinal system ; but B^rard 
hjiiS met with one case of the disease on a ganglionic 
nerve. The nerves of special sense are but very rarely 
the ae«t of this disease. Indeed, the only recorded case 
with which I am acquainted of a neuroma connected 
with one of these nerves, is one described by Lideil, of 
Xew York, of a neuroma of the optic nerve filling up 
tbe orbit. Battening and protruding the eye, and extir- 
pnted. together with the contents of the orbit, by that 
burgeon. 

Most commonly the tumor is single, and is usually 
paialen. As it increases in size it may become the seat 
of severe lancinating or neuralgic pain, which extends, 
however, only to the parts below the tumor, and is com- 
■Kwly panixyBmal. The motor function of the nerve is 
very seldom affected. The pain is evidently owing to 
tbe stretching of the nervous twigs as they pass over the 
tumor. A single neuroma is sometimes not only paio- 
fnl, but acutely tender when touched ; but when many 
tuoior* are present it is a singular fact that they are 
alwav» fiaintose and unattended by any inconvenience 
except »U(-h a<> arises from their numbers and bulk. Tbe 
number nf such tumors is sometimes amazingly great; 
ihu?. in one <>f R. W, •'■mith's cases, described in a monograph which con- 
tains the fullest and most accurate account of this disease, he counted in tliu 
two lower extremities alone more than 250 of these tumors, besides those in 
other r*rts nf the body. In another ctise related by him, there were upwards 
•■f *>Kl small neuromata scattered over tbe sides of the chest and abdonirn. 
■I5«t iin the right lower extremity, and upwards of 300 on the left; altogetln-r 
prohahly not less than 2000 of these growths in " this unprecedented com ." 

Other tuniorK besides fibromata are occasionally met with in cimiiectinn 
with nerves. Myxomata are, perhaps, the most frequent. In 1870 I aiii|)u- 
tatHJ the leg lor a spindle- eel led sarcoma of considerable size, whirh was 
fuund i>n dissection to have sprung from the posterior tibial nerve. 

The jtaiiifvl ntbeutaneout tubercle (see p. 947, vol. i.) is probably- alsn a 
tibn>n>a connected with a nervous twig. 

Tzmamatic Henromata may arise from the wound or partial division <>f a 
n^rve. The central end of every divided nerve becomes more or less bulb- 
ous, the eolar}>omeDt being composed partly of dense fibrous \\s?.\\e und 
Crtly of newly formed nerve-fibres. As a rule this condition, which must 
rfgard«i as normal, is unattended by any pain or discomfort. Occasion- 
allr, however, the enlargement reaches the size of a nut or pigeon's egg, uud 




Fig. 421.— Neuroinn 
wUh Nervoui Filn- 
mentt fjiread out 
□ Ter Tuiiiiir, 




1^5 




— X> ■ntTMB* AooU be iuarfcrwl witli n»lei* it u caaiii^ 

by 1^ (MIS il ciTct viae (« or fa^ tai balk. If it beeooMi 

U> nli«T« ibe paUMl. ezcMMi of ibe (um<ir t« lbs 

rftrwlMaii. la iiliifihii ■iwi—ra ilii iriinnit iniut 

■^■■iie- Wf aatioM dMKcOott. to w wr g Un tOBor rnm the nene 

_. Uib MfiML Thii eM be dooe n iMfll cmm mjth>Mt difl- 

^ it » iwHiMilito to mm tbe «bok HaA, « fcw fiMflieuli may 

W ■nKTwo, vbieb irill mamtaia tbe eAatinaitv «r th« nrrvr noJ 

■■Mfimit icMimtiiHi. Tf caanplete itivWoa a iiaavnt.lnMf, nn 

be Bade ta Mtan tbe dividad cad* altar rdaxiai: -^ u 

— fw iftli by pgwdoa. Ewa if ihw ftnl. nnimriiia of i oiar 

Mkaplaee. 

BearooMta of atamp* are treated br cxewon. 



TTTASTK 

M a diiean eosrietlBr eeeeoitallT io aa exetlad atata of tbe sfaaal 
tbe medulia obloosata — in bet, of tbe whole tnu apiaal ■JAeel^ 
to painful aod onniiniied vpaams of tbe Tolastary faoBclea atiil tba 
alternating Kitb iucnntplete relaxatioa, and OMiallT teraioatiag 





Caowb or Trta vi'H. — This, wbtcb ib one of the moat eerimiB and dittr 

tn vhirh the nrrvnas arsleiii if liable, is in the great jnnjnritr n( 
Af Traaoutio nri^n. imag the enaaegoenee of aome wmind that 
I or iiritatnn a piirtinn nf the periphemi oervooi sjntem : the local 
produced being pmpA^ted in the nerrnns oeotrcs, the exdtatioa 
af wbieh beoomes penistent, and conttDUffl after the local cause haa baea 
lesoTrd. indaeiair reflex mtucular movefuenia in viirioa» parte nt the body. 
neirritatioQ of theoerrouafyBtem. hAwever, that in<1uo«>i trtAnuK, may arin 
from other Nturce* beeide* surRical wouods, oocanooini; tht* Idiopathic form ^ 
•f tbe disease ; tbuB. for ioBtaace, tbe preaeiKe of wnrnw tu thr inrr^tinal H 
taaal, expnmire t<j cold and wet. the timiture of tbe ambtlioal rord in iofaD(«, ^ 
■A>) rwn the uterine irritation fullowint; abortion, biive been kn'^wn to occa- 
awa it. These causes, however, rarely inv« rive to it in this counlry. 

Tetanus raay occur at all ny^x. from the t^arliest infancy to an advancad 
period of life. In hot climate* It is omnxm Brixinunl newly bt-rn Infiints. in 
tbe lurtn of TVumu' AVonofenun. In this country It rarelr o^-cun at this' 
Tcrr early period of life, but is comnion iu yoiinK adults. Whave ni«9t fre-j 
ttnenllT ohaerved it between the a^ea of IG and 'i-'). and aAer that in old' 
people; but It may neciir at any period of life. It is far more common 
aninnitat mo/m than femaica— io the proportion of about four tu one. Seiuan 
mfthe yrar tieemtt to exercise little influence over iL It occur* lu all stalra of 
(be almivphtTR, and at all periods nfthe rear: but is certainly m<«t cntooMa 
rhi>n the Wfeihrr is tttiddenly chan^enlile — altemsting fn>m hcnt tn culd. 
Iff . ^ ''■':!* exposure to cold and wet, more parliculariy after the b-Mlr has 
', is thn most cnmmun r&uae of tetanus when it nccure indepen- 
iwv '■[ fiurf^eal injury, and is a iVequent prediapoeing caiae to penuui 
who havf IxTO woiindi-d. 

'Tins mav \m' occasioned by injuries that do not pTO rfae in brendi of 

: thua 1 hav^ known it to occur in a child who was ffoddenljr tbrown 

its back by anoihi-r at plav. in a pr! from a boy jnmpine im Ui 

in a ImI by anolhi-'r fttriking him on liic buck by running a 

wt him; aod Ueid mentions a caae produced by the stroke of a 



1 




TETANUS — CAUSES. 61 

vhip ; but ID tbe great majority of cases, it is directly occasioned by a toound 
uf suDie kiod. G^Derally a oerTous twig lias been lacerated, divided, or 
iaflaiDcd ; and this seems to have been the startiDg-point of that disturbance 
uf tbe spiDa] system of nerves which leads to the tetanic spasms. 

Tbe kirtd of wound, as well as its situation, doubtless influences materially 
tbe occurrence of the disease. Though it certainly more frequently follows 
punctured, torn, and lacerated, than clean-cut wounds, yet it occoBtonally 
eDiDpliotes these, even when they are made in surgical iiperations; thus, it 
has been known to follow the removal of the breast, amputation, the liga- 
ture of the larger arteries, and the operation for hernia. 1 he minor surgical 
operations also are not fi«e from the potsibility of this dangerous complica- 
tMQ. It has been observed after the operation for fistula in ano, the ligature 
of piles and varicocele, the removal of natal polypi ; and I have seen a fatal 
ease resulting e%'en from the introduction of an issue. Burns are peculiarly 
liable tu be toltowed by tetanus. It is the common belief, both in tLe pro- 
l»iun and out of it, that wounds of the hands and feet, and more especially 
of ibe ball of the thumb and of the great toe, are more likely to be followed 
by tetanus than those in other situations. I think the truth of this opinion 
nay be doubted ; though it is not improbable that tetanus may occur more 
frcqoeotly after injuries of these regions than of other parts of tbe body, 
■Dpiy because punctured and lacerated wounds are more common here than 
elaewbere. It cannot well be supposed to be owing to the tendons and fasciae 
that abound here, as Hunter imagined ; fur it is seldom, if ever, met with 
after operations for tenotomy, which are so commonly practised on tbe feet. 

Tbe statistics of the American Civil War are very complete on this point. 
Of oOo cases, 21 followed wounds of the head or neck, 55 of the trunk, 137 
of tbe upper extremity, and 292 of the lower. Of the 137 wounds of the 
■pper limb which were followed by tetanus, all but 4 were above the wrist ; 
aad of tbe 292 of the lower extremity, only 57 were of the foot. These 
siuifltics do not therefore justify the popular belief that wounds of the hand 
mmd foot are particularly prone to be followed by this affection. 

TelADUs may occur in all conatitutiotu — in the strong and robust, and in 
tbe feeble and emaciated. It is especially apt, however, to occur in feeble 
aod debilitated individuals, and, indeed, may be looked upon as a disease of 
debility: hence auy condition that lowers the tone of the nervous system is 
especially likely to occasion iL When it occurs in persnos who are other- 
wise stmtig and in the prime of life, it will be found that they have been 
expD«e<i tu causes of depression influencing the nervous system. It is lose of 
nervous tone, and not muscular weakness, that di8j>oBe8to this disease. Thus, 
in tr>>pical clinrates, as in some of the West India Islands, and amoDget the 
iBai%h«« of Cayenne, it occurs with peculiar frequency, the most trifling 
tcratcbes or punctures being followed by the disease. Polaud, who has 
esbaU5ted the statistica of tetanus, states that the mortality from it is in Lod- 
<kia .*X£-\ whereas in Bombay it causes 2.5 per cent, of the total deaths. It 
it intere^itiDg to observe, that the natives of hot climates are far more liable 
tu this disease than Europeans resident there. In the American Civil War, 
'4.1 per cent, uf the cases occurred amongst the negro troops, who furnished 
only -.7 per cent, of the b>tal number at' wounds. 

lu miiit'iry praetiee tetanus is of common occurrence. Its frequency varies 
much in dittervut cam]>aigos and uuder different circumstances, aeauon, and 
dimate. In the Peninsular War, it was estimated to occur iu the proportion 
■jf aitirtit one case in every 200 wounded ; in the Schleswig-Holstein war of 
I»4!*. accunling to Stromeyer, once in about liaU cases. In the Crimea it 
^»pvar« to have been of rare occurrence. Alcock'a estimate of ime to every 
TV wounded is evidently too high. In the American war it occurred in 0.2 



DtBSABEB OP THE NERVOUS SYSTEM. 



oenL u( ibp wouihImI. A ftcr naval eoKagemeDta, however, tho nmrUlity 
utVri b«*n high, ntort- particularly it" Un-y hnve lalccii placf tu tr<>[iu-ftl 
rliniiitrs. 8ir G. Blune state* that, alier limloeyB a«lii>u iu tliv Wcvl liiiUe*, 
nut ut' ^10 ntiuiuleil 'Jft were aitackeii with (eUiniiB, beio); ornf iit 4U- All 
Kiirri)iettti Army Siirt^euii? are ngrei^l, thtit Mjd'icn vhaogvs I'runi hcnt lo ruld 
are aiii(>n};»L tli>^ nii«t t'reqiieutruui^iMi uf teUnu* MinoDg»l (h« wouixJed. Thua 
Larrvy slali?» that, slier the hattle *>f Mmkuwu, iillliou^li thr ttuiiibrr itf 
wuiinaeil wn« immense, there were few c«w« uf telsuus. Ili« heiil being rery 
jitreal and coutiouDue ; whilut afUr Bautxeu. where the wuuud(;4 wens JeJl ua 
ibv lJel<i all oi^Ul ex|KM«<l to ncvvre culd. mure thou 100 had tvtuniie ; Rod 
alter the butllc ut' Drcadeo, when great lieMt was Julluwed by tuiicb wet awl 
ci'ttl. the wouuiled euHeritl muat severely. Ho, alter buiiil- uf the Imlian 
baltle«, «e Chiliauwallnh and Feruzej^vre, wherv the wuuiitled lay vxpuoetl 
to cmM nights tiller very ln^t days iMacleud), teuuua was tif very rre4iiet)l 
oceurreoee. The caee a(>|>e«rB to have Iteeii difTereut in America, when 
letuuua duea nut Reeni to have aritfen I'ruiii ex|io9ure ut' the w-'uuded tu culil 
antl ni)^ht-air. ('hishulin staleti thai aUhuu]i;li, from the vvtxxleil nature of 
llie Country in which the balties wer« ul'ten lought. wuiiniled luen werv not 
unlrefinently left for two or ihree days uu thi* gruuud, lelanui;. did not appear 
to h«< ninni fre^iuent aniou>rHt ihent than in th(«e immediau-iy <-areil fur. 
Hennt-u Hiulea ilial u draught uf air, wbellier but or culii, direuil^ bluwiag 
on the |iatient, is the ni<»c Ji^rtile cause of tetanuB. 

Ttif iri>queui7 with which tenaaua ocrura varies much. It oflca happens 
that mil one cane octrurs in a hije|iical fur HOine years, ami then several an 
riiLT with in clow BUccceaioit or iiiniultaoeouAly. 

I*i:hioi> up 0(xt;KKKNCN. — Tetanus mar tiike place at any jieriod after 
the inrtictiun of the wnund that ocuaeknu iL In ont climates especially, it 
umy oeciir very r|>e«dily ; thus, liobinaon relaten ibe case nf a negro serraot 
in the West Iiiditw. who mnitobed bis finger with a bntkeu plaie, niid died 
lit' tetanuit in n ipiarier ot* an hiMir. U ia very Mldom, Imwever. in tetuper-j 
ute clinintrtt. that it enitervenea be/ore the fourth or fil^b lUy. uaually ^^40^1 
thai to the tenth day. I^arrey, who had great es[MTienire uf tbb diaMH^ 
(luring NHiKt](>^>n'« campaign! iu F'g>'pt, met with it ni<«t fre<iiientlY between 
the tilth unii litteenth dayo alter the inHiotiou of* the wound. At/cordiog 
to ibf experienw ut' the Snrgeonn of the Peninsular War, under wbu«e ob- 
wrvnlioii iiiHiiy hundred auea came, the tliiteaiie does not i>>h>iw it««lf alter 
the twenty •iM-cinid day ; but, though tbi» may be the general rule. Sir G. 
Blune ha» ndiiied a raw in which it took place M late n» a. month after lite 
intliclion of the wound. It ia Ntated that il may take place after the 
cicnlriyjitiiin of a wound h completed ; when thin liappena, the diaeiuw niuat 
rather be lo<>ke«l u[kiii an Itring idio)iaihtc, accidentally occurnng tn a {ler- 
sun who luiH l)^n recently injured. 

In Ibe American War uut *<( dlST caaes in which the day of appearmiic« 
nf the dixeai^ » not4-<l, it lollowc<) secondary amputation* iu iwenly-ou«caMa 
during Ibe lintt day alter the o|M-ruti<»i ; and in nix it appeai'oil m llie firat 
tweniv -fKiir luxir* alV<r the original Wound. Aller tbui but few case* ap- 
praru«'l till tlic tilth dnv, when I!^ arc reo^rdcd. The highest number waa 3(, 
on the eighth day, nmf by the litteenth day ibr number leil to G. tieveo raann 
occurml between thr '.*t>th and '<ii*lh dayn, nud )iZ after the end uf ibv nuotb. 

Futuia. — Tetanus may l>evlr«(<«or ('Aronir; being in foiue inatauca fatal 
in the ctHirvc ot a lew houm, but uaunlJy lusting lor three or fotir daya. Po- 
land fiiaiea that at (.luy* 6l (ler rent, ot Ihr caaes were fatal liefure tb« fiiUi 
duv alter iavn^inn. In llie AtucHran War, out ol -i^t* cnset, 1 rrcorcred and 
61* dad during (he hrvl day; I recoverrtl and ^3 died on Ihvpecotid day; 
•If da-d 00 Lbo third; 31 on the lourtb ; 'JU *m th« filth; 19 ua tb« aixtk. 



TETANUS — STHPTOHS. 68 

uid 14 OD the seveotfa, and 7 od the eighth day. Thus of the acute cases 
2, evidently slight in character, recovered, and 294 died before the eod of 
the ei^th dar, and ia 203, or more than half, the disease did uot exceed 
ibree days in duration. From the ninth to the nineteenth day inclusive, 36 
died and 6 recovered ; from the twentieth to the twenty- seventh inclusive, 
7 died and 7 recovered, and 6 survived beyond the twenty-seventh day and 
SoallT recovered. The longest period during which tlie disease la^ited was 
fortT'nine days. These interesting statistics coiitirm the view that the mora 
cfantoic the disease becomes the better is the diance uf recovery ; indeed, if 
the patient survive the tenth day, the prospect of a favorable issue to the 
case ia materially increased. As a general rule, those cases are the most- 
&tal which are most active in their syniptonis ; danger being in the ratio of 
the acuteness of the attack, both as to severity and also as to rapidity of in- 
vasion after injury. 

Symptoms. — ^The invasion of the disease is sometimes preceded by a gen- 
eral uneasiness on the part of the patient, a feeling of illnese or weakness, 
or a sense of im[>ending mischief. Abemethy was of opinion that tetanus 
was usually ushered in by a disturbed state of the digestive organs, the stools 
being offensive and indicative of much gastric irritation. When the disease 
sets in gradually, it may be somewhat difficult of recognition in its early 
Maga ; if it come on suddenly, its nature is immediately evident. It is a 
reiuarkable fact that the cramps do not begin in the part injured ; but, 
wherever this may be situated, they are always first noticed in the muscles 
of mastication, of the face, and upper part of the neck ; and, throughout, 
these aod the muscles of respiration are principally affected. In tetanus, 
the circle of nervous disturbance is at first very limited. It is confined to 
the muscles supplied by the motor branch of the fifth, by the portio dura 
of the seventh, and by the spinal accessory. These nerves appear to be 
alone afected ; the sensory division of the fifth is never influenced through- 
oat the disease. The spasm may be confined to the muscles supplied by 
these oerres, as is the case in trismus ; but it soon spreads to the true spinal 
aerres, being, however, confined to their motor divisions. The first symp- 
toms uiiually consist in the patient feeling a stiffness or soreness about the 
iaw^ aud throat, being unable to open his mouth widely, to take food or 
drink, the muscles about the temples, jaw, and neck feeling stiff and rigid ; 
(ht» o-'Ddition has given to the disease the popular term uf lock-jaw Aa the 
aflectii>n advances, the countenance assumes a peculiar expression uf pain 
and anguish, the features are fixed or convulsed from time lo time, and the 
ugl*% of the mouth drawn up, constituting the appearance called risua »ar- 
lionin^. When fairly set in, the disease is marked by spasms of the volun- 
tary ntuivles of the most violent character, with much pain and only partial 
retois^ions. The pain is of that kind that attends ordinary cramp in the 
Riuscl*^. as of the legs, and is usually very severe. The spasms are of^eu 
jr-rkiug. the patient being suddenly thrown up or twisted on one side ; the 
breath is drawn with a loud sobbing catch from spasm of the diaphragm, 
ud fjn>m the iwme cause there is usually violent pain experienced in the 
epigastric region, darting across to the spine. Tbe muscles uf the trunk are 
tteually affected next in order of frequency to those of the head and oeck, 
th« b<Wy being bent backwards so as to form a complete arch I Opisthotonoe) ; 
m->r¥ rarely it is drawn forwards ( Emproetholonoe) ; and slitl less frequently 
Ui one fcide {MeurotthotoHOg). In some cases the body becomes perfectly 
rizi'l, like a piece of woo*i, the belly being drawn in, an<l the cheet expanded. 
It u oaid that in severe cases the spasms have been so violent that muscles 
bave been ruptured, teeth broken, and the tongue lacerated. In the num- 
truus cases of tetanus that I have unfortunately witnessed, it has rarely fallen 



64 



UIBKASBS or THE KEnVOCS SYSTKK. 



to mv l<jt to tee any rtTecU of tliw kiii*l |>ru«iticc<J ; ttic epasms, iudccil. t>ciD^ 
in geueni uot verjr viulcot, ibuugli cutiuuuoua aitd very paiulul. The uoljr 
nuHclea thai I liavc aceu luru faavb been ttie recti of the alxlomcri. 

Tii« iotcJleutual facultits arc not tliBiurbtiil, anil ttie niiuti cfjiitinuc* c\eu 
tu tbe last. Ca«ee uf tetuiu« ucuaaiuaally prove &t«l wjlliuut auy elevatioa 
of icmpcruture ; but id iuuhc iti«taai.-vs ttiere are grt'at lieut of surfatv, firth 
fuK' awfubs Biifl quickutiBBof jtulae; uutsoniuch from any febrile (ItsLurliaiicr, 
but u[)pur«iilly I'runi tbe vmleuce ui' the muscular cuotractiuna. In muet 
van-n UiiH fljiupUiiu is peculiarly uiarktnJ, ee]iecially towards the end nf ihn 



ca»(?. when Lbc lemperatnre 



< may rspiillv rise to extraurdlnary herehls. 
a case in which it reached l)2.'>&'' r'ahr. i 



Tbns. 



dialflv In ti.r.' .leaih. It may riw u lew lonthauf a degrw" bigluT after death 
ill lUt.'f i\.-t'-. The jimlon/ation ul'life appears to depend ^Tt^Atly ii|H>n the 
ioleuaily oj'tlie convulsive luoveineots: the more aerere thfse art', the (tomer 
does death result The fatal termination oocurs not so much from any ^reat 
phynical li'siitti, or disturhaui-e of imiiortaut porta, as {rom exhausliun ooo- 
acauetii on the freouency of the teimiic spaftnu. 

PATnoEXKiv. — 'Ihere in surely nothing more reiiuirknbl« in lite wbol* 
liisiory of dtaease than that, in c<»ise(jueocie of a trivial wouu'l inHictexi on a 
distant part of oite »t' tbe extreiuitie« of tlie body, an uthirrwim apfiarf-utly 
healthy nian should be seised with a spa8mo<iic arfecttoii of the muM'lva of 
the jatrs; that this apasm should extend to the trunk ; and that after a few 
hour* it fliiould 1m* tallowed by general conTuUive lunvemenls which will, in 
tiie ([real majority xf instances, speedily end in death. It might reaiMiuably 
be ex^H-rtt^l ihxL xueh a train of pheooiueua would leave the niovt unrai*- 
takablv fviduiR-en of the conditions that bad given risp to theiii ; and that 
IJHili<>li>t|;ietil HUMluiiiy would »l onoe, ao<l in tbe cleAreat inuitnvr, tenable us 
l» iinnivel thf myrtlirious liouds that connect a graxi.* of thv fuoi with a 
Mtnnni of the uiuMrle* uf the neck itnd jaw. But in tbia mv ebiill tte f;rievouely 
uiM(p[M>i tiled ; for tliv morbid appearances found alUr death from tetanus 
thn>n' but little light on Ui« real nature of tbU atfection, — «o little, iude^, 
that it bas been Irequently described as a " funcliuunl dieetuuL" But in 
anyiug that this ur any other disease b fuuctioual. we express only our ignor- 
ance of ita real cause. There is no lunetiou without au organ to perform 
it ; and there can b« no darangetucut of a tunctiuu without a corrvHponding 
and cuucuumant disorder of tbe organ that produces it. iDvery Tunclioiuu 
diaaaM must, therefore, at last be reterrod to an organic lesiuu. Tbe term 
"Ibnctiuual" la employed only when we are not acquainted with tlie true 
nuturu of tiK? dipt'iue. As le« n knowrn of tbe real physiulaffy and paLhulogy 
of liif bruin and ttpinal cord liMn of other organt of [he thMlr. we have oiura 
" futii'ttonul " dti^'iuiee uf the nervous sy»tcni than of the circutatory ur re- 
ajiiraiory. But, as pathological nnatumy becomes more atudit'd, and ■■ 
intnutu luvCKtigatioU!) into structure are eutored upOB.so the chias uf so-eallad 
" funcliuiial " diseates bccoiua narrower. We do not •}>eak of " funottan^ " 
ouuiu, because we can appreciate the didercnt conditions thai occauoa oo»- 
prabiiui of ibe brniu ; but w« siill sometimea apeak ul lunrtional cuoTaliiva 
atHaiMs and of functional amaureaia. The opblbalniusc^ipe. however, has 
shown thai " lunotional" amaurwdt does one eotiel, but thai the &ilure of 
visual power b always dependfnt on eume change of simciuro in the interior 
of ihv eye; and advances in pathology nill doubtless show that other m^ 
called funeuunal disesuea uf the nervous f^stem are in realitv dcpendeai oa 
Mirurturwl Iftiona. 

Sutc of the VoTTM At tht Smt of I^|vy.— There is one morbid ooikH*^ 
Ltun t]iaL will, I tliiuk. invariably be foond in tetanus, vIl. a marked 
IfCBtioo and inflaoimatioa of the narv* «onn«cied with, and l««ding froea. 




TETANUB — FATHOLOOICAL CHANGES IN CORD. 65 

tbc woand that bu occanooed the diseaee. Tbis morbid state I have never 
found wantiDg. In all cases of &tal tetanus that I have seen in which a 
careful dissection has been made, the Bigos of infiammation of a nerve 
eonuBunicmttng with the wound have been found; and the vascularity, 
which is often very intense, may be traced up the neurilemma, often to a 
OKiriderable distance. In a case of tetanus following a wound of the knee, 
in a pfttient who died in University College Hospital, a small branch of the 
internal cutaneous nerve was found to have been injured, and was inflamed. 
In another patient who died of tetanus about sixteen days aiter treading on 
a rusty nail, a black speck was found on the internal plantar nerve, wnere 
H bad been wounded by the nail. In a man who died of acute tetanus a 
week after receiving a lacerated wound of the dorsum of the foot, the digital 
nerves were found to be sloughy, and evidences of inflammatory irritation 
extended some distance up the musculo-cutaneous nerve. In another case 
under my care, in which tetanus resulted from a bruise of the back, and 
terminated in death, the injured nerve (a dorsal branch) was found lying 
bare and reddened in the wound ; and, on tracing it up to the spinal cord, 
iu sheath was found to be much injured and eccfaymosed. In another in- 
stance, in which tetanus followed a wound of the wrist, the external cutaneous 
nerve was found in a similar inflamed state. 

Tlie Pathological Conditions found in the Spinal Cord in cases of tetanus 
have been studied by Rokitansky, Lockhart Clarke, Dickinson, and Allbutt. 
Bokitansky described them as consisting chiefly of a proliferous development 
of connective tissue, composed of young celts. Billroth doubts the correct- 
new of this observation ; and many competent observers have failed to 
discover anything more positive than ecchymosed patches and interspaces in 
the spinal medulla. Lockhart Clarke has in at least six cases ooserved 
lesions of structure in the spinal cord, consisting of disintegration and soften- 
ing of a portion of the gray substance of the cord, which appeared in certain 
parts to be in a state of solution. The fluid thus formed was in some parts 
granular, holding in suspension the fragments and particles of the disinte- 
grated tissue, but in many places it was perfectly pellucid. He considers 
ihb due to hypersmia of the cord, accompanied by exudation and disinte- 
gration. Dickinson has described intense hypenemia with a structureless 
exudation poured out around the vessels in many parts of the gray matter, 
breaking down the surrounding tissue. He observed also some hemorrhages 
in the «rbite columns. These observations have been confirmed by Clifford 
Allbutt, but the exact significance of the changes observed is still uncertain. 

The absence of any constant and distinct patnol(^ical lesion has led to the 
hypothesis of tetanus being dependent primarily on blood-poisoning, and not 
•iO a lesion of the nerve-centres. Billroth, who inclines to this idea, admits 
that it is a mere hypothesis. This theory of blood-poisoning being the pri- 
mary cause of tetanus is based on the following line of argument. A 
chemical substance, capable of producing convulsive moveraeuts when it is 
abii>rbed into the blooa by its action on the nervous centres — of acting, in 
fisct, like strychnia — may be supposed to be generated in certain circum- 
Kaoces, whether due to some individual predisposition, or to some peculiar 
fermentative process in the discharges of the wound or at the seat of injury. 
We have the analogy of hydrophobia in support of the idea that, in certain 
circumstances, such an agent may be generated in the system, rendering the 
fluids — blood and saliva — poisonous to others, and capable of developing a 
courulsive disease in the animal affected. We have, bowever, no evidence 
as yet that the blood or any one of the secretions of a tetanic patient is 
capable, when inoculated, of producing a similar disease in a healthy animal. 

There ia one objection to this theory which appears to me too serious to 

VOL. II. — 5 



w 



DISEASES or THE XEBVOfS STSTBJI. 



be overlooked, viz., thai tetanus hu been arrested, if not curnl. h^ Uk 
diraion of the principfll iiervuug trunk lesdinj^ from the seat of injury, M 
tbe pOAterior tibial nervi- in caM» of tetanus arbiuv fn>ai wouml of ibe «•■!« 
of tllQ foot. Tbiii fact a|)[)eAiB to m« to jxiiiit ratlipr to » primary uervout 
IcAioti than to bliMMl-pittimiiiii]; a» tht exciting chusv of tliv tHtanic cuiivtilnioOA. 

TltEATMKST. — Tbe trcatiiit>i>t of U'lnniis if of a l»cai aud of a tMinfttltU" 
tioim] c!iamrt<T. The Local Treatment ha^ tor ita object the remuval of the 
irritatioD that liaa imluced the lutanic conditiuD. It is true that, whvn oitor 
tetJUUC excitement htu be«u »et up in tb« I'onl, il has a tvndencv t«i c"a- 
tione, and to be iucapiablL* uf removal bj tbe mere abftmolion or tfcsaattoa 
of tliu local irrltnliou which gave rise to it in the 6tvt ta»taace. Il iv. 
buwevu', odIv reaaonaUIe to BUppoee that other treatueoL will succeed beet 
if local irritation be removed ; and, indeed, »o long as Chis continues to keep 
up the centric uej^'ous diBlurbance, no general means cau be expected to 
niccced ; aa they n-ill have not only to combat already exiitiog diaeaae. but 
also to overcome the continuous excitement maintaiuod by thelooiil dbtoHt- 
aaoe. Hence il in of ini)>>>ruincc tu bring tbe wound into as heallby a state 
as pceafale, and to see that il is cleoii, free from torc'T?ii bodiea. and dbI 
inflamed. In order effectually to remove all local disturbance, rMoum hai 
beeo bad to anipiitntion; but though ihig may have succeeded in chockioe 
some of the more chronic forniD of [he dieeiieo, yet oilier and milder local 
moana have sufficed equally well, and in iho majority of coat* it ha^ had ae 
efl^t, and henoe bo severe oo operation can scarcely be recommended for 
adoption. The division of the truak of the injured nerve, at some di»tanoe 
above the wound, if there be one that bae becu punctured or taoerated, ha* 
occaaonatly proved 8uecca§ful. Thuii, iu a caae of tetanus following iojurv 
of the guprnorbital nerve, Larrey cut ihi« at-roea, and ihe patient recovered. 
lo a midshipman, id whom tetanus came on the day after the eole of the foot 
had been wounded by ireadiog on a rustvuail, Murray divided the posterior 
tibial nerve, and ihe patient f^ot well, to ilio«c case* in which no special 
nerre appears lo hav*; iax-u injured, Lijtio)i'!i n-coiumendaiion of making a 
y\-aluipe<l incision down to the bout.-, and above ibe part, »«• as to iiuulale il 
compk'Iely, may be advantageously followe«i. After the nerve ba» Iweo 
divided, or the i>an pniperly insulated, gome solution of atropine inuy be 
carefully apjilied to it, so as stilt further t^) leeeen local irrJtalion. lu!>t«ad 
uf dividing the nerve leading from the source of irritatioo, it has l>een »ug- 
geited thai Uie ofteration of stretching should be performed. This baft been 
done in a conniderahle number of cases, and as with every other of the voora 
uf reme^liefl, lucal tuid consLilntioiial. that have been recommended for 
tetanus, recovvriuef have taken place after its employmeni. On Lbe other 
hand, in acute oues it has proved us impoteot as the rest. 

In tlie OoDsUtatiODal Treatment of the disejise. it is neceaury to bear In 
mind that teUtnuM is an affection of dchilily, the violence of the spasmodic 
poruxyamfl giving an appearance of false strength to tbe patient; and that 
the pnnoipal source of danger aoti death is the exhaustion induced by the 
enrtrio' of the muscular muvcments. The mmnti adopted should. ibetvJore, 
have for ihuir object tlte removal of irrilfition aud the support of the patient's 
strength, so as to enable him to hold up against, the dbeaae. 

Nothing can be more unMati«factorv than the ireatmeiit of tbe Atmie form 
uf traumnlic tt'tnnus. In it. nil medicines are ueeleM as curnUre agent*. 
Hut. though meijicim's are of no avail us means of cure, they may act as 
palliativ{«, and sHonl relief to the jiatieai; and much may be douu by the 
£>urgeoi). by removing all sourceti of eilenial irriuition, ti> mitigate bis aulfer' 
[Sngi, and to place him In a favonthli' condition to withstand tlie cKhauniion, 
and |o Ifwien tbe lonure of the ftpiunn. With this view, th<' first thing lo 



I 
1 



TETANUS — TREATMENT. 67 

be done U to clear the bowels out well with an aperient dose; aided, if 
oecw— ry, by a turpeotioe enema. The patieDt should theu be kept perfectly 
i^uiet ID ■ room by himself, a ecreeo or muslin curtains, as recommended by 
Marshall Hall, being drawn round the bed, as noise or movement of any 
kind iocreaaes the spasms greatly. In order to allay the spinal irritation, 
the moat efiectual means consists, perhaps, in the plan recommended by 
T'^dd, of applying ice along the whole length of the spine; this is best done 
by a caoDtcnouc spine-bag. This is a powerful depressing agent, and, unless 
care be taken, may lower the heart's action too much, or, indeed, completely 
extiDguisb iL It may, however, be applied with safety for six or eight 
hours, the condition of the patient being looked to in the meanwhile. Seda- 
tive or antispasmodic agents are of no use whatever in acute traumatic 
tetaniu. I have seen many drugs of this kind employed without producing 
any e&ct in lessening the violence of the convulsions. In most cases, 
however, the inhalation of chloroform, or the administration of chloral, 
materially lessens their severity, and gives the patient at least temporary 



In the Subacute or Chronic form of the disease, recovery is much more 
likely to take place ; and it is only in these cases that antispasmodics and 
aedatives bare been of use, and in these also chloroform and chloral are far 
iu<>re beneficial than in the acute cases. There is a kind of trismus occur- 
ring in females, often of a hysterical nature, which is at once removed by 
the inhalation of chloroform. Almost every drug in the pharmacopoeia of 
m tonic, sedative, or antispasmodic nature, has been employed in tetanus ; 
aod the recovery which has occasionally resulted has been perhaps over- 
haetilv attribute to the remedy, rather than to the employment of those 
dietetic and hvgienic means which are of the 6rst importance, by enabling 
the patteot to live on until the disease wears itself out. Tunics, especially 
irai and quinine, have been employed by some. Elliotsou was strongly 
imprened with the value of the carbonate of inm, Sedatives in nil forms — 
oonium, belladmina, opium, and their alkaloids — have been largely and most 
ineflectoally employed. Miller speaks highly of cannabis indica pushed to 
narcotism, three grains of the extract, or thirty minims of the tincture, being 
pveo every half-hour or hour; and Ilaughtoii has employed nicotine in 
one-^lrop duses, administered every second hour, with complete success in 
severe cases of traumatic tetanus. 

The (.'alabar bean (^Phi/gogtigma) is the remedy that, perhaps, deserves 
physiologically the most attention ; for as it is nearly, if not quite, antago- 
nistic to the tetanic spasms of strychnia, it was hoped that it would be tound 
t-qually useful as a sedative to the spinal cord In those arisiug from traumatic 
causes. In K. Watson's bands, very successful results followed its adininis- 
tration. Vet it is far from being a specific. I have tried it in several cases, 
with no appreciable good effect. It may be given by the mouth, hypoder- 
micallv. ur ptr antim; in the form of a solution ur a tincture of the extract 
in half-grain doses, by the mouth; hvpodermically, iu doses of one-sixth of 
a grain : per anum, in grain doses. The dose should be given at least every 
?«c'>Dd hour, until complete contraction of the pupil occurs, ^^tiniutunts, as 
brandy, should at the same time be given to counteract the depression that 
will result from the use of the drug. At the same time th:it recourse is had 
!•> «uch measures as these, it must not be furgotton that the <lisease is one of 
i;rc«t exhaustion and that the patient wilt die worn out, unles.~ he he sup- 
j.!ie*l with plenty of nourishment. Beef-tea auri wine should, theretore, be 
administered by the mouth, as long as the )>alient can swallow, nnd nutritious 
"nirmata by the rectum; and iu this way the pnvers of life may be sup|iiirted 
until ibe violence of the disease exiwnds itself. I am, however, disposed to 



DISSASSB OF THE LVMi'UATIC STSTKU. 

think that ev«u in tbeee chronic ca»c«, much more may be don« b; fiinple 
than by irpecJfJc Irvatroeni. Clearing out the howcU by a turpentine eoenia. 
brt^alciu^ the violence of the spaanu and gtviog the patient rwt and «rk by 
chloroform inhalations or bv chloral eneoiBta, and Iceeping up tb« |>ou'vra «f 
tbeiyvtetu by injectiout of D«ef-tea, egu. and brandy into the rectum, till Ihe 
doeaae weiue itself out, appear most likely to be (bllowed by a c«tl»ractury 
K«ult, wheD u^ in flddilivo to the hygienic tseaaures recunioiended in the 
acute fonii of the diaense. It is certainly more ratiooal lo employ tuch 
meaeur(-8 as these, than iu the vniu hope ot finding a specific fur letaiiuf, to 
be constftntly recurring lo ftntiepB&modic and Bcdatircs, which n-pesUil 
experience htti proved to be uaeleu as curative agents. 



CHAPTER XXXIX. 

DISBA8E8 OP THB LTMPHATIC SYSTEM. 



INPLAMUATIUN OP TUK LYUrilATIC VEMKL^ 

Lymphangitii, or, aa it was formerly called. Angeiolettcitia, la n diffuse- 
inflanimalittn of the )ytn]iLutic vesaeU. 

Cai'SF*.— Id ihe va*t majority of eaaes it arlHea from the irritation caund 
by the prvsence witlitn the vessels of the product* of an infective Inflamma- 
tion aflecling tlic tiMuea from nhicb they derive their lymph. It thuk foriii« 
rather a conipliraliuti of these indamuations thtin an inde|>endent diaeaae. 
Moet couinionh' it is atMiociated HJib cutaneous eryci^elas, but it ia alto nwC 
with in other forini> of infective inflanmiation : thus it ie a frequent result of 
the iuoculatiou of virulent matter from dead hodiett, and is occusionallv aeen 
in the lymphatics leading from a aoft chancre. Iti moct caeea, (hcreJbre. a 
wound or nbrasion servca as ihc starting-point uf the inflaminaiiuD. It is 
very rarely, indeed, thnt lymphangitis occurs %(ithuui some such exlarnat 
cause : yet we arc certainly warranted iu eousidi.-nn)' it aa of idiopathic ori^ 
in auiiiu iuetiLuctf. I have at least seen casejt tu which Lwreful examinauou 
hna failed iu detecting any breach of surface or cvideiic-e of local infcctiuu. 
The iliwase is predisposed to by Ihe same camwa that favur the dc%'elupmeui 
of erysipelas, aa by atniijepheric vicii«itudeB, by particularseawitu of the year, 
more ospecially the early spring, ami by epidemic influences. Broken health 
and the ueglret uf hygiunic precautioike uIm) Lend to induce it. 

MoKniD Anatomy. — The wulln of the inflamed ve»els becnme swollen, 
■oftetieil, An<l iufittraii^d with small niiind eel b. and the endothelium dea- 
quamates. Tfwier Btates that ihe lymph coagulates, forming a rosy clf»t 
which plugs the ve«.<^l. The inflammation, thbii^'h oommmring from irrita- 
tiou within the ve>iicl,9iion extend.* beyond its wall*, the !-urronnding areolar 
tissue becomes fiwolh'n and infillratcd with inllahiniatory produelii, and toin^ 
times suppuralioD may take place nrnund the inflamed lympbntic. 

SvMi-roMs.— During the progress of au ordinary injury, the |>atieDt ta 
eeiu-*! with chills or nj;on>, with considerable elevation ot ten|>erature reach- 
ing 102° F. or 103° r,, attended, perhaps, by vomiting or diarrh<«a. These 
syuptvtns mny precede by twelve or fourteen houra the local signs of the dtt* 



LTUPHAKOITIS — DIAGNOSIS AND TREATMENT. 69 



■ tmaty bat.inore commoDly accornpanr them. On examining the part it will, 

■ if snperficial, be Been to be covered 07 a number of fine rea streaka, at Brat 
^ icattered, but graduallT approximating to one another so as to form a distinct 

baad, about an inch in breadth, running from the part affected along the in- 
side of the limb to the neighboring lymphatic glande, which will be felt to be 
enlarged and tender. The band itself feels somewhat doughy and thickened. 
Sometimes one lymphatic can be felt hard and isolated like a piece of whip- 
cmi. There is usually more or less oedema of the limb, from the implication 

• •f the deeper lymphatic Teasels and their obstruction by the inflammation. 
Along the course of the inflamed lymphatics, erysipelatoua-looking patches not 
unfrequentlr appear, and coalesce until they assume a considerable size, and 
onstttute a distinct variety as it were of erysipelas. In some cases the glands 
are atfected before any other local signs manifest themselves, owing probably 
!■• the deeper seated lymphatics having been first implicated ; or possibly to 
the direct absorption of and deposit in them of some infective matter that 
o»nstitute8 the primary source of the inflammation. Not uncommonly 
throuiifaout the disease the inflammation continues to be confined principally 
t't tbii set of vessels, giving rise to great and brawny swelling of the limb, 
but without much if any superficial redness. The constitutional disturb- 
aoce. at firet of the active inflammatory type, may gradually subside into 
the asthenic form. 

R»^^■LTs. — The disease usually terminates in resolution at the end of eight 
or ten days; not uncommonly it runs on to erysipelas; and in other cases, 
azAin. localized suppuration may take place, sometimes in the form of 
•>ae large deep-seated abscess in the iliac fossa or in the thigh if the lower 
c-xtreroitT, or under the pectorals and in the axilla if the upper extremity 
tw' the seat of irritation ; or a chain of abscesses may form along the course 
"f the inflamed lymphatics and in the glands to which they lead. In some 
ia^tanoes, after the disappearance of the disease, a state of chronic and rather 
f-Aid oedema of the part may be lefl, giving rise indeed to a species of false 
hvpertropby, and constituting a troublesome consequence. More rarely 
death results, either from general blood-poisoning, or as the effect of exhaus- 
tion fmm prolonged suppuration of deep-seated abscesses. 

The Di.vGNOi^if) of inflammation of the lymphatics has to be made in its 
•^^rly stages from phlebitis and erysipelas, and of the abscesses in later stages 
I'r-im th'»e of py»mia. From phlebitis it is easily distinguished by thesuper- 
ri<'ia! redness of Ivraphangitis, and the absence of the cord-like plugged vein. 
Fmm erysipelas it is distinguished by the want of a defined margin to the 
reilnese, and by its extending in the line of the lymphatic vessels only ; but 
the affection in most cases is closely allied to erysipelas, and in others merges 
into it. and consequently the distinction is often of little consequence. The 
scute lymphatic abscess is usuallv distinguished without difficulty from the 
pv:t>mic; the lymphatic abscess Wing, if deep, solitary; if superficial and 
Hjaltiple. confined to the tract of the previoualy inflamed absorbents; in 
.--iiher case being always between the starting-point of the primary source 
■•I irritation, or wound, and the glands ; in the calf, thigh, or iliac fi>ssa, if 
I be primary irritation be in the lower extremity, in the axilla if in the upper. 
The fever is moreover more continued, and the severe rigors and sweatings 

• ■!' pyemia are wanting. 

Ti:l.vtmknt. — In superficial lymphatic inflammation of the skin and in- 
t.-jum<*ntal structures, the local application of belladonna, as recommended 
t'V C. Heath, is the most efiicient agent in subduing the local process; a 
\-3fie of equal parts of the extract and of glycerine should be thickly smeared 
■Ter all the inflamed parts, and covered with a thick layer of cotton-wool ; 
the limb at the same time being kept elevated. As a substitute treatment, 



70 



X»IS£A&B8 OF THE UYMPHATIi: SVaTKV. 



^fhougli of Inferior value, hot popjiy-iiiiKt-nlfitiMiw remj be hwU. If afttr th* 
ibtial of the acute inHfttntnntion niucli chronic indunitioa and iiHleioa occur. 
IwtiHagiiig, su D* lo c(>mpre»ij the limb, nod njeliiodical friclioo will b« of 
wn'ice. If nbsc«tB«» form, ihey »hi.'uld be optiied early and trvaled oo or* 
dinary principle*. 

The coaHtiluliooal trestnieot is Ihe mluic bb lor cry8i|ielas. No ilcpletiuu 
b ever ju»liGnbt«, oud etinttilanU are ofleo retjuired iu consiilerable ijuaiiti- 
dcB, nitfa abuQiJaot liquid food of a Dourialiiug kind. Perchluride of ima 
and (|uiaiDe are oHea uteful. 



VARIX UV TBK I.TMrilATH' VlBgErA 

Tarix of the Lymphatics has been occasionally n>et with, boib in the 
auperlicial and deep nciworks and iu ihc lymphatic Irunka. The pan moK 
commonly found ofTectcd tms been t|io ioDcrsiJcof theihigh ; but tncdIaeMe 
hae been seen also in the Anterior wall of the abdomen, about the ankle and 
ellKiw-joiu(«. and DO the prcpuci^. Iu tbe ^fupt^rficial lyinpliatii.'fi. the varix 
fin>t a|>))i^tini in (he form of »ii)hII ti'lvvations. giving tbt? vkiu an ap|iearaDc« 
which has been coiupaired to Ihe riud «f an orange; It flubsefjuenlly lakes 
the form of tiltle vesiclts covered with a ihio layer of epiderniin. Varii 
nf tlie larger lymphatic trunks frequently accumpauie^ the cuudilion ji»( 
dewribed. The vevselB may either be dilati^j cyliudricnlly into round beaded 
eiiliir^icnieiiti!, often Kmi-traneparcrnl, Had but •lightly ct'mprt-wible: or 
atnpultie tuay be formed on them, giving rise (o more or lets tofl swelliag*. 
Sucttifiting under the lin(.'er. There is some a-dema, nUributable either Ut 
iil>«trttiiit>n of the lymphatics or to the impede<l flow of the lymph. 

Iu 't1 uut of oo recortled ca^s, u discharge uf lyotph (LympboiThiBa) Una 
l»eeu obeerved. Tbh^ ban been i^een to occurnlso without varix,n« the result 
of wound. In the latter en^e I he flow iscouiiuuouH; while iu the lynitihorrIi<t« 
nhich Htteiida varis, is is lo «ome extent iulermiltent. The iilentitv of iho 
flui<l difchnrgtHl with lymph hn» been e^iabliithed by chemical nnd micro- 
Bcopic exuitiinntion. An excessive discharge of the fluid h liable tn produce 
ttvmptoms of general debility, of the tame kind aa tboau induced by hemor* 
rtiBge. 

TiitMTiir-vT. — SpoDtnnooiu cure of lymphatic varix ham been ol)iser\-e<l iu 
ra»ea where the penin waa nfiected.the discuse being the remit nf the obfttrur- 
tion 10 the How of lymph cnut>ed by buboe«. In other inatniices, varioaa 
plane of ireniment have been tried, with apparently indifferent mull. 
CaitMics have been u»ed by aevernl Surgeons, but, aa the dii-eaw is otten 
deeply »ea(ed as well »a superticial, with but little result. Beau treated 
three ease* nuci-eHfulIy by intriKJucing a seton into the ililatcd lymphatic 
Vef>)ielt>. and ev<-itiug HHhei<ive iollAmntation. B. Bell advise* ligature of the 
lymplmUe vexee), from nhieh the discharge of Huid takes plni.-<<. I.'umpre*> 
aion by meaiM of a tiandagv ha» been recotninetide*! by Niilatun. 



I 



EtKpnjiynAris of tob legs a>u spnoTtTi. 

Elephantiasis Aiabum, or, as it is often callc^l, iho Barbadoes Le^. is an 
atfociiuji tbul ib t^x<mmon in miiny tmpicjil coualrieH. in the VVec<t Indino 
Islands and in Bonth America more iiarticulurly. U ix met with, tboueh 
cumparalivolv rarely, in J-Jirope. Ttie di£«aite usually afTecta one of toe 
lower extremllicB (seldom bulb ', the scrotum, or the Inhia, which may be> 
«otike enormoiialy enlarged and hypcrtrophictl. In the &ce it ia often mtt, 
I with ; [n the upper exiremitiea rarely. 

It ii not my iDtentioD toenter intoaoaccoantof thabatory, thasyraptt: 



■ LSPHAyTIASIS OF THJ! LEGS AND SCROTUM. 



71 



or the caoMa of this remarkable malady. It is Bu£Bcieat for my purpose here 
to wmj, that it appeara to consiit in disease primarily seated in the lymphatics. 
The f^aodB, as Virchow and RindfleiBch suppose, become impervious to the 
trmnsmiHtOD of lymph, and the hyperplastic deposits that characterize the 
diseue are, together with the general stretching and hypertrophy of the in- 
t^amental structure, the consequence of the plastic efifusion into the areolar 
ti»ae. 

Trextuest. — When this disease attacks the face, little, if anything, 
avails in the way of treatment. When it affects the labia and scrotum, the 




Fig. 432.— Weit Indiao Blepfaantiasis. 

enlarge*] and diseased part must be removed (see Diseases of Penis and 
!*crototn I. But wheu the leg is affected, surgery can effect much iu the way 
of cure. In the slighter cases much may be done by elevation of the limb, 
mdhndica! bandaging, and perhaps, as Kayer anil Lisfranc recommend, the 
effiploymeot of scariHcation. But in the more severe cases, where the limb 
ha« swollen to a monstrous size, and has become shapeless from the groin to 
the ankle, the skin sallow, covered with nixlulea and'overlnid by branny 
d««<:(uamation, with a tendency to unhealthy and incurable ulcerations — in 
thff!^ aiivanced and serious cases, more active measures are necessary. 

Ihifour seems to have been the first to propose diminution of the supply 
of anerial blood to the limb as a cure for this disease. This he effected by 
compre««ing the femoral artery by means of a kind of truss, and was suc- 
cecvt'ul in four cases. This practice of compression has since been succes.v 
fiillv followed by Hill, Cockle, Vanzetti, and others. 

To 4 'amoeban is due the merit of having recommended the ligature of 
the femoral artery as a means of cure in these cases; and, in whatever way 
it «<^. there can be no doubt of the excellent effects that have followed this 
metho'] of treatment, little as it can be explained by the received patbologi- 



72 



tllSKASXS OK TIIK ItYMPUATIC SYSTEM, 



cftl views of the iHikhw. Iu oome iuBtances, aa by BryauL, Bucfaaoaa, and 
Simon fof Hvitlclbeiyt, tim ext«riial iliac has be«n advantageously tied. 
The 0|>erHtiun «ii this arl«n' has tht> recnmineiitlNlion not only of b«ing coot* 
pletvly aUivtf the liniits of the disease, and consequently in parts thai are 
quit« healthy, but also of more completely controlling the nutrition of the 
limb than cati b« done by ligature of the superficial femoral. 

Eppner, in 1881, collected the records of 49 catH» of elepbaatiasia treated 
by ligature of the main nrtery leading to the diseased part. In 40 of these 
the femoral was tied ; in b, the external iliac; io 2, the popliteal: in 1. tbe 
anterior tibial ; and iu 1, the brachial. Of these 31 are reported to bare 
been cured, 3 relieved, 1 unrelieved, and & died. Of the cases reported as 
cured 9 8ul»ec)ueDtly relapsed. The result of tbe operations appears to hare 
been fairly cucuuragiug, although in a certain number of coses it is evident 
that little, if any, improvement ttxik place. 

LYUrUADENnUi, OK INPLAM.'tlATION OF THE LYUPRATIO OiaKSe. 

Acute loflammation of ths Lymphatic Olanda almost invariably results 
from the irritation of srime noxious material conveyed to them by the lym- 
phatic vesneU. The lytnphaticj through which it passes on its war to tbe 
glandft may thenuiei ves he inflamed, hut more trequcntly they escape. Thb 
fact would ^em to indicate that in the majorilT of co^es the irritating mat^ 
ter is particulate and not in solution : as we know from experiment that 
solid particles pass readily through the lymphatic vessels without lodging, 
but are arrested in the lymphatic glands. In every acute inflammation the 
quantity of lymph passing through the glands in connection with the af- 
fected area is greatly incrcoiic'd. In simple ittflammations in a healthy sub- 
ject tliis causes slight swelling, which sulfides m so<»n as the cause is re- 
moved : but In itcrofulous subjects, as heforu pointed out, there is a peculiar 
tendency to tnilummation uf the tymphutic glands from slight causes, and in 
them the swelling may jwrsist, and may jiiuis on to suppuration or chronic in- 
flamroatiun. In infective in Sam mat ions the iuHammutory products cuutuin 
thespecial virus Vi which the iutlammutioa is due, and this being carried by 
tbe lymph-slream to tbe glands may excite a. similar process in Uiem. Many 
specific intlammattons are accompanied by the presence of microscopic orgao- 
istos of a definite form in the exudations, and In such cases the organisms caa 
frequently be demonstrated by the uiieroscope after death iu the lymphatic 
glands Dearest to the :wnt of the disease. As a rule, tbe secondary iuflam- 
mation in the glands closely resembles in character that at tbe primary seat 
of dieenH?. 

Thus, iu cutaneous erysipelas, the glands are invariably swollen and ten* 
der, but seldom suppurate; in soft chancres, suppuration commonly takee 
place: and in diphtheria, the glands are always enlarged and painful, but 
pus mroly forms, while in scarlet fever suppuration is oAen vcr^' trouble* 
some. In syphilis, the change that takes place in the lymphatic glands ia 
identioid with that occurring at the «>at of inoculation; and the same is 
the ctuH^ in Mcondanr tuberculosis. 

Some infective inSammalions, as hospital gangrene and phlegmonoue ery- 
sipolas, have hut little tendency to infect the glands. This is possibly due 
t*i coagulation of the lymph in the spaces of the inflamed orca. [ 

In the nmjoritv of cases there is no difficulty iu discovering the source of 
the irritation whrch has caused the glands to inflame. In sororulous subjects, 
howe%'er, the effect may be produced bv causes so comparatively slight thai ' 
llifir detection becomes proportionally difficult. In some eases it appears to 
arise simply in consequence of a strain, as in over^valking. In children, the 




LTMFHADBNITI8 — PATHOLOGICAL ANATOMY. 73 

^lauds are more prone to suppurate from slight sources of irritation during 
cuDvmlesceoce from measles or some other acute specitic disease. 

Pathokigieal Anatomy. — Inflammation of the lymphatic glands may be 
a<:ute, subacute, or chronic. In the acute form the gland is swollen, and at 
tii^t piok in color and soft. At a later stage yellow points of commencing 
tfuppuratioD will be observed, both in the medullary and cortical part. At 
a still later period the greater part of the gland may be hollowed out into a 
cavity filled with pus. The appearances of subacute ioflaramation are much 
the same as in the acute. The microscope shows the usual changes observed 
ID all inflammations; the vewels are distended, and the gland is crowded 
everywhere with multitudes of small round cells. These very early choke 
the lymph-sinuses. As these cells exactly resemble the normal corpuscles 
uf the gland, it is impossible to determine whether they are formed by mul- 
tiplication of the normal lymphoid cells, or have been brought to the gland 
with the lymph from the inflamed area, or have migrated from the vesEels. 
The capsule and trabeculse are similarly infiltrated with small cells. The 
formation of pus takes place in the same way as in other parts. In the less 
acute forms larger cells are found, formed by proliferation of the flattened 
Lvrpuscles that cover the trabeculse and the inner aspect of the capsule. In 
the more acute forms the surrounding tissues are early implicated in the 
inflammation. 

(.'Anmic Inflammation of the lAfmphatie Glands is regarded as the most 
characteristic feature of scrofula. In it the gland is enlarged often to many 
times it« normal size. In the early stages, it is usually more opaque than 
natural, and of a gray or dull pink color. At a later period, yellow points 
appear, due to caseation. These points gradually increase in size, and coalesce 
till the whole gland becomes a uniform casenus mass still enclosed In the 
capsule, which is often considerably thickened. The caseation may terminate 
the proce«, the cheesy mass remaining dry and encapsuled without further 
change. In other cases it is followed by deposit of lime salts, and the dis- 
eased glaad forms a hard calcareous mass. These formations most commonly 
occur m the glands of the abdomen and thorax. In superficial glands the 
caseation is more commonly followed by softening of the cheesy mass, which 
break.- down into a thick fluid not unlike clotted cream. The softening is 
accompanied by inflammation, and the stow formation of pus in the tissues 
r.'und the gland, the capsule gives way at the most superflcial part, and the 
fluid gradually approaches the surface. The chronic abscess thus formed is 
vrry slow in perforating the skin, often undermining it for some distance 
>>ef<.>re finding an exit. Microscopic examination of these glaods shows in 
the early stages a great increase in the lymphoid corpuscles, not only in the 
f't!]icl«> of the gland, but also choking the lymph -sin uses. Amongst the new 
4i'rpu^-lt:« lai^r cells are found many times the size of a lymph-corpuscle, 
aod apparently developed from them, as all intermediate varieties are found 
Ixrtwtr^n the two forme. The flattened cells covering the trabeculie, and 
lying on the meshes of the reticulum of the gland, proliferate, and may 
r-mtftin>e* be recognized forming a coarse network amongst the lymphoid 
•-•rpuscles. At first the gland is more vascular than natural, but from the 
{■reri#ure of the accumulated cells the vessels soon become obliterated, and 
D*-D-vai>cular areas are formed. At this stage, in a very large proportion of 
f- roiulous glands, giant-cells surrounded by a zone of larger cells, and again 
by Ivmphoid corpuscles, forming thus the anatomical structure of a tubercle 
n->iule. are met with in the non-vascular patches. The caseation commences 
in the non-vascular Bp<its, and gradually extends. The trabecuhe disappear 
la#t in the caseating process. In a large proportion of cases examined up to 
the present time, the tubercle bacillus has been found in the cheesy glands. 



74 



niSEASBS OF THE LYMPHATIC SY8TSM. 



Ill the pr<wi)t stnle of uiir knonleil;;?, U u not pooeidle to define nccurawTi 
tlif retniion of tiil>»rclft M chronic grlHticluUr inflnmnmlinn. In ihoae nt»» 
in whicli iheglftiitliilnr (liH«^^ ij* W'C4>iidi»ry in «. iiibcrciilar aflV-rtion of tbr 
rejjion JWini wliicli ihcv rfc»?ive their Ivnijih, |li*y ore pruUnldy titbfrrulAr 
from the tre^inniiij;. it\ i>lh«r vtavn thi- ihniiiir iollnmnintiuii mny be ante- 
Ci'itent to mill ii pn-ili0|Hi!>ing (.'anHV of the ileviplupiiiviil. of lutirrclr ; ami ag>in 
it 18 |>r<)bii)il»f llint ghn-Dic intlniiimatiou followwl by c«#*i»ti"i> ninH •oftcniti^ 
rtifly lake lAatx without tin; prvWM beiug at «uy tiiiiu tul)«r(.-ulnr. Tb« »oll- 
etie«1 cHsvuus pro<luct of clironic iaflnmiiiatton uf tbv lympbattc glanrla hm* 
betu bt'licvtrd fur maov jeare to be a toutcl' of jtein'ml tubercular infectiuD. 
the fioc trmnulnr tlibris entering the circulation and bMlsing in distaat pari*. 
and there causing the growth <d' tubercle. ISince Kocli's divcovery of th* 
badlluB of tubercle, this organism hns been believed to be the actual infectire 
iiiiileriiil ia ^iieh cnses. This ]j;eneral infection vrbcn it lioes occur it, how* 
ever, merely an at.*c)dcninl occurrence, the vnHt majority of patients who raflbr 
from oueating lyniphaiic glands escnpiog with nothing' more than the tuoal 
disease. 

Indumtion of the gland, duo to thickening of tbu trabocuW and capaatv. 
and of ihe meshes of iht rctiforni connective tt«8ue, is not tin uncommon 
neult of slight degrees of chronic inflanimaiion. 

tn whatever wiiy occurring, intlAminnlion of the lymphatic gliutd« alwan 
causes obstruction to the flow of lymph thn)Ugh them, and if the whole or 
greater part of the g1and« of a limb be affected, rrdema, often of u solid char- 
acter, may occur in the parts from which they receive iheir afferent lymphatic 
VG«Bebi. 

.S\'MPTOMiL — In Acnte Lymphadenitis there are pain, twelling, t*ndt!ifc 
n«w, and Mtiffnn*)) about the a)feoti-d ijlande, vtith a dull heavy MtiMtiou in 
them. The otilline of the swollen ylncid i» at firitt cl«irly detiueiH, but 
••"•II beo^iiie* concenled by the tnt^aiii inn lion extending to the miiligMuu* 
|irei>tar tiwue, Before luug rfhicw, n-'ic-nia, ami the olhi-r »igr>« "f acut«^ 
»bMMI innke their Hp)^M.-ii,r»ui.-e. In Bnbacnte Lymphadftnitii the glnntU 
btonMBKullen. t'ulnrged.und lender, and un.- inaltitl logeiber by inltanima- 
tory exudation inu> ihu nurroumliny tiKeurs. If abeceas rnrni, t't fretjueniJy 
commences in the alnieturetj arotiiiil the glands: and ihoaw are, i>erbapi<, 
eventually expueed at the bottom nf thi- cavity that reeultc. Thb is espe- 
cinlly apt to hapjK'n in riiL-bei>li<ianJ strumous |K>rRou(i fntm t>tighi sources of 
irritation. Very conmioQly in hucIi HilijeetN llit.- inflnmniation of the ^flatids 
runs into a chronic elate. Chronie Lymphadenitis ur Stntraons Eolarg*- 
ment of the Lymphatic Glands may ari^e m n He<|uence of eiibaeute inHani- 
mntiim. but tiKirt' commonly the glands gradually enlargr- without marked 
pain or lendi-rnes^ in con9ei|Uence of chronic irritation tit' some kind. U is 
not possible to make any accurate distinrtion rlinically between nmple 
dlKHtio inflammation, strumous enlargement, and tnlM-reuIar dtseasft. 
Chrwnic inllmnmation if the glands i^ commonly bmktHl up< n aa thv nioal 
marke^l churncti-riatic of the »truniiiU8 dinthf«il^, and ihe ri-lntion of the pro* 
cesA to tnbi'rrle has been nlremly sufficiently discussed. TbeM i-hnnge* twcur 
princi[uilly in children and young people, and moot freijiiently in the neck, 
c-|>oci»lty in thv Hubmaxillary gtamh Mini the KlNnduln^ ctjncatennttf, ami 
••■metimeB in the axillary and in^fuinnl glnndit. The glands nlowty increnae 
in the, at firrt remaining clearly defined an<t distinrt from i*ach Mher. Thty 
may after a time cease to enlarge, and remidn ixTninnentty without further 
chango ; but more commonly, aftvr continuing in this itntv for months or 
Venn*, thry soften. The inttnmmntion then extends to tbo surrounding 
itimurs, nnd the glnmlif become adhf'rent to neighboring parts, and Rnnlly to 
the skin. .Several glands may thus become fused together, forming a large 




LYHPU ADENITIS — TREATMENT. 76 

intlurmted and nodulated tumor. Suppuration takes place slowly, and the 
?kiD becomes thin, blue, and uoderniined. FiDalty, it gives way by a small 
opening, and curdy, uohealthy pus is discharged, mixed with the debris 
from tne soAeued cheesy matter from the gland. The discharge may con- 
tinue fur weeks or moDtns, being kept up partly by the gradual expulsion of 
the remains of the degenerated gland, and partly by the thinned and 
undermined akin being too feeble to take any part in healthy repair. The 
■opening may close for a time, bursting open and discharging again at 
ioten'als. In other cases the thinned skin perishes, and the remains of the 
gland may be exposed as a reddish-gray or fleshy mass protruding in the 
midst of the sore. Wben these sores finally hea), they leave thin, blue 
cicatrices, finally forming irregular puckered scars. 

Treatment. — ^The local treatment of inflamed lymphatic glands varies 
according tu the variety of the process. In all forms tne local irritation to 
which the inflammation is due must be removed if possible. In acute lytii' 
pkadfnUi* the application of glycerine and extract of belladonna in equal 
parts, and hot fomentations may prevent suppuration. In the ntbacute con- 
dition, spirit lotions containing iodide of potassium will sometimes subdue 
the inBammation and take down the swelling. If an abscess form, it must 
be freely opened and the part dressed with some antiseptic application. The 
sinuses which are often left when the abscess is imperfectly opened, or allowed 
to dischai^ by itself, require to be treated by stimulating applications, 
especially the nitrate of silver ; but very commonly they will not heal unless 
thiey are laid open and dressed from the bottom. 

'.'AroRi'c or Sarofulout Jnjtammation of the Lymphatic Glands requires to be 
treated on different principles. When there is merely chronic enlargement, 
without irritation, methodical friction with iodine or iodide of lead ointment 
will sometimes produce absorption of the inflammatory products, constituting 
the bulk of the enlargement; and this in some instances may remove the 
tnmor entirely. In other cases, painting the part with tincture of iodine, 
and improvement of the general health, will cause the removal of the disease. 
When the gland has softened and is becoming adherent to the surrounding 
part^, it becomes an important question, at what period it should be opened, 
ft.' a? to insure the speediest recovery and the feast scarring. It was for- 
merly advised by many Surgeons to leave the gland until it becnme distinctly 
adherent to the skin, and until it was so complctety softened that the whole 
of the chevsy matter might be discharged at the time of opening. The result 
of this plan was usually to leave a deep puckered scar, and healing was 
jieidoDi complete for some weeks or even months. These unpleasant consc- 
•jurnct* can frequently be to a great exterit averte<l by early opening, and 
Ire* ^craping with a sharp spoon (Fig. 95, vol. i.). As soon as the pland is 
evidently softening, the operation may be performed. The gland is steadied 
between the finger and thumb of the left hand, and a puncture made into it 
with a scalpel about a quarter of an inch in width. A probe may then be 
{xui^tl ailing the scalpel, so aa to serve as a guide to the opening in tlie cap- 
•nle. The scal|)el is then withdrawn, and a small sharp spoon |)assed along 
thf pp-br into the gland. By forcibly S(|ueczing the gland and scraping 
with the s|>oon, the whole of its caseous contents can usually be removed 
without difficulty. A very fine drainage-tube may then be inserted for a 
few days, after which healing will probably take place without difficulty. 
Thf rc#ult« of this little operation are very much better if strict antiseptic 
prf cautions are observed; for if the cavity Ijccomes filled with decomposing 
dM-harge^, troublesome diffuse suppuration may follow in the areolar tis-fuc. 
I'--i>rf..rm iir salicylic wool forms the best dressing in most cases. If several 
slaod? lie cliise together, it is sometimes possilile to scraj* more than one 



Ttt 



UlSEASKS or THE UYHPUJkTlC SYSTEM. 



frviiii a single opeuing. Th« scan leil after this mode of treatmcDt arc vtrf 
•li^ltt. 

Il'»t> npcrture alrcaily exisu leading dowD tn an indarated niaae, th<>iiiitM 
limy Ik> freeir Kraped in the mme way. aod huliag is often basteoed by tbe 
iuwrtikiD vfa amaU -luantity ol' iodof»rm into the track left afler the opera- 
tion, tr uftcr an abacces has fornied and been opened, an irregular cavity 
i* li-ft with nintfoa of degeoemtiDg gland-tissue projecting into it. thew mar 
hv »ti'upcd away by a iborp spixin, or destroyed by potASM ftua. In apply- 
ipg ibc cnustic potash, care mual be takeu thai ita actioD doea Dot spread too 
widely ; ihU may usuallv bo avuidcd by cuating the iurrouadiDg inte^- 
incotH with oollodton. U'hc blue undermined iMtio left after i<poolanenua 
l)ur»iing uf a scrufuloua nbaeew of the glnods delays bealiDg, and is uselea 
itaolf fur any purpoaca of repair. It niiiitt. tbcrofore, be deau-oyed, however 
large the reaultiug aorc may at lirvt appiwr to be. This may be done by 
OMKOS of polana fiua, but nulling it with Kcistnra in a uamber of linei 
radiating from the central onoiiing will u-'^ually make it in great part melt 
uwuy. oud, al the same lime, is free ffim the ri.4k of destroying more than is 
neceaaary. 

Extirpntiuti of chronically infltimed and ciueatin^ lymphatic gtunda haa 
been reconimendtMl, with the view uf pn> venting general tunercu tar iofc<ctioo; 
i>ut, for this rpfl.4<)u nlone, it is not to be recommended. It is impoasible, id 
the vast majority of cases, to remove all or ne-arly all the aflected glands, 
nnd, if undertakeii, it may lend U* more serious and extensive dtHecliooB 
ihnn might at first appear requisite; for a chaio of disposed glauda oftea 
extends a considerable dUtsuce, aud after one has been removed othen 
come into sigbu Cas«i«, however, ••ccastoually occur, in which such a pro* 
c«dure may be deemed advignble. the utfecled gluuds being large and inda- 
rated, and the diseiuie of many years' standiui.' ; their exiirpalion may then 
be pruper, and I biive iftit unfrequvully bad occnsiuu in such cirimmnUnoei 
to remove llieni from the axilla, from the submaxillary region, and from the 
poslerior triangle 'if the neck. 

Tile coiistitutiuiifil treatment of chronic atrumoua diaeBse of the glauds is 
fully described in the chafiCer on .Scrofula and Tubercle, vol. i. p. 1022. 

I.YMPnADENOUA. 

This diMuse has been already dncrihed in the chapter on Tumon (tqL L 

fi. 9o4 ), and hut little remains to be said concerning iL When the diaeue is 
imited to the lymphatic glands, the question uf their removal often oomea 
before the .Surgeon. 

If the tumor be large and single, or oompoted of an agglomeratiuo uf 
muliijile niiis4>i-)i. luid fo situatt-d tnnt it can be tAken out with safety, its 
removal i* [>ri<i><-r. nndahimld be practised. I have several times removed 
lv( mttla from the nxilla nnd upper ]»nrt of lh« neck with great 

I. J when the itisea«? is mulltplc, single large masses (hut are 

ipt -] > ■ I ililc should be dissected out. In one such case a tumor, 
rn* i<- i:i>^' '"* * '^^> ^'^ removes), in Luivenity College Hospital, 
■le axilla. The patient, a delicate woman, had n group of similar 
t in ihe neck, which had remained stationiiry for twenty years. 
')" r.Kion sh<7uld nut be undertaken when the patient is very weak or 
■■:■■■■' especially when there is perHsteut elevation of temperature. 
viog figure (Fig. 423), Irom a pntieot under the caro ot 
.>'trn([ ii'aili. is a good .illustration of the appearances produced hj 
when aH'octing the glands at the root of the neck. 



VENOUS THROMBOSIS. 



77 



With the exception of lympbadenoma, the lymphatic glanda are siagularly 
czempc from the growth of primary tumore. Rouod-cell sarcoma is said 
occauooally to be met with, but It is probable that some of the tumors 
fbrmcrly described under that name would now be classed as lyrophadeno- 




Fi(. 423.— Lympb adenoma of GUndt at Root of tbe Keck. 

Bita. Secondarr tumors are, however, extremely common. All forms of 
tuctt tend to affect the glands at an early period of their growth. Round- 
fttled ind melanotic sarcomata also frequently give rise to secondary tumors 
in the glands. 



CHAPTEK XL. 

DISEASES OF VEINS. 



VESOUS THROMBOSIS. 

ThnmboiiJ, or coagulation of the blood iu the vessels during life, is very 
(oiDDUiD in the veine. 

f'lutu. — The views generally entertaioed at the present time with regard 
to cuaKulation are that fibrin does not exist as such in the blood, but is 
fum«d by the union of two substances, fibriaogeu aud paraglobuliu, uuder 
tbt iofluenoe of a third body of the nature of a ferment, kno'un as the 6briu- 
fcnnenl. The fibrinogen is always normally present in the blood-plasma and 
ihe paraglobulin is supposed to be contained chietiy iu tlie white corpuscles. 
Tlw fibrin-terment is not supposed to be present in a free state in the blood 



76 



UISBASKS OP VEIVfl. 



■i H arealatM n tbt bodr, bat b Ubcnied from tk« white coip uael M note 
ooiaia cwMJitiow. Blood, in coatact vitli At w«11b of Tend*, vhtck. Co IM 
Calnhifai'a •spraiioa, are id ■ eute of " pbysiol«giaU iau^ritjr," riiova M 
KBdiaty to eoagvliitc, but when ii is bno^i in eoMMS witb diead nvllar 
dooiag ukn pbcc. la the mme wtr. if Ut« iiitc«ritT of the t— tin k 
duemgai hj d'mtase or iojury fibris beoMiw^ dcpoaitea at the dunaged ifmt. 
The pmcnee of fne A»meat io the bliRxl loaj atoo eauae eoacrilaiiaii in Ui« 
HrEn^ hod)r. KAUer has ihoira thai if a sufficient quaotttj' oi fibria-fennait 
be experinuotally introdoced into the bl(Kid-»ti«aui, rafod coagulation will 
lake pUc«, even iu contact with h^lthv vf>«»eU- If m Mualler quanthj ji 
injwtMl therv ia tevetu febrile iltyturlmiict^, but ihrnmboni doM not lake 
|>l*ce, the iullu<!ric«! iif the bt«]thy wallfi i.if lli« vefkwU brin^ iheu *appuMd 
I'l be Mufbcieut (>JBrrC9^t c»a;riilat)gu until lh<- ferrafnt U eliinitialiMl frani tba 
Mwh]. RctarilnlJou, nr nrn^t nf the tikmd-^trt^ni, mcl» a* a powerfal pfe- 
t]»p(i»iii^ c»u*^ of thnimlM^U. Thc«c OQiiitiuiis NJ>plv tw)ually to all veiielft, 
vr hither art«ri(*, cA|iillnriisit, or veitit, but we have to coiHider them here in 
reference to the veiiia utilv. 
The cauaee of veaous tliromboaii ma^r thus lj« clasified : 

1. Otanges in ibc cuudition of the wall of the reaeel due to ia) injury; 
(.&) tnflauiuiBtiuu ; <e» degeaeratioii. 

2. Altered c<>ndition« of the blutxt io which there ia cnppaaeil to bea 
liburatjou uf the feriut^uL 

•I. Retardation ur urmt of the blood-etream; due toCo) diminished ruta 
terga; (b) prcmure on the veaael ; Tr^) tiil^irruptiiip uf its rutitjiiuiir ; (if) 
obetniction by a thrombus due to an; of the preceding rau^e. 

1. Changes in Ote wall of OitvemeL 

a. Injvry, — The elfect of any ftpvere injury to the coats of a rein b 
either to exlin^iah, or wj hir to dinitotsh, tlu' vitality of the injurec] fwrt, 
that it hfhavee towards ihe blc»od as a fnrei^ body, aodsooa>'uluin i> formed 
on ihe (laniaged part juat as it would be on a pieoe of wire ioiroduivd into 
iJie vein, Vfia" are noeasionally (leneirat^i by foreign hodicn, as when a 
nature is Accidentally pasMd tnroagh a vein in ligaturing a contiguoiu 
artery. Under tbeae circumfttanoe? a clot will ()uicklr form upon tbc furei^ 
body. 

h. TnJltmmatioM. — tt liss already been pointed out in the chapter ou In- 
dammation thai the mnsl eaaentiaJ feature of the proceea is a diiufnisbed 
vitaiily of thr aftWotod part to a de^^rec gbort of actual death. If the io- 
tlarnoiation in NulHriently intense the wall of an inHamed vein behaTes to- 
wants the contained bliKMl ai* if it were dead niatl4>r, and CKAftulation coo- 
seqiientlv taketi place. TbroinboBiii tbuo forma a inarkeii feature of all 
forma of phlebitis. The catiua of iiillttromnlinn of veins will be d«»cnbeil 
later on (see I'Klebitisy. 

r. Dtgenemtitrn. — Out(*^erAtioQ of the cfiat* b leas marked In the reins 
tliaii ill the »r1<'rif«. In vitririute veiuH, the middle coat in greatly ihii-ken«t) 
by thn growUi of Hbroid ti»Miie, am) cali-areotie plates are «uRH<titiir« tuet with 
in it; but the endothelial lining ih untially intaet, and con»r>iji]enlly thmm- 
bulb oontparatively rarely take* place as a consequence of this alone. 

2. Altered (vndii!ont oj the btood. — The exact nature of the Ganges of the 
blood that prodisposc to thrombosis Ji very imperfectly known. Tbsexperi- 
uenls before alluded to show that no excess ot free lermeot in the blood may 
act as a powerful pradiapoaing cause, or even Uie 8dI« oanae of ooagulation. 
In sepiicajmia. pymnia, and many other acute febrile dbeaiM, then b con- 

aole d«struDtioa of the corpusclea, ami very probably id this way fer- 
,il libtfBted. and it is well Known that thrombmis \a ronimou tti tbeae 
Jons. The mere exeen o\' whit« corpotdleB, aach aa is obaerved in leu- 



THE PROCESS OF THROMBOSIS. 79 

owrtluemia, does not Beero to prediapose in any great degree to thromboBis. 
Kttch hu obserred, in pyaamia experimentally induced in animals, throm- 
b<_«i8 of unall Teseels apparently originatiDg in the plugging of the channel 
br microicopic organtsma, and powibly eome auch condition may be con- 
cerned ID lome casea of venous tbromboeia. 

3. RtAardaiion oj the blood-ttream. — Perfect rest of the blood when with- 
drawn from the body delays coagulation, end free movement hastens it It 
ia imnoMible, therefore, to auppo«e that retardation or arrest of the flow can 
act directlT as a cause of thrombosis. Nothing, however, is more certain 
than that it does form one of the most important causes of coagulation in 
the Hring veaieU. It may act in various ways. First, if the arrest of the 
circulation be complete and of sufficient duration, the vitality of the part 
will »utrer until the vessels come to act as foreign bodies and coagulation takes 
place. Secoodlv, if a part of the vein is already diseased or injured the 
retardation of ttie bloou-stream will iavor the adhesion of the white curpus- 
oie« to ihe unhealthy sur&ce, which is the Brst step in thrombosis when the 
bl-ywi \i still moving. Thirdly, if the blood stagnate tor a sufficient time 
the white corpuscles may perish from want of oxygen and disintegrate, thus 
libermting the ferment and inducing coagulation. Lastly, it is possible that 
the nutrition of the endothelium may suffer from arrest of the now of blood 
thntugh the vessel even when the circulation through the surrounding tissues 
i^ sufficiently active to maintain their vitality. 

Ketardation or arrest of the blood-stream may arise (a) from diminished 
rit a trtgo. This may be due to want of power in the heart from old age, 
hatl nourishment, exhausting fevers, or from shock, loss of blood from injury 
vr operation. Interruption to the proper distribution of the force through 
want of elasticity in the arteries acts in the same way. Obstruction of the 
main artery of a limb or arrest of the capillary circulation from which a 
vein derives its blood, will in tike manner retard the venous flow. Another 
Terr common cause of retardation or arrest of the blood-stream in the veins 
i# tte obetructioQ caused by the preaence of a tumor, or the contraction fol- 
lowing chronic inflammation of the connective tissue of an organ ; examples 
'-■f tb^ conditions may be frequently seen in the iliac veins pressed upon by 
■ prfgnant uterus, or an ovarian tumor, and in the vessels of a cirrhotic 
iivtrr: and it must be remembered that h tight bandnge may act in the sftme 
way. 

When a vela is divided in a surgical operation, it empties itself and be 
i-'-mee colla|i3ed as far as the next pair of valves, but above these it may 
remain full of Htagnant blood up to the point at which another vein enters 
:b«- trunk. When a vein is ligatured in its continuity there will be, iu addi- 
li<<D. stagnation of blood below as far as the next collateral branch. 

When the circulation is too feeble to press the valves back against the 
«alU of the vessel, or when in consequence of diliitation they are never pn>- 
I*rly closed, but project into the lumen of the veiu, it not uncommonly hap- 
fieiis that stagnation takes place in the sinuses of the valves, and small 
tbr-'nibi may thus form, which finally project into the lumen of the vessel, 
and by (cradual increase may at last close it completely. 

The ProeaM of Thromboaii. — Thrombosis may take place while the blood 
i* mnviujc, the lumen of the vein becoming gradually tilled with the coagu- 
luDi. or while the blood is at rest. 

The appearance of the thrombus varies with the conditions under which 
tl \i forraetl, much as the coagulura obtained by whipping blood diHers from 
That f'lniK-d when freshly shed blood is allowe<l to coagulate undisturbed in 
a vQCfl. The process of thrombc»is has been observed experimentajly by 
/aho iu the veins of the mesentery and ti'UgiU' of the fro^^. A large vein 



80 



DIBKASBS or VEINS. 



being cli(W«n, its wiili^ w»e injured hy placiDii; a cmuU of oitnaioi 
Dtair or directly uver it. On wntchiog the injunii fput. the white corpaicin 
of tbe passing bluoii were seen to adhere to it until thev were beapol op, 
aoai«tiui(« to such nu extent as to obstnict compleU'ly the veio. If ihf 
mastic uciiou of Uie mlt had not been very Kvero, they might bnmk loott 
wain sod puaa away into the blood-stream ; if it had been more powerAil, 
the oorpiuclcfl remained udhereut. After some hours ihcy were k«ii to an- 
dergo a marktKl change. Tlio greater part dtaintfgnited, their outlioo being 
lost Bud their oaclei uo longer being rucngnizablp, and a fine granular ma*. 
bftTiDg the appearance of freKbly furnietl Ulirin, apptrurei) in tbe place they 
formerly occupied. This nbeervation u in hurmony with the view that the 
libemtjon of the fermenl by disintegration of the white corpaaclea pUyv «n 
iniptirtADl part in the procejw of coagrdatinn. The thromouB thun formed 
wai in KilDc cnM« pure white in color, out mor^^ commonly a few red cnrpiw- 
cIh were entangled nmongst the white. The more rapidly the plugging of 
the veael took place tbe more red corpuades were entsneled in thv throm- 
btu. Wh«n coagulalioD takes plAc« in a v ea a e l in whtcTi thf tlow i» com- 
pletely arreal«d tbe clot differs in no rctpect from thnt formod in hiood 
drawn from the body. It entangles in its roesbesall thv corpusokit. both r«^ 
and whit«, and pre«cnt« the tamilittr dark red color. 

These ubservatiouB explain the different appearancev of the thrombus nr 
the diff«reut circumstaocee in which thrombi<aui takev place. The clot formed 
above an injury which completely obittxuctj) a vein, as when it is divided or 
tie<), 19 uniform in structure, dark red in color, and nl 6n)t but IoomIj ad- 
herent to the inner coat o( the veaael. At a later period, as in tbe ewe of 
a IigBture<l artery, it bec^imes denser in coo»i."t«oce from i>^utratrtioo, and 
more firmly adhervut, and loseit it^ color in consequence of dtuntegration of 
the red corpUBclea. A Ihniuibus formed by gradual deposit from tbe circu- 
iaiing blood upon the unhmlthy walls of a vein is cither white or mixed in 
tint, ucconling to the rapidity with which il t^ formod. It i« lirmly udhereut 
to the inner coat of the vein aud laminated in Hructure. Mtcrot^oopic ex- 
amitiatioii shows il to contain n few red di^ks, but numerous white eornusrles 
which have esciipod dieiutegmtion are uaunllv lound between the lamioie. 

As a rule, the thrombi urtsiug in cases in which an altered condition of the 
blood is supposed to be the cause of coagulation are white or mixed, tbe 
librin being dejioeited gradually on the walls of the vein, startiug I'rora aome 
|H>iiit where from diaeaec or iujurv* the endothelium is domognl. 

Whi-D a vein is completely ubiiieruted by a white thrombus, the stagsont 
blood on each side coagulates, forming a red clot adherent to the white 
After death a further cxtennion of thb red dot takes place. TbeK poat- 
mortem clots are reoogniuMi by tht-ir softQess and by their floating fre« in 
tbe veaael. 

Corail and Rauvier have supposed that in many case* at leant the central 
portion of a laminated clot, and not its periphfra] layers, nre the oldciil, tbe 
fibrin bavitig been fint depoinied on the wall of the vein and tbrn M-pamted 
from it by cuntraction, though prevented from p«tsalng on toward* the heart 
by the prolongations extending into the collateral branches. This view, 
however, seems far from probable. The only appearance soggMtiag lucb ■ 
process is met with in the clotx exlendine irom the boan intoUi« puuDonary 
artenr in cases of oirdinc thromboeis. Theoe are commonly fuuoJ to fill th* 
voMed incompletely, and often present perfect easts of the pulmonary TaJraa. 
In thoN Dlnce», however, tho coagulation lakes place immediately before 
death, and vt-rr probably tho contracliuu is poet-morlem. 

TUv Fate of tae Thronboi varies aceonling lo tlie clrcumstanoes in which 
K is plnoed and the cnuwa of its formation. Thrombi arising from injurr 



4 



i 
I 



EFFECTS OF THBOKBOSIS. 81 

uojergo the same changei as those forming in arteries under similar circum- 
Kaaces (vol. i. p. 308). The restoration of the channel through a vein, 
when the cuotinuity of its walls has not been interrupted, takes place more 
rcsdily than in similar conditions in the arteries. It is pitssible that in some 
cases this mar result from disintegration of the clot, the debris being carried 
•war and lodged in the lungs, where, if non-infective in character, thej 
vuuld cause DO serious symptoms. The normal process of restoration, how- 
ever. U effected by the clot becoming infiltrated by new cells proceeding 
from the wall of the vessel, as in the permanent closure of a divided vein. 
Xew veaaeU afterwards penetrate amongst these cells, and by means of these 
» commuQicatioD is established between the permeable portions of the vein 
above mod below the clot. The channel, at first small, gradually enlarges 
by absorption of new tissue through which it passes, and thus, at last, the 
full calibre of the vein is restored. 

Sojfiesattg and DinrUegnxtion are common changes when the thrombus has 
been formed in consequence of inflammation of the vein, or as a result of 
those altered conditions of the blood which accompany septictemia or malig- 
uaot fevers. It is a very frequent occurrence when the affected vein leads 
frum a wound, the discharges of which are in a septic state, or from an area 
afltfcled with some infective inflammation, as in acute necrosis of bone. 

S»ftening most commonly takes place in white or mixed thrombi. It com- 
mences in the centre of the clot at the part furthest removed from the walls 
of the vein. The clot if mixed becomes completely decolorized, and grad- 
oally breaks down into a creamy fluid resembling pus in appearance. 
Mtcrofcopic examination, however, shows that it is not pure pus. In some 
cases it is composed merely of granular debris, no corpuscles of any kind 
being recognizaole ; in others a certain number of pus cells may he mixed 
siih the debris. These are white corpuscles, which were either contained in 
tbe clot and have escaped disintegration, or have wandered into it from the 
samMinding parts. In most cases in which softening takes place, micrococci 
are found io abuDdance In the puriform fluid. The effects of the process of 
tuftening will be discussed immediately. 

GdeiScUion of a ThTombua is of rare occurrence. It occurs chiefly in the 
fmall clots that form in varicose veins in the pouches behind the valves. 
TaiSK calcified clots form small rounded bodies, varying in size from a 
multard seed to a pea, aud are known bv the name of phleboliths. 

Effects of Thrombosii. — The first etfect of thrombosis when not arising 
from '.betruction is necessarily to arrest the flow of bhwd through the vein. 
If a single superficial vein is obstructed, this may cause uo marked symp- 
t' ■m.T' : but when the clot is situated in a main trunk, as in the femoral at the 
ifOfin. great lederaa of the parts below results. This is commonly seen in 
the to-callcd "while-leg," which occurs after labor. If, the vein remains 
pc-rmant-ntly obstructe<l, the ledema may subside after some weeks or months, 
in« oillattrral veins gradually dilating, and the free return of the blood being 
thus r^-tablisheit. In other cases the ccdeina diminishes, but does not com- 
p!<rtc-ly dtiimppear, the limb swelling considerably when in a dependent posi- 
ti -n. Wht-n this occurs, the areolar tissue is indur8le<i, the oe.lemft becoming 
ID .re *'« ilid ■■ as time goes on. The nutrition of the parts is interfered with, 
ao'l c)in*nic eczema or ulceration of the skin from slight causes is not aa- 
c>*mu'>n. 

Tbc relation of thntmlxtsis to inflammation of the vein is a subject on 
R&icn there has been conitiderable difference of opinion. Patholo;rists in the 
••r:v pari of the century regarded the presence of a thrombus iu :i vein, 
ri-vpi when obviously due to mechanical causes arresting the flow of blood, 
■• evt<lfnce of previous inflammation of the coats of the vessel. Some later 
VOL. II. — 6 



DISEASES OP VBIKS. 



paifaulngists, OD the other hnn<l, have maiutaine<l that when thrombfletti i» 
lounil JiKtoclated with iuduminutinti of the coatti of a vein, the latter cnndi- 
ticiD 18 lilwnys secondary to the former. The tmih pmhably lien l>eiwcen 
the two views, A vein may become inttamed as the resiitt nf niechaRical 
viulvDci', ur of being laiil bare in an operation, and subftequentiy expoAed to 
the contact of decomp4iiiing diftcbargeft, or by being implicated in iinbealthy 
ulceration of the surrounding itructures. In other cases difluse iDdamnaa- 
tioD may spread frnm a ^ejiiic wound in the looM areolar tisfu« surrounding 
the <rcin. lu all tbcM- cniiditioo^ the phlebitis prec^lfH the thr<inilKN>i«. 
The opjKiiiite cnnditiun may be met uith when & vtrin hai) been wounded, 
and its divided end filled with a clot ia eX]j<>8ed in a wptic wound. Tlio 
clot then becomes inipre^naleil with septic matter, Hml fn*h c^iag^latiuu 
takes |>lace Lipoii itN pn^ximal extremity; septic disicttep-ation of th« vh)C 
iol]iiwii, »nd tlie coals of the vein beeoiDe inllnnjed fruiu the contact of th« 
irritating products of ttie process. Thus a spreading throiiibo)>i», follower) 
bv diginlegraiiun of ttie clot and inOanimaiioiL of tlie vein, niiiy be iwl up. 
UhiB is a condition tri-i:|iit.-Mtly met witli in pvii-riiia, and is especinlly common 
iu llio inicelivc inllammation of buuc known us acute necrosis, in »ome 
casus of pyieuiia, tbrumboRie, with aoliening of the ihmmbtiB and inHamma* 
Lion of Ltie cnala of the veiu, ta [net with in {inrla having no connection with 
tbtf iirigiual wound. Here also it t» only reuKouablc to suppine thai the 
irritating pn^pertieu ol the throiiibiuj uru duu to the presence uf the infective 
material in llie blond from wliic^h it ia fnrmetl. iijimjile coagulation of healthy 
bIwHl in a vein doea nut eauiH! acute inflaniumtion of the cinite of llic vessel. 
Ailer the operation liir varix the %'ein can oltcn lie dearly felt on each side 
of the iibiiterutedfiput us a solid cord, but uune uf the dgns ol phlebitis are 
present. 

The moet eertoiiB c<msu<]iience of venoti» thrombwiH ia Embolism, or the 
wparalioo of a clot, and its entry into the circulation. When the formatioil 
of the thrombus has been due Ui mechanical injury, this compHcnlion rarely 
takes place. Occa^iunnlly, however, alter a surgirnl operation or parturi- 
tion, a Inrge clot may he dislodged and cause sudden denth by obatrueliug 
the pulmonar)' artery. If the clot is not large enough lu obstruct the main 
trunk of the artery, it may lodge in a smaller brunch. A typical caM of 
this kind occurred not long ago in University College Hospital. The (latieAkt 
had been coufined to bed lor sonic weeks with a compound distocfltioo of the 
ankle ; the wound was nearly healed, and be vaa apparently in good health. 
He suddenly woke from aleep with a violent paio, which scem«d to shtiot up 
from his leg to his che^t. There was immcdintcly intense sense of dyspnera, 
althcMigh the air entervd the lungs freely ; the pulee roiM) to 120, and the 
action of the heart wa« violent and irregular. The eymptoiiit gradually 
lubaided. and on ^he third day after the attack he expectorateil a »nialJ 
quantity of bloo<l. Within a few hours of the attack, the symptoms of 
obstruction of the fenmral vein manifested themselvet*. It whs alightlv 
tender, and could be f«lt as a hard cord, and great i^ema of the limb 
apjieared. li>i>iue weeks after, the veins of the opposite limb became plugged 
in the same way, but no embolism tixik plai.-e. 

Embolism 19 more commonly the reHiilt of sollening and disintegration of 
the clot. It is possible that a heallby clot may iu this way be removed 
without giving rise to any deliuite symptoms. When the softening » due to 
Kptic duinges in Lbe thrunibua, or when the clot is impregnated with the 
priHlucii« of an infective inflammation of any kind, the virulent fragmctita 
set up inflammation wherever tbev lodi'e, giving rise to the form of general 
infection known as embolic pytcnna. The pathological cirects of simple and 
iDfective embolisni have been already described (^see FyKiuia, vul. i.). 



PHLEBITIS — CAUSES. $8 

A aofteiuag thrombus does not oecessarlly give rise to embolism. Id the 
common form uf so-calied idiopathic phlebitis, suppuratioo frequeutly takes 
place itMiod tb« thrombosed veia, the middle part of the thrombus is softened, 
the walls of the veio give way, and the debris of the clot are discharged with 
tbe piM of the abscess. In these cases a portion of the thrombus on each side 
lemaiiM uoaoftened, aod undergoes the ordinary changes observed in closure 
of a divided TesHel. 

The SyjtPTOMS of thrombosis are merely those of obstruction of the vein. 
If superficial, the vein can be felt as a hard cord, with knot-tike projections 
ai the situaUona of the valves. If a deep vein id affected, there is oedema of 
the part from which it comes, olten with dilatation uf the superficial veins. 
The awolleo parts are white, and pit deeply on pressure. When the coats 
of the vein are infiamed, the symptoms of phlebitis to be presently described 
will be manifest. 

The Trbatmekt depends entirely on the cause. When it is a part of the 

Ejxauc process, it is that of pytemia ; when associated with phlebitis, it must 
e treated as described under that disease. CEdema must be treated by 
eteratioD of the limb and careful bandaging with an elastic or stocking 
banda g e. In all cases perfect rest of the part must be maintained, in order 
to (Aviate as far as poesible the risk of embolism. 

PHLEBITIB. 

/jt^aauNofton o/* the Veins, originally studied by Hunter, has in later years 
utracCed the attention of many distinguished Continental and British 
paxboloffistB, amongst whom may be specially mentioned Breschet, Velpeau, 
Cruveilfaier, Amott, Henry L#ee, Tessier, and Virchow. 

Causes. — Phlebitis may arise from injury of the coats of the vein, from 
inAaoiiiiati<Hi of the tissue surrounding it, periphlebitis, or from the forma- 
tion of an unhealthy thrombus within it. Each of these causes may occur 
separately, but frequently more than one are concerned in the process. In 
mber cases phlebitis is said to be idiopathic, which means that the cause 
eanooc be accurately ascertained. 

Traumatic phlebitis may be simple aud localized, or septic and spreading. 
Th« t-tjata of a vein, in the same way as any other tissue, become inflamed if 
cubmitted to any injury of suflicient intensity, whether it be the application 
•>f a ligature in a surgical operation, accidental mechanical violence, or the 
action of caustics. A^ the result of the injury, a clot forms within the vein, 
adherent tu the damaged spot. If this completely occludes the vessel, it 
«xu-D<b upwards and downwards as far oa the vein contains stagnant blood. 
Tbt: inflammation is, however, limited to the injured spot, and shows no 
tmdency to extend. Ultimately the clot may become absorbed, and the 
rbanoel of the vein restored, or the vessel may become permanently obliter- 
al«il by the processes already described as occurring in arteries under 
fimilar circumstances. 

Traumatic phlebitis does not, however, always run this simple course. 
When the discharges of the wound through which the vein has been injured 
are in a septic condition, and the plugged vein is exposed to the direct con- 
tact of putrid matter, the thrombus may become infected. It then softens 
and decomposes, and thus excites inflammation in the coats of the vein, 
Mtn-ading beyond the part originally injured. Fresh clot, which in its turn 
•MO'inpiMs, forms in the vein as far as the inflammation extends; and so 
ifae pnicesB mar spread until some part is reached at which a large vein 
>tittf the afl'ected trunk, when fragments of the softeuing clot are washed on, 
(iving rise to the dissemination of septic emboli and pyxmia. It ia this 



M 



DI*SA»a or TKIS*. 



TWtu4«r 



■liPCkM 



•Tibsi 



(Mspitml pcB«d«3>. 
iua of tbt Tcio M 
; cl»s it ■ nmiij do* 



■■ mmr txuoA 'mta 
ifcadrt li I Ml 

I oTlfca 



tfa 



it frOM 



:r 






wkfa tfc« iafce* 
m tbeae jnrt 






tha lali— i aivB or thnioil 
mad TCBvicL la dibcr bh 
im mMtrrnl, aad 

la aoaa eaH> ef pyaaih or aifMaeaiBM, tfawhwh aw •eeor, a* bai ban 
alnadr peioud oat, m pam dkuat froa tfae «at ef jafctJog, aad ia tboa 
warn* H aoAo* aad caaaa iah»a«ioa of tfae caata af thm wuml. ll 
MMlUa ■■y**»*iin» of liiia pheaaawaaa Umi ifca hlaod caaiaiaa h a fcft i 
latioBiBBi Boxioas amerial, wkkk eamm tba aab^^aMt ■dfaaiag' i 
Ipnytkat. Ia wappon at this iheoiy ia tka flua ibat ■i e f Be a e ci arc fband 
abatidaailT ia ibe d«bri» cf ih« bnika-<Ian dflL 

DlffuM wflamaHttan ipnadiag frooi aa aalteal tby waaad along tbe areolar 
iMMu Mrrouadiag a veia aHy^ia inair ranri.giTf riM to iaflaauaaiioii of iu 

Id ulditiuu Ui the abave fernn of tbe divaae, pblebtti» is fm^oendv met with 
wilbout our bdog ahle deflniicljr ia exptoin iu mode of oriitiD, and it baa 
tiM^rvfore bees aaid to be idiopalbie. TWta form almoat invariablv afl^da 
Mic of tbe large vHna of lh« lower extreBhjr, osuatlr tb« aapbena, b'al occa- 
viouBll)' tbc p^liteal. fcaiunU, or Utae. Moat fumtnanly Ibe vein attacked 
bi» \"D^ iuHered l>»iu varix. It aeeaia to be araat fretjoent when erraipaJaa 
i» epidemic, but the relatioo betweeo ibe two alR-ctioiu m oot proved. The 
iftuaimaliou ex.teod« to the aurrooDdiM are«)Ur tiaaue. and mar oecaaioD- 
ally, but rarely, end in cuppDraliao. lae dot then diaioiegratea, the wklb 
of tbe vein give way, aod the dCbria mix with tbe aurrounding pua ; but even 
wlirii Lliia bappeoa, there ia but little lendaioy to ealeikakui of tbe ntiachiftf, 
tliu dwiiiiegrating clot Iwiog eliut otf oa each aide by an adherent aaaofteitrd 
tlirotiibuii. Wbeo suppuration do«s doC follow the risk of dtsiotegrBlinn and 
csiboltNiD ia very Bliglit. but ii does 8u<D«timn octmr and cauae death. 

Hir Jamea Paget baa pointed out that "idiupalbic" pblebitia connaaaly 
afleoUug tbe long aapbesooa, hut occaaionally tlic deeper vt^ina, ia not ooeom- 
ojoD In gouty Mibjecta. It may occur in di^rent (utrts of the same vein at 
the Minw lime, and is very liable to relapses. He baa tt^riued the aflectioa 
" K"*>Ly phlebitia," and beiievea that it commenctrs aa a gouty iuBatomaiion 
ol the ouats of the vein, 

pATimuHiicAi. Anatomy. — Tbe cjals of an indamed vein are awollen and 
ritcid. and of a redder tiul than natural from injection of the reaKla of the 
uuivr i-oat. Tbv flurruuiiiliii>; ttwieit are usually o-dematoua. Id arptic or 
iiilt'clive phlebitifl tbe wnll* of the vein are aoUened, and often ^ire vay 
op]i<j«ilt' tlif disiiili'tirtitiii^' |)orttoiis of the clot : ami wherever thta bappeiM 
a DoUevtiou of pus Jorniii ouittd^* the vessel. Tbv (.xinditiona of tbe throiubi 
m luSanied vrina have already beeu tuffieiently di-acribed (see Venoua- 
Tlir"nitK)«ta'j. Micruscopir i-xnnjinntiou ehoHe tlir ronis of the vein to b« 
ii)filltatv<l with Ninall rotiti<l uells ; the t-ndoiheliinii ii at tirsl twullen, and if 
•otlcjiioi; of Lhf llironihua takes place is luet in the cliHtntegraling clot. 

HYMi'ioMf, — hi idiopathic or |Cou(y phlebitis of n superficial veJu tbe 
Bjm|>i<iiii« arc very cvi4lent. The patient Iiub ueuiilly sufTen-d from farit!caw 
L-iiiH hdloru the ntlack. TIte inflsiiininlinii )» localized, usually aflecting a 
inchi* of tliu veaaci, and s«;nieLitiii-s two or Diorc (mrta at the same time. 
< win brvouira bard.swollen, knobbed, and painful, ibe knoba coaatitating 



i 
\ 



SYMPTOMS AKD TREATHKNT OF PHLEBITIS. 85 

distinct ealargements opposite the valves, or in the poucfa-like dilatatioaa of 
the variciiae vein. The skin covering it aBsumea a i^dish-purple color, and 
there nuj be stifiheM, or iDability to move the limb. There may, perbape, 
be DO pain when the limb is at rest, but ia some cases there are severe shocKS 
of pain, resembling neuralgia, darting through the limb. Id all cases there 
M acut« tendemesB over the course of the vessel. There is always some 
vdema aroond the inflamed vein, but if a single superficial vein is affected 
tbere is but little swelling of the parts that supply it with blood, owing to 
its free oommunicatioDs with the deep veins. 

When thedeep veins are affected the most marked signs are deep-seated acute 
pain and teoderness, with marked cedema uf the parts from which the vein 
derive! its blood. This aedematous condition of the limh is a most important 
diagnostic sign of deep-seated phlebitis when the vein cannot be felt (as in 
the pelvis, for instance), and mEiy be the first symptom observed, coming on 
cither suddenly or gradually. The oedema may give rise to a hard, white, 
tense condition of the limb, which pits on pressure, though in some cases the 
hardoeas is too great for this, such as is seen in the ordinary "white leg" of 
the aoooucheurs. Occasionally in deep phlebitis the lirab may suddenly 
•well to a considerable size without there being any subcutaneous (Bdenia. 
In phlebitis of the deep veins of the leg and thigh, the calf of the affected 
limn may suddenly enlarge, with great pain and much distention of the super- 
ficial veins with fluid blood, but. without any subcutaneous oedema. As the 
inflammation subsides the pain and tenderness disappear; and if superficial, 
the distended vein, with its solid contents, hecomes more clearly defined. In 
varicuee veins complete obUteratioD of the vessel may take place, the hard 
eord gradually diminishing in size till it is no longer perceptible. If the 
deep seat e d veins are affected, the oedema continues long after the signs of 
tnflanimation have disappeared, perhaps for many months, till either the 
channel of the vein has been restored, or the superficial veins have enlarged 
sufficiently to carry back the blood without difficulty. If suppuration takes 
place in phlebitis of a superficial vein, the symptoms are those of an ordi- 
nary acute abscess. When the deep veins are affected, the symptoms are 
Um clear until the accumulation becomes of sufficient size to give a distinct 
eeoiw of fluctuation. In these cases there is but little fear of pyiemia. as the 
vein is closed by a firm adherent clot on each side of the part in which sup- 
puration is taking place. After the resulting abscess has been opened, 
buwever, spreading septic phlebitis, followed by pyiemia, is very apt to occur 
unleM proper antiseptic precautions are taken to prevent it. The constitu- 
ti*»nal disturbance in this form of phlebitis is not severe unless suppuration 
takt« place, and even then it speetlily subsides as soon as the pus is evacuated. 

The symptoms of spreading teptie phlebUis of the deep veins are less evi- 
df'Dt. being concealed more or less completely at first by the unhealthy 
inflammation taking place in the part from which the mischief has started, 
and later on by the grave constitutional symptoms of pysemia which speedily 
manifivt themselves. Pain and tenderness in the line of the vein, with 
conM'lerable u* lenia rapidly coming on, would lead to a suspicion of its 
occurrence. The superficial veins are less commnnly affected, but should it 
happen, the symptoms are those just described of superfioial phlebitis, differ- 
ioz only in the steady extension of the redness and pain up the course of 
the vein, and in the presence of the general symptoms of blood-poisoning. 

Tbkatmext. — The first point to be attende<l to in the treatment of phle- 
biii^ i* ahwdute rest of the limb in an elevated position. The importance 
"f nsdl in these cases is twofold ; first, to prevent pain and increase of the 
local mischief; and, secondly, to guard against the danger that may result 
fr>m the detachment of the thrombus, which, carried into the circulation, 



niSKASKS or. TEINB. 



iDny occaeion siiddeu tit^aili l>y plugging ur the pulmooary artery, or 
remotely, in oases nf aeinic phleniits, by nya-inia. 

In simple or gouiy pnlebUiB. nmch 1(h*b1 ivmfurt is (Jerivtvl from ihe anpli- 
ralirm of extract or w>!la«liintm ami t^lyceririe. in filial pans. r*jvereil t»y « 
thick layer of (:iiltuii-wiM)l aiiH a bumlage. .^huuM l>iiii applicatinn nol he 
at haixl, hot rumrtilatioaa will aflonl greut relief. The Cfinatilutinnal trrat- 
metit moat he conrlurted on ordinary nteflical principles in Bn'onlancv with 
the age and strength of the ttalient, alwnye avoiding depletory meamirrt. 
which are not well home, an*) early having reeonrae to a tonic or stinnlat- 
ing plan. The hardnem that i^ often leA fitter ooheidenre of the itifltinima- 
tion may be removed hy salt and nitre pouhicca, as rc-coni mender! by BasKam. 
If a>dema of the limb eontioue, the preaaare of an elastic roller nill remtive 
il> But if the a-dema has been extennrt and chronic the limb rarely, if 
ever, completely recuver« its nattirni sixe. 

If absceaees form they must bo treated by free and early incbioDS, and 
the mo»t flcrupu)ouAntt«rnlion being paid to the prevention of decomp<i«>ilino. 

In Bpreading aeptic phlebitis treatment is of little avail. If a Bujierficial 
vein id affected, it vould he justifiable to expose the vein above the affected 
part and remove a wirtion of it to armt the progreas of the disease. If 
the deep veine are affected and the diagnoeis can Iw clearly mtabliflhed, and 
especially if rignrs and other aymptomB of bloo<l-poi!inning are prefeni, aro- 
putnlion may give the patient a last chance. Tbiit form uf pblebitia ia, 
nowever, almo«l certainly preventable by any efficient antiacptio motle of 
treating n-ounda. 

In thc«e casea in which q similar condition is aet up in the vein leading 
fmtnan arm of infective inflRmniati«n. not eeptic in chnracler. as in acute 
necroeta of the bone the diagnosis ii atmoet imposrible till it ia too lata for 
Bmpuiation ti> be of any service. 



I 

I 



I 



VARICOSE VmVS, OR VABtX- 

Ry Taricose Veins, or Varix, ia meant a pennanent dilatation of ^he. veina 
with thickening nf their wtilltt. U rautt be dietlogaished fVom .itmple diU- 
tation or phleheelaais Buch a* arises from acute ohatnirttoQ to the return of 
hlood, or from the pKsaure of a tumor or aneurism. tStmple dilatation aub* 
aides aa«nnn aii the Cfluae ia removed, and it is not aivompanied hy any defi- 
nite change in the structure of the walla of the vein ; varix ia {MTiiiantrnt, 
and ia alwaya aaactcieted with degenerative changea in the cootc of the af- 
fected veMsel. 

Cxv»w». — The CflkHtec of rarix are generally »ueh eondilionn a* imlvcr mora 
or lest jmrmantni or frequently rtptated diiteittiau uj ihe v^nt. Thus, for in- 
filauce, Mrainii anil habiiual itvi-rexorlioD itf iho limb, by driving the hlood 
from the deep iuin the »iilM.Hitam>uus veins, may give rise to their distention; 
»<> alw> aedeniary nceu{>ali-ms and prolonged standing lend to finvor accuniu- 
latiiin uf bl'KMl in the veins of the lower extremities. Any otNtijicle to the 
return of blood from a vein (aa the preMure uf a light garter below the 
liuec, or of a tumor upfin one uf the large venous trunka). may give rt*e to 
jiermaDent distention if it net for a sufficient length uf time. When the 
vein has become sufficiently dilated to render ita valves inct)m{ieu-til. Ihe 
tou«ioQ of tlie walls of the vein* I-* greatly increased by the weight of the 
UDbrokeo column of hliMxl, and the condition thus becomes aggravated, la 
all eaaea io which the li»ura are cimgeated fn>in anv obtlniction to the re- 
turn of bliK>d t« the heart, the wnllft uf the veitu nider with the other jiarta. 
aiid thus are rendervl more pnmi.' to undergo degenerative changea. 

Ia aome caaee the afTcctluu. or Uie diapositiua to it, appears to be hrredi- 



TABIC08K TKINB — MORBID AHATOHT. 87 

tary; aod in many instancM it is difficult to KGOgaizjo aoy cause except an 
mjeebied and relaxed tiate of the vtaiU of the Teeael, such as is met with ia 
tall, debilitated, and phlegmatic people. Age infiuencee materially the occur- 
rence of the disease, which, rare in the earlier periods of life, gradually ia- 
cr easM in frequency as the individual advances in years up to the middle 
period of life when the tendency ceases. In women, especially, the affection 
H common ; in ooosequence, partly, of natural debility, but more frequently 
frum the preaaure of the enlai^ed uterus during pregnancy. 

LucAUTT. — The veins of the skin and the mucous membranes are those 
that are must liable to varix. It is most commonly met with in the legs, 
and more particularly in the trunk of the iDternal aaphena. Simple dilar 
tation may be met with in any of the superficial veins, as of the chest, arms, 
head. Deck, bypogartrium, or thorax, but true varix in these situations is 
rare. The veins of the anus and lower part of the rectum are especially 
liable to varix, as they are but loosely supported by the surrounding parts, 
and are liable to over^distention from any cause that obstructs the hepatic 
circulatitm, such as a cirrhosis of the liver. The spermatic veins also oflen 
becwme enlarged, constituting varicocele. 

True varix is infinitely more common in the lower than in the upper part 
of the body, owing evidently to the influence of gravity in causing tension 
in ibe more dependent vessels. Dilatation of the veins at any point above 
tbe pelvis arises in most cases from the pressure of a tumor of some kind 
npoD the lai^ venous trunks, the superficial veins being enlarged to take 
the place of the deeper vessels that are obstructed. This condition may end 
io true varix, but if the enlargement is sufficient to enable the vein to carry 
tbe required quantity of blood easily there will be none of those changes of 
tbe cnats which constitute true varix and are the result of abnormal tension. 
Tbe deep-seated veins that are principally affected are the iuternal jugulars, 
xfae vena azygos, and the veins of the prostate. 

MoBBiD AxATOMY. — Veins that are simply dilated difiTer from true vari- 
cose veinii in being merely increased in size, without any alteration in struc- 
ture. Their walls are thin and soft, and they collapse readily. A varicose 
vein is increased in diameter and elongated, forming curves and bending 
back on itself. Sometimes the enlai^mentsat particular points appear mul- 
lil><cular, the vein forming a series of curves and lying closely packed to- 
gether. The coats of the vein are opaque, and thickened often to such an 
extent that the divided vessel stands open like an artery. Occasionally cal- 
careous plates are met with in the thickened walls. On opening the vein the 
valves are always found to be insufficient ; sometimes they have disappeared 
all->s^ther, and in other cases they form small ridges or bands projecting 
frim the wall. When the vein has been cut up, it will be seen that in some 
'•{ the p>iuch-like dilatations the wall has become greatly thinned. The 
inner c-ut of the vein appears smooth and but little altered, beyund being 
ntwa marked by longitudinal strife. When the vein is subcutaneous, the 
tmall branches entering the trunk from the skin are often dilated, and this 
o>jB-iiti<in may sometimes be traced here and there into the cutis, which is 
thinned over the dilated vessel. In the wall of the vein and in its sheath 
•mall dilated veins belonging to tbe vasa vasorum are very commonly 
whM-rveii. 

Micr>iM»)pic examination shows that the thickening of the vein is chiefly 
■iue to a development of dense fibroid tissue in the middle cont. The mus- 
rular fibre-cells are somewhat increased in number, but are separated widely 
fr^ni each other by the fibroid tissue. The outer coat is also thickened ; the 
iaat^r shows but little change. In the thinned pouches, the middle coat is 
atp>phied, and may have completely disappeared. 



DISEASES or rsiKS. 



Aptkakanceb xvd Symitoui;. — Varicoee veioB are tortuous, dilated, nod 
sacculated ; ttiey are serpeDtioe iu tbcir course, and feel thick under the 
finger. When superficial, the disease '\m olteu liniiled to ooe of the larger 
TNKHiB trunks, the aaialler branches ool being ciigat.'cd. This wo cotnmoalT 
Ke in the inieruul 0U|ilieiui. The poucli-likc- dilulatiuns njar ol\ea appnMui 
very clusely [o the surface, the skiu boin^ thinne«l ovt-r ihctn, nud the blut 
tint of the skin bcia^ readily ))eri-t.-piibl«. When the patient ih erect, the 
vein beconiPd mi>rc pmuiiuetit and teii^c In uther ca^OH the t^riiall girjicriidal 
TciuB are ufl'uL-tcd. iip;M_<arin^ in the skin aa a cKwe network of a purnlii^h-blue 
eolor, oauKJiig nnu^h dtstrnlorutioD (if the parlifi. Both iH!lii of vit'twlt' nuiv he 
inplicated. In oontMN^ucnce nf the incompeteni'v of the valvt^, an impulse 
ean uAeu be felt even below the knee wlifn the (uilient ii« made in rough. 
Varix tff till! dt-ep veins is lew common, aa the veiwelH an; better nupported 
by tiie t^itrroundinp fmrlA. They ^i re rute to nn apjiearanre nrhic-h ran t>e 
KCOgni«*d during life. N'arir^iHe veins cause a fteiise of tendon and weight. 
often with t-oiiaiderahle f<marttng or prirking pnin in the purtH from which 
they return the blood. tSometimefl they niay caii-te nund)n(>s8, iliffirulty of 
movement, or even some kiea of jKiwer in the aflected limb. Tliese symp- 
toms aic tt^ravnted by exertion. In dc«{>«>ated varix, these «yniptom« are 
often very marked. 

PlWMiREM AND Effects: — Varicose vein* never uttder^ spfuitancowt 
cure; when once formed, the condition in permanent, unleM the vci»el 
I become pluggt^l by coagnlum, when it may bv oblitt^ruted. The current nf 
blood i» then diverted int<^ other chnnneU. 8i)d,R« ii rule, lh<?»e in their turn 
becnnie vnrt(.'««e. The mnin evil that roulu fmm vuriLxwc veins in the lem*. 
is the change (hat h slowly induced in the nutrition of the »kiii, and >>iibcu- 
taneous areolar tituiie, by (be relArdation of the circulation, ami the inter* 
fereocc with the due return of blood. The pMrtu frfim which the vein 
derivte its blood are nflvti edightly (edematous. Atler a time the subcuta- 
neous fat becoinefl iuilurated, and the skin loses its elasticity, becomoj rigid, 
and often darkly pigmented iu places*. In coneetjuence of the imperlect 
jiulritiuu of the parts ulceration frequently takes place, especially below the 
middle of the leg. The ulcer has a great tendency to assume the chronic or 
callous form. Chronic eczema is a nrcaoeDl consequence of the congestion 
of the skin rauaed by varicose veins. There is another accident that may 
occur as the remit of varicose veins of the legs, vie., that the varix umy give 
way, the vein may " bur^t " ss is generally said. In these cases, the word 
" burst " ii> scarcely correct. The varix docs not give waysolely by pressure 
from within, but a process of ulceration goes on from without by which its 
ooals become weakened, so thiit at Inst a pinhole nperinre fornis, giving riw 
tlo profuse heninrrhage. Tlic blee<ling ia oHcn so profuse ea lo iniluce faiuU 
, and wmelimes even death in a few minuter. This bleeding lakes place 
in a different way from ordinary venous hcrnorrhnge, the blood coming 
chiefly fn>m the cardiac and not the dii^lal side, the inconii)CteDt valves not 
presenting the ordinary obstacle lo the downward flow of niood. It is this 
that causes its extraiinliuarv cnpiousnc-ss. In most coses this so-called 
** bursting " is not so sudden but tlint a Surgeon may for&«cc the probability 
of its occurrence, as tt most commonly tBkc« place cither iju the surface of 
an ulcer, or is preceded by induration, reddening, nnd thinning of the 
iDtegunienta covering the diseased vein. In some catcs, however, the warn- 
ings may be very slight. A few year* ago a man was brought into University 
Cullcge Hospital who had died in a few minuter from hemorrhage from n 
varicose vein. There was nothing to be sc«n on the body but a minut« 
hole, surrounded by apparently lientthy skin. Water inj<-cted into the vena 
cava readily flowed out through the aperture On injecting thcapccinicu 



i^-. a^f^ ^ I •*« ^-aa 



OPIRATIVE TREATUENT OF VABIX. 89 

laddimecting it, a large mass of tortuoua veins was found, but the hemor- 
Ai|e had coTTie from a amall cutaneous vein which joined the dilated trunk. 
ItMd been dilated to the size of a crow-quill, and the cutis covering it was 
teied. Varicose veins are very prone to suffer from iaflammation and 
flnaibosts. The symptoms are those of phlebitis, already described. The 
■JMBmatioo is always localized. Suppuration occasionally takes place, 
kit ipreading phlebitis and eoibolism are rare complications. After an 
•tti^ of phlebitis the vein is often obliterated, and the patient cured of his 
Sttaae. 

Tbeatmfvt — This must be conducted on two principles — to palliate and 
to are. The PftUiatiTe Treatment consists in moderate compression exer- 
ond apon the vewel, so as to support its weakened and dilated coats, and 
tkoi prevent its further distention and the pain occasioned by this, as well 
■ tbe other consequences — such as cedema, induration, and ulceration. The 
prarare must be applied very smoothly and evenly, lest it irritate the skin, 
udcaow ulceration, or produce distention of the vein below the part com- 
pUMil. For the purpose of compression, bandages and elastic stockings 
■R commonly employed. The soft "stocking bandage" is one of the most 
eonfi^able. If an elastic stocking be used, care must be taken that it 
wHt fits evenly. They are often made too tight at the upper part. 
MutiD's India-rubber bandage, applied in the same way as in the treatment 
rftke chronic ulcer (vol. i, p. 278), is a most efficient and comfortable mode 
tf tmtment if tbe patient can wear it without its causing eczema. Elastic 
pnsare by means of a vulcanized India-rubber band or garter applied 
■naod tbe limb, so a9 to simulate the action of the valves of the vein, and 
^iticnmpreseion to cut off the weight of the column of blood from tbe 
tonnioal branches, has been recommended ; and Colles advised the applica- 
lu of 1 truss to the upper part of the sapbena vein ; but, as a rule, these 
■"l«of treatment only aggravate the symptoms. 

If 1 vein burst, the hemorrhage is easily arrested by placing the patient on 
Ui btck with the leg elevated and applying a compress and bandage. When 
iptiient is in danger of hemorrhage, he should be advised to have the vein 
■•once obliterated; and if this cannot be done, he should be warned and 
Kwibst if bleeding comes on he has nothing to fear, if he lies on his hack 
•ad fltvates liis leg against some convenient object nearly to a right angle 
»iUi bis body, till afislstance can be obtained. The application of a finger to 
tfce bleeilin;: !ii>ot would immediately arrest the hemorrhage. When death 
tik« place, it is while the patient is foolishly running about to seek assistance, 
Ae bleeding coming from above, not from below the opening. 

In certain ri rcu metances, it becomes necessary to change the palliative for 
a CKrative plan. This is especially requisite in the following three con- 
ditions : Lit' the varix be so large as to pro<Juce much inconvenience, or to 
jive ri>e to -ievere pain by its pressure on the nerves in its neighborhood ; 2, 
if a varicose vein have burst, or be on the point of giving way ; or, 3, if an 
BJcer dependent on its existence will not heal. Various plans of curative 
treatment have been recommended ; most of which have for their object the 
obliteratinn <>f the vein at one point by exciting inflammation there, and 
tbofl causing it to be filled by a thrombus which will extend as far as the 
Mzi branch on each side. Finally, the vein becomes obliterated and reduced 
to a 6bp'iU!« cord. As the treatment involves the artificial excitation of phle- 
bitia and thrnmbneis, there is necessarily some little risk of its assumint; a 
ipmt'ling fi-rni with softening of the clot and eubm^quent pyiiniia. This, 
bowever, cold iiccur only if septic inflammation were set up round the vein 
M a ccn^^juence of the wound made in the operation, or if the patient 
U the time of the operation was suffering from some serious general dts- 



90 DISEASES OF TBIXS. 

eaic. Bt ft little cEotioo, therefore, Micb accideots can ftlmnst certainly be 
preveDted. 

By these means the trunk of a Taricwae veio and the larger nuuMs of varix 
may be occluded. Bat can the diflea«e be cured by the local obliteraUun of 
the raD? To this question, I have do hesitaiion in answeriog iu the nega- 
tiT& Though the tniitk be obliterated, a collateral renoof circulation is set 
up, which is very apt in the course of a few iDoaths to take on a varicose 
oonditi<»i. and thus to cause a return of the disease. Bat, though the cure be 
not radical, much benefit may often beeffeded by removiDgTaricosekDnts that 
oceasicMi pain or inconvenience, by enabling an ulcer tocicatrize. or by occlud- 
ing a vein firom which hemorrb^e has occurred or is threatening to occur. 
Various plans for obliterating the veins have been recommended. They 
resolve themselves into five principal beads of treatmoit. 

1. Diriium cf tke Vam has bera done by a subcutaneous incision followed 
by the application of a compress and bandage. Kxcisinn of a portion of the 
vein between two ligatures is a most efficient mode oi treatment, and can be 
safely nndertaken if any efficient mode of antisepde treatment be adopted id 
the treatment of the wound. Without thic. it is not unalieoiled by danger 
of septic changes in the thtombu* followed by pyemia. It i« convenientlr 
d<«e by makiag a small iMintudinal wound about one inch long, in which 
the rein may m exposed. Two ligatures either of prepared catgut or car- 
bt^ized sUk may tbeo be applied, and the [Hece of veu between them cut 
out with sciators. 

2. It has be^i reoommended by Mayo, Seu(in.BoDneC,andothers,toeie»(« 
imflammaiiom in tMe vein by producing a series <^ deep eschars or issues in the 
■kin, covering it by the application ^ a caustic, but such treatment has, very 
pniperly, been long abandoned. 

3. Cwgulation of the blood in the vein by eiertnfyu t has also been recom- 
mended. .\ harelip pin is passed under the vein.and a twisted suture applied 
over it. Two insulated needles are then passed into the dilated vein below 
the pin. and a galvanic cunvni of sufficient strength passed through them. 
The v«n »iioD becomes filled with clot, and hard, .\tter a ^w hi>ui«, when 
the danger of embolism is past, the pin may be removed. This plan has 
been trie<l at Cniverniy College Hospital, but seemed to preseut no special 
advanta^R*. 

4. InJ^iom cf tke nrnr Ajr a few dr«^ M q toiutitm #r* Ou ptrtMaride of inm^ 
as r«o>mmeoded by Pravai. is a very ed^tual method of pHMruriog coagula- 
tion of the cvMitained blood and ci>nsolidati->n of the varii. moK particularly 
if it be very large and sacculated. In employing this meaui«. it is essential 
to c«.»mpre« the vein by oKans \.4 a tourniquet applied above the \mrix, which 
must U'.K be removed ult half an hour at least aiier (he operati'Xi. for fear of 
embolism: the $t^lution » then i>^ he in}ecte«i in very small quantity — not 
m-ire than three <>r four di\>p» — by means of the frringe Tif-. 423) into the 
diUteil veins. C\>aLtcula{i<^D oi the bIo»d immediately tafce» place. The 
patient m-jst he o>xifiDed to his bed for a few tiar; «ith the limb raised, and 
a baudaze sh<.>uld be applied befi^rv he is allowed u* walk al>->uL This mode 
of tr^atm^Eii is very ed^ual in large varix. and may in such cases be advan- 
tageiHisiy ..vD'-uied with Ibe oext nieth<Lxl — the pins bein^ used under the 
venous trunks, and the s^'^iutioo iotrvxiukvd ioto the dilatni ma^we of the 
varix. Bji it i< not devoid of daa^r : a<.V)*.ita:^ such as Uh'aI suppuration 
and si'.>U£bio^. pyemic symptom:', aovi even tsial emWibm. have followed 
its us^. 

■>. Tr.<r r.i-«t convenient and s»:es; wsy v^f obliterating the vein in my 
a^pioi.-.t: . An-\ that which I always ec:ploy, cousbKs in «9m.^rvt*iny tkt vtMei at 
ttT<: -il yAnu. by paaeuig a harelip pin un<.iemeath it. Uyii^ a piece of wax 



OPEBATITS TBEATMBNT OP VABII. 91 

bougie over it, and then applying the twisted suture around the pin and over 
the bougie (Fig. 424). In this way the vessel gradually ulcerates by the 

Enure that is exercised upon it, and the presence of the bougie prevents the 
^ure from injuring the skin. In performing this operation, care must be 
eo that the vein be not transfixed, but that the pin be pushed, or rather 
dipped underneath it ; the ligature should nut be too tbio, and must be applied 




I I a 



Fig. 434. — ApptioKtion of Harelip Pioa to Vftriooae Vain*. 

tigfatlv over the bougie ; several pins, as many as eight or ten, if necessary, 
i^Mil^ be introduced along the course of the same vessel, at distances of about 
three^uarters of an inch from one another (Fig. 424) ; those highest up should 
be put in first, and they should be left in fur at least a week or ten days, by 
which time the obliteration of the vessel will have taken place. I believe 
that all the danger of the operation coDsiets in the transfixion of the vein by 
the pin ; the operator may always know when he has done this by the escape 
of a few drops of venous blood ; when the pin is properly passed under and 
dear of the vein, the operation is a perfectly bloodless one. If the vein be 
tiBosfixed, the pin should immediately be withdrawn and passed at another 
point : if it be allowed to remain in the vein, it wilt act as a foreign body, 
and septic changes in the thrombus may ensue. When the vein is properly 
cumpreased between the pin below and the bougie above, it becomes safelv 
obliterated at the point of pressure. By attention to these circumstances 1 
have never met with any ilVcooeequeoces, either from phlebitis or pyamia, 
in any of the cases in which I have performed this operation, which are 
several hundreds in number. 

In addition to the application of the pins in the usual way, H. Lee has 
recrimmended the subcutaneous division of that portion of the vein which ia 
iacluded batween them, afler coagulation of the blood has taken place. 
This I have found to be a useful addition to the ordinary treatment, and to 
ioMire the obliteration of the vessel. 

The poinu of the pins may be prevented from pressing injuriously upon 
the ekin, by putting smalt pieces of adhesive piaster under them. "Whilst 
the pios are in, the patient must not be allowed to move about, and after 
they have been taken out, the limb should be bandaged for some time. In 
gentrral, no ulceration takes place about the pinhole apertures; but occa- 
tionally. in debilitated constitutions, a sure forms, which requires to be treated 
on onlinary principles. 




AmutUib by ADMtomoiU is a diMaM of the arteries in whicli the voaeU 
W c'MW vscoiiTvIy «li>D]f]ite(I, turtiiouH, hihI MTiteitLiue; •omttiiiMt th<>r 
•MUOMR vaHeow nmtlitiou, being dilutv^ iuUi email itinUMB,UKlaf«aIwar« 
wry ttiiD walled, nvrmblint; retlivr vi-itis tlimi artL-m-e to atroeture. Thii 
kiu>l i>i ^ilstatioo of the rcaels givoH rtiw lo [mUatiu}; tumon, often of oon- 
•idflnUv uiCi and of a wrr urtive ami iliiii)!cr<iiia crharacler. Tbmf nay b* 
•tlualMt in alnioat any li.tsiiir or <jr):uii uf tliu bixly. but uru generally Mtirttad 
lu lh«> Biibmiiuuus «n<l subcuuiui-oua ureiilar li»)Ut% aud mnet freqMntljr in 
i\w u|i|tor pari of the b^xly, ui|it.>t!iallv ubtml (he ai-nlp, orbit, li)», and mod; 
bul infv bavp brro luet with in otlier siiuali<>i», Huch m \hv toiijiue, aod 
«v<«H iu inl<>rnal orgmiA, a» the livor; Hud 1 have »een very ntnive f^nivtha 
i\( tlti* liad on t)io sidi* of ihu ch<«l, natr^, nnd faau It will geDerally be 
Ktuiitl iliHt thi> arti^Tirs Itmling u> uii utii'uriKm by anaeliimnsiit, ihnugh at a 
tsiitwiilfrubbf diHtiinc«i fnim it, are t<ir(ui»tiii and cnlargpd, with thin and «z- 
|i4tii<l«>l iHini«. and piiltuilif it<-livt-lv: in fiirt, cmiiititucing tbatcnnilitioa which 
^tm by thi> nnmo of Cirwtd Dilatation of the renela. 

AiU'OrUm by anauUimfNiiH furnmtumon of varying mit^iriidennd tnvgular 

•hntN< ; tbvv ari< unually of a bluish onhtr, Imve n f>piin)>v fe*-!, an- readily 

)<itni|ir»^*ibli<, not circumscribed, an<l linvi* liirf*n tor(n<>ii9 ve^wU runnliiii; 

intti Mtnl rmni thrill on ditTcront side^. Tbt^ir tetii)K>raturo U [^-nrrally ntiovr 

Ibm of urtKhboriiii; (WrU; and a vihrattiry or piirrini; thrill, willi dinliiirt 

putoiiliiin ntny be f<-lt in thcni. Thi* (luliiaiiiin or thrill is »yncbronoiu wiUi 

tlw boart'ii Ittwt, riiiiy boitrr««t«d by conipr^fwinv the tumor or the art«ri«> 

^hi«ulli>lt lo it, ind returns with an ex|ianMV(>. lieut on tb» r^niovsl of tbv 

HMtwuri', Tlio bruit in often loud and Imrsh. but at other ttnics of a mfi and 

^^MnwinK rbunicler. The*H (jrowths mrely uwur in infancy, bat pioerally 

mukit llivir uji|K>iinino«in youn(r adult», th'untrh tbey may b« met with at all 

klieriicle (if life, often ai* the cunsfijiienw of injury. 
I>i4<iyu<>iB. — It in of iiujiorlancv ^t etlcct the diuKnaeiB between onlinary 
ujifttrum and that by anwtocnu«t». In innny ca«re Ibv Hiluattou of thetiiinur 
at H iliatiini'e from any large trunk. a» <in the scalp, the nul«ide of the tliigb. 
iir the kIuU-uI region, will determine this. Again, the mitiine uf the gr^wtb 
!■ Inwiltntinrt than in true ant'uriitn : and turtuoua v^fnela will Im< felt leadiu)^ 
V It from ililfi-rt>nl direotimiB. The nwelliiiff niao ia doiij;hy und vt.'rT ruro- 
ruauilile ; but. when the preMunt in reinove<l, the blootl eiitent It with a whix 
ml thrill, riot with the dwtintit pnl&»ting ntnike that i» foiiiiil in aneurism. 
he pulantion, not w> (broihleia in aneurism, ia mure heaving nnd expansile, 
faa bnitt ia hiuder. and more nujierficial. Kimetimea having a o«xiin}; tone. 
■lire on the urterira lesdinif Iu the tumor tbeM sigtiB are muially not 
jrnited, though diminittht'd in fore«, the blo«Ml entering It from th« 
ig partA, und in a lesa direct way. 








NAvus. 98 

Treatment. — ^The treatment of aoeurism by anaatomoeis tnuat depend 
upoD tbe siie and situauoQ of the growth. When it ia bo placed that it can 
be liyatitred or erdeed, aa on the lip, or when email, about the neck, face, or 
scaip, trunk, or extremities, it ahould be removed. I always prefer the liga- 
ture, applied as will immediately be described, as being the safest, and upon 
tfae whole the readiest mode of removing such a tumor. If excision be 
practised, it ia ncceaaaiy to be very careful to cut widely of the disease ; if 
it be cut into, feariul hemorrhage may ensue, which can only be arrested 
by preaHure, and which in several instances has proved fatal. 

If the disease be very large and extended, aa is commonly seen on the 
scaJp,or if deeply seated, as in the orbit, neither ligature nor excision of the 
tumor can be practised, and it becomes necessary to starve it by cutting off 
ita supply of blood. Ihis may be done either by ligaturing the principal 
branehtm leading to it, or the main trunk of the limb or part. 

Simple ligature of tbe arterial branehea leading to the turner has never, I 
believe, been followed by success ; at least, iu ten recorded instances in which 
it has been had recourse to, the disease has not in one instance been cured. 
It has, however, been aucGeaafutly conjoined by Gibson, in two cases of aneu- 
nam by anastomoeia of the acalp, with incisions made round the tumor at in- 
tervals between the principal teeding arteries, which at the same time were 
tied. 

Tbe wunn trunk leading to tbe tumor has been ligatured in a considerable 
■Dmber of cases. The brachial and femoral arteries have been tied for disease 
of this kind situated on the extremities, and in some instancea with succesa; 
but tbe carotid is the vessel that has been most frequently deligated, in con- 
sequence of the tumor being commonly situated on the scalp and in the 
urbit. Wyeth baa collected 98 cases in which the carotid was ligatured for 
vascular growths above the clavicle, and excluding caaes of "intraorbital 
aneunaai." The results bave not been encouraging ; in 73 cases in which the 
common carotid was tied, almost 30 per cent, died directly from the opera- 
tiMi. and about 50 per cent, only of those that recovered derived any benefit 
frum the operation. Both common carotid arteries were tied at varying in- 
tervals in 9 cases, of these 2 died, 1 was cured, 2 improved, and the rest 
recovered, but derived no benefit from the operation. 

Id many of the caaes in which one carotid alone was tied, the disease, being 
!<ste<l upon the scalp, was not cured ; and it was afterwards found neces* 
sanr to bave recourse to ligature of the tumor, to excision, and to other means 
uf removal ; indeed, when seated upon the scalp, this disease appears to be 
more iutracuble than in any other part of the body, owing pn)bably to the 
freedom of tbe arterial supply from the numerous vessels that ramify in this 
region. Here, however, much benefit might be derived afler ligature of the 
carvtid, by adopting the plan suggested by Gibson of tying the feeding 
arteries, and making incisions between them down to the bone. The liga- 
ture of the carotid has answered better for pulsating tumors in the orbit, 
but few of these are true cirsoid aneurisms. (See Intraorbital Aneurisms.) 

S.KVUS. 

Thia di«eaK-, under which are included those vnrious affections termed 
MoIMt'i Martu, Erectile Tumorg, and Vaicular Growths, conatitutt'S an ira- 
[■•■rtant and interesting section of surgical affcctiuiis. 

Natvi an i-itnimonly divided into two chief varieties, capillary or cuta- 
tiirM<ji>. and vviious, cavernous, or subcutaneous. Aueurisru by aiin:4lnmo»ls 
«a« f-irnit-rty included under the name of arterial nuivus. The simple capil- 
lary nxv\ are composed merely of the capillary vetwels of the akin greatly 



M 



DISSAflKS or BLOODTESSBLS. 



ineiCMed is liie sod DQmber: the cause of their growth b quite aokoova. 
Vbbow ur eaveniniM drtI are usunlly definitely circumBcribed tunuirv. cam- 
paMd of ifiaccs lined with an endothelium Hinilir to that of the reuu SAil 
DoinKled by a tliin wall. The wbute maie ia bouod tag^hcr br a delicaie 
ucolar tueue. The Bpacea are filled with dark veoooa Blood. The arterial 
Hipply is uaually Bioall, the arlerie« opeo dirL-t^tly into the space*, withuut 
the int^rveiittoa of capillaries. These okt! are Mtnctiniea purely rabcuu- 
■eout, but more comaooly implicate the skin. The moat common eooditioD 
b to tind the two furms of Dxvut conjoined, the diaean aMoming the captU 
lary form iu the tkin and the reooua bcDcath. lu aonie cam* the uibcuta- 
neoua tiaevus is not clearly defined, but consist* of a mass of tortuoQ*. thin- 
walled veins, surrounded by a considerable quaBtity at areolar tisane, 
sometimes eontaining fat. Id fact, the structure uf the various nsToitd 
growths differs coosiaerably in different caae*, and the various forma merge 
into each other. (See also Angiomata, vol. t. p. Ho3.) 

Xxri are almost always, if not invariably, congenital. Caveraoos nari 
occaiiooally seem to appear in young adult life, but it ii probable that Urns 
were origiDalty of ooageoital origin, and oomoMaosd active crowth at an 
unusually late period. Nievi are not associated, aooapt aceideDtally, with 
any "iher congenital defect. 

Capillary Veeri appear as slightly elevated but flat spots on the akio.of a 
brifbt red or purplish tint, and having occuumallr pfaanlar or papillated 
•levatioDs, with some larger vnsels ramifyiog on their aarftoe. They often 
spread luperficiallr to d cnusidenible extent; they are usually situated «a 
the &CC, head, oeck, or arms, but occasionallv, though more rarely, on the 
back, tbe nates, liie organs of geoeraiion, and the lower extremitiea. They 
are often at birth very small, not larger than a pin's heftd, from which they 
may spread in the course of a few weeks or months to patches an inch ur 
two in diameter. In many cases no inooovaniencc reeula from thb dtseass^ 
except the deformity it causes; but ooeirioaaUy, mare especially when tha 
gruwih is at all prominent, there u m great dtsposiiion to unhealthy ulcera* 
tioD, When bleeding oeoan fh>m a wound of the mevuld structure it is 
iiauallr in a trickling scnam, and without any degree of force. 

Tenotu or Cavenuras Vsvi are of a dark purple or reddish oolnr, asnaUy 
Very jirnminent. and often forming distinct tumors of ooikeiderable rite, 
which may either be smooth and ovoid, or somewhat Lobulated. On eaos* 
prcMLUg a gmwth of this kind, it subsides to a certain extent, feeling doogliy, 
•i>ft,aod inelastic; and on the removal of the prtMiire fills again. In some 
cases, when consolidated by inflammation, or cimtaining cysts, thev cannot 
be lesseuetl in bulk by pressure. These nsevi are usually of about the site of 
half a walnut, but sometimes much larger. I have removed from the nates 
and tli« bock, some quite as large as au orange. They occur leas frequently 
upou the head and face than the capillary form of the disease; most of tKe 
instaocea that I have seen have been met with in the tower part of the body, 
about the uatee, back, lower extremities, and organs of generation. 

When a venous nevus is porelv subcutaneous, tl forms n sot^, doughy 
tumor, uftun clearly de6ned in outliite. Its must chnracterietic feature m 
that it can be diraintihed by pressure, on tbe remot'al of which it slowly Alb 
out again to as large a siie as before ; it also becomes dbteoded when the 
ebild aoreams or straggles. It is usunlly oval, smooth, and uniform in oul- 
llos. Occasiooally the surrounding veins arc bluish and enlarged. 

Cysta art tooMtimca found in naivi ouuiainiug a dark fluid. They result 
jVon oblilcratioD of the oommuntcation between some uf tbe spaces of the 
nwrua »od the Tassels which carry nff tbe blood. Tbe tumoia once auppoMd 



I 



\ 



ytxYVs — pRoayosis — trbatmsnt. 95 

to he conaolidated nsevi, with cysts scattered through them containing clear 
fluid, are now rnmrded aa of lymphatic origin. 

Pbogxoais. — The natural biatory of Doevi has yet to be learnt — we have 
Tct to ascertain what becomes uf them when lefl to themselves. They are so 
commoDly removed by operation, that hitherto Surgeons have had hut few 
opp>rtuDitie8 of determining this. I have, however, seen several cases in 
which from various circumstances no operation had been performed, and I 
have been struck with the tendency that there is in the cutaneous ocevus to 
disappear. If left untouched, or subjected to continuous pressure, islands 
or patches of white skin will gradually appear on the reddened surface. 
These will slowly increase ana <k)ale8ce, and then the asevup, becoming 
gradually lesa vascular, may tn time disappear. Subcutaneous venous nievi 
will sometimes gradually shrink, but the active erectile neevus is progres- 
sive. 

There is usually a fear expressed of nsevi, if lefl without surgical inter- 
ference, leading to dangerous or even fatal hemorrhage. This I have never 
seen ; indeed, if the nievus ulcerates its tissue hardens, and the vessels become 
blocked up by coagulum, and hence less disposed to bleed. 

Trratmext. — In the treatment of nsevus, the first point to be determined 
is whether the case should be left to nature, or whether operative measures 
should be had recourse to. In deciding this point we must be guided by the 
site, situation, and character of the morbid growth. If this be small, cuta- 
neous, and superficial, so situated that it occasions little or no disfigurement, 
and if it show no tendeucy to increase, it may be lefl without interference; 
when, as just stated, it may eventually shrivel and disappear, or become 
Converted into a kind of mole. In some cases this process may be hastened 
by the application of tincture of iodine or liquor plumbi. In other cases, 
again, the nsevus, though cutaneous and superficial, is so widely diffused 
over the sur&oe, that no attempt at its removal or destruction can be enter- 
tained with prudeuce. But, if the ufevus be large, if it be Buhcutaneous, or 
if it increase in sixe, or if it be so situated as to occasion disfigurement, means 
muft then be adopted for its removal by operative procedure. 

Optratioju for the removal of nsevi may be conducted on six principles : 
I. ti> excite adhesive inflammation in them, and so to produce plugging and 
obiiteratitin uf the vascular tissue of which they are composed ; 2, to dt-stroy 
the pn'wth by caustics; 3, to remove it by the cautery; 4, to cousolidate it 
by elet-inilysis ; 5, to remove it with llic kuife ; or, 6, to remove it bv liga- 
xuTv. lilach of these different plans of treatment is peculiarly applicable 
when the disease assumes certain forms and atfucts certain situations. 

1. When the nxvus is of small sice, aud occurs in such situations that its 
destruction by caustics, or removal by knife or ligature, would be attended 
by ?eri'iu8 dpformity, as when it ia seated about the eyelids, upon the tip of 
thr iiiM^, at the inner anjrle between the eye and the nuse, or about the 
rfimtrs of the mouth, it is best to endeavor (o procure obtiteration, by exniing 
iajtiimm'ition in ii. This may be done in various ways. If smalt, the iia-vus 
may be vaccinated. If it be larger, the most convenient plan consii<tB, 
pf-rbap^. in jtassiug a number of fine silk threads across the tumor in diHereut 
•iirt^tion*. and leaving them in for a week or two at a time, until they have 
pn-luced sufficient inflammation along their tracks, then withdrawing them 
and fias^iii^ similar threads into other parts of the tumor. In this way its 
c>-DHiliilati(in may gradually be effected. Another very useful plan is to 
bn-aL up the cubs'tance of the growth subcutancoualy by mean? of a calaract- 
oeciU-, or tenotome, and, in the intervals between the different introductions 
••f xWi* instrument, to keep up pressure upon the tumor. In other cases. 



M&SASKS or BLOOUVESBSLS. 




■gaio, tlie rcfjuisiie amuuiu of oooHolidatinn will be induced bj paaHog 

ECUiiuocture-iiecdIeB ioui the dil-vui, and ihcu iKuiiug tlieui by nieaob tif ■ 

ftfirii'lanip. rcrtiops tbe mu^t elticitot way ut' ottniuiii}; tbia object U br 

iiijvi^LiiiK tbe percliluride of iron by meana of a email ^luf« Dyrioj^' with a 
MKW-puton riHl niid u fine, eharpiy poiuLcd plutitiiitu ui>ule 
^Fig. -J2&;. Ill doing ibis, cari: iiiu«t bv taliL-u ihut but a 
vi^ry small i|UuotiLy ur' tbi> doiutiun, duI more tbuu two ur 
tliri-L' dru})B, be iujemc*! al uiiu time. Tbe porcliluridu uf iruo 
[luiai'MM ejLLrauraiuary power of iitiagulaiiug lUa blood ; and, 
if tuure than ba> juat been meotiouixl bv throw u in, the tlaaue 
of lliC' iiiuvuA mity c-itbtr bavu iu vitaltiy dfairLi^ixl. uod 
viough, ur coaguluUuii ul ibu blood in liic vuiacU bvyuud the 
liifvuo fiiity uc-cur, Hliii a daugc-rous ur even Inlai cmbuli«tu 
ciikud from ibv ciinguloiii ihua Joroiud btdug Kuahcd lutit the 
currvut uf Lbt> i^irculatioo. Iu order tu |iruvciiL tiiiit laltvr 
avcidcut, a UiUroiijuet ahuuM be placed un u limb if ii Iw th* 
«vii( of the UIUVU8. Xl' ibe iiuivun is svated uu auy olhcr fuui, 
it ia bvllvr to [ww two harelip piutf U'lieaifa il, aud n[i|ily a 
Cciiipurary ligiuure btoeath tJiu (liiiv duriug tbe i;p«.raiiua; 
ihin uuu sttftrly li(j n-muved alter uboul a quarter i^t an b'vur. 
If |irclt.'rn.'d, tuiiuic acid dissolved iu uaier iu thu )iro[)(.>ruuti 
of ^ to ^, a» rt'U>>iuiueud«l by Biyant, or a k'w ilrojw uf a 
atroii): Milutiuu uf cbluride of xiuc, may bt: iujct:lc*d IU«UM<1 uf 
liir |N>rrhloride of truu. 

2. Wbru ttiv luuvuB is soiall. very aupcrfiditl, of iIm capU- 
Inry clmmctur, with au vxcwijiugly thin covering uf cuticle. 
aud HO aitualtid, at uftou ihu urui, uuck, or liark. that a 
modsnUti aniuunl uf scarriug a uf little ciiu«4!(|UtfU<%-, it mar 
niuHixutvutitntlv be ruuovcd by ike/rce ofipUcaUvn of nitne 
mdd, Tbia aliould Ik: well rubbed uo by iiitiuitJt uf a yieoe of 
slick. Thr skiu n>uud the uu,-vu8 way be grcajfod Uj prevent 
ila bt'iug acridrutaily tnuchcd by the acid; uid a^ auun ai 
\ht caiulic has brvii vuificieutly rubbrd in, it may be D«u- 
traliictl with aonic carboiiatn ul soda. Alter ibe •rpanuion 
of the flouiib, il« Bpplicalton most be r*-pr»t<tl i ~ ■ h» 
thfr^ U any a]>pt-amti<Y of prouitu'ut granulation- . ----i-^ 

< ' ' ' gccii*i<itiany baj<(M)tta at one augic of the wound, and iiMli<4U** a 

r> > V of the vaM-ulnr growth. 

3. Tba mftwot tatdm$ baa mm htrgtdy ubnI in th* irauaMat uf tuevi, aad 

b Ntimpalr c««ivcoi«Bt aad eika ci gi w la naay cawsa. It b Bvet applicable 

lo mix^ 70l»m'<>u« and MiboulaMetta tutxi. It iwty be uaod a^ tim ^klvanio 

raulrry ur ai IS>)i>>-lo>'> iK<>riii,.^-aiib'ry. The hratcd platinuiu wirv ur tbv 

pointM caati^nr U' 

ivuimI ita niarinn, t> 

pwn\7tHna. kacb - 

t«aior. A nuHW' 

MBlnl part* can t' 

•hNflu la tluB way a iar^- 1 

tlttla tw of akia. a aiaugdi >• 

nfaai llw afantiaa MMiw t;> 

wetatiua bvaek •«•»! otai. 



laflcthr li^Ht* 



tiiu » tnad« to puuviiirv th« gruwth 

■•r-'-,if an io'-l —'"■-,() the Mparabe 

the auU - purttuo uf ib« 

■I tu OMtk* too maay. lt»t the wbulo maai 

u be dwuuj wi with eaiB|Mmtiv«ly 

!■« left. U ■ eftaa naonaarj (u 

care ie rfbcud. Alter tbe 

. vr aiaple dnsiag ouiat tie 

*ant. i» b«| adafAnl to Iboee 
MMvd airri m whx6 elkev tViatiwi m diCnak. «r |» Uaae eo i 
nmk» tt UBptftaat, if friUe fei mvt iW afcaa. TW vfefatka it poftirnwtl 



w« 



( 




N^VOS — LIGATION — EXCISION. 97 

by punag into the oievus two needtea, insulated except for the last quarter 
of an inch, by a coatiog of copal varuiah, and then counecting them with a 
galvanic current of moderate streugth from one of the ordinary medical bat- 
teries. The current should be gradually increased and the effect watched. 
The tumor becomes hard somewhat suddenly, and assumes a pale or almost 
white tint ; this is a sign that enough has been done. The moment the 
earliest sign of hardening appears the needles should be disconnected, and 
ctmnected with the opposite p<)les of the battery, so that the needle which was 
negative becomes positive. By doing this hemorrhage is prevented when the 
needles are witbdrawn, as the salts of iron formed by solution of the end of 
the positive needle serve aa an efficient hsemostatic. If gas bubbles out 
alnngride the needles it is a sign that the current is too strong, and some 
cells should be taken oS*, or sloughing may result. In deep-seated ncevi the 
etfect can be judged uf only by the hardening of the tumor. The operation 
has often to be repeated several times before the dxvub is finally cured. 

5. When the neevus is large, constituting a more or less distinct tumor, 
and is of a somewhat venous character, it may occasionally be excised, 
Fridgin Teale has shown that some nsevi which are distiDctly encapsuled 
mar readily be dissected out. Should the nsevus, however, be diffused, with- 
out aor distinct limiting capsule, care should be taken to cut wide of the 
disease ; and no operation with the knife should be undertaken unless the 
gruwth be either so situated, as upon the lip, that the parts may readily be 
brought or compressed together, or upon the nates or thigh, where it is un- 
connected with lai^ bloodvessels, and is also very indolent and venous. 
It is especially when the nsevus is lipomatous or cystic, or is distinctly en- 
capsuled, that excision may be advantageously practised. 

A. As a general rule, it is far safer and more convenient to extirpate the 
growth with the ligature; and this, indeed, is the mode of treatment that is 
most genenlly applicable to tumors of this kind in whatever situations they 
may occur, as it effectually removes them without risk of hemorrhage, and 
leaves a sore that very readily cicatrizes. 

The ligature requires to be applied in different ways, according to the size 
and situation of the tumor. In all cases, the best material is 6rm, round, 
(.-■•niprt-ssed whip-cord. This should be tied as tightly as possible, and 
kn-'tt«ii securely, so that there may be no chance of any part of the tumor 
e!*«iping complete and immediate Btrangulation. It is well, if posi^ible. not 
t**i inclu<li- in the niKiee any healthy skin, but to snip across with a pair of 
s<.'i.-w'n« that portion of integument which intervenes between the cords that 
arc tied together ; at the same time, care must he taken to pass the ligatures 
wi-II hcTtind the limits of the disease. 

When the tumor is small, an ordinary double ligature may he passed 
a'.T>>Ni it^ base, by means of a commim suturo-neodlo ; and, tlie noose being 
cut »im1 the thread tied on each side, strftiif^'iilatioD will be efloc-tcd. When 
it i!< I'f larger size, and of round ehape. tli<; must convenient plan of strangu- 
latini; the tumor is that recommended by Li.-'t'm, It consists in passing, by 
mKiD>> of long ntevus-ncedles, fixed in won<ipii liundlcs, and having thoir eves 
Dear llieir points, double whip-cord lignturosin opposite directions across the 
tumor; th('U cutting thmogh the nooses, and tying together the contiguous 
t-ndsof the ligatures until the whole of the growth it< encircled ami strangled 
by them. In <ioing this a few precautions arc necessary : thus, the first 
nievus-needle should be passed across the tumor uniinned (Fig, 426 i, and 
u*-<i to mij* up the gmwtli somewhat from tlic subjawnt parts. Tiie second 
nf-"lle. arme<l as representol in the diagram (Fig. 4'2(>\ carrying the whip- 
cord ligature by means of a piece of suture-silk, should be pussL'<l across tiie 
tumor in the opixieite direction to, but underneath, the first needle; the 
voi_ iL— 7 



98 



DISEASES OF BLOODVESSELS. 



armed needle being withdrawn, the ligature is carried acroM; and the 6™t 
one, having been armed in the eame way, carries its nooee through the tumor 
as it is dniwn out. The two nooses having then been cut, an assistant must 
seize, but nut draw u|>ou, six of the ligature ends ; the Surgeon then, having 





Ftg. 42ii.— DUnram of tti« Ap|<>iniii>a of NifTnt-oecJlH. 



Fi(. 437.— DiBfrmm of 
Nuera* tied. 



divided the intervening bridge of skin, ties rather tightly, in a reef-knot, thfl 
two ends that are teA hanging out ; as »>oa as he has dune this, he proceeds 
to the next two. and so on to the last vFig. 42T). When he ties tfaeee, he 
must do so with all his fonv, espoi>ial ly if the tumor be large, as by drawing 
on them he tightens all the other nix^es. and drags the knots towards the 
centre *>( the gniwth. whieh is thus cBW-lually strangled. He then cuts off 
the tails of the ligature. The straugulate<l na^vus mar be punctured Co 
diminish the size of the sloughing niasis, and then pi.>wJered «ith iodoform 
and dn'sseil with dry cvtlon-wt.Ht!, the dre^iog being letl on till the slough 
separates Atler the tumor has sloughetl away, whioh happens in a few day*, 
if it In* pmjvrly and tiirhily strsrigieil. the wound is treated on onlioary 
prineiple^. If the na'viis l>e altogether subeutaiiev>us. the skin covering it 
should n<>t tv saoritiiT'il. but. b^'iiig divide\l by a crucial incision, may be 
turneil d^^nn in Ev'iir ll.-ijts. and the liiiature then tied as directed. 

In jnMne v'as<<s. the na>vus i^ so Am and eiougatevl that the application of 
the quailruple HintiunL*. a:> alv^ve dos<.'rilK\l. caunol include the whole of iL 
In those i-i roil msiAn(\<s. I have t'ound the liiir^turv alvui lo be described emi- 
uentiv us«'t'i:i. haviui; sui\t-S!i:ully emplivtsi it in a iirt'ai number of instance*. 
Its grt-ai advantage- is that. «hi!i.' it ovanpli-ieiy and very readily strangles 
the ttiin'r. i: d>x<s u.n enc^^M^ au undue ijuaniiiy of iDtegumeni, and (bus 
di«es not pr.^iutv a larger ciia:rix than is ne\>es»ary K-r the eradication of the 
grv'wth. 1: is app'i«>i in th» tMii^wiiij: way: A long iriangular needle is 
thrva.itAi .11 ;ho iv.i.idlv -i:' a i-ievt • f wi.iiwrii alv-u; i.-.ree var\is in length; 
o«*^ha'.:" .':" I!^i^ is >:,ii!u\i tvs.-k »i:h ink. ihv ■ trxr half is left uocolored. 
The ^l>:^i^ :* -.r.xrit'i ;:-.r.^-,:4:r. :( :">!ii ■ : ::;» s ;;:i-i sk:i:.ab.'>u: a quarter of an 
inch l'r.r.i • ;■,< ir.i ■ : x'v.i- ;.;ii-.r, Ar.d i.-ar.jvt rs* '.y t> :ht axis vf the same. 
It is ihtv. >-,-;rriiii x'v.t -.-.c'-i. v.v\:l. a >; ■.;;>!< :a:!. a: .last six inihes in lengtli. is 
lert hs'.i^:;:;: !'r.';r. ;;:i- :-.■:;!: *: whivh :; <r.:t r*\i : i: is uix: carried acroas ibe 
b«M> \i it.< tuni'T. iniiriui: aiui {>aN>;r.; .:: ~Oiyi.-u..i il? laural limits, so as lo 



N^TUS — TBEATMENT BY LIGATURE. 



99 



l«aTe a series of double loops about oiae inches in length on each aide (Fig. 
428 f. Every one of theae loope should be made about three-quarters of an 
incfa apart, including that space of the tumor; and the last loop should be 
brought out through a fold of healthy integument beyond the tumor. In 
this way we have a series of double loops, oue white, and the other black, ou 
each side ( Fig. 428). All the white loope should now be cut on one side, and 
the biadt loops on the other, leaving hanging ends of thread of corresponding 
colore. The tumor may now be strangulated by drawing down and knotting 




v.— Diagram of Fkt and Elongated 
Swu* tied. 



Fiy. 4S8. — Diacramof Ligatnreor Flat and Elongated Hictur. 

firmly each pair of while threads on oce side, and each pair of black ones on 
the other. In this way the tumor is divided into segments, each of which 
is straogulated by a noose and a knot; by black nooses and whiie knots on 
one ude, by white nooses and black knots on the other (Fig. 429). 

The cicatrix resulting from the removal of a nievus is usually firm and 
healthy; but, ia some instances, I have seen it degenerate iuto a hard warty 
maflB requiring subsequent excision. The ligature may be used successfully 
at all ages. I have repeatedly tied large active uoivi in infants a month or 
t«<> old without meetiug with any accident. 

In some situations in which it is very desirable to save the skin, the nsevus 
may often be cured by »iJ>cutaneou8 ligature. This is done by passing a 
curved D^evus-needle armed with a struug silk ligature as far as possible 
n>und the growth, immediately beneath tlie skin; on the eye emerging the 
thread is secured and the needle withdrawn. The needle is then passed un- 
armed so as to include the other half of the tumor; as soon as its eye appears 
ri is threaded with the end of the ligature and drawn back. The ligature is 
then tighlened, and the n.-evu8 thus strangulated subcutanenusly. If pre- 
f(Tr«), the operation can be done with a common suture needle, which can be 
withdrawo and reinserted where necessary without being rethreaded. The 
elk ligature separates by suppuration after a week or ten days. 

Attempts have been made to apply subcutaneous ligatures of carbolizcd 
Alk or catgut, and then to push the knot iti at the needle- puncture, leaving 
the thread to be absorbed. This method has not, however, been very suc- 
etaftful, as either the ligature excited suppuration and was finally expelled, 
or after its absorption a return of the growth took place. 

Widely diffused capillary nievi admit of but litile treatment. Various 
attempts have been made to diminish the dis6}rurement l>y the application 
of fuper6cial caustics, but the lesults of this treatment are not satisfactory. 

BalmanDo Squire has recommended scarification of the surface with an in- 



100 



DISSASK8 or BLOODTSa8BL». 



fill Till oom p atti tt ■ Baaibtr n( vf rr fine koife bUda aet dowly to^tli* 
maA ttou tkb M«« b«fMtl hM raulud. 

?»xvi n< Sraciju. ^jtvxtiovb. — Smi «f tk» Bmlp aro mora fraqnnit 
than ill BBV uUmt HtualioD. excvpt. pBffc»p». ihm Sue. Wbeo occurrio^ on 
thoK putt ifamt an eorend hj hair, tbijr an alnoai inrariably pronuacnt 
asd nbcBtaaaoui ; whoo mtad on tbo limbaHl. or on the bare tlnn bchtod 
the can, ibcT are oficn cataaeouL Tba ordinary cubcuianeoiH dwvui of the 
acalp is nmdil; raaoitd bj the ipalicalkMa of the mmtiinqtie iiyaturr. Car* 
nwt be taken in p— ing iha Dcvdfoe ant to iaclutle the icaduo of ibe oed* 
pito-frnotalts, or trottblaKMne aillulttu an>l. perhaps, atppuraiion may ooeur 
pcaeath thai meoibnuie. In general, it is better not to attempi the prrwirva' 
tioa of any of the iniegntnent covering the growth. It is inii' tiiBt, when 
leroored, a clean white ricatrix i» leA which nerer ooren it»-U' with hair; 
bat thia cao£nirt&, and in aftrr-lito beeooKB bat Ultla Tisible. The alicmpi 
to d itci dAwn the akia that raren the Mieraa u not oolr tmiibleaone, hot 
H attended br Tery onondemble. and preihiy daDgrriMiiit hemorrhain. Thnee 
Sal naevi thai are ntoaled behind the mr an> best treated by the free appli- 
caliuo of fuiiiio^ niirii- ariil. ur Paqueltu'a cautery. 

Vena of the gontanelle » the raoet imimrtant rariety of the Halp* 
B»ru», and oon«btute»a tittncwhai t'oniiidabte dtseaue. A laTM tmr|tl<' tumor 
u situated over the anterior I'natanrlle, rising and falling with the ptiUatioBa 
of the brain cnmmunicaleil to it, and becumiDg dtttettHtd and teoM when 
the child cries. The tumor is erid«itly c)i«e upon the niembraoc* of the 
brain, and this often detera pntctitiuDen from ioterferitii; with it : and I bar* 
But uufn^uentJy Been caMe in which the parents of the child have b«eD 
oouoMllud iiut to allow any operation to be practtKd, lest death ahoald re- 
■■It. Ytft thia tumor, 00 formidable in appearanee, and m deeply seated and 
doae upon the brain, may be remored mtn perfcct adeCy by ibe lijfotvre, I 
hmn aAen tied oKvi in this eituatii-n. and bare oerer ae«n any iII-o>DBi^ 
qii e n ea. nut even « convulsive St, occur. The daugv. then, frttm the mere 
BtranpiIatioD tif the tumur in thta Bitualioo eaunot be gnat : but there la 
anriLher and a epecial danger, vit., the risk of woondinir th«r uembraao of 
th« bnrin m pawin^j the ligaturai nnder the baae of the tiiBor. If uem*- 
aeadlea or anrp-puiated inacmiiieats of any kind be oaed. thi* accident will 
be Tery likely to occur; aud. if this «ere to happen, inevitably fatal ciinae- 
aamees will ciwoe. ThiB accident may always be avoided by operating [a 
UUi Ibllowiag war. A punctare '» made in front of the tumor throng ihe 
henltbr aoalp. An eyed probe^ armed with a double li^tun-, i^ then puahrd 
through thta openio;; acrma ih« have of the lunmr, ami lU end i« made to 
project on the oepoMia aide beyond it ; here aii<tthrr puncture >* madtr, and 
the probe and Inlare togellier arc dmun through. The same- procedure t* 
adopted anw the tnmor sKlciiay*. In lht# nay. a quadruple ligature k 
pMped acroga-the tomor in two >^ppi«it«r dirrctioint ; the rnde an then dtaro* 
gam), and the ligature i« tightened in the ordinari- way. 

mmri of tlte Ftee ere of very mcumon occurrront, and uaually cauae 
nuch dts^ufemrtit. Tht- [n-atinrnt to be adopted DeceMarily varic* grratly, 
•ce^irdiBg to the nature of ihtf nicvui, whether cnUneoacfobculaDeous, or 
both; bihI vprcially accoidhig to its ntoalioa. Tbe aaioe plan, which ia 
■dvantattwuitr adoptnl '>i> •>»« piu^ nay be alto g etbar ioapplioible in ai^ 
olhor. Wr ehall. a<'. ivaei^tvr the tRalmeol of tfaene raacular 

fniwiiff. a« thry afTrct i..- ■ ■ ■■'*.*, the iHwc, tlie chewkB. and the lipa. 

Vcnu of the Eyelidi i* usually cutaaeotu, coarating of ■ diMoloratiDo 
or aiaiainj;, ■» it mvtx, of the lid. without any tnatcnal twelling. Such a 
ilinMe ia. I ihink, betlvr tdl aotoached ; it cannot, af ooDr^*. be remnred 
«iibar by tha knih or bf eawtin. withooi produdi^ wane ranilte ; and, aa 



K^VI IN SPECIAL SITUATIONS. 101 

the skin is always deeply involved, milder means are inoperative, or possibly 
equally destructive. I nave heard of slouj^hing of the eyelid being occa- 
siooed by the use of aatrioeent iojectiona ; though, if the nicvus were subcu- 
taaeous and constituted a aistioct tumor, passing perhaps into the orbit, de- 
BtructioQ of the growth by electrolysis is the safeBt and most efficient mode 
of tn«taieDt. 

'SmwvM of the Hoh may occur in two situations — at the root, or towards 
the al» and apex. 'When seated at the root of the nose, upon the bridge, 
or at the lower part of the forehead, between and perhaps extending above 
the eyebrows, it is often subcutaneous, and may attain a very considerable 
magnitude. lo cases of this kind, I have found the quadruple ligature the 
readi«8t means of removal ; and although the part included may be of large 
Hie. the resulting cicatrix is wonderfully small and narrow, usually becom- 
ing borizootal, BO as to fall into the folds of the skin naturally existing in 
that situation. In the case of a little girl about three years of age, under 
my care some few years ago, I removed a mevus that was cutaneous as well 
mi subcutaneous, and as large as a walnut, from this situation, by means of 
the quadruple ligature, with the most satisfactory result, the resulting cica- 
trix being remarkably small; and in another little girl, from the bridge of 
whose nose I removed, some years ago, a mevus as large as a marble, very 
little scarring or deformity resulted. In both these cases, the ntevus was 
cutaneuu5 as well as subcutaneous. If the skin be not affected, the applica- 
tioo of a temporary ligature followed by injection of perchloride of iron 
may be advantageously employed, or the growth may be destroyed by elec- 
trolysis. When the tip and alts of the nose are affected, the nsevus being 
cataneous, we can seldom do much to improve the appearance of the patient. 
In such cases. I have tried breaking down the ntevus, and the galvanic cau- 
tery, without any material benefit ; the destruction of the tissues soon afler- 
vmrds leading to deformity. When the nsevus is subcutaneous, occupying 
the tip, ala;, and columna nasi, galvano-puncture, or injection with perchloride 
of inm, are the only means that I have found of real service. If the per- 
chloride be injectecl, care must be taken not to throw in too much of the 
li'iuid, lest sloughing ur sudden death result. 

JTstI of the Cheeks may occur in three distinct forms. 1. There may be 
a -tniple cutaneous mevua, a mere staining of the skin, a " mother's mark." 
Thb ailmits of no satisfactory' treatment in most cases ; and the subject of it 
mu&t submit to ctmtinue through life to exhibit the cliaracteristie discolora- 
ti>-n. 2. The elevated cutaneous mevus may be raised above the surface, 
bt^ing I'f a deep purplish-red or plum-color, and covered with a very thin 
iDte^ument. In this form of the disease, I think that the application of 
c>>Qfeni rated nitric acid is the best means of extirpiition. By one or two free 
spplioatiun." of the cau.4tic. the growth is remnvcil, and a dense white cioa- 
irix. prvstnting little disfigurement, is left, in iUs place. 3. The ikcvus may 
inv'-lve the whole thickness of the cheek, being scarcely, if at all, culanemis. 
>';»-vi of this kind cannot, of course, be extirpated, either by the knife, liga- 
t'ir»*. or caustif!*, le^t the cheek be perforated, and the most serious distijrure- 
Dient ennue. In such cases we must endeavor to obliterate the structure of 
irir narvu!" by galvano-puncture, by exciting inHamtnntiou in it by setons, or 
itv breaking <liiwn the structure of the growth witti cfttanict-iicedli'sor a fine 
i'-D'>ti>me. la a caw which I attentled sume years jigo, I nirfd a Uir^c and 
.:r?>-ply «eate<l mevus, which occupied ()ne check, by |)nsffin;.r a iiiiiiiber of 
r.ut^ -ilk threads acro«>s it in different directimis, ami gradually breaking it 
•l-.»u pi*H"e by piece, with a cataract-needle; no iiisfigiirenient whatever being 

Irfl, 



IflS 



DI8KASKS OF BtOOPTBSSBLS. 



ViDvi of the Lips rroutre (liflrreot trfntrnrnt. ficcordinj^ ns tlirr ueuip^ 
the margin or Itiivt- irivolvttl tlic ttlioleciiUdiiJce of llifse ptrla. Wlit-n mM 
Bt (he maririD.us prcjcotiug Mud i^onifwhul pcudnloUBgroKtiiK. they may vtry 
readilr be rcmuvttl bv a double or qtisdtuple ltf:titurc'. arc«rdiiif( l<> tbeiriuze. 
This was the practice (luniued in thecii«« Iroui «hich theRCCutii|iHi>y)nfidraw- 
iDgR U*')gs-'*30, 4iil) were taken, where a nioet vxcelltjit result was obtained 
bv the UBe of the ligature, followed at a later i>eriud by it 



Vyg. 4.<tfi.— Nttvu* ol Lower Lip : 
From Vl««. 



fill reFuii wnsoDiaiPM] ^ 
by iDJcctinn orjwrchlo- fl 

tip: 8i<l>l'l»-. 



ride of iron intOflomeof Ihemore widtly diffunpd parts of the growth. When 
the niVTus iuvolves tht:- whol*^ lliictincra of th« lip, micIi nH-deurrfc arc not al> 
ways available, in lhv*v ca*^ jralvano-punclure, r«f(»cated at inter^'aU of 
ahout a wwk till the whole growth is conHoHiJutwl. is p^rhap the wlrtt aod 
beat treutDieut. The iojectiuu of perch luride itf inm, intiuicacid S(>lutitiD,<?r 
chloride of zioc, may eflect u cure in mtwl cum-s; but n lemporsry li^atttre 
should always be applied, aod left on tor about a quarter of nti hour, to 
prevent uoy accident arinin^r from the direct entrance of the elyplic fluid 
into the bl'xvl-slreani. 

When the whole «tibt>lnnpp of the lip is inrolvefl. inclusion and Klmngnla- 
tion of the morbid ma« by mcaos of ligature arc seldom availablo ; the 




Flf. -is;.— t*r(* Nirrw of Uppar l.<|t: 
I'mnl Vliiw. 



PI(. US.— Ur(«II»rMart;| 



amount of sk)U(rhing being very great, and tho child, abwtrbingthfputrfwCTit 
nmUere from the sloughing mn» which rc<»olt*. incurring iht danger of being 
poboned from this sonrce. In nn infant with n very Inrge nivvus, including 
om half of the Up, which I lignlarcd at the Iloepital some ytiua mgo, dvatn 



I 



VMVl or THK ORQAXS OF OBITKR ATIOIT. 



to mull fntiti ib\g cau)«. One uf (be iiioH rurinidiihlc canes nf 

th« lip iKnt I hikvts ever had lo do wtlh, iitid in it« rt-Aiilui iho. most 

Httaikclunr, wr« miui to mo Mvcrul jrcuni agtt, by Budd, of Barnstapt<>. Tlift 

p«li"-» - little girl five year* old, wn* (lotitvd nt birth lo harr a rt-d strealc 

«Mi i! -idd ol' the up|)or lip; this rapidir developed into a lar^^ tumid 

|Mrp>r ujL-\un, which, when thr ca»c ramo under my observation, wad nbout 

Um mm of a larfn- walnut, inriilvinj^ tbc whole of the «tnictur«i of the lip, 

fran ' \i» ti> thr roucouM fiiirfa<*f« ; it wma of a deep mulberry color, 

•»< :<> the median liii« of the lip to the aoule of th« mouth 

;.;,;. Thin inltyumentD covtrinij (his j;rowtb were exi.*ediiij;ly 

. ■ ■ Himor itwif ws» in the hi^litiit dcKr*** vascular «ml active. 

I lo b« out of th«- i|U<-«Liuii ; tlia ligature presented litlle to 

ijiM-tiunft with th^ |ien-hluride of in^u and lh« iulro<luc'lioa 

itf M-uMi* »erp »ucc\-*MivRlY (ri<^l, but ueltberuf (hei^v roeAn» produced any 

rfStwl na tbrr tunmr, which c<>mineiii!e<l to t-xlend upward)) into the uuetril. 

I »cn»rdiMglr d«t*rminBd on usiu^ cBurtirs. Nitric acid w»a fin»t emphn-cNl ; 

but, AA tfatii did uut pn^lucv sulGueutly ducp ifupm»lun un the gruwin. I had 

i«ODUT«c t«> tba potaaHL cu»i cahx. £ty inuius uf thia, tha tumor was grad- 

tmilj neaMfcd : ihe bemurrhagc which occasionally resuitiKl bein}^ rvstrainecl 

br prtaura. Xutwithslaiidiug thu amount of titaue dtstlnived, ihu resulting 

oralrJT irar rninll. r-r-m'-lin;: tliiitof a Iwdiy unilfil hHrelip. Three yeara 

■Airwarda tfai* child vtae bmu^hi to me afniiu, aud 1 nas uuich struck by the 

'Waaderfal imjirowmeut that had taken place since the removal of th« iiievuB. 

The Hp wn* «ni>»oth, the cicatrii iii a jzreat degree worn otit, and oompara- 

.tin-! dicfintrement was left in the countenance of an exi^eedingly 

prvt: , < ongiBg child. Finding, however, that the lip wna atill drawn 

>ar tucked in uj a venr dense band of 

-«iaBXnci«l tiwue, whten earned a deep 

of the ala of the nose, on 

wit. I divided Lhia, and the reanlt 

«■■ ntcM latia&ctctrr. 

It baa htm recummradod when the 
rruwtb invade* the Bubstaoce of the 
up <tecply for a limited extent, to re- 
muTii It by an ••[iC'ratioii aumewhal 
■iailsr Ut that for the rviuovul of au 
•fH^diuaM; th«wboleaub»tauceof the 
Itp being cut ihroiitrb widely on each 
aiaa, ana the fu\v» »f the wound 
bi«D|{ht loftrlber with hureiip piu^ 
8nah opMmlioiM arc, however, not ad> 
tjmMi, m Bfan frum the danj^r of 
haaorrbaite, ihe discaftc van nlwaya be 
caml by pomr of the meanx above 

dcacribnl, without lmt[n|{ the auiuunt of deformity Ibat would reault frum 
in fwnaivaJ by the ktiiAL 

Vvru of the Ton^oe is of rare uccorrence. 1 have, however, sucoeasfully 
•i|i»r»tMl by mi-nni of thr ^cmeeur in one ease, in which the whole uf the 
flnv cKCnmitT of the nrinio was involved (Pig. i^-i >. The psrticuiara will 
k And iB Chapter [.IX. 

Iiavi af tlw Orfvu of OcQeratioaareuccttflonally met with in ihe female, 
b«t rmn>)v in the mati-. Thr only inalanorof yrrmtf of the Pfnia with which 
I fcA*« oaal u«eamd in ihe cn*^ >\\' n gi-nilemnn thirty-two veareof age, who 
vaaoUcd moiiMM yearM a^'» l>ir » gmwth i>f (bin kind, a« fai^ as a walnut, 
t*lrn*H ssder the rrflexioo of the preputial mucau« membrane. li had 



Vig. 4X1. — Kairas o( TonxiiB. 



104 



DISEASES or BI.OODTBS6BLfi. 



uated for manr ycwi witiMal giving mit aaaoTBBoe. bUL m U Hul or laic 

in to enlargf. slid nfc—JrwlW b> bleed, be ra deifavai of baring It 

tuviid. Thii I did bT spplria^ tb« <{uadniple I^atafe^ after baviai; dk- 

dic miioHJf) meinbnuie doirn. 
Variof the VolTa ue bjr bo meaoatinrreqaeBt. We bare bad aBTefiU ia- 
Maac«oftbfckUi<liatheHwpha]oflaleyaai«. Tbe]rai«w«all7TeiioaH,oft0a 
attaio a large nze. mad tnajr aooMiteMi invalTa tbe mUgaPK,aUl Arudani 
on the inside of tb« tbigfa, or oo tba periftanm, m «cU at tbe Tulva. Wbca 
the growth i» coofiaed to the rulra, b i* but Kmaved bf tbe ligaiBni Soaie 
time ago, I r«;raoT<id id this aav B large pcsdaloM w ao at aMnia, ai lame 
UM two ur liiree flatt«itiil walautft, from tbe left labtan «t a little rlri Mr 
ytu% of age. In tbU caae, I found it inoM coaveaiant to etoploy Inn cna- 
tiDtwot ligature. Tbe fame nieaitiMcr^ hod recoaraslo ia order lo extirpate 
large onvm from tbe labium of a cbihi ihrrc n'ranaf age; l^iit in thi* ttutt 
tie nueaee exteaded to the iDt<-cum«^[« of tiiv fwriaetua and Inner #i<)r of 
' tbe thigb. and wm here rtmovca b_v tbe apfiticattoa oi ftroag nitric acid, 
after tbe Inrir^^r irroKth had wparated. 

Od the Extreautiea. Veek, aad Tmak everr posible Tariety of twrua 

ocoufB. WLl'u tbe diceaw u Oai, oiiuutiDg ratbcr of itataiag of tbe ikia 

tban of an<r actual tumor, it lua; coiomoiilT be tivaied KKGoafullT bv tba 

appUcatioQ of the atnmg tiocture of ic<dine : or kbuuld it be tbouf&l Amir- 

t-able to reiDOTe it. thia may be aflbetcd br rubbine it witb rtnog nitric add. 

[If tfa« owoa avume tbe Ibrm of a tumor, it will almoeC inrariablv be of a 

'venoofl diaracter, aad tben nfumval br cxi-iBioB br BiMUia nf tbe ligawre 

habould baalRcted. If tbe groinb be niund.th^ordiuarTquailnijile lij^tan 

'may be emplojrad; if flat ur elongated, ibv Itingitudioal eoniiuuotu ligaturv 

ia prelerable:. 

N.KTorD Lii>oHA. — Thia a a fnrm of ncrua wbirb I hare occasiaoallT 
8e«n, but wbtob doei ni>t aniwar tu bare aitrartral much milirr, ahbnugb 
N^latfrD apealcs nf h, aad Killmth aye that in lij>i>ma be bae «.>vrral times 
met with ravcmouH diUtaliiin of llie veiiw. It ik a tumor in which the 
nnvtiid Htrurture is ouioiucd with a fattjr growth uttuallv more fibrouii tban 
an onlinary lipoma. Thui dtneMP in inTariuhlT •'vied npno the naua, luck, 
or thi;(h. It oix'un ta a nmouth, doughy, indnlent tumor, incompreMibte, 
not varying tii mun or ahapp-, without heal, tltrill, or pulMtion u( any kind, 
|Mi«»ihly hnvirijr m ff?w v^inn rnmifyiog over its surfacf, hut no di»tinct va^ 
culiir npiwiimure. It in u»umlly conj^nitnl, or has been nolired in early 
childbcKKl ; Mrid it cmlinufv without any \-ery miilerial chatij:e in shape, 
BiMi, or aji|wamii(xi, until ihw incjuveuieoce «r def'Ttnity ««c-c)i*ioned by il 
rt-quiriw it« rvmitrsl. Thio Is beet eObcled by the knife. After removal, tbe 
turner will he found to hi.' wmpoeod of a tnaw <>f librous fat. having a Iar;;e 
uumlx?r "fveim rntiiiryini: tlipjUfih il, eo us tu oustitute n dbtioct raacaiar 
riemeol, uflen c>iiimiiiiicAtiii|; uith small cysts eoutaiuiug a blo«>dy fluid. 
Tbe tumor lias 'K-t'iui'^nally a leudenvy to recur after removal. In one oaae 
I have o]>erute<l tbre« times tor the removal of a large growth of this docrip- 
lion. Biluat(.*d on the bult<ick, and extendini^ forward ti)wanU the perineum. 
^^The flm "{tfrnliori was performed in IHol ; tbe aei'und iu 1S5A. and tbe 
IMtient. ill' II I'inhttwn years of ace. apaiu preaeiilP<l himself in 1M3 with a 
iK-c Mt the growth in an uln'raied iilale. in the ricairix of the former 
«p, The situation in which I have fie«-n mieb tuniors occur, where 
n ri«' to m«»t inconvenifnoe. and wher« their remi'val hu requlrvd 
Most <■««•, biw (wen the iitiliTtor part of the thi>:li. just below Pou. 
•r [toll iitid nliiKwi in eniineetion with the femnral 

, ,|iti'(i], uhich was »ent to me by Gdwanb>, of A 
enllKiiMiu of that island, bad «uflerei(( for some yean 



HEMOPHILIA. 106 

duoDic solid <edems of ooe of his I^, appareotly dependent upon the preg* 
tare exercised upon the saphena and femoral veins by an elongated indolent 
tDiDor just below Poupart's ligament, and over the course of these vessels. 
This tumor had existed from childhood, and presented the signs that have 
JDCt been given as characteristic of the disease under consideration. It was 
lemoved by an incision parallel to Poupart's ligament, some careful dissec- 
tion being required to separate it from the femoral sheath, more particularly 
towards the inner side, where a prolongation of the tumor dipped down by 
the side of the femoral vein, compressing that vessel, and thus causing the 
sdema of the limb. After removal, the tumor was found to consist of a 
nas of dense adipoee tissue, with much vascular structure intermixed, and 
lome small cysts. The cedema gradually subsided ; and when the patient 
left England, about three months afler the operation, the limb had nearly 
regained its normal size, being but little larger than the sound one. 

HEMORRHAGIC DIATHESIS, OR HEMOPHILIA. 

In connection with diseases of the bloodvessels it may be stated that in 
lome constitutional conditions it is found, though fortunately very rarely, 
that there is a great tendency to very troublesome, indeed almost uncon- 
trollable bleeding, from slight wounds. An abnormal tendency to bleed is 
Ktmetimes observed in persons who are " out of condition," and whose tissues 
ire soft and flaccid. They bleed freely from slight wounds and bruise 
utmeively from trivial blows. In these cases the bleeding appears to be 
Buistained by the laxity of fibre preventing the proper contraction of the 
diTided or torn vessels; and the tendency to hemorrh^e will vary at different 
times in the same person according as the state of his health improves or 
deteriorates. In other cases abnormal bleeding may be due to a diminution 
in the normal coagulability of the blood. This state is sometimes met with 
ID Kurvy, chronic jaundice, and albuminuria. The disease known as 
Hsnophilia or Hemorrhagic Diathesis is quite independent of such condi- 
ttQUis these. It is a peculiar constitutional state, always congenital, and 
onn frequently hereditary, especially in the male line. In some families 
the males only have been affected, and the diathesis has been transmitted in 
(te second or third generation through females; who, themselves being uii- 
■fected by it, have had male children who were the subjects of the disease. 
A ven- remarkable genealogical account of such a family has beeu drawn 
up b_v C. Heath. The diathesis occurs in persons without any other apparent 
d'rtDgement of health or morbid condition, innate or acquired, to account 
^rit. In such cases the family peculiarity is usually recognized, and well 
konK-n to those liable to it. 

The ontr constant sign of the diathesis is the free and often almost uncon- 
troliablt; bleeding that takes place from trivial wounds; life being put in 
jmpaniy and even lost by the hemorrhage resulting from the extraction of 
• liviih, the opening of an abscess, lancing of the gums, or some equally slight 
oniiDpurtant surgical procedure. The blood docs not flow in a jet, but 
CTfliinura to trickle in an oozing stream, apparently from the capillaries 
fsther than from the larger vessels of the part. In these ca»e.a, also, there is 
* freat tcmlency to inordinate ecchyraosis from very slight contusiun. 

In thwe families of bleeders, it is scarcely necessary to say that it is 
imperative to l>e careful to make no surgical wounds, evt-n of the most trivial 
ffaaracUT, if they can [lossibly be avoided. Above all. the extract ion of teeth 
muM be avoiijetl. It is afler this slight oporation that the most iMu-iiiitnil- 
iahlcand fatal hemorrhages have occurrefi. Tlio lic>m<irrhages,thougli usually 
tnatuatic, may be spontaneous; they then usually proceed from the nose. 



v. 



HEMOPHILIA — TRKATMKNT. 107 

Tr£4T1ik>'t. — In true hsemophiUa no remediee appear to exercise the 
•lightest influence over the diathe&is. At the same time, it would be wise 
tbat the subject of this unfortunate condition should attend tu those ordinary 
rulec of health, the neglect of which, by lowering "his condition," might 
fivor the tendency to bleed. Legg especially reconimends the use of cold 
baths of plain, sea, or chalybeate waters, residence in a dry air, and the use 
of warm clothing. The preparations of iron are usually given in a routine 
way, but it is doubtful if they have ever been of service in preventing the 
heruorrhages, certainly never in arresting ihem, though they may be of use 
in removing the aniemic state left after a copious bleeding. Ergot has been 
given during the bleeding in many cases, but without evident effect. 

The Loetu Treatment is that on which most dependence will necessarily be 
placed. It consists in the use of three means, viz., Pressure, Styptics, and 
CoiH. 

PreMon is to be relied on only in one form of hsemophilic bleeding — viz., 
the continuous hemorrhage from the socket of a tooth after extraction. In 
these cases the cavity should be cleared out and carefully plugged from the 
bottom by means of lint or agaric, the whole retained by means of a piece of 
cork and a gutta-percha cap to fit over the neighboring teeth, and compressed 
by a bandage applied under the chin against those in the sound jaw. When 
the hemorrhage occurs from the soft parts, pressure must be used with great 
caution lest sloughing occur; the integuments being extremely liable to give 
way eitenaively under very moderate pressure, large subcutaneous extravasa- 
tion developing at the same time, and thus increasing materially the danger 
of the case and the local mischief. 

Compression of the main artery of the limb is useless and liable to the 
objection of the development of ecchymoses and subcutaneous hemorrhages. 

Styptic* of all kinds have been used as a matter of course, and the per- 
chloride of iron has enjoyed especial favor. I have used and seen it used 
frequently, and can safely say that I have never seen any permanent benefit 
from its application, or that of any other styptic, in these cases. Indeed, 
great evil nas often resulted from the inflammation excited by the applica- 
tion of styptics of any kind. The parts become swollen, fall into slough, and 
a? they sej>arate the oozing may recommence from the raw surface, and the 
same process has to l>e gone through again. 

The actaal Cautery presents the same inconveniences as ordinary styptics. 
It may arrest temporarily the bleeding, but inflammation is set up in the 
pans Ifcyond the limit of the eschar, and this on separating leaves an ex- 
ten<le<l ulcemting surface which bleeds again, and perhaps more freely than 
b^f.-re. 

Th*" continued application of Cold appears to arrest hiemnphilic bleeding 
more effectually than any other means, and this circumstance would lead to 
the belief that the hemorrhage is due to want of contractility in the smaller 
arteries rather than to want of coagulability in (he blood. The cold may be 
appliei] by means of irrigation of iced water, ns has been done successfully 
by Marvhatl, or by the application of ice either directlv to the part or laid 
ap<>n a sjxtnge covering it, as has been done in some nf the cases of h:eiito< 
philia (X'curing at Uni%'ersity College Hospital. Simple water may be uec<l, 
or a w«ik antiseptic solution of boracic acid. If the bleeding wound be in 
the extremities, the limb should be elevated and ke|)t at rest on a splint. 

The Surfreon has already been cautioned as to the inexpediency of per- 
fomiinc any operation, except under circumstances of the most urgent neces- 
•iiy, on any member of a family of bleeiier!", or on an individual known to 
be the subject of hiemophilia. Should an operative procedure become neces- 
lar^-. it should, if possible, be undertaken with Paquclin's thermo-cautery. 



108 



OtSEASES OP ARTKRIBS. 



if it In- (Iwiri'tl to make a simple iacuioo ; br ihe j^lvauic ^cruwur. if it be 
tiXfMtlirin til romuvc a part or Vj (lerturin u iimall miiiHiUiti'io. In tbe event 
of Uio ifalvanic 4cnaeur uiA btrin^ at bund, the etastte Ugalnre would be the 
bvtcsulielituu.-. 



CHAPTER XLII. 

IJISEAKES OK ARTRltlES. 

Am'RRiiM am lisblf! ti> num«rt)UB diwoMS which deriro grmt imptirtMDoc 
from iht^ rdt'ClK thBV produce, lh){h upon iJic vtwacle tbcnuwlvca hiuI up<m the 
ptirlM to which they carry the blood. AiiioiigsC the nioat im|>ortAiit Are ibe 
vuriotiA forinit of infliimnintion or nrtt-riliti. 'flie intianimaKiry H0ectiua» of 
itrli-rti>4 nre divided lirat into tm> clnss^a, vik., thuoe raiiiUing tntm injury, 
mid those tirt»iiii; from ;;i-ncrut or Incut cnuftes not of a tntumiitic nature. 
Iritlciiiimatioii of the nrt4-rie« ut divided also into endart«-ritt4, in which it 
alti:-<'tA Drimarily or chictly tlie internal roat, and pcri-arteritii^, in whirh tbe 
pntcf** coniniPHce* in lh« outer ci>at or sheath. The- term mes-art^ritin has 
uleu bevu iru^jn^^tcd fi>r iiitlunimnttoii of the middle coMt, but it is of little 
tl»e, a« liu truu iiillHmtn»lJ>ry ntfcvtiim commences in that part of the ve«»el. 
Sumo forms of arteritis nre unmed frum (he caowrof the duense, as syphilitic 
or cinl)olic. A» id other «lruetiirr«, the inflammatory proc««a may be acute 
or cbronic. In addition to the «bi>ve diseases, arteries suffer fr)m variotia 
detfvncrativu chauuvi-, some of which ar« pninary, allt'ctiug the original 
ttraiies of the vessels, oth^TS are secjodary, tbe deigeiieratiuu taking place 
L-hii'lly in the products iii a c-bronio iuflaniruatory proce&s. The»e varioua 
pr'Hve»i-8 are slill further complieuteil by eeetmdary effecle. fuvh as tht; furin- 
Btiou of ani-urisui. from the tlis^-nitiHl wall; of iXw artery yreldini; liefore the 
pri'Mun* of the bIwKl, and thnimbii«i» of the atfivteil vceeel folkiwod by its 
oblitt'raliiin, and stimutimee by embolism uud ^aii^'rfue. 

lu di.iciiiv<in^ the dlseast's nfnrti-riua, it « ill be mwt cunvcDient 10 coDsIder 
timi the vari'His forms of inflammation; luvuiiilly. the degeaeratioas ; and 
Itutly, tbe reiiioter eflevte of these ebautjix. 

ARTEIilTtS. 

AOQt« Artentii of idiojiathic oriifiit, ttiat in to Miy, ariiiin^ as an indepeo*' 
dent nHVi'tioii liir wliieli no t-videut cniiHe i-aii he totiint. win* formerly ltelicvf.>d 
to be a iMmpnnitiYely I'onimon nllW'tioti. It wax ntlppiHeal ti> atfrrl thr inner 
cufflt, sprt*adiut: ulonii lb<> vi*<«ifl in the dir^^i'tion of the otrculatioti, rikI fn>m 
this fact it HAS )i|»ik**n of as tliHutt' or erviiipelaloUiii. [l 'm now kuonn, bow- 
ever, thai nofiueh aHVelion really exi-u. and that the errxjr ar\«e partly from 
avamio;? tbnt thnmibusb ii iuvariublv erideooe of previous inHauima'tioa tif 
the allrctrd vemi'l.aud |nnly from oi'islakiogfur tbereilaeMof luflanimatiim 
tbe staining: of the iniima, so ofleu ohMrved as tb« mult of obaU)C>-R in tbe 
bl'hM) with •lisinte^ration of iliL> red rorpuwles, ooeurriag eiliier durtD^ life 
in acute fomis of u|iHtd-poiN»iiintf suc^i as sepuettmia or Bftliguaat fuvsn, or 
after death as tho result of putrvfaclion. 

Truunatio Artaritii.. — Simp)'- artite imumatio iaflannitatiao limited to 
tho part iDJur«d and showing no tendency to BXianaioa, is ^miliar tu orury 



I 



YABIKTIES OF ARTERITIS. 109 

Surgeon in coDoection with contUBJon, laceration, wound, or ligature of 
art«n«s; for in the early period of repair ailer any of theae injuries, inflam- 
matorr exudation from tne vaBa-vasorum forms an essential part of the 
pruceas. For a deacription of this condition, the reader ie referred to vol. i. 
chap. xiv. 

Arteritu by Extension, from infective inflammation or ulceration of the 
tiMiues surrounding the vessel, has already been described as one of the 
daoctTb acciimpanying these processes. In inflammation affecting an artery 
io thia way, the process is the same as in other tissues. The vessels of the 
uuler coal are dilated, inflammatory exudation with migration of corpuscles 
take:) place, and the wbndering cells infiltrate the coats of the artery, which 
become swollen and softened. The process spreatls from the outer to the 
inner coat, the endothelium desquamates, and fibrin le deposited upon the 
di0«-a«e<l surface. In the smaller arteries complete thrombosis takes place, 
and the clot extends upwards to the nearest branch beyond the inflamed 
part of the vessel, and may then undergo the changes already described as 
tNTcurring in the permanent closure of an artery (vol. i., Wouncfs of Arteries), 
and hemorrhage is thus prevented. In arteries above the size of the radial, 
however, the closure of the vessel is frequently not accomplished before the 
crata are so far softened as to give way before the pressure of the blood, and 
thus fatal hemorrhage may result. This is all the more likely to occur 
when the inflammation and subsequent ulceration affect a limited portion of 
ooe side only of the artery, as in those cases in which it is due to the con- 
tact of an irritating foreign body, such as a sequestrum. In the larger 
arteries complete thrombosis occurs much less readily than in smaller 
Tcnels or in veins, the rapidity of the flow of the blood being unfavorable 
to the adhesion of the white corpuscles, which is the first step in thrombosis. 
In arteries which have been divided and secured by ligature or otherwise, 
the extension of unhealthy inflammation from the wound to the exposed end 
of the vessel, followed by softening of its coats, and disintegration of the 
eootained clot, is the commonest cause of secondary hemorrhage. 

Bnbolie Artaritt*. — Moxou has pointed out that a form of acute arteritis, 

resulting in softening and swelling of the arterial wall, thus leading to the 

fitnuati>>n of an aneurism or to rupture of the vessel, is in rare cases the 

rvauit of the Iwigenit-nt of an embolus. A simple fibrinous embolus lodging 

in an artery merely obliterates the vessel without causing softening of its 

oKiL'. In order that inflammatory softening may occur, it is necessary that 

the trmlHilus should l»e derive<i from a part which is the seat of some infective 

inflamiiiaiion, and that it should carry with it the unhealthy prmlucts of the 

pp-ctT^-. Kmlxilic arteritis is most likely to occur in the somewhat rare 

aiTi-cli'in kntiwn at> ulcerative or infective endocardilift, hut it has also been 

ku<i«n t'l fullow embolism during the course of an ordinary cnso of acute 

rheumatism. Localized arteritis arising in this way is believed to l>e the 

m'»?t citmmon. if not the sole cause of spontaneous aneurisms in children, 

acil in the smaller vessels of the extremities in adults. Husliton Parker has 

Ttc-tpieti a case which well illustrates this form of disease. A boy, aged 14, 

during an attack of acute rheumatism was suddenly seiziHi with pain in the 

f'trvarni, toiloweil by swelling of the limb. The general swelling soon snli- 

*ide<l. leaving a <leeply seated circumscribed tumor, which steadily increased 

in r'iue for the next four mtmths. On laving this o]>en, a cavity was exposi-d 

o tiuinin;; more than a pound of dark clotted blood, and tlie anterinr inter- 

riNiroui' artery was found to i-oumiunicate with it by an ojiening ii quarter of 

an inch in length. The vessel was sucit'ssfully ligatured ubi>ve and below 

ill):' ofK'ning, and the l>oy rec(»vercd. At the time of the o]>eratton there was 

a hwd double aortic murmur. 



no 



msBASKs or aktkkies. 



Aoate Endarteritii. — Comil hikI Unnviur ilesiTriW un'lvr this iMni«i 
iiirt'cii"!! nl (liH ititirr riNit, iiitt with rhiflly iti thr utirta, but (Kvasioni ^ 
wAf^> ill BiiinllvT voflwls, ra))ccially tu>ar witiittilvi. It is [rjiiirnftprir^il, Lo tbe 
nnkciJ ryo, hy |inimiiienl [lalciu'-i fnnnetl by a nwcliiiij; of ihc iiitiiiin. They 
aro circulur ur nval in ontliiu*, iiiul tielftniii exrpi^d hull' an inch in dtatntWr, 
though both their tbrm and eize may lie alcerecl by the (.xiale»«*t)ce of neigh- 
bnring patohw. They are pale pint in on\»r, and si!mi-trani<pnr«nt or 
opalnoant; in oonsistence, they nra »ilt and eia«(ic, almost ^latinuus. The 
ioteraal surAice bu often lt«t its pnliah, in oonneqiience of the Irregularity 
of the ■welling, but it« endothelial covering is usually intacL The middle 
orwt bencnth the patch appears usually to he aomowhat fiwollen, and thie 
cunditiim is more marked in theodventitia. ^Ticr'»copic examination ohowa 
lliflL the svrelliiij; is due to nn accnmuliition of ?mnll pgII^, cither round or 
aUghlly jrre|a:ular in outline, between the tibre^ of the i*ub-endothe1ioE co»* 
neoijvc tiuuo and the elastic layers of the inner coal. These eoll» have a 
dialiitct DUcli>us surrounded bv a small quantity of protoplaam, and fthnw 
ll\^^xn iif ac'livo (ircwlh. Oornil mid Rnnrier Wlieve they are pr..ducfd by 
pruliiVralion uf the originitl cell* of the part. The swelling of the exierua) 
coat is CouDil to be due U> the preaeuce of numerous celU id new f<irmalioQ 
aauanilinji; lliu fibres of the counecli%'c tta;j>ue. 

The uouditiiios under which aciit« eudarterilU occur are not clearly d«ter- 
niine^l, but aa every intermedixte condittoo between it and the chn>nic form 
t<j be iniiuvil lately deacribed, is to he met with, Boroetimee even in the aame 
veiael, it wenia Co be nothing more than the same prooeaa iocreaaecl in 
inii'ncity. 

Chrome Eadarteritia, Arteritis Beformaas, Atheroma. — Thb is by for 
the mimt ctiiiHiKiu diseaae to Hliich arl<.'n<.'!» are liable; id fuel, il is very rarv 
alU-r middle life to find it cwni|ilelely abs'.'nl Ju the larger vvsm-'U. It ocearn 
Id ita nit»i marked fonn tu the aorta ami the large arteriea of the uvck, 
■bdomen, ihv upfier |varta of (he limb«. itod the base of the brain. It im leai 
eoiuBHMly iH.'vn in the smaller veHScla, in whidi the muscular cuut is niure 
ftillr devt'lojied. 

Chrmto eiidarieritis Urat appeam aa pale yellowith i»tchea or etreake, 
amooth. slightly elevated above the anrfiwe, and eefdeotly seated in the 
drnjier layers of the inner ciiat. They are Irregular in uolline. ihuir long 
diami'itT is uauallv in tlic line of the vcMel's ooarw. but they abow a sperial 
prwililrctioa tor tfif moutha of the bnoebeB tearing the mala trunk, round 
wlitrhihnv form annular eleratiuna. TbeiroutliuebeeoaeanjbaeqDeoitymore 
trrvgular liy theooaleeccDceuf neigbboriDgpatebeft. Aa tbe dheine arU-aocea, 
ih* palehe* betMme more elevated, often reaehiag a tine or more in thicknw. 
At tbi« stairs' thcr arv gray. M>m)-tran«p«reDl or ufialeKeat, and inelastic, 
artilagioooa in appearaaee aaij wimjiwec. Tht^omditino 
y followed. bcCire the patehia bare reacAH mort- than half 
ail I iiuctrr, by a ehauge to aaopaqae ydlewcfdMr, ebe altrratVm io 

tiui ' ing in ihf ceatraf |iarta. TMa CMti^ is due Ut fiitty degenera- 

lk)ii,asdt> aocttnimnicdbyaeawloaiof tougboeaa. The farther prograae uar 
ba In one of two dirpotione; tbe growib amy •ofteo ami bnab «)«ira. or it 
BBT oalmfir. When BoAeaiog lakea plaee IM paldi beooae a ootivartad into 
a pttltaemn or cbeasr aMia, aod eveo a wwietl MM « D<<a<yea ootapMe Im|1>»- 
lactkKi into a yellow crvatay fluid, which has been miatakcti for true pot. 
and lenocd aa ** mA^rmm^tom* 9^tn<m." It ia thia chaaE* that led to the term 
nlbawia ^xin^ applied tn the dwaae. the ptvdocia of tbe aoAnniBqi of the 
peablmg tbe oMtenIa of aa a t hw u wai oM nn( of tba Am. The 
aw eAm artanJeJ In all ifgii of elinak egj ar ier ili a. 
iba mnem naebaa tba am n J i— u w l aMnitbaau 



Wb« 



middle euat Ea 



ABTSBITIS DEFORHANS, OB ATHEROMA. Ill 

aflected, fint hj chrooic inflaniinatioD, and subsequently by eoftening. At 
UkeNiaiettiDe eooaidemble thickeaiDg of the external coat takes place by 
tbe fbnnatioii of dense fibroid tiaeue which is not prone to fatty degeneration 
■wl Mdcoiog. Up to this stage the fatty patch is covered by the most !□- 
terual laren of the iotima ana the endothelium, which are not affected by 
Uteriirooic inflammatory process, but after complete softening these give way, 
ml Uie atheromatous fluid is discharged into the circulation, leaving the re- 
mtin of the patch exposed to the blood-stream. The raw surface thus 
fbnDrd is called " an ataeromatoug ulcer." The debris which enter the circu- 
ktioD are carried on and lodge in the capillaries, but not possessiog any irri- 
tuiog properties they give rise to no evil consequences. Although on the 
fcraatittt of ao atheromatous ulcer a considerable part of the inner and 
■Diddle coats are lost, perforation or rupture of the artery rarely takes place, 
aad it ii only in exceptional cases that the blood forces its way amongst the 
emit of the diseased vessel. This is due to the fact that at the margins of the 
pallet, the chronic inflammatory process baa led to firm matting together of 
tbccoatiof the artery. At the same time the thickening and induration of 
tbeextemal coat prevent perforation. It is especially opposite the deeper 
ud Dure eroded atheromatous patches that this consolidation of the exter- 
Btleist takes place. The change, although described as a chronic inflam- 
Bitioo, is strictly conservative in character. The new growth of fibroid 
timeic not confined to the external coat, but extends to the sheath of the 
T«el, and, by soldering it to the contained artery, greatly adds to the 
(tRogth of the vascular wall. 

Akbough perforation is thus prevented, the new tissue but imperfectly 
rqiraeDtJ! the normal structures of the coats of an artery, as it is entirely 
noting in elasticity. Consequently it is very apt to yield slowly to the 
pRSMire of the blood, and thus lead to the formation of a sacculated aneu* 
fixn. the mouth of which will correspond to the damaged portion of the wall 
<i the vessel. 

Complete softening, with the formation of an atheromatous ulcer, is not 
ir toj means a necessary consequence of fatty degoeration of the patches 
ntalting from chronic endarteritis. In many cases the new tissue, after de- 
^oerating, remains as a firm, yellow, opaque mass, and may undergo no 
^rther change, but meet commonly lime salts are deposited in it« and it 
^ndually becomes converted into a hard calcareous plate, over which the 
tuperficial layers of the inner coat with the endothelium may remain un- 
broken. Sometimes, however, these seem to wear away and the calcareous 
plate comes in direct contact with the blood-etream. This change was for- 
merly described as "' otsification of the arteries," but it need not be said that 
no true bone is formed. From the arrangement of the calcareous matter in 
plates corresponding to the atheromatous patches in which the lime salts 
tkave been deposited, this change has also received the name of laminar cal- 
tiieatioju 

MieroMopic examination of an atheromatous artery in the early stage of 
the disease shows that the morbid change commences in the deeper layers 
of the inner coat by a proliferation of the flattened cells that lie between 
th*- laminae uf connective tissue of which it \a chierty composed. The new 
*elU are arranged in lines between the laminir. With the proliferation of 
ibe cells there is a growth of new laminae of connective tissue closely resem- 
bling that of the healthy inner coat, both in ap|)earancc and in arrnnge- 
Bcni. The change is therefore a true overgrowth of the deeper layers of 
the intima. The relative amount of cells and fibrous inlercellular snbstiiDce 
varies in different cases, but the chief bulk of the new tissue is always com- 
fioeed of the latter. The cells are small, rounded or slightly flattened, and 



IM 



MSEASes OF BLOOOVKS8EL8. 



exisU>4l for many yeani witlioiit ^vin^ aii%- annoyance, but, as H b&d of lite 
b«)j;un to «Dlai'^c, and occa»iun»lly to bleeil, lie yttta desiroui of having it 
reniuved. Tbi« I did by applying tbe tjuadruple ligature, al\er linviog di»- 
8ec'l4><l the mucoiH memoraue down. 

Kevi of the Volva are by no meuBa uDfrcquenU We Lave hod sevirnl id- 
etaiiLHXofthu kind iuUiuHoapitaloflate yean. T)ieyarcueiiiiIlyretiou8,4fleii 
Bttaiu a largn size, and may vometinics iuvdItc the iuti'jiumcnUil siruciura 
on the inside of liie tUigb. or ou Lbo pcrinvum, as well iu> the vulva. Wtieo 
tbe growUi i» oon^ucil Ui the vulva, it ii^ bcbt ttriuuved by tl)« ligature. Sutm 
time ago, 1 removeil in this way a largo p«nduli>uti wunus uirvus, as Utre 
as two or three UatteniHl walanis, from Uie !i-fl labium of a little girl six 
jeara of age. Id thia case, I fuuml it luml ooovenienl to omplor thn con- 
tinuous ligature. The same means were liiid reonurse to in ordrr in rxur[iati) 
a Urge dictob fntm the labium id* n child threo yenrn of age; but in thin caaB 
the ofiMoae e:i1<'udi>'l tn the inleguinenljs of tin* |ierineiim und inner mde ot 
the thigh, and was here removed liy the apidiRatiim nf strong nitric acid, 
aller thn lnrg«>r j^rowth had nepamted. 

On the Extremitios, TSeck. aad Trtiiik every poMible variety of niemt 
ocoura. When tiie di>^ii.te i» Hat, rnnsltitiag rather nt' «taintBg of the akio 
than of any actual tumor, it may commonly he treateil auiTceiwftitly bv tbe 
apblicalion of tbe strong tincture of iodine ; or should it bo thought Jc«ir- 
Bule to remove it, thia may be effected by rubbing it with »Lron{; nitric acid. 
If the nievuB assume the form of a ttiniur, it will nlniot<t invariably bo of a 
venous character, and then reiuuval by excision by nic-anM of the ligaturo 
should bv efl'ectad. If the growth hv ruund, the ordiuurv (jundruplv ligaturv 
may he umpluyed ; if Uut or elongated, the lungiLudiual continuous ligature 
is prelerubie. 

N.KVOtD Lii^MA. — This is a form of ntevus which 1 have uceasionallr 
Been, but which docs not api>ear to have attracted) much notice, ullhougb 
Nilattm vpeuks of it, and Billroth buvs that in Iip4)nia he has several tima 
met with cavernous dilatation of the veins. It la a tumor in which the 
sievaid vtructuro ii* comuined with a fatty growth uttiiatly more fihrnus than 
an ordinary lipoma. This disease i» invarinblyse-nted upon the oatefi. back, 
or thigh. It occura »a n smooth, doughy, indolent tumor, incomprRwible. 
not varying in eize or shape, without heat, thrill, or pubation of any kind, 
pn«ibly having a few veins ramifying over its surface, but no distinct vb»- 
cular appenmnce. It is ueuiilly conv;euilul. or has been noticed in early 
obildhooa; and it conlinuF« without any very material change in shape. 
aiz«, or appearaDco, until the incunvcuicnco or deformity occasioned by it 
requires its removal. Thi« is best effected by the knife. After removal, the 
tumor will be found to be compoaed of a naas of fibrous fat. having a targt 
□umhor nf voiua rauiifyin): through it, ao as to ooosiituto a dlMJaot vaWDlar 
element. oAen oommunicKiing with amall oyvts couiainiDg a bloody fluid. 
The tumor baa occasionally a teodcDcy to recur after removal. In Mte com 
I have operated three times for the removal of a large growth of tbt* de«eri|^ 
tion, .-tiluated on the buttock, and extending forward towards the perineum. 
The 6nt ojienttion was perfonned in 1851; the second io )H-'>o. and the 
patient, then eighteen y*-un of age, again prevented himself in IS^Vt with ■ 
recurrence uf the growth in an ulcemtetl slate, io the ci^trix of the former 
operationv. The eiluation in which I huvc seen such tumon 'Kvur, where 
toey gave rtse to motrt inconvenience, nn<l where their removal bns ret^uirvd 
the greatest care, has been the anterior piirt of the thigh, just below I'ou* 

1>arl » Hgamenl, cIom* ujMin niid nluio«t iu c<Jum>etton with the iVnioral vr^rls. 
n a atao ot'ilii^ dt^vrriptiou. which wa)> ^iil to me hv ^^lwa^I^ of Antigua, 
tbe patient, a gentleman uf that ialaud, hod suflareif for some yeata from • 




HJEMOrniLtA. 



105 



(bwCMlid ctdcmn nf onfi nf hia Ipp, appnrftitly dependent upon tlie pr«- 

.-•T- *T-f-if«e<l upon the saph^'nn ana frnmral T<^in9 by an clnnptl^d itxiolent 

: below Pouparts liRflnifnt, and over tlift cfninw. of these vessels. 

r had existpd from childhow). and presented the signs that liave 

.iveu a» cftnractfriettc of the di*«'a»e under coneideratioo. It "wiuj 

, au iiici«on pnrallel to Pooparl'ij lignmeiu, »ume careful dJssoc- 

reauirc*! (o iK-p«ri>te it from [lir reinumi sliealh, more [MirticuUrly 

■■ iDuur side, wlivrf » pnilon^jntioii of tin? tumor dijiped dowu by 

■ ; the ft'inoml vein, cuiri[iri*>*iiijr that vewsel, and ibus oaueiujj tli« 

!■ J. II vl" Ibf limb. AClvr rcirioval, tbe Uimor w«8 fuund lo couswt of a 

L - .if .[^n^' adipope liwuv, with mnch vusvular structure iutermisviJ, nud 

Tbt' a-doma gradually Bubsidcd ; and wbi-u the palieiit 

.. .„ ;_i _. .J>out lliree moutbe »Itvr tli« opernliuu, tin.* limb bad uwirly 

Rfitned its Doroial &iz«, beiug but little larger tbau tfa« Bound oue, 

nEUORKUAGIC DtATUEBlS, OR USMOVniLU. 

lb cnnnection Willi diseases of the bloorlvcsscla it may Iw Rlalnl that tn 

MWDC miiiiKtitutinnal conditions it t<i found, tbougb fortunately very rarely, 

iW tliere t> a great tendency to very troublesome, indeed almnttt uncon- 

tnillfll)le blei!dinf;, from iili^bt vtnundit. An Abnormal tendency to bleed is 

murlimM i)b>ier%'r-d in |>er»oiii^ who are " out of condition, " and whoiu> tisAUcs 

Mift Hod tlaecid. Thi-y bloed freely from slight wounds and bniise 

trii»iv<.'ly from trivial blows. In these case* the ble«?<linp appears to be 

nvd by tb* laxity itf fibre preventing the proper rontraction of the 

or lorn vessels ; and tlie tendency to bemorrhflge will vary at dilferent 

io tbe same person aocordlug a« the ^tatc of bis liealtb improve* or 

deteiioraUa. Id otner cases abnormal bl«cdiu^ may be duc> to » diminulioa 

io the oormol ooogulability of the blood. This state is suiuvtimes met wilb 

in icur\-y. chronic jaundice, and aibumiuuria. The diitenev known aa 

Uamupbilia or Hutuorrbaf^ic Diathestti is quite indt^pL'ndeut of such condi- 

Uooaw these. It ia a peculiar consliluttonal etate, alwa^'s congenital, and 

noM &i!i|DenUy hcredibu-y, e^liecially in the male line. lu some families 

the malsB only have been ailected. and the diBlhesis has been tnuuniilted in 

tbeseeood or third generaiion through females; who, ihemsalvcs being un- 

iftded by it, have bad male children who were the subjects of the disease. 

■A.terT remnrkablu |;t>iicalo^lcat account of euch a family has been druno 

up by CL Heath. The dinthti'is occu ra in persons withoui any other ap|Mirent 

wfaagrtoient of health or morbid condition, innate or acquired, to account 

'xr it. Id such cbh:* the family poculiariiy is usually rccoguised, and well 

Ur'on to those liable to it. 

The only cotun.int sif-n of the diotbesis is the free and often almost uncon- 
tnllablK bleeding that takes place from trivial vounds; life li«iiig put in 
joi^rdy and even lost by the hemorrhage resulting from the extraction r»f 
^^ tooth, the opening nf an abso^M, lancing of the gums, or some equally slight 
^Bjmportant surgical procedure. The blood does not flow in a jet. but 
^Kntion€« to trickle in nn oorJng stream, apparently from the cDpillaries 
^Hlh<>r than from the larger ve«ela of the |iftrt. In tficse cnacs. alao. there is 
^Kgrmt Cctutcticy to inordinnte ecchymosis trom very slight contusion. 
|Blo tlwM famiiint of blirt-ders, it is scarcely n«ccitsury to say that it is 
^nipsraliv« to be imrefut to nnike no surgical wounds, even of the most irixial 
[ thtnv ^tr, \* tbi-y can |K»j*?.iblv be avoided. Above all, the extraction of teeth 
^■^^^^hMde«I. It ill nllf r this i^li;;lit o|iera(ioBi that the most uncfintrol- 
^^^^^^■Ual btimorrbugtvbavt'uix'urred. Tho hemorrhages, though usually 
' tnujajaticroofty be apooiauL-oiM; tbey then usually proceed frtrtn the suae, 





106 



IIKMORRIIAOIC DIATHESIS. 



I 

i 



bowel, kiiluvv. or stiUcutanenus conneclive liseuc. In women ther UWBW 
tbo L-)iiirA<rter of profiiiw and uncontrollable nienurrhiigin. The hctiiorfbagM 
are KecuiupuniRd by ttie ^vrnpuinis de^cribt'd at page •iOA, vol. i., m ohftnc- 
teriziug L'X(-(!i^iv(! liittt* of bl<.M)d ; and after their ocp^utioii tbo pnlit^nt rctnAiiiH 
niiiL-mii; ti.nually for nmiiy weeks ur months. The quiuilitv of blood lost is 
often cnurniouB, ainountiog io some caam to Bevcmi paunds in ibe twcnlf-four 
liuurs. 

The lendeocy to bloediiig is chiefly from recent woundt or be«liJiy niuoooft 
mombrunea.iiDd sumetimca does not occur from diseased surfacct from vbtdl 
it preauninbly would h« likely to happen. Thus a member of one of tbc thrve 
faiDJtles of blcedeis, nho have been fre^juenlly iunialex of Uuiveriity CoIIcm 
Hnspilitl. iiii-<l iululy of pbthiHi!*, u-itb larf^ cavilienin ibe )uU|p. Afcwwe^sEft 
before htA death ho Imd nearly died <>|' |ieiuorrlia>;e aO«r tbe t^xtraciiuu of a 
tooth, but be bad never «ii[fered from iwriuiiit hivmuplyt^in. Io another «aae 
the patient paxMed ihroiii^h an altHck of lyphi^id fever without BtTiuiia bemor- 
rboge. Io another a lar^e «luii};b formed iu the ekin nller thi.- applii-altun 
of perchloride of iron, cold, anil pressure to urreot heiuorrhnge from n puDc- 
tured Wound of tbe Iv^. yet tbe slough EepnruUHj, utid the Urge grattuUttiDg 
Btire healed without auy recurreocB of the bleeding. 

tVrnierlvit wasauppiKed that fecniilcs were exempt fnira biemuphilin. But 
Wickhnm Legg. tu whom we are iudebleil for an excelleul mouogmpb on tliia 
coaditiuu. slatea that thiit assumption can no longer be tnaintaiueU, altliougb 
women ant far leas dit<pi«ed to ilie diRease tban men; thuc they praent few 
instaacw of the more typiml forms of tlie diseaiie ; and thai it u Uob fiual 
in them than in men. Most of the fatal m»e« in women have occurred by 
hemurrlia^'e from the genital nrgatis. and Lopiir quotes a eaae from Wa dt- , 
emutb. "where the rupture of the hymen on tbe marriage night caused ^^HH 
death of the bride from hemorrhnf;e." ^^^^ 

A frequent symptom Hccompanying this dinlheiis iR a painful and sudjni ' 
swelling of one or more ii>int« cither oeeurring sponlnneously. or as the mult 
of aome slight injury. The sivelling u the result of nn etTu-sion of hinod and 
aVDOVia into the synovial m«m)>rane. It is ueuully accom|)anied by mmo* 
slight febrile disturbance. It may last only a few days or may endure for 
nionlhs. The joint b olUo permaneotiy weakened, and relapMa are fr»quei)t 
during the core. 

Pathoijdgy. — LilUe if anything a known with certainty about the nature 
of thi# pttculiar aflection. It has been itatetl that in some case* the inner 
coat nf the arteries has been found aboornially Ihin.and degeneralive cbangea 
have been observed io the endothelium, but tbe observat)<'UB are not suffi- 
ciently numerous or uniform for any theory to be founded upon them. Fmm 
the inlluence exert<xl by cold iu the nrreet of the bleeding, it may be n-owia- 
ably susnertexl that a want of proper conlrnctilily in the arteries nmy have 
tuimv influence io causing the bleeding. With i-egard to the <<ondition tif tbe 
blood, rnrying sialcnonta have been made: it has bem laid to be watpry, 
deficient in eorpuacles, Bod uneim»;ulablL-. In the caaea, however, which have 
been admitted into iroiven^ity Colle^'e Hoapiiul.tbe blood in the earlier stani 
of the bcmorrlia;:e coaguluted healthily and was of good color, tliongb luiar 
grttat loss tbe lint became puler and (he coagulum less firm. Accurate anal- 
ysea of the blood from blcc^lcrs are atill wanting. It boa been cuggeetcd aa 
another explamitiou of the diM-ase that its real uiuee Ia an execs of blood, 
but of this al«<i there is no deftnite evidence. It would appear then that the 
only facts of iuipurtamre thai we at preaeni possess to throw light on tbe cnuie 
of htriiiophiliaarR. rbat it t* horrdiury ; that it u fur more freaucnt in mnlea 
than in femalt^ ; anil that it is ifxij^enitiil, and may occur in all race* and In 
nil couutries. 





IIJ[H01*UII.IA — TBBATXENT. 



^^■■■mIKM'. — In tnie hipmnphilia oo rcnivtlive apiKrar U> t;x<;rt*itii ihe 
^VqBBFnitiufDce ovenlie <liatheais. At the 9»me lime, il would liu wi»e 
liiil tb« aubjcct of* thU uDlurtiiDnte c^'udilion sliouM attend Ut tliuM^ urdinary 
tula I'f health, the neeletl uf whicb. by loiivering "Wte eoiuliliuii," might 
brarilie teDdcDCy to bleeU. Lfgg especially reeuninifiids iJie u»« iif cold 
bubs of plain, fipa, or chalybeoic watei-e. remdencc in a dry uir, and the ufe 
vtwm i'lothiQf>- Thf prt'paraiion* of iron are uaually (livun in a routine 
WT. but it is doubtful if lltey have ever been of serviL-* ju |ircvontiiijr the 
Miorrhagca, certainly never in urrcsting then), though they may Ih^ of uKe 
ID imoTing the sua'iuic state Icjl after » copious bleciltng. Kr^tit hua bei^n 
firCD doriDg the bleeding in many cuses. but witlioiit evident etfitnt. 

Tlie Loftu TVeatmait is that on whicli most dt-pondcnce will nce(»»arily )k 
ftlan-d. It couBUte iu the use uf three nieiin». viz., Prer»urL', Styiitica, and 

?MlilTe 18 to be rt-Iied uu only in oik- form of hxmophilit! bliHHJing — vix., 

tbcufiliDUOUei hemorrhngi; fmm the ftieket of n tixith ul\er i:;xlra(rtioii. In 

AeBt cftjkj the cavity shnulii be ctearett out and carefully plugged fmin the 

betioni by moans of lint or agaric, the whole remined by meanH of a piece of 

torlLiuda gultn-pereha cap to Bt over I he neijfhbnring teeth, and coniprewicd 

byabandaijie ap|)lied under the chin n^insc tlii)»« in the oound Jan. When 

le hcRiorrlmt^' oeeurs from the 9of) part^, prr«siirc must he iiited with j^rent 

ulha im »ti>ttj;hing occur; the iocegiinienl? being extremely liable to give 

ir eiiefisivi'ly under very nxidemte jirewiore, larye aubeiitaiieouji extravasin- 

ioD developiug flt the Fame time, and thus iucreH^iiig niaterinlly the danger 

the ciue and the toml mischief. 

Compression of the main urlery of the limb is iweleM and liable to the 
ibjiTlinn of the develtj|imeiit of eochymuseiii and subcuHuie'nis hemorrhages. 
Styptics of all kinds have been uyed as a matter uf couree, aud the pt>r- 
Wide of in)n baa enjoyed CBpeciai favor. I have used uud seen it used 
^ifuenlly, and can safely say that I have never seen any perumneul benefit 
i^iu it£ application, or that of any other styptic, in theite cases. Indeed, 
»tevil has ufiea resulted fmm ihe indamtnatioQ excited by Uie applica- 
of ityptics of any kind. Th& {mrts become swollen, fall into slough, and 
tf separate the oozing may recommence from the raw surface, aud the 
pmecfiB has to be gone tlirough again. 
Tbe actual Catitery presents the «imc ineonveniences as ordinary gtypties. 
It may arrest tcmpnnirily the bleediug. but intlammatiun i» set up in the 
]«r;» beyond the limit of the est'har, and this on eeparaling leaves an ex- 
tended ulet-nittng surface which blct^^s again, and perhaps more freely than 
before. 

The continued application of Cold appears to nrrert hicmophilic bleeding 
more ellci-tunlly than any other means, and this clrcumstanoe would lend tu 
the belief that the hemorrhage is due lo want of contractility in the smaller 
arvn'es rather than to want of cnagulabilitv In the blood. The cold mny be 
applied by means of irrigation of iced water, as has been done eucee.'«fuliy 
l^ Mareball. or by the application of ice either directly to the part or laid 
apnn a aponpc covering it, aa haa been done in some of the cbbps of hiemo- 
philia occunng; at University College Hospital. Simple warer may be uw<l, 
or a weak antuwptic solution of boracic acid. If Ihe bleeding wound be in 
^ihe exir«*mitita, the limb nhoiild be elevated and kept at rest nn a splint. 
Hk Th«> .burgeon ban already lieeii canlioned a* to the inexpediency of per- 
^Bbro'ioi: tiny op^-nilion. except un<ler circtim»tanee«of the mo3t urgent necea- 

^v I- of ft fnriiilv 'if bleedprs. i>r on an individual known to 

i- mophilia. f?hoiil<l an operative [iroeedure become neees- 

wry. it abuuid, it punible, be undertaken with Paquclin's t her mo-cautery, 



li 




108 



^ISSASBS or ABTSRIKS. 



if it be doaireil tf> ninke a niinplA incision ; by tlit- jralvanic ^cnuctir, if it 
expedient to rum-ive a part or to pertWui a euinU siui>uUHtou, In tbo cv< 
of the gmlvBitic ^rawur nut t)eiug at band, the dvutic liytture vuutd bo the 
beatoubatitutf. 



CHAPTER XLII. 

PlSEAtiES OF AKTEKIES. 

AitTEuiB? nro liable to numerous diseases wbicb derivo great imponuoM 
from tbi* pMW-Ls they pntducr, both up<>a tfae vcMels thvmftelvce and upon ibo 
pnrts to which ihcy carry th<> bhiud. Amongst the must iiupartaot are the 
various fitrms of inflaimiiutiun or arieride. The intininmatory afiirctioiid of 
nrterioe ar« divided first into two cla^ws. viz., those reaultiug from injarj, 
■ad those nrisint; from gonoral or local causes not of a iraimiatic nature. 
Inflammadon of tlic aru-ri« i« divided also Into I'ndartt-'rittft, in which it 
admits prininrily or chtctly iho internal mat. and jueri-arier ilia, in which the 
proc«M coininpiK-cs in ihn oniiT C'tiit or sheath. The term mw-Rrttrritis has 
alw) been au^f;<<9>tei) lor iDHniDrnation uf the middle coat, but it is of little 
UM, oi no iruK iiiKHtninutiii-y alffctiKO cuniiMUCM iu thai part of th» va»d. 
Somt! foriiH (if art^ritii* nn- uamed frurii the cause of the dtttettM!, aa ityphititic 
or embolic. Aa in lUhcr HtructurM, the iiillAmmatory proceas may Xm acute 
or chronic. In nd<liti»n lo the ahove dith'OAeii, nrieriei snller from vnriuu* 
degenerative clinn|f<#, »<ime of which are primary, nfTecling the uri^oal 
ti.'tsuea of the vesiwrls. olhem aro necimilary, the dejrenerutioo taking place 
chietly in the pro<)iicU of a chronic inHniumatory procnc. TheM> vari<ru& 
pruciaaca arc sliU furth«r complicated by aecuudury effects, «ueh at the furm- 
atiod of aneurtam, from the dtsen^eil waits of the artery yielding b<Mt>ra the 
pressure uf the hlwid, and ibromboeis of the iilfi-L-tcd veeaol folKtwiMl by its 
ohlitcmriim. and tiiiniciimes by embolism and gungrooc. 

In discuGding the tliMntKea uf arlfries, it will be most coDveuient to ronsidrr 
firat the vari'ius formal i)f inllumiiiation ; aecoodly, tliu dcgeuuratiuiu: and 
lastly, the remoter eflecls uf tliesL' ebauges. 

AKTCRITtS. 

AODtt Arteritis nf idiopnthic origin, thai ix Uf ^mv, ariatn;; as an indepeo- 
dent nlleetiiiri for which no cviih-iil. eatim.- can be tounti, was formerly believed 
to be a com ]>u rati vely nmimon nlleclioti. 1 1 wasriifipos*^! to alledt the inner 
coal, spreailinji aioniz the veMt>l in (he direclioii uf the circulalion. and fr>m 
this faet it ViU6 »{i<ikcn of ns ilitliise or erysipelatous. It is now known, hot*- 
ever, tlxat ni>AUvh nlfoction n-ally exi^li*, nod that the error anwe partly fnm 
Mwnning that thromhogis in inviiriably evidence of previous inttnminnlinn of 
the atTorted vi'aeel,a)iH partly from miHtakingfor tlic redniSHof inllnmnialiott 
the Btaiuing of the inlima, Ki often nliwrveil as the rrauitof ehangnu in the 
hloiMl with disintcgrntioa of the ml enrpuscleti, nocitrring either duriog life 
iu acute forms of ulnod-poiaoning such as aepLiciemin or maligoaot fevers, or 
aiW death as the rcHjlt of |>utrefacLion. 

Trauutio Arteritis.. — Simple acute trnumntic inflammattoD limitnl to 
the part iujured and showing no tendency to extennon, is fiimtliar to every 



VARIETIES OF ARTERITIS. 109 

Surgeon id coDoectioD with cootuaioD, laceration, wound, or ligature of 
BTtenee ; for in tbe early period of repair ailer any of these injuries, inflHrn- 
nuitorv exudation from the vasa-vasorum forma an essential part of the 
prucc«& For a description of this condition, the reader is reterred to vol. i, 
chap. xiv. 

Arteritis by Ezteiuion, from infective iuflammation or ulceration of the 

ti^utre surrounding the vessel, has already been described as one of the 

dani^eni accompanying these processes. In inflammation affecting an artery 

La this war. the prncees la the same as in other tissues. The vessels of the 

outer coat are dilated, inflammatory exudation with migration of corpuscles 

takes place, and the wlmdering cells in61trate the coats of the artery, which 

bei-^ime swollen and softened. The process spreads from the outer to the 

inner coat, the endothelium desquamates, and iibrin is deposited upon the 

dteeaseil surface. In the smaller arteries complete thrombosis takes place, 

ujd the clot extends upwards to the nearest branch beyond the inflamed 

part of the vessel, and may then undergo the changes already described as 

occurring in the permanent closure of an artery (vol. i., Wounds of Arteries), 

and hemorrhage is thus prevented. In arteries above the size of the radial, 

however, the closure of the vessel is frequently not accomplished before the 

mats are so &r softened as to give way before the pressure of the blood, and 

thus fatal hemorrhage may result. This is all the more likely to occur 

when the inflammation and subsequent ulceration affect a limited portion of 

one ude only of the artery, as in those cases in which it is due to the con* 

tact of an irritating foreign body, such as a sequestrum. In the latter 

arteries complete thrombosis occurs much less readily than in smaller 

TeseeU or in veins, the rapidity of the flow of the blood being unfavorable 

to the adhesion of the white corpuscles, which is the Brst step in thrombosis. 

lo arteries which have been divided and secured by ligature or otherwise, 

the extension of unhealthy inflammation from the wound to the exposed end 

of the vessel, followed by softening of its coats, and disintegration of the 

ooDtaiued clot, is tbe commonest cause of secondary hemorrhage. 

Embolic Arteritii. — Moxon has pointed out that a form of acute arteritis, 

resulting in s^iflening and swelling of the arterial wall, thus leading to the 

ffrmaii'in of an aneurism or to rupture of the vessel, is in rare cases the 

rrtult of the lodgement of an embolus. A simple fibrinous emboius lodging 

in an artery merely obliterates the vessel with<iut causing softening of its 

caiff. In onler that inflammatory softening may occur, it is necessary that 

tW i'diIkiIus should l)e derived from a part which is the sent of some infective 

influmniatiiin, and that it should carry with it the unhealthy products of the 

l'^'^.f>s. Kiuholic arteritis is most likely to occur in the .somewhat rare 

a^i.-ii<>n known as ulcerative or infective endocarditis, hut it has also been 

iLiiiiwn to fiillow embolism during the course of an ordiuiiry ca-^e of acute 

rheumatism. Localized arteritis arisinjr in this way is believed to be the 

^■fi common, if not the sole cause of spontaucoud aneurisms in cliildn-n, 

U'l in tlio smaller vessels of the extremities in adults. Kusliton Piirkcr has 

rn-'iriicd a case which well illustrates this form of disease. A boy, uged 14, 

iluriii): an attack <if acute rheumatism was suddenly seized with piiin in the 

I'^rwirm, fullowotl by swelling of the limb. The general swelling soon suh- 

fiiif 1, leaving a dee)>ly seated circumscribed tumor, which steadily increased 

iD»iu t'lr the next four months. On laying this o]>en, a cavity whs exposid 

'"■ntaiDiu^r more than a pound of dark clotted I)1o(h1, and the anterior intcr- 

'•*e..uii artery was found to communicate with it l\y an opening u quarter of 

1' inch in length. The vessel was successfully ligatured above and below 

tltf 'iitcnini:. and the hoy recfivered. At the time of the o])eration there was 

* Iftuil di^uble aortic murmur. 



110 



DISBASKS or AKTEHIES. 



Acate EndarteritU. — Comil «n'l Ritnvi^r deevrilii^ utidf-r ihienam^M 
ulllH^Liitii ul' till- iuiier coal, met wilh cliietly in lliv hufIu. IiuL Murjmiojmlljr 
ulwi ill aiuKller vcsm-'U, oniwcially iic*Hr Moiiixle. It is cliiinictfrked. tn tbe 
nakvii eyv, by )in)rniu<;iit (mtclicri r<iniiuil l>y a t^nellin^ iiftlie intimii. They 
are cimiilar nr i>vnl in outline, tinil Stildoiti i.-\i!t-tfti hiilt' iiii iiirh in (lianicrUT, 
though both their ttirrii and Kiu- muy btt uIutflhI by ibe cobIkkwik;*-' of uetg^- 
bnring patchiia They are jnilu pink in ctilor, uml kc in i-tntn^ parent or 
opalescent ; in ounsist«nce, ihi^y uro Botl nml tOaKlic, almmt gelnttnoiifi. The 
internal surface has often Itwl it^r polJFh, in tmnsetiuence of tbv irre^uliiriLr 
of the swettinf^, but it« endnLheliiil (tu-vring is lutually iotacl. The middle 
coat hcneAth the patch appeHTM iMually U* be mmewliat swollen, and this 
c4>nHitioii ismnremnrkt>d in theuHvenli'tia. Micrwcopic einmination shnvs 
thai the swelling U duo in an nccitmnlaUon of 5innll cel)^, either round or 
slightly irroiiular in onrlinc, between the fibrw of the euh-enffolhelinl con- 
nective tissue luid the einetic layers of the inner coHt. These cell? have ■ 
distinct nucleus surrounded br ii small qunntity of protoplasm, and fthow 
oigiis of active iiriiM'ih. LWnil and Rauvier believe they arc prixlmx-*! by 
pruliferHtimi of the uri^iiiikl <^^l|g of the jiart. The ««i.'lling of the <:'\IernAl 
coat i» found to be due U> the presence of nuuieroiw cells of n«w f..rroalioo 
aeparatiug Ibe iibresof llie connective tissue. 

The oonJilions under which acute endarleritia occur are not clearly d«t«r- 
minetl, but aa every intenuedinte condition between It and the chronic forn 
t<i be imniediiilvly de»cribeil, u to be met with, eometintes even in the ■&»« 
vesel. it »tH!iua to be nuthing mora than the wme prooeaa iuct«a«ed io 
iutcntiity. 

Chronic Endarteritis, Arteritis Deformatu, Atheroma. — This is by Ihr 
the inoflt comni-iu diwase to which arteries are liable; in taot, it is very rare 
nlWr middle life to find il completely absent in the larger veasela. It occurs 
in its must marked form in the aorta and the hirge iirluriu of the twck^ 
abdomen, the upiwr parts of ihe liiul», uud the base of the brain. It is leas 
commouly eoen in tne tjmaller veasels, in whiuli the musculur coHt is more 
fully developed. 

Chronic endarterlttii iir<t iip|)pan< as pole yellowish patches or streaks, 
smooth, slightly elevated above the surTacK, and evidently -wHte^l in the 
deeper layers uf the inner coat. They are irregular in outline, their long 
diameter U usually in the line of the Teasel'a oourie, but they sliow a special 
prcdilectioQ for tbe mouths of the branches leaving tbe main trunk, mund 
which thcv form annular elevations. Their outline becomes aubaequcntly more 
irregular by the coalescence of neighboring palchea. Aitbe ducnseadvancMa, 
tbe patches become more clevnted, often reaching a lino or more in tbickn^MH 
At this stage they are gray, Kcmi-traitsparent or opalescent, and inrisj^^H 
sometimea almost cartiluginouA iit appearance and consistence. This (Niinlittoa 
in. however, speedily fnllowwl. bLlnrc the patches have reached more than half 
HD inch in diameter, by a ehnuge to an opnijue yellow color, the »lt4>ral>on in 
tint c»mmenctn}{ in the central parts. Thi^ change is due to tiilty degenera- 
tion, and is accompanieil by srmie InMof tougbnen. The furtberprograssmar 
be in 000 of two directions; tbe growth may aoften and break down, or u 
may calcify. When soOening takes place thi patch becoroea converted iatn 
n pultaoeous or oheeay mass, and even sometimes undergoea complete lique- 
faction into a yellow creamy Quid, which has been mistaken for true put, 
and termed an " atftemivitotu abuxsa." It is this change that led to tha lam 
atheroma beint[ applied to the disciuc. the prodocta of the aoAcDin^ nf Un 
patch reaambling ibe oontenta of an atheromatous rvst of tbe skin. Tha 
term is now oftaa aitandad to all stages of chronic endarteritift. 

Wbea the proous raaebea tbe more advanced stages the middle cuat is 



ABTSBITIS DEFORMANS, OR ATHEROMA. Ill 

■Sected, fint hj chrome inflanimation, aod subsequently by softening. At 
Uwrnne time considerable thickening of the external coat takes place by 
ibe formatioD of dense fibroid tissue which is not prone to fatty degeneration 
asd tofleoiDg. Up to this BtH&;e the fatty patch ia covered by the most in- 
tfrtal layers of the intima and the endothelium, which are not affected by 
tbecbronic iaflammatory process, but afler complete softening these give way, 
aad tbe atheromatous fluid is discharged into the circulation, leaving the re- 
attiui of the patch exposed to the blood-stream. The raw surlace thus 
fenwd is callra " an atneromaUme ulcer." The debris which enter tbe circu- 
ktioo are carried on and lodge in the capillaries, but not possessing any irri* 
tatiog properties they give rise to do evil consequences. Although on the 
fenatioo of an atheromatous ulcer a considerable part of the inner and 
middle coats are lost, perforation or rupture of the artery rarely takes place, 
aad it ie only in exceptional cases that the blood forces its way aniongst the 
tnu of the diseased vessel. This is due to the fact that at the margins of the 
ptk-b, die chronic inflammatory process has led to firm matting together of 
tbe coats of the artery. At the same time the thickening and induration of 
ibt externa) coat prevent perforation. It is especially opposite the deeper 
and more eroded atheromatous patches that this cunsulidation of the exter- 
nal coat takes place. The chan^, although described as a chronic inflam- 
BtUoo. is strictly conservative in character. The new growth of fibroid 
QMe is not confined to the external coat, but extends to the sheath of the 
vokI, and, by soldering it to the contained artery, greatly adds to the 
Anngtb of the vascular wall. 

Although perforation is thus prevented, the new tissue but imperfectly 
nproeots the normal structures of the coats of an artery, as it is entirely 
noting in elasticity. G)n8equently it is very apt to yield slowly to the 
pnnire of tbe blood, and thus lead to the formation of a sacculated aneu- 
na. the mouth of which will correspond to the damaged portion of the wall 
of the vesKl. 

Complete softening, with the formation of an atheromatous ulcer, is not 
hr uy means a necessary consequence of fatty degneration of the patches 
Rniltug from chronic endarteritis. In many cases the new tissue, afler de- 
gntenting, remains as a firm, yellow, opaque mass, and may undergo no 
Airther change, but most commonly lime salts are deposited in it, and it 
pidually becomes converted into a hard calcareous plate, over which the 
Nperficial layers of the inner coat with the endothelium may remain un- 
broken- S«)metimes, however, these seem to wear away and the calcareous 
piste comes in direct contact with the blood-stream. This change was fiir- 
Berly described as '* o$tification of ihe arteries" but it need nut be said that 
nutrue bone is formed. From the arrangement of the calcareous matter in 
plates corresponding to the atheromatous patches in which the lime salts 
Bare been deposited, this change has also received the name of laminar eat- 
aieation. 

Micracopic examination of an atheromatous artery in the early stage of 
the disease shows that the morbid change commences in the deeper layers 
of the inner coat by a proliferation of the flattened cells thnt lie between 
ih^ laminie of connective tissue of which it is cliiofly cumpused. The new 
«lls are arranged in lines between the lamina'. With the proliferation of 
ike cells there is a growth of new lamina: of connective tissue clusety reaeiii- 
btioir that of the healthy inner coat, both in Hp|>eanince and in urrunge- 
Btat. The change is therefore a true overprowlh of the deeper layers of 
the intima. The relative amount of cells and fibrous intercellular giibstitiice 
Ttrie* in diflerent cases, but the chief bulk of the new tissue is always com- 
jnwd of the latter. The cells are smalt, rounded or slightly flattened, and 



112 



DISEASES or ABTEKIKS. 



;v*, 



'• »: 



'^- 



«Oo- 



contain a nitcUus of coniii(l«rabte size, round which it is oft«n ilifficutkj 
recxi^uizc aii>' proUipliMii. Xu vesBela pviiclrate tb« uew Iimup Kml 
({uciilly nlu'i) iL r*iii:bit< u ct-Tbiiu eU^ of dcveiopuieut the a-utral i^uU; 
but iniiHTlK-lly iiDuri^heil, uud J(.-ut>uer«tioa ocMnmeaces. Th<- wU» b 
Hhrivutlcil aixl i^rauulur, ami futty ]eriiuuli-« ah" ip{n-ar lu the intrrurllu 
8ubsUuic'v. At u luler atagu uuIvuiuihik };rauukw muy bIimp lUMkc their 

upitratHiice. ir wiltunjog Lakus (iluef, the &t- 
gninulcs increaee iii <iunuui)', ami «>luliiia of the 
inlt-ni'Ilular substance iultuwa. If ooni|iIeti- li' 
luction takes place, ibeathnromiiuiaa fltiiii i» it 
under the inii;ro6c«)pe to be Cximpoaeil chlpflj nt 
tiitly debris and oil-globulea, and very Irciiueotly 
it ennlainB plates of obolCBteriDe {Vig. -i'Ab). 

The aorompaDjing drawing C^'ig- -^''^^) illu»- 
trat«8 the alnioture of an utheromatutia jiatcb 
very well. 

"the chants in the middle and out«r ooata r»- 
qiiire but little notice. The middle cnat iu tb» 
Iftter stages h oflco iitvaileil by a gntwih Bimilar 
ill eharacler aud 8tniclure tt> that xhich origin- 
ally «LurtC<] in ibe inner cnat. In tact, it ^efiun to be an cxieiivion nf th» 
aame gruwth, the true vtructiirm •>( thv middle cnat l>eing atri)|ibi«tl fnim 
prewure. The uuter cuat ehows a gn>wth oT new libruus tlnuu eootittning a 
number of small runod, or elon({al«<l cella. 






^^j 



He. tSA.— AUierMM, wUh 
tboadMil Ckol«it«rtDr. 



fff^JS^ 



M t 



rif. IM.— AtlMriMM «r Aorta. '. tlulla IftnlMK ; m. Bl4dU egkt ; t, InUrSkl sMt ; /, tka aw 
fttiHh aa<l«rc«tn|t bUty ilifMMrMino. 

Hatarfl and Cautet. — ^Thc views as to (he nature of Ihti dlKaao have nn- 
dergniir vnriiiua ehuugca, but at the present time it is ainiuft univrmUly re- 
garde^l as n chr>uic ioflaniuuitary prvceaa, eharacterized bv over^iwtb of 
the ttttect<-<l ti»uo followed by rleg^neration. Gulliver Kaa long ago inclined 
tu this opinion, and it has been e8|iMnally inaislcil uu by Vircbow, Killrnth, 
and Moxon. That It belongs tu the cIom of morbid procoBBes almost uni- 
venally sjMtken of an chronic inHammattnns, may be aaid now to be geaer^ 



NATUBE AND CAUSES OF ATHEROMA. US 

sIIt accepted, but the difference between these and acute inflainination is 
■o marked that probably, with the advance of pathological knowledge, a 
eoaplete aeparatioD will be made between them. 

The moat important cause of chronic endarteritis ia mechanical strain. 
Thifl maj be constant, as the result of abnormal resistance in the capillaries 
or smaller arteries, or intermittent, such as occurs during violent exertion, 
io which, while the heart is beating forcibly, the resistance to the circulation 
m increased by the contraction of the muscles. Moxon has bniught forward 
abaodant evidence in proof of this theory. He points out that atheroma 
occura more constantly and at an earlier period in males than in females, 
and that when extensive atheroma is met with in women, it will usually be 
fuaod that they have been engaged in hard manual labor. In men, the most 
marked examples are met with in those whose occupations have involved 
rioleat physical exertion. In wasting diseases, in which the quantity of 
blood is diminished and the arterial tension reduced, atheroma is seldom met 
with, mod in the pulmonary arteries, in which the pressure is greatly less 
than in the systemic vessels, chronic endarteritis is rare, being observed only 
io those cases in which the right heart is hypertrophied in consequence of 
efaroDic bronchitis and emphysema, or obstruction at the mitral orifice. The 
earliest patches of atheroma are moreover situated in the parts exposed to 
the greatest strain, as in the arch of the aorta, and at the points at which 
taive branches are given off or a trunk bifurcates. It is common also to 
find the disease more advanced in those situations in which the artery ia 
placed in close proximity to a bone, as in the femoral at the brim of the 
pelvis. The fact that chronic endarteritis is always more marked in the 
vessels of the lower limb than in those of the upper may also be explained 
by the pressure being greater in the most dependent parts while the Dody is 
in the erect position. 

Among the constitutional affections which predispose most powerfully to 
the develttpment of atheroma is chronic Bright's disease, with the granular 
contracted kidney. Gull and Sutton have demonstrated that this disease is 
asanciated with a general change in the smaller arteries and capillaries to 
which they have given the name of arterio-capillary fibrosis. It is charac- 
terized by a fibroid thickening of the external coat of the smaller arteries. 
In the diseased kidney, Johnson has described a thickening of the walls of 
the smaller arteries, which he believes to be due chiefly to the hypertrophy 
•t( the muscular coat. The nature of these changes and their extent is still 
a matter of dispute ; but whatever the exact pathological change may be, it 
if beyond a doubt that it caui^es considerable ob^ttruction to the circulation, 
a (act which is made evident by the hypertrophy of the heart that accora- 

ries the disease and the evidence of increased arterial tension aa indicated 
the sphygmograph. The granular contracted kidney and the general 
vascular changes asaociated with it are very commonly the result uf (/out, 
K- much so that this form of Bright's disease is often termed the " gouty 
kidney." Gout is usually the result of an abuse nf alcoholic stimulants, and 
thu« habitual alcoholic excess comes indirectly to be an important cause of 
ehr>oi<' endarteritis. 

The influence of typhilis in the causation of atheroma is a more doubtful 
p'-iot. Aitken attaches great importance to it. The effect of syphilis in 
eau*iug disease of the smaller arteries, and fibroid induration of organs and 
ti«u«-». ha^ already been [xnuted out (see Syphilis, vol. i,"), and it in evident 
that tht-se changes would tend to obstruct the eirculati<)n iind thus cause 
inrrt«j>e<i arterial tension. Whether it acts more directly as a cause of 
athtroms is uncertain. 

The m(»t important predisposing cause of chronic endarteritis is old age. 

VOL. II. — H 



114 



UlliBAfiKS OK AHTKKIE8. 



After R rerlniii perirxi of life tht- nricrieis in ctuniiioti Mitli olher (i»»»ti« 
impaired iu etructure. This iiiuuitdilM itecll' chit-Uy by r (Jittiiuutiuu 
□oniiHl elasticity of tin' coals, so tliuL ilicy becumo leu capable of witli 
iag auy i^train lu wbicli thur iimy Im; ux]K«(!d. So lV»)ueut. oud ludeeit 
cuDHiaul Hi'c t]ie«Q irauafurtuatiuQs ol' tiio arterial uoau duriuii; llie lit^clioe ul 
Uf«, that tliuy way he uoDsidonHl tlic natural ri«ult ul' ihi* tlimiuutiou of ititf 
DuLrioot activity muscqueut upun ndvnuce in yean. Guielia lias I'uuDd that 
them is a |iri>grcasive iiicrcuie in lliv curlliy iiiiilli'-n! cmitaintHl iu Lbe ccmuI 
of lieallliy urtvrius a« llic tudividuul udviiiiceii in lifu. Thus b« aacettWoed 
that Ihi! a»h uf the arlerim of a newly born child yiclila t),ii^ per cMit. «u 
phiuphutii of' limn; ihcr hpallhy urtcricK of un adiiU l.'lii; and liioae of aa 
old mnn 2.77 of thr tiHtnc Katl; whtlot I he ciilcitie<l Hrterie^ of aii age<l man 
contain 4.01. There Im no precim* period of life iit wliirh thcne chaoen «e( 
in ; old age \n a relative term, ami, stt soan a.^ the sv-Htt^ni haa paased lU full 
maturity, iii whHteve r year of lifV' this mnv happen, there ts a tiindency for 
tiwae def^nerntlve «han>(es to tiike pince. The lendeocy to enrlj d«gmumi 
iioD of arteries h fre.|iieiitly hereditary. i 

Effects of Chronic End arteritis.^ A# n coii^quenre of the htw> of rlai^ 
ticily rifiilliii;; iVorn tlu- clironio inflnnimiitury and dejjenemtivv chaiit;;v» ia 
tho cuul« of the arterv, it usually yichU mure or \es» before th? tli»(i<»din( 
fore** of tlie heart. Tim change in ni<«it marked in the aorta and it» [iritnarjr 
dirixtons, but i» occasionally wen in tho femoral and hmehiiil art^riea. Tfat 
dilatation may be regular, or pouch-like projections may form h«re and there. 
At the Miue titue the vckkI is uAcn somewhat eWugated »o as to aasuoie t 
tortuous furiu. il is in couseiiueucc of lhe«e chao^fev that tho name arteritit 
liefvmuiiu, was )pvvn to this disease by Virchuw. The interior uf the dilatiid 
VMBol is rough and irregular iu couBei^ueiice uf tht: projecliou of the iitbero* 
matous patulie» : when sifrteuiug has Uiken place, " titlivrunialuUB ulcvrv" 
may be scattered here uud there uver the surtk<;e. and in other cases it may 
he paved witli cl<.«.ely »et ealcareuuK plates. When the dilataliuu readies a 
certain dv|;ree and is limited lo a deiinile area, the eutnliliuii is deecribeil nc 
a Ibsiliirm aueuriBm. the distinction between tliat aud simple dilatatiua I>ein2 
oiilv one of dvj^rce (see Aiieurism i. 

The lues of elasticity in the coals seriitut^ly interferes vitb the drcuhuina 
through distant partt<. us the natural etora^ ufthe heart's force in thcelastia 
mills of the larf^er vessels by which tlie oonUnuous flow between each systoU 
is muiniuincJ, is no hin^^r po^ible. The circulation in tho exlremitim tl 
therefore usually feeble, and the nutritioo of tJia jiarts correspond Uigly im* 
perfect. 

Narrowing or Oeebaion of Ihe Brancha leaving the Atharomatoui TVvnl i* 
hj DO means uncommon. As bet^tre ^tawd. the oriAoea of tbe brmachrs from 
tlifr main trunk are common etnti of thcearl]«8Calheromutou» |tatchc». The 
thickcnins of the intinia may take place iu a ring rc>utid the mouth of tb« 
veasel andthuH gnidually uitrrow it. The coincident thickening of the out«r 
coat may still further coiilrnct the urifice. When ct>mptfle obtiteratioa 
oocun the 6nal obstruction probably takes place by the fornmtion of a throoh 
bus in tho diseased artery immediately above the niirrou-e<l orjticv. CvDipUu 
obliternlion \» m>.>stcommun in those cases io which theililstation of the Dialn 
trunk hits reached such a decree a» to merit the uameuf a fusiform aueurisu. 
la a ease in University College Hospital a few years ago, in which tlie left 
carotid was tie*) lor oneurifm r.4' the innominate artery and the arch of tba 
aorta with nu immpdiately fatal result, it wae found that tbe right suMavian 
wu obliterated «b«re it left the dilated innutniniite.the right earutid waBpvr* 
moablo, but prcMed on by the aneurism, and the aortic openilig of the 



SS3ULTS OF ATBEROUA. 115 

rabdarian wu completely closed, thus the artery which was tied was the only 
KBwl carrying blood to the brain. 

Xarrowing of the coronary arteries by an atheromatous ring at their orifices 
it % common cause of fatty heart. 

Tkivmbo$U is an occasional consequence of atheroma. So long as the patch 
ii cohered by an unbroken layer of the inner coat with its endothelial cover- 
ing, there is no tendency for coagulation to take place upon it. When, how- 
errr. tbe patch has softened and discharged into the circulation, leaving an 
"atheromatous ulcer/' or when the thin covering over a calcareous plate has 
been worn away, the diseased structures come into direct contact with tbe 
bloud. If the surface is tolerably smooth, the rush of blo<id past the dis- 
eawd patch is so rapid that adhesion of the corpuscles is barely possible and 
Consequently no thromboeis results; but in pouch-like dilatations it readily 
takes place. In the same way it may occur in a very dilated vessel if the 
heart's action is unusually feeble. A clot thus formed may gradually Increase 
in nize till it fills the whole vessel, but more commonly after reaching a cer- 
tain bulk it is washed away and carried on as an embolus to some distant 
part. If it be of sufficient size to obstruct a main artery of one of the limbs 
at iu bifurcation, gangrene will frequently result. Smaller fragments lodg- 
ing in the extremities usually produce no important effects, the anastomosing 
circulation )>eing sufficient to take the place of the obstructed vessel. If 
lodging in one of the solid viscera, it gives rise to a hemorrhagic infarct (see 
ToL L p. 904). but does not as a rule cause any serious consequences. 

Sypoilitio Endarteritis has already been det*crll>e<l < vol. i. p. 1048). 

Artmtii Obliterans or ObUteratiTe Arteritis (Friedlander). Endar- 
ttritis Proliftnuis or Hyperplastic Endarteritis ( V. Winiwarter). — Under 
these names have been described certain rare cases in which obliteration of 
arteries takes place as the result of infiammatory changes in their coats, not 
erideotir dependent on syphilis, embolism, or injury. The disease runs a 
dimnic course, and may cause spontaneous gangrene of the parts supplied 
bv the affected vessel. The symptoms will perhaps be best illustrated by 
qaoting a tvpical case latelv recorded by Pearce Goutd. Tbe patient was a 
brickmaker, aged l!l. In May, 18S3, the fingers of his right band became 
congested and sometimes dead white, with much sickening pain. Afler a 
&w weeks' re:it he improved, but soon relapsed on returning to work. Afler 
»>me months the pain extended into the fUrearm, and completely iucapaci- 
laled him fmra working. He came under Gould's observation in October, 
l'"^3. At that time the right forearm and hand were cold and somewhat 
waftei). and he sufforcti much pain, especially at night. The brachial artery 
wa^ hanler than natural, and pulsated more feebly than that on the opposite 
li-ie. The radial could be felt as a solid cord. There was dry gangrene of 
the tip* of three fingers. >'o constitutional affection was found to account 
fir the condition. Two weeks af\erwania (he pain increased till it became 
aertnizing, requiring hvpoiiermic injections of morphia for its relief. At this 
time there was slight eles-ation of tem p(f nitu re. The brachial artery then 
became i*<mverted into a pulseless cord to witliiu one inch of the teres major. 
!>>m after, the subclavian artery was found to be prominent. In December 
the pain graduallv subsided, and one mcmth atier he was apparently well. 
The brachial arterv remained a (tolid coni, nnd the tirst joint of the thumb 
and <if the index finger separated after beciimin<r uiummified n'i(/c Trans. 
Clin. Sk'. I'"?4'. a rtoniewhat ^fimiiar ciwe occurring in a female, aged ;J5, 
it rec<jrded bv W. It. Hadden in the same volume. The pathology and 
aiu»« iif thi->'rare alTection are still uncertain. It commonly occurs about 
middle life, Gould's case being the youngiwt rocitrded. 

The disease <lc«cribed by V. Winiwarter un<ier the name of endarteritis 



116 



DISEASES or ARTKRll£a. 



prolifcnins ii> prohnhlr of the same mtturc. lit.- Atntfo Oiat it ooi-unt 
auna apj'tirtutlv licnllhy ia otber respects, and give? rwe tu frp<iti(nut.'<>iui' 
gsmgreui- usually of ihc tout. Id one cum* in which llie v^ewlfi wef« exaaiiovd 
aficr ai»{>u(nti<Jii vt' tbe limb tlie •jblit^rnliifti wus louod tu be tlir rt-c>uU of a 
greai pruliteratiou of the cudothelJuii). with oarruwing of tbe luruifu of tha 
vetsel, Uie linal ublitcriitioD being brought about hy ihrombuBiii. New voavls 
were rouuil pcuelruiiug I'roai tho outer coat into (he pruliJerating eoduUielium, 
whiuh with the ihtoiubus nus fbuud in the older pane lo bv uudurguitig 
changci^ einiilar to th(.<e already dtrtcribi'd un (»ccurtii)g iu closure uf aa 
artery alter tigaturc. Biilri>lh siutiK that the dieeusf is pruredcd by fMbJr- 
neKnfcirculatJou,aud obscure puin,ofLeii luHLiDg Tor moutlmoryi'en. Therv 
is no drltiiiU' trt'utnient liir thetM^ (■om-s. 

PeriBTteritis.— By [M-riurlt'riliii ie meant an iiiBainniulidD citmtiienciDg bi 
the outer cual or j^ht-utli of the iirtery. It' we exclude urteritit* by extetudon 
from eurrounditi^ tieMui-s and iratjiuatic arterilis, periitrU'ritis in a rare dis- 
ease. Charcot and liouehurd havi^ deiicribe<) Biieh an nflectiun in the veaaeU 
of the brain, commencing; an an iicctinmlation <it' fmall nnind cells in the 
perivflscMilnr Dhealli!!; ihfge penelmt*? the coat» from withimt nnd lead ti> 
SoAening, frequently fitlioned by the formntiou uf minule aneurtant^ and 
final rupture. It is a senile disease, and according to Charcot » conimoii. 
cauw uf aimplexy. 

Ad aHectioD of the arteries of an uncertain nature not causing obliteration 
has been observed, which, from its giving rise to aeute pain and tenderness 
with Auiue fiwelHng in the line of the veseel, mutil be eupp)j#«tl to be iuflani- 
matory. A eaee of this kind bns been recorded by J. H. Morgnti, in the 
Transactions of the Cliuicat S<.K.'ivty for IStJl. The patienl, a oiau aged 4ti, 
was ailael(ed with severe paiu iu the line of the right femoral artery ; the 
veael was acutely tender, but tb^Te uas do redness of the tkiu covering it. 
The oiudiliou was at lint limited to a few inches uf the artery near the 
groin, but gradually exleuded to tlie iMtplitenl space and leg. Slight tedeoia 
mod aume awelling of tbe lymphatic glands became apparent when the 
dlwoH reuclii'd the leg. The vessel pulbatv^l forcibly and ihtre was qo 
thrunibnsis. Hu hud boriie years nreviously suffered from a einiilar aflecti^ui 
of the opposite leg, and. while still under obeervatiun, the right brachial aiid 
carotid were suceemively al)e<^'led. Altogether the second attack laste^l over 
live months. It was nut apparently due to syphilis, guut, or rheumaliam. 
From the alm'nve of tlirunilMwis, it would seem probAole that the disease 
ira« ft periarteritis. 



PRIXARV DBDRNERATIOm OF AKTKKIH!. 



roT^fS 



Fatty Degeneration. — Fntty degenrmtion, except as a part of 
«DdiirtvritiD, in not a |>Mrti<.;iilArly iW-^ioeiil <>r im(K>rtiini chaoge io arteries. 
Ill the aurta.even iu young wutijecu, yellnw patrht* of Dmall siie and irregu- 
lar liirni, and very »li)>htly if at all vlevaied aUive the nurinnt surlaee uf the 
iotinia. are not unci>niiiit>n. If uue of these be peel«d olT and examined 
tuicmscupically it will be found t» present stellate patches of fat-granules in 
tbe most superficial layen of the iuiima, immediately beneath tbe endothe- 
liucD. These are the result of laity degeueratioD of the braucbetl cells thai 
are normally present in this part.' The afleotioo seems of no importanoa, 
and its cause ii not known. 

In later life, liitty degeneration afTectisg tho intima more deeply issomih 
limes met with unaccompanied by any of the signs of nihcruina. The 
degeoemtion may cxtvud to the cmlothelium, which then dieinlegratrs and 
ii cast off, leaving a rough surface exiHiseil. This condition boa been do- 



CALCAREOUS DEOENEBATION. 



117 



fcribed u fatttf erofion. It is most coinnion id the arch of the aorta. 
Thruugh such a surface the blood may force its way into the middle coat, 
toil thus give rise to the coDdition to be aubsequently described as " dissecting 
at^ttrism." 

Fattj granules are not uncommonly found iu old age in the external 
ooats of the smaller arteries, but they are of no pathological importance. 

Calcification or Calcareom Degeneration. — We hnve already seen that 

the calcareous plates so common in the aorta and its primary branches are 

the result of the calcification of the products of chronic endarteritis. In the 

HDsller arteries, principally in those of the third and fourth magnitudes, as 

the popliteal, the tibials, the brachial, radial, and ulnar, primary calcification 

i* c-tmmunly wet with. It commences by the deposit of lime salts, in a 

fTtnular form, arranged in lines running transversely tu the axis of the 

ve«fl ; these lines gradually increase in breadth until they coalesce laterally, 

tk iotert-ening spaces being filled up and the vei*sel converted into a rigid 

tobe. In the early stages while the calcareous matter is arranged so as. to 

fono lines round the vesEel. the condition is termed annvlar caleijicatioji 

■ Tii. 437 K When these lines have coalesced, it is often called tubular ealei' 

fintm (Fig. 438). 

When this pnK«&s has reached its highest stage, if the artery be removed 
fmm the bttdy and drawn through the fingers, a small rigid tube, composed 
of the calcified middle coat still lined by the inner coat, can be squeezed out, 
IttTiDg the external coat apparently healthy. In fact, the toughness of the 




Fif. -l-iT. — AoDular (^leiGestion. 



Fig. 4^3.— Tubuliir Caloifieation. 



fiti-rital r.iat is so little impaireil that sucli vessels can be tied, and even 
t»i*:(ii, almtto'l us safely as a healthy artery. Annuliir and tubulur cnlclfi- 
faii.o mrv almost invariably associated with clinniic eudurteritis, and its 
•n^-n-lary dfgtneratinns in the larper vessels, and in the inter mediate 
in'-ru-^. such as the axillarv or popliteal, and snnierinic-s even as low as the 
tjiial', h'lh conilitionn are observea side by side. 

Tht- <'xi*tfnce of this degenerative chanjre i:- upniilly recopnized without 
■iilfi<-ully liuring life in any artery that can be e.xainined with the finger. 
The v»"n(W'l fecU hard and less compressible than natural. Its longitudinal 



118 



DT8BASE» or ARTEHIBB. 



vlaaticilv U ]vf!«di'iJ. ho tbat ii w Uirowu inui a wnvy lino when ivlax«d 
IcDjeiluuinnllv bv fifxinii tif tlii> limb. 

Tiie [ui>rbi<l c(iti<litit)ii cutisists eaH-iilialW ul' a dej>OMt of limu mlu to the 
mupoiilar fibre-wIlB tiflhe middle i^i*!. Wo iIiub inily nn-vl wHIi it in tb«wi 
\-ct«>el8 ill wliifh thi< uiusrulnr ti»ue is well deTeln|>ed. In llio largvr anrrin 
lliv niusculHr ivUb arc so i<<.itut,v urn) &> tnt ctniceaM by the elastic linue 
tlial if i\u» change dura occur in ihtm it is diffic-ult Up reruitoiw. Tbt; inner 
coat in the larger vcwiOF usually ^liowrs tlii- urdinary &i]jiia ol ciirinln 
endartcritiii. Id the #nmllcr it may nt tin^t lie healthy, l)ul later nn cal- 
careitue pUtc« may form in it. It liae bet-n iHiinled unt by fiiua that the 
flvninietry of the arrangement of tho9C morbid H|i{)4-itrnnrt« in the cof- 
mponding veuela on xppnsile sides of the br^ly '\» rcmiirkably prt-ni, the 
arteries of one Itmb being ofltn the exact counlerpiirt in I liia respttt Uj ihuae 
of the other. 

The caascs of ealoification of the muscular flbre-cells of the iniddlc c«AI 
are unknown beyond that it is alwayj> a senile change. 

The eflevU of nnnular valcifivatiun arc lo rvuder the venwl ■ rigid tube ou 
longer capable of regulating the flow of blou<l to Ihe parte it suppliv*. At 
the same lime its calibre ts alwH>'B diminislipd, and the nutrition of Ihv pArta 
beyond is seriouuly impftired. Thus in the limbs vre have idl the signs of 
dcleclire circulation, coldneeeof the fret, cnim|>» and Hpspmsofthe muscles ; 
whilst, in orguns, softening of ti^ue, fatly degeneration, und other evidencoi 
of wnul of a proper supply of blood are observed. SpuntHneous aneurisim 
rarely result I'rtim this t-hange, the coals of the artery being tnorr resisting 
than naturnl ; moreover, primary cnlcificnlion is met wiin in the Tcfltela 
below the axilla and knee, and sponlnneoua aneurisms beyond thn^ jwiints 
are amongst the curiosities of surgery. Thronibti^is is occnsionnlly met with, 
bat is not coinnjon, as the endolhclial lining i^aflected only in exirt-me rasfs 
and late in ibv diseui^t.-. The lodgement of a small fibrinous embolus cajTifd 
from alberuniatoiw urieriea above is an oconsioual occurrence, and is Terr 
likely t(i cautfo gangrene even when only one vessel is bloeket], as the c'>l- 
lateral arteries arc no longer capable of enlarging to carry on the cireulntion. 
Oceluaion of the ralcilied nrltries by thromb.isU or onibolism Is the ci>mmoii 
cause of the dry form of senile gangrene. The moi!^t form arisrs fnmi in- 
flammation taking place in ii««ue^, the vitality of which has brru grrntly 
lowered, tri oon»e<pienee of thr diminished supply of blood whieh 6ud9 its 
way ihmngli thf narrowed vessels. 

Ouiflcation of Arteries.— The formation of true bone in the coats of an 
nrtery \» nn extrt-nu-ly rnre ix-ciirrenit. I am aci)U)iinteil with only one 
nutheiitic mrv of thie elmnge. The lipcciraen w«a pxhil>i|ed at tbf J^utbolo- 
gicnl .Stcirly of London, by II. G. IIoww, in 1877. The patient whb a maa 
Bge<l, 'M. who was run over by n csrt, the wheel piiwing over his shoulder 
iTie axillary artery was mplnred. nnd dealli oct-nrred t>e a result of the acci- 
dent about a moulli ollerwiirrls. A ntnall plate of cancvlluu.i bone was ftiUDil 
in the injure<l vi-atwl, apparently developed in the middle and outer custs. 
Its greKl<.-»t ihiekneu was about a tjunrter of un inch. 

Efi-'wi> or I)jfii:Ahi> oe niE Aktkkies. — The various eflfects nrdlsrue* 
of the arteries have already been mentioned with the afU'clions to whieh they 
an due. Iwit it may U-ad in a clearer conijirehenBionof the suhjivt if tliry are 
amin referred lo. as ihe same effect may riTsull fnim more ihtin one cam*. 
TIh' nio.-! im|>ortant efTet-lc of arterial diwase are Ulcernlion of the CVutta of 
the Arlery ; .S(»onlHm,'oii» Hupture : Contraction or Occliijuion of the Vesael, 
and. lastly, I)iliiiatii>n into tiome of the various forms of Aneurism. 

Dloeratioii of Arteries. — Lij»» of subslann^ in the inner coat results fruto 
Bttperflcial falty ilegen^ralioufp, 116 k, and from softening of an atheromntuui 



EFFKCT8 OF ARTERIAL DISEASE. 119 

pitch' p. 110"!. Neither of these processes is a true ulceration. Genuine 
ultfnttifio of the inner coat is in reality scarcely ever met with. When true 
ulwntioD of an artery takes place, it is theresult of causes acting from with- 
out, uucking first the external coat, ae iu the case of a sloughing sore open- 
iBgimiiD artery, or the pressure of a sequestrum in the popliteal space 
^iBt the vessel. 

SpOOttDMIU Snptore of an artery is rare, and never happens without 
pRTimis disease of its coats. Experiments made by Peacock, which I have 
r^MiUd. aod theaccuracy of which I can fully conKrm, prove that a healthy 
inerr will sustain a very great pressure from water injected into it, without 
iu lilUgiving way. But, if these have been softened or weakened by disease, 
tbrr DMT be unable to resist even the ordinary impulse of the blood ; and if 
Hiu be iJriveD on by any unusually forcible action of the heart, as under the 
influeoce of sudden violent strain or exertion, they may give way. This 
ocnrrence would be much more frequent than it is in atheromatous and cal- 
etreHu patches, were it nut for the inflammatory consolidation of the external 
ciatofthe vessel supplying that resistance which has been lost by thesofteu- 
iop or destruction of the internal and middle tunics. Hence this rupture is 
■Mt trequeot id thuse vessels the outer coat of which is thinnest, and in 
vMdi, consequently, it can least supply the place of the others, as in the 
utfrieiof the brain and in the intra pericardial portion of the aorta. The 
liibility to rupture of a diseased artery by the distensile force of the blood 
inpelleil into it, is greatly increased by the exis^tence of an obstacle to the 
frnflow of the blood out of its terminal branches in consequence of a con- 
P*ted, infiltrated, or chronically thickened state of the organ or part supplied 
brit 

Cntraetion and Occlusion of arteries are by no means rare sequences of 

Ittiom of these vessels. Narrowing of an artery may take place in various 

*>n; the orifice of a branch leaving an atheromatous trunk is often narrowed 

^ibe formation of a ring-shaped tnickening of the inner coat (p. 114), and 

iDecalibre is diminished in calcification of the middle coat (p. 117), syphilitic 

irieriti« 'vut. i. p. 1048), and endarteritis proliferans (p. 115). Causes acting 

ftom without, as pressure, or contraction of chronic inflammatory or cicatricial 

tkme in the immediate neighborhood of the artery, lead to ii mirrt)wiiig of 

iu lumen. Id this way the axillary, the iliac, aiui even the aorta, have been 

ooeIu-]trd. Tiedemann reconls from various smirces n() fewer than eight cases 

in ffhich the abdominal aorta wa.s coni|)letelY closed, in all of which so full 

U'l ftiicit-nt a collateral circulation had been set up, that the vitality of the 

iiivrr part t>i' the IxmIv wa.^ ]>ertectly maintained, and in most the mtirbid 

■uii' w.i« not 9n-i[)octcil during lifo. Besides those chains he states that there 

iTe iin reci-rd twelve instances of great uarrowinp of the uorta, at that point 

wbt-n- ihe ductus arteriosus is implauled into it in f.rtal life. Thesewould 

apfiear in sorat- way connected with the closure of the duct ; as in every case 

tiu indentation wa.-< greatest on tlie convex part of the aorta, which had been 

dnvn in towards the mouth of the duct. 

The final oblitenition of a diseased artery is most comrnoTily tlie result of 
tbnmtxRti.^. Thrnmbosis takes place in arteries under much the same coniii- 
ti>n- as in the veins. Whenever the iioriiial eiidotlielial lining of the vessel 
is 1-wt "r iu ■■ pliy>iidiigical integrity" impaired by degenerative changes, 
tbf bl'nnl tends to coagulate upon tlie <iiseased surfice. The rapidity of the 
arterial flow, by preventing the adliosion of the white corpuscles, coiniteracts 
thin tendency to a c«Ttain extent, hut when the hluod-streain beeuiiies 
iUckfnr<l either by great dilatation of a large trunk, or hy iiari-.iwing of the 
orifij« of u lirauch, or feebleness of the heart's action, a deposit of lihriri very 



lao 



IflSEASES or ARTERIBS. 



rendily laVc* pliare. An artery of the second i»r third nmunilude rua^ttiiM 
W i4ili(vrnl(^. Wht^u n thrombuii bns formed in a bniiR-li it may c-xl«n<l by 
fresb >it:poeit iDU< Ihe main iruok aad form n mnas of fibrin pnijcrtiuif into 
ita lumen (Fig. -439). ThromboeiB uf ihe diseased artery ')» jirobublr in a 
cotuiderable Dumber of cases the fiual dotermiiiing cause of drjr gaogreiK ia 
old people. 



\ 

¥it' <»■— Throat botli «r Iwo <4 lh« 
rhUf branobe* af th« Ab<1«iBlii«| 
AiMt* : fttiijvellon «t ibi Throabw 
tMg llio Duln truKb. 



rig. 440.— Bn.b«l(«ia at tbi 
Axillary ArlHji with 
Tlinioibn*t»t.( lln BimdtU 
hr Mtmt* dtaUKc* b«hi*r 
Iba Enbnlai. I. Subol*- 
vlan; 3.Aill)Br; Art«rj i 
3. SBbacB^ulu and l>oK- 
tlroitniilti AtIwI**: i, 
flrBrhUI. 



Complete ohi iteration of an artery u in laauv i!a««« thcrtsultof embolkm. 
The emuulue is usually coaip>iaed of a nmn uf fibriu which hn« bn:o depiMtl«d 
on Kxmv tlibeoDnl part uf tlie larger vixmUs, and eui>sn[)urotly washed awnjr 
by thf hlood-stnam and loilgod in eumc pout at which the irunk auddetdjr 



OBLITBBATIOy OF ARTERIES. 121 

auTHWi wheo bifurcating or giving off a large trunk. The source of the 
rabiiluin may be the vegetatioDS furmed upon the valves of the heart in 
aoite rbeuma'tUm or ulcerative endocarditis, the fibrin deposited in a pouch 
of t<iilited aorta, or on a projecting calcareous plate, or a fragment of a 
dot |ir>jectiog into the main trunk from a thrombosed branch, as iu Fig. 439. 
Tbeeflects pnxiuced vary with the nature uf the embolus and its size. When 
itmfi fmni the vegetations uu the valves in ulcerative endocarditis it may 
p^t rile to inflammation and soAeuing of the cnat of the artery at the point 
tlihich it lodges (see Embolic Arteritis, p. 109), more commonly it leada 
nwrelv to obliteration of the artery by tlie ordinary processes already de- 
Kribeil. If it lodge in a small artery in a part in which the anastomosing 
cin-uliiinn is free, it produces no effect beyond the permanent closure of the 
Tmel: if it lodges in a terminal artery, as in one of the abdominal viscera, 
il give* rise to the formation of a hemorrhagic infarct (vol. i. p. 904) followed 
bj ihe subsequent degeneration, and shrinking of the affected area. These 
old iorarcls, forming wedged-shaped buffcolored patches of considerable 
u>U|;hiif68, are commonly met with in the spleen and kidneys in cases of 
•dvanped atheroma or fusiform aneurism of the aorta. When the embolus 
Wlire«and lodges in a main trunk, as in the popliteal at its bifurcation, or 
in lb« axillary, spontaneous gangrene may result. This is the cunimon 
fMneof gangrene in young people, and is probably the immediate cause of 
icertiin proportion of cases of senile gangrene, the embolus in the latter 
Ott beiog derived from the diseased surface of an atheromatous aorta. The 
CM* frvm which the accompanying drawing (Fig. 440) was taken was that 
of 1 wnruan ^y^ years of age, admitted for spontaneous gangrene of the lefl 
■nn; the embolus lodged in the axillary artery had caused gangrene of the 
linib. The 6gure Illustrates also the thrombosis of the vessel below the part 
Uvbich the embolus has lodged, which frequently aids in the production of 
pQgfeDe. 

Ondual narrowing of an artery, ending perhaps in complete obliteration, 
aoKs few or no symptoms when the area affected is limited in extent and 
ibe collateml circulation is sufHciently active to keep up the supply of blood 
tiiht [tarts In-yond the obstruction. The gradual narrowing of a consider- 
•blr rjit-nl of the main vessels of the limb, such as is seen frequently frona 
ctlrarnius dcgeneraliun t)f the tibial arteries, gives rise to more or less defi- 
ninrtTects, such as cold feet, cramps, numbness, and weakness of the legs. 
^Ulh ^TnlI.tllms are often tlie premonitory signs of gangrene (see vol. i. 
^*4'^.aIl.l are au iniMratiuu that care must be taken to keep the parts 
*»mi hy appropriate clothing and to avoid any injury. Tlie symptoms of 
^nibi'lism of a large trunk have been described already (vol. i, p. 8oO>, 



122 



AKEUItlflM. 



CIIATTKU XLIII. 



ANEDRISM. 

Bv Aneurism is meant & lumor, Ksuliioff from ditatauoo of the nliot« or. 
n porijui) iif ttic coou of an artery cauiied by tbii jireMure of tlic cooiAtnod 
binikd. nod otmruunicfllinjL' with the iutvrior uf the vi-Jwel. 

Tniuiunlif AticuriamM have lk-4.'ii nIrDHiIy dcsiTilfctl > vul. i. p. 44G>. !Mi»a> 
tADCOiisaDfUriaiiiit, nri^iug from dbeasic <>I the l-uuLs ul' thv nrti-ry, mrv olitnn 
eonsidt-retl in the prtw^iit chHpter. 

Cai'm^x — The cause!) of aneurism are divisible Into thnee tbat predufiive 
t'>, Bud those Lliat excite the dieeuee. Alieuriitu) i« Frediapowd tn liy anr 
aSeclioi) of iliu arterial cu»t« lliat luweos llic elutie revilivncy it{ thv vtiavi, 
and at the eaaio ciuio vreiikeua iu rcftistiug {jower. Whvit au nrlery baa 
uodergoue any of the rbaiiifi^ d«»orilx.-d iu (he last ebupter by wliich tho 
oatunil elasticity of the walls is diniiui^bed, it beeontes lets able to uoutract 
OD its ftntciila. aud U> recover duriug the diai^tulc fDui the distentioa occur- 
ring (luring lliu systolic itnpulsc. nnil ibuH eitlit^r t-iiinpleto or imrtial diliua- 
tiou of tlie cavity takett place. I Ik-Huvc tbal this Iws uf claelii'ity aud oi 
jHiu'or of corilnic'ting on iu omteiKit, which evciiiuatly nwull> in the dilatk 
tion nf iho vo)ss(i|, never occun^ except as the rfsult uf pn'vioun ilbtdaae of the; 
oonu. Tn the very nunieruns Hpeciiiii'ii»<)t'diliile<l arteries that [ linve exain- 
iiied. 1 have never found niie tliHt hn.« nut uiidiT^nni' falir degr'iicrHiion, ur 
aibehimaloLiH buflening. Calcification prevpnis rather tban favors dilata- 
tion of the artery, by lianlenin^ the tMHts Hud convt-riing ibeni into ri^fid 
ineUiitic tnbei> ; but atheroma aoAcne them, and caii«ei> yieldin^c of tbat wir- 
tion of the veese] nllt'«ted by it. I have fmjuemly oW nrcd tlmt the wnul* 
of an artery might be healthy except at one part, wburu there vraii au athercH; 
niatou« |>nlch, and where the vi-«)«i;l was ililnltftl ; or that the whole of iVt 
Ctnitt might Ih) caloifitfl exc«pt at one spot, nberv •oftcniog had lakco placSi 
and where coitiwquently thry bad yielded undur the outwHpI pretwuru of th« 
conlaiiieil bioiHl. I 

Ak aneurism, tbcrurorc, raay be looked upon as one of the Bequenco ofl 
atheroma, the prcdi!)|Mising causes of the one conditiun must necewarilv b* 
tbv tniuv lis those of the other. Hence we tiod tbat age, gout, and svphilia 
intluencv the •>ccurren<.'c of the aaeurismal diaeuM by laying ita foundnlioD* 
in the develi'pracnt of ntheroma. 

Ag« exercises n powerfully predi^poetng influence on the occurrence of 
nneiiriem. It t» during ttio nnddle period of life, about the agn of thirty 
oud forir. that aneuriiims arc niuei frtqiieutly met with ; nt thuee age«, 
indeed, when tbu arteries have olreadj oommeiieed to lose their elusticttjr, 
in eoosequence of def^ncralive clinogee, whilat, at the same time, the htiuC 
bna nut logt any of its impuUive force, or the genernl muscular srstem h4 
ooairaeiile vigor; and when the enfeebled and inelastic veaiels, beci>miujc 
exp'Micd to powerful cpum?9 of dUletition, mar readily give way or Ik ex- 
patidttl at some one weakeneil poinL This diaease is cxeesaiTcly rare bvfi»ra 
puberty, yet ia occasionally met with at early p^riotls of life : thn» Sym« 
mentinua a case uf popllival aneurism iu a boy of «>vcu. Ilodgtun had* 
preparation of a carotid aoeurism lit a |jirl of ten, aod Hehniidt a osar of 




CAUSES OF ANEURISM. 123 

ipHitiD«0U8 ftDeuriBin of the radial artery ia aD infant eight weeks old. 

K. \V. Parker, in a inoet valuable paper on aneurisms in young subjects 

mtl before the Medico-Chirurgical Society in 1883, states, that after a careful 

mrch io medical literature, he has found only fifteen cases of spontaneous 

UMimm reconletl as occurring under the age of twenty, including a case of 

bi^iinn of inguinal aneurism in a boy aged twelve years and eight months. 

Id fight i)f (he fifteen cases there was disease of the valves of the heart, in 

fiH ih€ state f)f the heart was not recorded, and in two only was it healthy. 

A forcible, imgnlar, and occasionally greatly increased action of tne 

hmtti the immediate cause of the over-distention and dilatation of the 

tmkU, ind thus of the production of aneurism. Hence we find that this 

dittiw is especially apt to be induced in those individuals in whom the 

vsHular system is called upon to make sudden, violent, and intermittent 

exertiotu; as, for instance, in men who habituallr lead soruewhat sedentary 

Um, but occasionally and suddenly change their habits, and indulge in 

^>rtf, Mich a» hunting, rowing, or a long day's shooting, which they might 

■itbout ri«k have practised in early life, but which cannot be taken up with 

iniNiDitT at an age when the arteries, having become weakened, are unable 

uiWr the same strain upon their coata as heretofore. I agree with Porter, 

is thioking that continuous, steady, laborious employments do not predis* 

p>Etn aneurism, as this disease is seldom met with amongst those of the 

*'>rking clti<>a who labor hard and uninterruptedly ; but it occurs rather in 

tif^ «ho, after long periods of comparative inaction, are occasionally and 

iwWfDly called upon to make very violent muscular efforts, disproportioued 

to their Mreogth, or, at all events, to their previous habits. It is in this way 

(hit nldiera, sailors, and members of the wealthier classes in society, are 

nnlered peculiarly liable to aneurism. As violent muscular strain and 

amioD predispoae to this disease, we should necessarily expect to meet with 

itnnn fire«iueDtly among men than in women ; and accordingly Crisp finds 

tilt, of .551 cases of aneurism of all kinds, more than seven-eighths occurred 

■ dko. It is important, however, to observe that different kinds of aneu- 

rim occur with varying degrees of frequency in the sexen ; thus, this affec- 

ttrto U mot with in the carotid artery about as often in women as in men, 

•hilet the other external aneurisms occur in tlie proportion of thirteen cases 

10 males to every one among females. It is remarkable, hinvever, that in 

ibe di#*ectin? aneurism the proportions are reversed ; for every one case in 

ifcn, twn i>cour in women. 

Clioate exercises an important influence on the occurrence of aneurism, 
»hich is far more fre<tuent In cold than in hot countries. It is not, hnwi'vor, 
tl* p-<igra[ihical ptisition or the meteorological state c)f a country that exer- 
fWs anv direct influence over the occurrence of this disease. It is in reality 
tin? hahit.'i of the peo]>Ie that dispose to it, and that rojrulate its prcvnlcnrt' ; 
»iH it is in the mnn- energetic nature and the more active physical habits 
'if the norihi-rn nations that we must loi>k for an explanation of its greater 

Ertralence amongst them, than in itie mure indolent inliabitnnts of the South. 
r»c may judge of the prevalence of aneurism in a country by the number 
ff [tublished reports of cases, I should suy that it is of more cnninion orciir- 
Mice in '^irent Britain an'l Ireland than ('Isewlu-re: indeed, lioux states 
tUt it is U-r^ fwrjupiil in France than in Eii^'lainl. In America, it is also 
''f fn^iut-ni oi-ourrence ; liut in the Kast Indifs it is comparatively rare. 

Cachexy induced by any cause, sucti as syphilis, ehninic gout, or rlieunm- 
ti»Bi. the abuse of mercury, etc., has a tendency to occasion disease nf the 
"•Ik iif the arteries, and thus to predispose to aneurism. Rut, though nier- 
mrr snd ^vphilis are conunonlv said to tend specially t(» the production of 
tki» dii«aiie, I am not aware that we are in p»ssessiou of any definite facts 



124 



ANKUniSM. 



that would wnrntnt us iu coming in tliis concliimuu ; llmugli it is probable 
that llie caclipxy thuti imliicod riiiiy c)i«|t(jee It) it aa aiiirli tis any (itlier cause. 
It is rcriiHrkablb tliat phlhlsis is Hiit»t?>tiii9lic to uneiirHiii ; ihou^b pnibably 
this may arhi} fmm (lie fucl^ tlmt the henrtV Hinion \.^ fueb)« io tliut <liwii9ti, 
anil that, violent muscular exertion is seldutn utiilertaken by those taborlog 
umler it. 

Any obstacle to the hee flow of blood through »n organ or ibe capilla' 
riesot » purt, cxorci^e^ :iii iiiiporlniit influence in ili^pix^ing to aneurism, u 
it tbrowa nn incrcaiif' i>f prc'isure on the interior of ihe nrtery. Chevers be- 
lieves that nbt)Lriicti<m in ttie Abdominnl urgnns rretpiently occnsiona aneu* 
risnis nf the nbtli>minal »rt<^ric«. i^potitnneou^ nueurl^nis of the anialler 
arteries, us the riKlial, ulnar, or tibials, are believed in the great tnajority of 
cases to be due t>> the impnction of an embolus wnsbed ou }Vom a diieascd 
heart ; but in these cas&t the obstruction to the flow nf blood plays but 4 
secondary part in the process, the most important clement being the soAen- 
ing of ibe cunts of the vessel consecpienc upon the irritating Jiatureof th« 
ttiftterial of which the embulus is composed. There !a no reason to beliera 
that a tinipiti emlwjiis ever cauK-s aneurism f pee p. 109). 

The only Exciting or Direct Occasioning Caoseg of aneurism are btowa, 
violent atruius, and wnunds of an artery. When an ntberomatous artery ii 
cvncu^ed hy a biou\ the lining nienibraue covering the soflened patch may 
be niptured, the atheron>a beiu}; poured out into the interior of the venel; 
and ifie external cout, M'itb perhaj^s a p'irtion of the middle adherent to Jt^ 
beeomini: thuK exposed to the pressure of the contained blood licfore it ha* 
been fully coneolidntetl bv chronic intinnimation and the fi>rmalion of new 
fibroid liisue, the fuuudatron of an aneurism msT readily be laid. In reir 
forcibJe muscular eflbrts, it is easy to understand} bow aa already weakened 
porlitiu of tiiR vessel inny betronie diluted by the increased preasun; (hat is 
thrown upon its intHrior; ni;casi(in»lly even the vessel maybe eumpletely 
tnrn arros^ by » violent strain. M'owuh iniplieaiing arteries are common 
causes of tbf>5e vnrions formt) of anennitm that have alrvu<]y been diHcusseil 
iu confiderinp Injuries iif Arteritat (vol. i. p. 44t)). / 

Classification. — Aneurism nmy he i-tn^ilied as follovi'S: 

1. Fif.siroKSi.— True. 

2. SACCtrLATEU. — if' t/y*"' (a. Circ'iiniscrlbed. 

1. Faaiform or Tubular Aneurism.— This h a preternatural dilatation 
an ftrltTv. nil tli« iwMn of whi^'l: ai*e equally expnnded thnmyh tlic wholo 
circumference of tlie vessel. It occurs most fre<|iieritJy in (lie aorlu, and 
may, though rarely, be iiiel. with elsewhpre. The lusifurm uneurism is uoi 
a mere dilatation of the %"v*sel, for th(^re are eloiijrntion. thickening, and de- 
generation of its walls «» well. The elorigwlion of the iirtery in tht- fusiform 
aueuri^ni is n^ ninrked ns il« dilidatiotL, nnd is iilways very considerable. 
Thus the arch of llie aortii mav be ini-rerised in length by souie inches, with 
ft considerable sjKice l>etween the origins of the iniximiiiate, the carotid, aod 
tl)e subclavian, at the same time lh:U iti* walls ni^ greatly thickened, nodu- 
lated, and rugged. Sometimes several tubular or fusiform aneurisms are met 
with iu Ibe same ve«tH?l, with henhliy portions of the artery between them. 
From these dilalatiuns, sacculated aneurisms not uncommonly spring. 

On examiniug theetructure of a fusii'oriii iincurisiu, it will be found that 
it ie composed of an expHueion and outgrowth of the ofmts of the uriery. 
The thiekneKS of the ivall ie iiiniut.-iiiied Ijy growth from Ihe inner and outer 
ouats, the middle cvat being stretched and atrophied in proportion tu the 



SACCULATKP AKEmiSM. 



125 



Tlit> tuner coat preti^nUl)iechaiig<!«nlr«)i(ly detcribed 

' trti?ntu: it U tUff, rufig^, and tubvrculatcd from the 

ii« patches. Riid frei]uently calciireoiu pUt«8 nre 

mwi v,\- Tli« outer coat is thickened mid oompofled of 

ifilvoid uhuv. UicroMopic exainiuacioii shows thut tbc luiildle coat is 

1 la {Mvpfinioti lu the Ue|;reG of dilataliou. If the niieuri>-ui iaul'aav 

biMbbIiIi. >ik. /nt>« are Tuund liere sod there in which the middle i-oal u 

«iBtia|, ihe (lijcaum iuavr mat cuming ioto direct ci>Dtact with the thick- 

mdmaaamt. N'l cuagula uru fouud id Oie diUt^iliuu, but a few lilainen- 

aijtbnd* of fibrin an* (KTBijioiiiilly neon to be atlachexl to the inner wall. 

TWifttrim that iin^ usiinllv the wnt^ of ftuifurm aueurtsm are the arch of 

ibiKtii'PiK. -141 \ the ilnu'A, ihp fenio- 

aii,iD4ocea«ionully thcnxillirirs. Thid 

iniealar form of an('ijn.>ini vicciirs mi^i^t 

WnUj m rcncli in which the vi?ll<>w 

iUc eaat ia tar^geljr de\v|o|)ecl. and 

kaft ii rarvljr nicl with in nrleric« 

taaBtt tbao thv f«Tui>riiI ; it <K-cun'. 

kvtnt, io the btteilnr artery of the 

TW fiBifurm diUtxtirtn, <»]>«rtnlly 
<ltt waled io th« arch of the a»rln, 
■VUlaio a tery cotiBitlemblv magni- 
1m, twl iDBjr oiDBe<iueiitly exerciff« 
^ Mornnu preosure uu coutigUKue 
p»ni,lsiii pniductDg great distress aud 
^aprof lifr. It i^ usually extreuiely 
(krwie. inrreaaio^ very hIowIv. and 
Ik^ ir>jni|Mt)ble with e-xiittvuee for 
Xi/ 7«ar» ; but It uiunlly ilts^troys the 
fUicM ai last, and iniiv "cviisiou deuth 
Uatfifal wars. Thii5. if it l>e ftUial^^'d 
IB iW aorta timth ma v take )iIii<.iMr<im 
■noBfc Tbia mar Ge raiiiM^i by the 
■ihftof thf inrhulic anrta t» fill the 

ommtrr arUTie^ diirinjfihc diastole of the heart, or from imperfect iitipply 

'4 UhmJ u> tiif brain. Then, again, death may mult from prt-^mirc on ([»• 

fvtaat partii, hj on the bronchi or irsophagug. When, however, a tuhiitar 

lofthfi arch of the norta oO'Upint the Intrapcricnrdial portion of the 

Bi.t unl're<)iH'nlly lutppetw that, owiny Io the absence of a »lieHth in 

ii.>n ihr nrt«-rv mnv ruptun^. It ittimt conitiiuuly bapfteiix (hat a 

_ it «>urfe of diKcnitit'orl, but not 

•>ea«ct ■prinK* Inim it» i^ide; and 

iiK iii»r« turmttlubi*; ulivctiuti, may destroy life in tome 

(.1 it. 

t SMcalal*d Aaanriim. — By the >accu)at<od aneuri*ni itt meant a tumor 

I *pi^iic fruin tin aide of an artery or uf a lubuUtr aneuriani. with the iate* 

twtif •kieh il coiuoiunicaita by a narrow aperture, called the mouth of the 

^^^^By. ii'l). It M> ^neraily divided into the True and Fattr varieties. 

^^^^^Saccuiatml AaearifiB,— By thi« ia meuat a partial dilatation of all 

^^^Bt- - — ' !'- -\tjiteiicu has bveo deaiml ; thus Scarpa doubta 

lU^v 'L*, and Bixut seems disp««ed to coincide with 

k*«. jidla.howei'er.Icauuotagree; and though 

!«■*>. 1 the so-cnlltid " true" aaeuruuta are not 

■• ni ra^iu^, yet i catmui iluultt. Irom repeutiid obeervntiuD, thai Hodgson ia 



V\g. KI. — Large Puiirniai AkAdrWlB of 
A*c«fl>l<ag AoiU hur«liii( knt> P«tlt.-M- 
iliium. 




k 



12« 



ANEUBItiU. 



riglit ID «ayiiigtlmt in their early gla^p* twccuUted aneurifliMliro on* ni 
qui^'Uiiy ut llie truu kinJ. Ttius. w« ocuaiiouully tiiirt.iu iVitock Iiob fHiiiiif*] 
uut, BOiitll (iigiial jMiuclif* Bitriiifjiutr from Uic walls uf wrnic of ihr lurErr 
nrteriea, Ihrou^^li tin- wlioio lA' ishirb the oxteruui. iipiddlc, and inlemal c<«W 
oin bv <l<^titiitiptniu<il liy iiian^raliou to c-xi^t; nutl in tliuK anvurisan whidi 
lire rormetl by ilie <iilii(»tii>ii of a (?i>iii|)arHtivQly lurge portion of tli« ■rlrrial 
wall, it not unfrequ^utly liu[ipc'iis that ibe tumor remaitu uf tbe true kiad 



Fig. 44Z.— £MmiUl*d AneMriiiu Af Ai««nillii( 



Flf. 443,— l|<|>«r ).iirl vt IV 
Aoila Iki'l 0|i«n, fbavlng ikm 
of ih* (MC of lui AniiKiUtn. TlM 
eu«i rimiiiJ ihi u|.«dIo( I* Imfiter 
frOBi [valiiha* ol ■tbarana khU 
«( Ahtlu. 



for BOtoe time, as I have avcertaioed by careful diMectioD. But afW an 
Mieorisni baB attaioed a c^rtnin size, its coats beconie »o fu»cd tofivtber, and 
to oIomIv incorporated with the ut-isbburiui; tieeuea, that tbeir picciec struo- 
turo cannut be made out. ludeed, for a aaoculated aueuriiin tu be uf the 
true kind. I believe that two couditiotu ore ueceesary; 1. tbat tiiv tumor 
it«elt' be Biimll ; and, 2, that the nioulh uf the £U0 be uf tuWablj largo diiueo- 
aiuufe. Furter aaya that he hoM ucvcr iiivl with u true uneuri^ni larger than a 
small orange : and. eenarnly nuue uf tluioe that I Jmve necn, provided ihey 
were xf the eacculatcd kind, haw exrecdod this itiui. lu tru« uccubiteil 
oneumius, also, it ia oeccesarv thai the luoiuh of th« sack, ur tbut piirLiua uf 
it whieh coramuoicates with tne interior id* the artery, should be uf j^Nid kisc, 
and not hear um great a dinpnipnrlioti to tltK wall of the tumor. I cannot 
conceive a l&r^ sac with u ^mall mdiilh to be n inic luieiirism. But io all 
casc« of true nneuriBm, howi^vrr Bmall they mny be, the »ik- oI' the kul' greatly 
cxive-lH tbnt of its mouth. It iii thorefore elenr ibm there muBt have bt«a 
not imly L-xpanuon, but u dc^riw ot'hyjWTtruphy mxl «vorKr<'Wth of the wall 
uf the vea94>l. jufit lu in the lubitlnr aneurism, nlhi^rwi:ie titc mc would be 
ihiuDod io the exact pniporlion nf lUt ex)kau»iun. ThisoviTt;nmth Lakes place 
t?biefly fp>m the outer ciHit, imd, in n Icnit decree from the inner and uol at 
all from the middle. When the sac tit very small tlio expande«l middle Ciul 
can Ik traced tbrouf(hout it; when «oraewnal lar^r, |Mil<:hc« of the txii<]dltt 
coal can be recogutited with wi<l« jjafis between them; but when it rcacUe* 
any couaidonble aitm the ({reiiter |»iirt ti composed of dense fibrmd li8iu« in 



UISSECTINO ANEURISM. 127 

«Wb none of the proper structure of the middle coat, and in most cases of 
the iDDer also can be demoDst rated. 

TbIm SftMolated AnetuiBm is that variety of the diBease in which the 

'muraal. ur the inteniai and middle, coats have beeu ruptured, and are con- 

Mqai-ntlr deBcient. This is by far the most frequent form of sacculated 

uturisDi, and is that which is met with of so great a size. In by far the 

mtjority of caaes, the internal coat, and the innermost layers of the middle 

w«, hive been dealroyed by atheromatous degeneration, leaving an erosion 

«iieprea§ioo in the interior of the artery, with weakness of the corresjiond- 

iDgpiiniiHi of its wall, which becomes expanded by the outward pressure of 

ihv blood. In these cases the sac is formed principally by the outer coat, in 

vhich «ome remains of the middle may still be recognized. That the sac is 

fiimied by inflammatory new growth in the external coat and not merely by 

HptuioD, is evident by its being tliicker than the corresponding coat of a 

bnlthy artery. The thickness of the sac is increased when it reaches any 

C'D^idtrable site also by adhesion of neighboring parts to it, which become 

fuKil into its structure as a consequence of the chronic inflammatory process 

KtupruuDd the aneurism from the pressure it exerts on the surrounding 

itnjdures. The formation of an aneurism by the hernial protrueiun of the 

loterul and middle coats through an ulcerated aperture in tlie external coat 

^ been described ; but, though there is a preparatiim in the Museum of the 

i'ollegr of Surgeons, that is supposed to illustrate this fact, I doubt the exist- 

toce iif such a ft)rn] of the disease, and after careful examination think that 

ibF preparation in 4]ue8tion represents rather an artificial dissection than a 

Inie rupture of this dense and resisting structure. 

A &lse aneurism may always be readily distinguished from a true one, by 

tlie greater magnitude that it attains, by the size of the sac being out of all 

})n)f»ntoD to that of its mouth, and, ou a section of this being made, by the 

niddle coat being seen to terminate abruptly in a thick and dense ring, imme- 

diaietr around the mouth and neck of the sac. A false aneurism may either 

fce *> from the very first, the internal and middle coats having been destroyed 

braofteniDg and erosion, and the external expanded and hypertrophied iuto 

• sac; or it may originally have been a true aneurism, and have been converted 

into the false variety of the disease by the giving way or atrophy of some of 

its OtAtS. 

Surg»>n3 generally recognize two varieties of false aneurism — the dreum- 
tcribfd and the diffiued. By the Circum'^cribed False Aneuriem is meant 
tliAL form of the disease in which the blood is still contained within a sac, 
formed by at least one of the arterial coals, however expanded and altered 
in its structure this may be. The term Diffused Fake Aneuriem includes 
two distinct varieties of the disease. In one case there is rupture of the sac, 
with general and widely spread extravasation of blood into the areolar tissue 
of ibe limb or part. In the other case it happens that the sac formed by 
tbe dilatation and hypertrophy of the outer coat of the artery is ruptured, 
and tbe blood, although effused beyond this, is still cimfined in a sac of 
oiodeneed hreolar tissue, formed by that of the iitructuri'8 into which the 
bhMid has been efi'used, matted together with coagnlum and iuflummatory 
exudation. 

3. BisMCtiii^ Anenrllin is a remarkable form of the disease, originally 
dcfcribed by Shekelton, in which the sue is situated in the wall of the artery 
betwe«a its coats. It originates in consequence of tlie internal coat of the 
T«Mel l>ect>ming enHJed, and givii'g way heturc any of tliat adhesion and 
nulling together of the tissues around tlie patch ha^ taken place, which pre- 
xtnVk the blood from Iteing forced between the diH'crent tunics of the artery. 
Tbe ruptur«, although originating in the internal coat, always extends 



128 



AMKURISU. 



between the layore nf tlie mttldlo ane, splitting this up into two laminte, and 
in Bome CHses it ■eparotea alao the middle fi-uin the external luiiic of the 
vPAtel. On examining the arter)' in a caee of di3i<ectiug aneurigni. its coata 
will nUvays be found to be etieiiy EvpHnihls from one aDuthcr, and to be verjr 
taccrable, often appearing sofl and ttoddeu aa if macerated. For ibc pro- 
duelion of tbis diseaae, indeed, two conditions art nco«*8iiry : 1. That tbere 
be atheromatous dlaeaae of the artery, deatroj-ing n portion of the inU^nial 
and uf the iDiierraost Itiyere of the middle coal; and, 2. That there be alM 
a general softening of the tissue of the middle coat, with waut of c<ihe»ioa 
between the different tunics of ihe artcrv ; this, indcwl, may be considered 
as the essential condition disposing to tlic farniati^ju of n dtooeling aueu- 
rum, and causing the di«enee to assume this rHlher than ihcBai^uliileil form. 
The rupture constituting di^dt-etingaDCurltm nlwaja takm placf longitudi- 
nally along the middle coat, and may olli^n ext^'iid tn a very <^>nHiderabIe 
distance. Thus It may reach from the- arch nt the aorta to the iliacc, or 
from the ^aniu part to the bifurcation of the carolidn. The disease occun, 
however, only in the aorta and its principal branches — in thoiw arterie*, 
indeed, in which yellow elaaltc tissue is abtindanl in the middle ooaL 

Cluies. — Dimectiug aneurisms arrange ibeiuselves into three distinct 
elasHis: 1. In one class, the blmtd, aflcr having passed for a distauce of 
uvcral inches, ur even more, through the subeiauee of the middle coat, 
buKts through the external coat, and becomes eifused intti the areolar tissue 

ouLsidf the vee«cl tmd amuud the seat 
of rupture, or into the neigbboriag 
cavities (Fig. 444). lu these case*, 
which couHiitutc the moet comtuoa 
variety uf the disease, detilh usually 
uceurs rapidly, the |)ulieut fueling in- 
teune pain along the line of rupture, 
and falling into a ttule of syncope 
2. The external coat may resist the im- 
pulse nf the blood, which consequently 
continued to pan between the layers 
of the middle coat until it meets a 
softened and atheromatous patch, and 
then again burats into the canal of the 
artery. In this form of the disease. 
the {Mitient may live for years after the 
occurreuee of the rupture; the new 
channel that the blood hns taken be- 
coming lined with a denae, smooth 
nieinlirane, and reetfrnbling closely the 
interior of t he artery , from which, 
however, it is Bepanitfl by a kind of 
septum. The apjfnriince brre pre- 
seuled by the veeael has occnsioiially 
been erroneously described as coiitiLi* 
tuling a dnubti< anrls. H. The blood 
may hod its way between the Inminie 
of the middle eont. but does not escape 
further by rupture of the external, or 
by the giving WHV of the lining mom- 
brane of the vc-wel. A eae is cuuse- 
quenlly fVirmed in ihe substance of 
the middle coat, which may become oaronic, but which will at last rupture 
externiilly. 






.fcfM 



-t^ 



^.s 



Fif. 441. — RtitilarBof l.lnlni( M«Hilir>n« of 
Aoru, gliini: (>*• to* UljiaDiIng Antu- 
rinn ohinh bnul iaio PeiianrJinut. AaitB 
m»eb dilatad aatl cotersit wltli C«lc*r*<mi 
PUt«», e3c*|>l mbtn tlit Anenrffpi ca- 
euri«il ; Itiere It >*< atli«r«uialuii<. 



STBUCTURE. 129 

pRWEW OF Formation of an Aneurism. — The progression of the 
cfcangm leadinc to the formation of an aneurism is brieny as follows. The 
artery having been aflected with chronic endarteritis, a patch of athero- 
mat'Mu sijflening forms, and the lining membrane covering it, perhaps with 
a portion of the inner layers of the middle coat, becomes eroded ; or the 
vmlU of the vessel may be weakened at this point without any destruction of 
their ooat«. Cohesion, however, takes place between the tissues of the vessel 
at the eroded or weakened spot ; and the outer coat becomes strengthened 
MBtd thickened by the formation of dense fibroid tissue. Dilatatiou next 
takes place at this point ; if of the entire coats, a true aneurism is formed ; 
if of the eroded tunics, a falne aneurism occurs ; but if do cohesion have 
previously taken place between the different coats of the vessel, the blood be- 
eotoes etfused into and between them, thus constituting a.diasecting aneurism. 

^"TKi'CTfRK OF AN Anecbism. — An aneuristoal sac, if it be composed of a 
dilatation of all (he coats of an artery, may be recognized on dissection by 
tbe atheromatous and calcareous patches which are met with in the tissues of 
which it is composed. If it be a false aneurism, it will be found that there 
b little, if any, of these deposits in the walls of the sac ; that the middle coat 
QMjally terminates abruptly at its mouth, and that the external coat is greatly 
tbickened and strengthened by newly formed fibroid tissue. An aneurism^ 
MC may vary in size from a tumor not larger than a cherry to a growth of 
the ma^itude of a cocoanut or large melon. The mouth, which is oval or 
roaod in shape, varies greatly in size, being always very small in proportion 
to tbe sac Usually the interior of an aueurismal sac contains a quantity of 
cnlorless fibrin, arranged in concentric laminie of but moderate thickness; 
tbcMf lamtn» of fibrin are of a pale-buff* color, dry, and somewhat brittle 
wherp they are most closely applied to the wall of the sac ; the more external 
were fir»t deposited, and occasionally are found to have undergone a kind of 
fcttr degeneration ; as we approach the interior of the vessel, they become 
softer and more colored, and at last, in the central portions, dark masses of 
coa^lum are often met with. 

This colorless laminated fibrin was termed by Broca the aetive clot, as it is 
deptvited only when the blood is in motion in the sac of the aneurism. It is 
f<>rme<l in the same way as a colorless thrombus iu a diseased vein (see p. 80), 
thv limit i^tep in the pnicess being the adhesion of a layer of white corpuscles 
to the diseased surface of the aneurisnml sac. The.-'e disintegrate, and thus 
del^rmiiie the formation of a layer of fibrin. The mioniscopic examination of 
r*c*Dl laminated clot shows the presence of numerous white corpuscles which 
bavf- <-»cape<i disintegration l)etween the layers of fibrin. It is thought by 
*'me phy?i<>lii);idts that possibly these are of a different nature to those which 
lake part in the proeem of coagulation. In the older layers of clot no cor- 
puM-U« are recognizable, but much fatty and granular matter is always found, 
■ hich may have rwiulietl from their disinte^'ration. The part played by the 
aiihi-^ion of the cor[)ucles in tlie I'urmntiou of lamiuiite<i fibrin explain.-* the 
ioduence of retardation of t!ie blood-streuin ou its fnriiiati<m. In fusiform 
aofuri^ms in which the flow of bloixl is rapid ihrougliout the dilated vf)>(>el, 
atihM'-n takes place with difficulty, and no clot isi usuitlly found, while in 
eacvulateil aneurii'ms in which the movement of the blood is nceessarily 
mu<'h !il>iwer. laminated fibrin it> always abun<lantly ilepo^'itcd. It will be 
aturaanl- ?wn that th<we mmlts of treatiiu'nt by wliiih the flow of blood 
ihr-.ugh the sac i.-» retarded, exert the nio.it powerful influence in determining 
ih* dri*«"it of lavers <if clot. The color of the tlot viirios in ditfereut ciu-ies ; 
the nior* rapid llie flow of blood, the fewer re<l (.■orpiisclcs will be entangled 
ID th»f ci»;tguluni, the shtwer it is the darker the clot will be. Compk'te arrest 
of the circulation leads to the formation of an ordinary dark blood-clot, 
»yL. 11— 9 



130 



ANEURISM. 




Ftg. m. — 1.*rgf> Ativuritin n/ Atocndlng 
Aorta, ]>rnJ«o()a|t B^ioat {•ml f-rnlrudlDK 
outnard*^ the rib*. laMjrEn of lid mill Bled 
Fibrio %tr»mfti in (lio JIiocIIdd oI ttas 
Cufr«Dt uf tbe II1i>o<l. 



exactly like that pn)duce<i whcu Llood. wilhdrawa Iron) the body, is nllowcd 
to ooagulBte. Clot nf tttis kind U always I'uuud poec-mortem in (be mid<ll« 

oi'tlic eac«jrtheani-urtBiii, and is lliea 
formed probably ini mediately befura 
or alter <ieaih. Those modea of treat- 
tiieut Mhich completely arrest the fltiw 
of blmid into the aae cause the furoia- 
lion cifa similar cougultim. It is tin 
paesiii! clot of Broca. 

The Iuyer« of librin id the laminated 
riot arn more or Itt^ conrenlricnllj 
arranffi'd, hut un t^inylc- lauiina reacbe* 
over the whuU* itac. The older layert 
bfar bvideniK; ol' liuviiig betn formed 
whrn the isar was eiualU-r and aulH 
ee4]iipntly tlatieiiK] otitagainKt the eo 
Iflr};f>d walls of lliit mc 'Vi^, 445). 
The deptMit of kminaled fibrin exertK 
a pnwerfiil iiiiliir'tioe in preventing tba 
too mpid increase of the titmor. Thft 
linini; nf llie walln of the sac with 
eiK'h a toit^fh and eliistic material as 
the (Stratified fibrin, most jjreatly 
tend lo deaden and hroAk the force of 
the wave of blood that ia projected against wlmt would otherwise be an UD- 
pn>t4^eted mettibraoe. Another ^reni jHirpoite it serves is to lessen the ca|mciC]r 
of the MC. and thus to diiiiinHh Ihe prciwuro on surroundinj; pnrls, the dia* 
tending force of the anetirism bciug pruportiuual lo the area of the sac tj 
well H» Ut the force with vtbieb the blond is driven into it. lu tboae caaesin* 
whieh tbe lumiuuted iihriu u griuH in c|imnLity or altogether deficient, the 
aneuristiotl tumor rajiidly iucreaeeti nith u forcible pulfiatiou that it) not met 
with io wther eircumatanees. The dark eoaguluw or puaive cint of Broca is 
a leas eftlcieul support to tbe wall of an aneurism than Ihecolorleas or active 
clnt. It is much eofler in coo&iHleiice, and at lir»t eoutniun a comsidcrable 
ami>unt of serum : thij) gmduallr si^ueezes out a» the clot contnict« and thus 
it becomes eoiiEiderably diminished in bulk. If the clot completely filla tbe 
sac this contractiou may ])<it«ih]y be fidbmed by tbe reestabliehnieot of a 
cavity, but the experience vf some of the miwlern modes of treatment ahowa 
that it is not very likely to ocvtir, the eonlraetion of the clot being accompanied' 
by a oirresponilin^ diminution in the size of the bhc, chiefly due to the pres- 
sure of the snrrnnnilin^ slruclures. The clot further diminishes fnmi the 
disintegration of the red corpusclca whieb form the chief part of its bulk. 
Ah this lakes place il becomes decolorized, and thus, if the sac is only partlj^ 
filled by a dark clot, this b«oamcs flutiencil out and tinally forms a layer in- 
distin[;iiis<bi(b!<> from tho laminic of colorless fibrin. 

PniBure effects. -~A« ibo sac of an aneurism enlarges, it eierta iniurioua 
ood often fatal cfl'ccla by ila urcasuro upon ointiguous parts. These preeaure- 
effi^ts deserve attentive stuny, as they constitute an impurtant and. in some 
tustances, the sole element in the diagnosis of aneurism. The pressure oa 
the surroundinjr parts inereaaea with the size of iho aac. Dr. W. H. Stnoo 
thus dc«crib(ii the inlluenee of incr<>aM in size on pressure. "The hydrnstatia 
force rises rapidly as I he .hac ettlaree*; in fact in a modified (^metrical ratio 
as against a itimple arilhmelical ini-rea(>e of the heart's impulse. We ara 
thus from the fir»t I'^mlng grouml, nnd the iiinlailr is (fining on us acc4>rdin) 
to some simple fuoclionof the funditmenlal law of e<|UHlity of pressure In al 
directions. naught4^m estimates tbe bKmostatic pressure of tbe blood in tbe 



PRE3SURE-KFFECTS. 



181 



huniBD arteries as equal to a column of 9.923 feet Takiog the aneurism asof 
3 iocbes in diameter, its internal surface wil) be 28.27 square inches, which 
^vca a tension of 12.24 pounds. If the sac rises to 4 inches diameter, this 
increasefl to 50.26 inches of surface and to a tension of nearly 25 pounds." 

One of the inoet common pressure^ffects of aneurism is the occurrence of 
oedema of the Hmb or part, owing to the compression exercised by the tumor 
DpoD the large and deep venoua trunks in its vicinity. The consequent ob- 
structtuD to the venous circulation in the interior of the limb may give rise 
also to a distended or varicose condition of the subcutaneous vessels, and id 
■oue instances it may even go on to the production of gangrene. The pres- 
sure of the sac, also, on neighboring arteries, or even on the upper part of 
the very vessel from which it springs, and its interference with the general 
capillary circulation of a part, is commonly associated with compression of 
the veins, and may considerably increase the ill-consequences resulting from 
iL The pressure upon a neighboring artery may go on to perforation of the 
Teasel by the sac, and so a communication between the two may be set up ; 
thus aneurism of the aorta has been known to perforate and communicate 
with the pulmonary artery. By its pressure upon neighboring nerve«, an 
mneunsmal sac may give rise either to great pain io the part supplied by 
them, or to disturbance of their function ; the nerves themselves becoming 
in some cases, expanded or flattened out, and ribbon-like (Fig. 446), and 
in other iostaacee tort;ious and wavy, being considerably elongated. The 
pain in the nerves is often one of the earliest signs of the existence of an 
uieurism. The pain is usually of two kinds : it is either lancinating and 
radiating along the course of the nerve that is compressed; or, when the 
tnmur presses severely upon neighboring parts and tissues, more especially 
if it give rise to erosion of the bouea (as in Fig. 445), an aching, burning, 
teariBg. or boring seosatioD is often experienced in the 
part subjected to the pressure. la other cases, again, 
important modifications in the function of parts take 
place, in consequence of the pressure that is exercised 
apuD their nerves. Thus, for instance, the compression 
of the recurrent laryngeal nerve will occasion hoarse- 
•eoess of voice and difficulty of breathing, dept^ndiiig 
on >pasm or paralysis of the abductors of tlie vocal 
e«irri». On the bonejs an aneurism may produce very 
impi>rtaDt eflecw by its pressure, often eroding deeply 
the oeseus tissue. If the bone be a flat oue, as the 
surroum, the aneurism moy perforate it by making as 
eai->>th and round a hole in it as if this had been 
worked by the trephine. Glandular organs nnd their 
dttfU in the neighborhood of aneurisms sutfer the most 
injurious effects from the pressure of these tumors, 
their functions being arrested, and the parage of their 
secretiitQS interfere<l with ; so, also, by the pressure 
exercised on the trachea and cuophagus, respiration nnd 
dciflutitiim may be seriously impeded. 

Xl'MBLB. — Aneurism8,though usually single, are not 
Tf-rr unfrequently multiple. There may be more than 
one tumor of this kind in the same limb; thus the 
iliac and femoral arteries on the same side may both 
be affected. In other cases, corresponding arterit.>s in 
(^prjsite limbs are the seat of aneurism ; thu:^ the two 
popliteals are not unfrequently found t*) be the seat of 
this disease, and occasionally an aneurism may exist in 




Fig. 4J(1. — Klutlening 
itnil Mrctcbiaif of Poi' 
tehurTILilal Nene bj 
pre»aure oT ftn Aneu- 
ritm of tb« Cftif, 



132 



AtTKUKISH. 



<^ llic limbd, and trthen id the arterirc uf ilie iaterior of tlnfaody* 
nnefouK aaeoriuBal tamnni are at times in«t with in the H«w pMaoaj 
u, P^lletan MOnrda a case in which do fever than stztj-flv* ««re uh- 
ved. 

DcKATinK. — Tht-- dnration of an anearism x»ne» rerjr greatly. In fnaog 
^1bll-UoiMl«d persoDt it often osakes prugras with threat rapidity ; whrr*«9 in 
elderly people of leeble oonstitatiooa, in whoni it io acc<>ntpat)i<4] witli mnn 
or \em cffttilitv of Lbe beart'ft aotioD, the dtitf^w may amurk' a very rlintTiic 
fcriu; ibus. llodgson relat«« the ra^c of ati nn<*un«m of the ffn)<>ml dru<ry 
of twenty yvan dumtioo. Much aIjH< nill de|M-iid oo the siiimtinii of tho 
anruriam, the »ize uf the iiiuuth ot thv sac, and tli« n-latiuii of the rac to the 
impube uf [he hluod tutu it; the laq^r and nmrv iltn-ot thi" nmuth of th« 
tumur, the more rvadily will the blood be pnijcctcd in it at each imjiulM tif 
be»n, add the mure qnicklv will the tumor expand. 
Symi'I'OMk. — The symptofna uf an aoeoriem are uf two kinds: I. Those 
that are peculiar to this disenae; and 2. Tbuee that are eiraply ilf|w^id«>nl 
on the presence of the tumnr oncasitinfd by the pnlan*iuf[ hhc. The pe<ni- 
liar *\r pathognoraooio signi are those that nre dp|Kiidi-nt no thu (■oiiiniuoi- 
nuiim of the sac with the artery; they nmsist of aigiK nttunJed by the 
[maoual and aosoiltjitory ezaminaii'm of the tumor; thtwe that are de- 
leot OD the mere elte of the growth are the prewnre-etl(H:tR. It !• of 
ine only in ext^mnl aneurisms that thoee signs which are ascenHioablc 
maoual czaminatiun of the tumor can usunlly be rpco^niiied. In iolemal 
^MwarutDs, in the majority of cft««, the a^cultatory signs and the preasure- 
eflects afford the best iDdicatioDs of the presence and nntiire of the wmor: 
thoagb, when this approaches the surfiwe. mach information can h« gained 
by fialpati'iD. 

' Bymptams of External Circumscribed ABearitm. — ^The tumor is osually 

round or oval, didiinctiy circumscribed, and situated upon and in riose am- 

nectioo with some large artery. It is at fint somewhat roniprenibic, hut 

afterwards bec-^roc» more and more solid as flbrin is dcpo«iic«l in if. The 

moot marked sign la. perhaps, the puliation that lb felt in it fmra the very 

[first. This is of a dinleosile, eccvntric, and exjiau<liug character, se|>arating 

the hands when laid u[m)u ettch side of the tumor, hy a divlinvl Impu' 

from within outwards. The puWlion is most foreiblv in an uiieuriMn 

which there 10 but little laiuinati-d hbnn ; and a* tht» increaw-B in quantil', 

the pulsation ^ruduully hiwn its len«f. expanding chamcter. bein^ cunverted 

Lintoadea«l fAud, and in some cHsea vetuing entirely. When ptilsation is 

jt^bscure, tile comprvs^ion uf the arterv below the («c will cause it lo iH-oume 

^urv distinct, ur it may he Increa^eil lu dislinilnesa by i-levaiinir the limb or 

tirt utTeirled. When the artery aNivc the «iL* iit eomprc»ie<l, (hf flow of 
Iou4J into the tumor a neceaRarily arrested, and a eonitiderable <]unn(ity of 
it« more Quid ci)nteol» may be ^pioczL'd out by gentle prewure. If the 
baDds be then laid upon each «ide of the- tumor, and the prpaenre imddt-nly 
taken off* the artery, the blood wilt be found in rush into and db'tcnd Uue 
sac by a Huddvn »tnike, separating the hands from one another. This Bay 
be l(M)l(e<l u[>on as one of the moat rharnctcristic ^gns nf aneurigm. 

The bruil or tound emiiuvl by the blood in its passage thnmgh an aoea* 

lismal sac was fint notif-H hy Ambrose Part. It varies much in i-harucit-r. 

Ibeing uaiiHlly loud, mitpiiig or sawing — loudntt and nmghcsL in loldur anru. 

riims. Occasionally tlic hniit u double, and if so, it clearly InrlimiiiA the 

sacculated naiunt of the aneurism. It is p>iMih]e. Imwcver. thai whm ttrrul 

iiSnrlio regurgitation is present, the biirkward nirrent of hlood in the large 

^Ycssels might give rise to a feeble dimlolic murmur in a fuiiitorm aui^uritm. 

lo many cutti-A it ts altogether absent ; this especially happein lo saoenhlled 






SYMPTOMS OF DIFFUSED ANEURISM. 183 

aDeurismfl with small mouths, or id those that are much distended with coagula 
and bluvid. The absence of sound, therefore, iu a tumor must not be taken 
a« a proof that it is nut an aneurism. The sound ia usually beat beard in 
aneurisms that are not too fully distended with blood ; indeed, it is usually 
mi»t distinct when the sac is partially emptied. Thus, fur instance, it not 
uofrequentlv happens that, in an aneurism of the ham or thigh no bruit, or 
but a very Jaint one, is audible so lung as the patient is standing ; but if he 
lie diiwo, and elevate the limb eo as partly to empty the sac, then it may be 
distinctly heard. Another sign of considerable importance consists in the 
dimmtUion in the sue of the tumor, and the cemation of thepuUation and bruit 
ou eompreMtnd the vetael leading to the eac, and the immediate and sudden 
return of these signs on removing the pressure from the artery. 

Many of the symptoms that have just been described are peculiar to and 
their combination is characteristic of aneurism, being dependent on the com- 
munication that exists between the artery and the sac. Those that result 
frx>m the pressure of the sac upon neighboring parts are common to aneurism 
and to any other kind of tumor ; but, thougn not of so special a character 
Mi those that have just been described, they are of considerable importance 
in determining the nature of the disease when taken in conjunction with the 
other symptoms. 

SymptOBU of Diffiued Anettrism. — When a sacculated circumscribed 
aneurism becomes diffused, the sac having given way, but the blood being 
Hill bounded by the tissues of the limb, the patient experiences a sudden 
mod acute [Mtin in the part, and usually becomes pale, cold, and faint. On 
examination, it will be found that the tumor has suddenly and greatly 
iocreased in size, at the same time that it has lost its circumscribed and dis- 
tinct outline. The pulsation and bruit become materially diminished in 
force and in distinctness, having receded an it were from the surface, and 
may disappear altogether. The limb may also become (edematous, or may 
mifkr in oth«r ways from the diffused effects of the pressure of the aneurismal 
vwelling up<m the neighboring veins and tissues. At the same time, the 
circulation in it being greatly obstructed, the limb may become cold and 
livid, and a sensation of weight and general inutility will be ex{>erienced in 
it. In these circumstances the aneurismal swelling usually becomes harder, 
in com^juence of the coagulattuu of the bluod iu the areolar tissue around 
the ^Ac ; by which, indeed, the further extension of the discuse is arrested, 
and a I'resh boundary is often formed, so as to tiinit the cxtravasated blood. 
If it hv left to itself, the tumor will now usually increase rapidly in size, 
••jmt-tinies without, sometimes with nmcli pulsiUion, so that at Ijist it may so 
■jwiruct the circulation throutrh the limb sis to occasion gangrene. The 
tension cau^eil by the rapid iucrease of the tumor excites more or less acute 
inflammation ii) thesurrounding structures. As it advances towards the 
Furfa<.t:. the skin covering it becomes tliinncil and reddened, the tumor be- 
•Muie^ 9*>ft and eemi-fluctuatiug, owing to the ooagulum breaking down, and 
evfDtually external rupture will ensue. 

In ^-mi- cas4>:i it happens that, when rupture of the sac takes [ilace, the 
«ffud«d hI'Hjd, iusteud of being limited by the surrounding areolar tissue, 
V-ri-iirae!' suddenly and widely extravasated into the substance of the limb. 
Wht-n this untowartl accident l)ap]M>ns, the shock and local disturbance are 
r--ry great, and the patient is suddenly seized with ii very severe lancinating 
and nunibin^r |iaii] in the part. Tho pain is must severe in thof<e ciuses in 
whit-li the rupture take^ place under the deep fasciie, by which tlie elfiised 
U.mifl ii tightly biKind down ; ami it may be so severe as to occasion syncope. 
In 'ither in-itances, faintness occurs from tlie sudden escape of blood from 
the current of the circulation into the substance of the part, being moat 



184 



AKECTBISU. 



mHrkcd in thoM- IntiLanoefl in nMcli ihe lilofxl ts aorldcniy ami Inr._ ' 
into l)ie areolar |tf«tit?. It' th& extrnvn^nlion hnppf-n in h limb, r •'^ 

OOnie grvnily swollen, h:in), hmwny, hikI iiilr). TIk* s'lpi-rlit-iiil vi tii> an 
OOOgetted, aud tliu circulaliun in th«> li>w«fr [uirle nt* ihti mciiilM'r '» soon r<>ni- 
pl«ieljr Brr«stnl by tlie pr«wtire of ihu extrtivMBBleii »tu\ KmiTfiagtilntrfl 
blood upon its V4-*vpls, more purliviilarly llie large vvnous triinkv. In 
ooostquenceof tlit».gtio)£rvni! ot a nn/ut kind uvualty makes ita appcaraitnt 
Uld speedily dealrovB the patipnt'e life. 

DiAtiMOHi!!. — Tbc diagnosia of nnenriera may in many ca»M be eflecl<4 
vith llie greatest pr^sible cece by a etudent in eurfrery ; in other inittaiieee it 
requin'B B vnst oniounl of care, sod llie nioet experieneed JudtrmeDt. to warn 
lu 11 correet conclusion a» to tbc nature of the lumnr. Thia is easily doa* 
wbeo the SDeurif m is guperficial, recent, and circurn^ribed, ihc blood in it 
betni; fluid, und nil the i^i^n^ of the diwii^e well mnrkei). The diagnoeia i> 
uftt'ii replete M'itli difiieiiliy when the aneurism Ib deeply Heated, or, if us* 
terniil, ulien it ie ohl and filled nilb n^aguln ; alHi, if acute inflamniaiiaa nr 
Huppuration have Inkeii place about it. or if it hiiTo become diffused. 

In rflcciing the dia(;uofcis ol'anfuri^m we have, in the lirM place, to ascer- 
tain ihp exlilenre or Hb^-ncc of a tumor: nud. after this has been done, to 
fiiicerlnin whether it he nnciirinnial or of *onie other cliaructer. Bulh poiuta, 
the latter esperially, are difficult to detfrmine in inliTnal aneuri'-ni.* ; in tbe 
exlernal, the douht in not a» to the prrwnrc of a tumor, but as to it» ualure. 
Th<^ tumor* with which aneuri^rnit may bo oonfoundetl may conveuirutly ba 
divided into two elnMca — thoise that do and tho^ that do not pul.onte. 

£v«rf pnliating tttmor it not an anetiriim. Thuh thpre may Ite pulsation 
in vnrioori kindx of ntri-jihuiniti iunmr or '1'/^ mtrcomn, or in (fnnrlfi* rampNWtl 
of mrvoul timU: In «ieli lase* as ihew^ iiinny of Ihe s-ign* of niieori»ni »r» 
prtpeul; thus the size of the hinior iii«y he diminiiihed by conijirei-jiivn, and 
the distinct inBux of bltHKl into it may he felt on the removal of the pre^ 
Dure, tbv tumor retuniinj; to ila original eiite witli a »>>i\ twvW'n)^ piilMlinn; 
there may also be a bruit, often of a loud and distinct chiinieler, Hat 
theae tumors may generally he diatinuuisbed from ancurinrnp in not Ireiug 

Suite so diHtinrtly circume<Tit>eil — iu being soft, spongy, and elostte, wilhoat 
leMnsBlion of lluiil that is met with in stHiio forms of am-urism. or of eailid 
ooaguin that occurs in others. A)^in. the hruit ie either Mift, hloaing, and 
more pr«)lunged, or eW oharp and suprrficial ; Ihe nulsalinn, also, is Dot ao 
iliatinct. and is mure of ihe nature of a general Bwellinf; and heaving of tba 
tumor than uf a distinct thump. Much lieht is (H-caaionally thronn upoo 
lhe?4* anVctiiiRS by iheir beinif met with in oiiuaiions where iint-urism cannot 
occur. fr(»m the abcence of any artrritH of sufficient rite to (live riw to it, aa, 
for iimtance.on the head of the lihia or the sidoof the pelv'w: hut if a tumor 
of thiH kind he siuiatcd ufKin or under n larjfe artery in the usonl sit* <.f an 
uoeurtsiii. tlifii the dineuoiai.-^ h cerlninly rcplelf wilh tlifficully. and cannot 
indeed in nmoy case's Iw made. Several instances hnve i>cetirr«I, in which 
SurfTfuiw ftf ihe jrreiUe«t -kill and ex[>erietice (a^Guihrie and Siiuileyl lisva 
ligntureil arteries on the sup|M<!iit>on llmt they had to do wiiK am-iirism, 
when ill n-nlity it waj« one of the puUiiliiig tnniors just luentionnl that rlnxvly 
simulntiHl jt. 

PulMilion may be communicat<>(i to a tnmor of a fluid chttrofUr wated 
upon nn artery; here the diagnosis, though oHen dtmcull. is more rmdilj 
madr than in the la^t raiw. All«-ntinn to the history of the cnv*. to th« 
imfMwiibility of dimiiiixhiog the tumor by prvRiure, cither directly up«ni it 
or oi) the artery leading to it, its fliictunti'^n, and want of circumscnptinn, 
will usually miint out \u nnture. E»j>ccinl attention should likewise be paid 
to the fa*.-!* tnat Ilia pultaition isadistinct heaving up and down of tbe tumor* 



pfjLOiroBia frum non-pulsatino tithors. 



185 



'BOCiwr fccrtilric nor ilistcnaik, and that the swelliDg may nOrn be 
"f or partly fojtBratcd, by niii?inp it up, frinn ihc nrifry lying Ijcnealh 
H. Br mttrDtMB lo tbcw puiiiU. absc«f#e» in ilie Axilla, iinilrr \\\c jM>ctt>rH)D, 
■I lliv root of Uw DOok, BOii ID other 8iliiiit)'>i)A whi^re pulsulion mny n>n«lily 
b» eawirnicftled to the fluid moss, en n tx' di»liiii;iii!t|ii-d frvini anenrUm^; 
jnivmn in disgDoais hare bappfDcd, aod uill continue to dnwi, frum the 
MtrinBic difficulty of the^ caae», and from do whdl of nltill nr rare on the 
part ut il»« Sar)^iu ; and tbuae will be tnoet charilablr in iheir criUcisms of 
tk« uiMftkcs of others, who hare OMiat 
tife^iMBtJy had o«caaioQ to vxperieoee 
thfM 4iABalllea in their nwu firat'tit'c 
TsBon tkat 4» oot pcUate, either by 

iWif \mn VfMfel* or by tbuwo tliat Vw be- 
■Mkk thfOi, an ucit •<« ruailily tMul'<iiiiiil(>d 
with aartirixii n* lb« t-Iuu of aKWirliimtt 
tkaf bas ju*t t>eeu desert Ix^it. Yet it tuutt 
ba boroe in mioil, tJiut in eoiuc in»taiR-v« 
Mwurifina du uut puUal^*, or hut 
iodbtiovtly M, having bi'oxiic filled 
wilh ■ iivn««t and tinri cuaKulutn. Tliu 
■aa paliUng tumors that rhietly require 
9t3mv6tKamnyhmdmlarKtTthtjrou.igv!fliiHtf». 
wmtaA tnrr Ibv camtid artery at the roiii 
rf iba Dwelt, ur in the |io]iliipal n\iUM. 
If iImw be iif a fluid rhnraclrr. thoir Muo- 
liua, uoraryinir oiKr. nnd the want of 
>Uno in tb«m, pnfticienLly indicate 
tiKT are not cuanecti^ with the 
fpini which they may alai frr:- 
natlv h^ «r;>Bnilp.l. nnd ufKiii which 
la*T ' moved. If siilid, 

„ I ur and uodiilnt^l 
nnil vnii freiiiienllT Im di^ 

iinj;irr<> )ivin){ pasM><l nnd?r- 

thrcn and rai^in^ thcni fmtii the 
mhj»'^"' " — '■'. TbMc is much daufier 
«r tr. a consiilidateil anetirism 

wkieb w i]i)<ifT|i[i^ing or has undergone 
«■ cun>, ami in which thvro is 
itljr no pulmtion. for n solid 
of anowkind. 1 have known one instance In whirh the thtj*h was 
for m very painful solid tumor «f ihv ]vi>|i]itfal npncp. which 
m dHMQlHa to be n consolidated nniiiiri^m jirpiwing upon the im)^ 

tibklMnra(rig. *^~ ■ 

II, more parlJL-ularly those thai anMlifTuMNl, have not iinfrpc|uentlf 
MbUkm (iyr abterua; aud it ti> no very unriimnKin thin^ for a 8ur- 
10 be caiied io an aneurism which, under Lbis >>upp>Miiiiiin, him hn-n 
lUr poultieed, or paiaml with t-Mlinr. I have twice liptture<l the ex- 
iltae ftir Mwurnau of ihft fnna that had been mi*tnken f^>r nbtwnMe*. 
OwgionsllT. ibe nvin fatal vrrnr hmt )>een fyirumitted nf ptmcturii)); the 
r -"■* *V? view of leltin(* out pu*, when n'»ne appeared, and, either 
r after a lapMc of n fiw h^iurs, prufu^c nrlerinl henifirrhn^ 
' - aix*ii)t-ttl Diny artw frcni the inlriiiAic dttfteiiltien nt' (he 
Jl^fD '- rn>ni the t'»ii thiit il hns hMp|«.'ned l>> ^iicb HurKr"!)* us 

DklBttll, i'ciU-Uu, UufmytrvD, l'iri>);iitr, and many other*. I have uncvH-ca 



Amy 
OO th. 

ttcbr. 



V\g. 4IT. — S«Mt(iQ af .tneniUia «( Catf, 

latoa tor Tuwor. I.tnili ■■■|>ulal«al. 
(u) ItUok tVMiit Caaniiluia Ijinx (n 
eeftlrv of Lantiniitcd FibHo. (A) Pm- 
iMiOT IMital N«rt« Vlratnhtnl, 





ISO 



ANEDRISU. 



thin «cci«lenl ocour to a Surgeon of oonsiHcrabIc cxiioricnco, wlift. mirtaVing 
a ditluwl pu|i|iii-al aoeurisni lor an aiHoeas, Of>eiie«i it witli a bistmirv. liin 

pfiadinj^ no put, applied a poultice; »larniing hemorrhage eosued in about 

'forty hours, aod 1 auijuitated the tiiigh on the itecoiid day nfler lhi» unto- 
ward occurrence. 

Tb« difficuliv in dUgDoait is eapeciallv apt to occur id thoae aoearinn 
wbicti, having Vecoinc (liS\]8ed, havo ceased to puliate, have do bruit, an 
elastic, auneued, aud ditHueut to the feel, and iu which the ikin ba« bccinia 
rcddvncd aud iuflaiucd by prra^u re from withio. It is only by careful attcv- 
lion ui Uiu bi«tury nf the cose, and by ekilful maDipiilatioQ. that the traa 
nature of the tiiinor can be made out. But an oueurbm may actually b»- 
onme assoriatod with an nUoe^ in one of two waya. Thue it may euppura 
tbe in flam mat inn takinj; pliu-o in the areolar tisuic aniniid it, with awelli 
redneas, a>d«ma, anil h<;iil of thu iiueguoi<!Qlal Mructurea, iocrrase at aiae 
tlw tumor, iind pn>tuthly Hiliilitimiion of it. It' tbie abecMB be opeood or 

rjallowed to hunt, 'lark grnnniuA hum u til ettoaiK-, followed by coeguln and 

^wnnnro of broken-down decnlorir^il tibrin, and ennierJmes nocomponied, but 
more uftunlly followed atVer n lapso' of some hours, by a free and perbapa 
Ht%\ di*cbarue nf fl..rid bUmd. 

Another form of combination tketwirti ab9ic«s»pi> and aneurinm ootuiata ia 
the opening of an artery by nlwration into the cavity of an abscets, no that 
the hlootl is pp>jecte<l directly into thi» from the opened vetael. In catra of 
ihi« kiod — of which the instance that occurred to Liston is a ^ood example 
— wi^ have the ordinary ei^'us of abM««, usually of a cbntnic cbnractfr, to 
which thoiH! of an nn«uri8m are geu«ra)ly superadded suddenly, with tnvat 
iocreaee in the hulk of tb« tumor. This accident hna been ohwerv«^l chiHly 
in absceBSw <>f (lie neck, opi^nios: up a ci>miMUDioalion with tbe cttn>ti<I nrlory. 
With rheonuitiim and neuralgia it «<jukl at liret ap|MTir to be diffiaOt to 
confound nn aiieuriain, but in practice it if not so. 1 have kuuwn seTerml 

! cases iu which lliv laucinutiug {mius of aneurism, more especially wbca 1^ 
tnmur woe internal, have bvvu niislakeu and treated for rheumatic or oea- 
ralgio afiectiuns ; and I hav<> even known tbe naio oocssionctl by the pr«»- 

jeaoe of a large aneurism of the ihi^h treati^ ftir tteveral weeka as rbcuma- 
tiam. In a larpe proportion of piiplttea] aneurixmn the ftatient tint pKBento 
hiniM'lf complaining of rheumatic ]m\m iu the kne« ; in fact bo frequeatly 
Is tbie tbe case that it is a good rule whenever a patient cnmplatna of ob- 
icnre pain in that joint, to examine the ham fur an aneurism n» li>e first 
aiep io making a diitgnoeii<. In such cnsea an ibcee, it is of (>>un»e obvious 
that a litltc care and proper examination will nsually serve to enable tbe 
Surgeon to avoid an error. The anenrianial may be distinguished fmm the 
rheumatic pain by its having a twofold charaflcr— being oolh lancinating 
and intermittent, OS well ba continuous, aching, and burning. When thb 
kind of pain i:i pcrsintont, etipecially about the hack, the sine of the head 
and neck, or arm, it ought always to muse the Surgmn '4 attention to be 
dir«cicd to tlte condition of the neighboring large vessels. 

TERMlXATlo^ift.— Spontaneons Care .>f an aneurism is of very rare occur- 
reooe. Tbe ronon«r in which it hiippens has been espccinlly and ably studied 
by HodgND, and more recently by Ucllingham ; and the pathology of thb 
prooen is ofcousiderablD interest. I'roui its bearing npon theourtof loediaciM 

I Dy surgical operation. The spontaoenus euro may Bcoidentally. though very 
rarely.occur by inflammation of tbe aneurism and consequent oblitenuaoB of 
tbe art/;ry iscc Suppuration of Shc)j but nio^l fre<)uenlly it is by thejtradiial 
deposition of Inmiuated fibrin in the interior of Uie aac that it is filled Dp 
completely. Thia pDccKt usually takes place io nneurisuu oifecting arierim 
di too aeooDd or third magnitude, rarely in tbuae of the aorta, though both 



DO- 



TERMINATIONS — SPONTAXKODS CDBE — SUPPURATION. 187 

HimIesod and Bmca have met with instances; and it can happen ooly in 
ncrulated aneuriams, the fusiform not admitting of it, it being necessary that 
the blood flowing through the sac be somewhat retarded in its pasdage, eo 
ta to favor the deposit of its fibrin upon the interior of the tumor. This 

Erncen, wfaicb is a very different one from the sinipie coagulation of the 
lotid, is the increase of a natural condition always going on in the sac. In 
all cases of sacculated aneurism, there is a tendency to the production of a 

rDUneous cure, though this is rarely accomplished. The tendency to it is 
WD by a coDtractiou and partial occlusion of the artery below the enc, and 
the ooDsequently diminished force of the circulation through it, by which the 
depocitioD of fibrin is greatly increased, at the same time that the collateral 
Tecsels given off cibove the sac often enlarge to h considerable extent, and 
thus divert from it blood which would otherwise have passed through it. 
This cunditioo of the vessel below the sac may be looked upon as the first 
mod rntwt important step towards the consolidation of the tumor. The process 
is also roatenally assisted by the mouth of the sac being small, and so situated 
that the blood cannot be directly driven into it. 

For spontaneous cure to take place, it is by no means necessary that the 
whole current of blood should be suddenly arrested. If such an accident 
occur, the aneurismal sac becomes filled with a large dark sofl clot, which 
may yield, if from any cause a pulsating stream of blood be again admitted, 
but which under favorable circumstances may lead to a complete cure. If 
bloud continue to circulate through the sac, deposit of laminated fibrin will 
take place if the impetus with which this fiuid is sent into the tumor be con- 
siderably diminished. This may happen from the occurrence, in the distal 
portion of the artery or the mouth of the sac, of some one or other of those 
conditions that have already been described. So, also, it has been found that 
in those ca«e8 in which two aneurisms are situated upon one artery, the distal 
cne is very apt to undergo partial or even complete consolidation, the blood 
losing its impetus in its passage through the first sac. Any constitutional 
cause or condition also, by which the impulse of the heart is lessened, and 
the force of the flow of blood through the sac diminished (as the occurrence 
of phthisis), will greatly favor the deposit of laminated fibrin and the con- 
sijlidatiiin of the tumor. 

A? the aneurism undergoes spontaneous cure, the pulsation in it gradually 
becomes more and more feeble, until it ceases entirely; the bruit pniportion- 
ately lessens, the tumor becomes harder, and at Uuit completely cousolidated ; 
al the same time, the anastomosing circulation is somL'tinies found to be 
established in some of the collateral vessels of the limh. Eventually, the 
f'lidified tumor shrinks in size, undergoing gradual absorption, with ultimate 
C"Uv*-r<i'iD into a small mass of fibroid tissue. 

Suppnimtion with sloaghing of nn aneurismal sue in not of very frequent 
occur ri-nce, but is especially flpt to hapi>€n in those casv.s in wiiich the tumor 
h** increased rapidly, or has suddenly become diffused, and thus is exerting 
great pre:wure and causing severe tension of the surrounding parts. The 
accid*-nt is not uncommon, also, after operations undertaken for the cure of 
ant-urism in which the wound coniei^ in close proximity to tlie siic. The 
inflammation is then merely an extension from ihnt in the wound, nnd is 
Usually de)>endent uprm septic contaniinution. Thoufrh the process is usually 
■|ir>keo of as suppuration of the s:ic, tht' intiammHtioii cornmenecs in the 
tia-ues i<urri>iiniling the aneurism, the slou^liing of the sao itself being a 
•eoiodary prowss dejK'ndent upon its nutrition being cut off by the pus that 
fjrms around it. Suppuration is peculiiirly liable t<> happen nrniiml tumors 
of a large size that have become partly diffused, that are tilled with masses 
of decolurized fibrin, and that are situated in plates where the areolar tissue 



ANEURISM. 



tbumlani antl lax, as in the axillai. The 8Yu.[it[iii» of ihls roQ(titii>D Im- 
Bildiii>c aru ftw«lliu(;, teiiaiun Miih licat, llirubliini;, nn-i n-<lui7>n ul' lliv imltu 

oiiiiil tilt! liiniur; the inu-Kumeuift cuvi^rini; il pit uti preaMiM, oud Are ef(- 
ly (itt'iily tiiflAmetl. at ttit.- xatm! liiuv lliut (hin.- is a good deal of f«ver 
auil gcucnil eotiHlituUuiiftt ilinliirluiiK^e. Aa ibu SU|ipurulum uilvancrs, ihit 
oriliiiiiry tiitcjia of ucutu ub«rcM in-ciir; the nkiii cruVL-ririj^ the tumor bcmmat 
n-«l aud livid UL oiic pan, where |MiiiiliDj[ tjikc^ plut-c; and if Lht> Suf^ntn 
make an iDcinitm into it, or if the tumor hunti (as aMuredly it will if lult tu 
flself \ B t|i)aiitity of pun mixofi with Inr^e iim9se« of bnikcn-duwti cuHKula 
will Iw let iniU The diiH-harKe "f the «'tinl**nl8 cif the aiifuriiiiiiU mic, nmy 
be fullowt^l hy ftij jirufufi: n gii<>h ufartcrinl hliuxl thnt ihtf jmtieiit i» »udil<-iily 
«xhnii«led. 

Ocniiiiiiiiiilly. however, m* a coitoetjuence of the iuflaniinntiMii iff thn tar^ 
p>iMiiliut; tisMii", tlivnrtery becunii-v lirnily plii^Kcd liy h ihruitihinnUivaand 
beliiw ihv (.iiH-iitii^ iut<.> the aut-iiriBrti Ixd'uru the enc ^ivcD uny, and Lbut 
itwniurrlm^^e tuny Ix- prewult^l iiud u »]»>iiIiiiivoiib curu rmult, lIiv cavity 
clii^iii)^ like ati nnliiiary iiliFi:i%s after iht* Hhiui^iia and tlie bruketi-ditwn cluU 
havi; Jnfii ilischarL'^^ii. 

Catues of Death from AoeiiriillL — An aiteurtHm may pnve fatal in varioui 
ways. It iUtea aa when inti'rnni, iiuml fretjiieutly by prrMvre on |inrU9 uf im- 

tnrlauceiu ile vicinity, I he patient heinj; iletttroyeil by ihi: exhaustion induenl 
y interference with iheir lunclions; this is tiMiully the wuy in wliicli aupu- 
risniH of the aorta occnaion death. In other cawH the tiac bumtji into tb« 
perioanliiim, pleura, or peritoneum, and Binlden death may occur from \nm 
of hlood; ortisphyxia may result from ita giving; way into the lra«h<« Tbett, 
B^in, death niiiy rf^ult by the occurrenc-e of ayncope, iDore ecperiallv if the 
aneurism be of large 8ii«, and siluatAd near the rwit of the aortjk. hitiboiUm 
of the oerobral arteriea may occcur in couaequenee of the detaohiuent of a 
clot. Kxtcmnl nneuriam most commonly proves fatal by mpture of tht aoe; 
this may eiihtT take place into the interior of u limb, giving riac lo «» cw 
Other of" the diflused (orms of aneuriam, jiud t#rmiuot< fatally by th« indue- 
tton of ayncopc or gangrene; nr an aneuriom may kill by rupture oocurriog 
externally, on one of the surfaces of the bodv. 

The rupture of nn aoeurtsm is not always iromediAlely fatal, the apcrtare 
in the sac being plugged up by a maea of coagulum, as happened in the can 
abown in Fig. 444 ; ou the gradual detactinient of the deeper purtiotu of which 
the bleediug may recur in siuall quantities at intervals, and more or lea 
speedily carry off the palieot. On the mucous surfacoa, as of the (Eeophsgvi 
or traclica, rupture occurs in a similar manner (Pig. 448). On the mtam 
irliues, as into the pleura or pericardium, the aneurism may bunt by a 
iro or hy a titellale opening (Fig. 44Ul funning in the membraoe. An 
ineuriam has beeu known to give way nnd <IWhurge hlood for aome ndn 
Jure it proved fnlnl ; and it may even han|M'n thul, nfUr the rupture has 
irred, uo hemnrrlioge may talte place, nut 'leuili may raeulc I'ruui tba 
lure of the Luinor. Thut. in the case of IjkIi'U, the aar a{ the uueurbm 
rbich caused \\w denlli of that great Hurgeim, hud actually given wav, a 
DHH of co4tgutuni proicding from it into the tnu'hea; yet lU-atb reMllnd 
from thct irritation imluoed by prvwiure upon th* inferior laryngeal nenra, 
and not fmm heinnrrhoge. 

TitE-vTMKXT. — Th« tnratment of aneuriMn is of two kinds — cunsiitutionak 
and to(«l. In many ruK-ii. ad in thu various fnrnis of inlcmnt anruri«in, far 
inmaunc, the constilntionid tr>-ntment can alon<^' lwrnipl>i}icd ; and in all niM« 
of rslernal aneurinm it tiitonid Iw had recuurwi to as an ioapoitaDt wljunct 
tu any Iim'aI im-ajiiireM that are adii|it<xl. 
In the ConstitDtionai or Medical Treatment of aDcuriam.the §reat object 



tJTDICATIOKS OF LIGATDHK. 




B. Sitlml Xifatnre. — Id sume ciwee id which the ti^ture cAnnot, for nnit- 
iMBtrml tTUuo*, be applied ua the proxiniul »uh of the- ancumm, at. id the 
mrtmn ftlmat the rtMit of the Deck, il wu recommcDded by Brn»dur, ft 
Fraacb f^awjpoa. nbnut the middle of the Ia»t centunr, 
t^Bl tht w^amr] shiiuld be tied on iu ditiat tttde. This 
■y »f»iJ oB. tiriptnnllr propoM>d hy Brusdnr. was first pcr- 
tmrnni by IW-hnmpe in ITKO at la CharitC in PariA to 

■ ama »il fimDral ADfuri^ni. Id prinojplc, it re»pn)bli« 
tba HitlitcriftB opemtioa, the object hein;; to nrre«t »o 

ni tW flow ipf bItMMJ thri>u(th the »nc tlial the cnn- 
lioo (if thi« nmy take place io the ukuhI whv. by the 
tt( laminatM librin. In thf Ilunterian opera- 
liitt, tilt* i» rtK-clt^rl by ilefKwtt from the lt>«f^riied qunnlity 
af bitud thai ttnwA thri'iiKb tht^ Mtr: in the distal n)iera- 
tiMk, it pi KNight v> be acx-<>nipli^he«l in th« twme way, and 
iW ■ UK I 3 — tif lb* operation niiiflt DeoeeMrtly de[>end, in a 
ifv. upDD Uw extent to which iho tiow oj' blood 
tbtt Hc u ioteriiand with. This uperaiioa, liow- 
r. « nudy vuocobAiI; for, indcpendcully of ih« ordi- 
wuy daaacrt rtsultioK trurn tli« appliciitinn of the li^'U- 
ai>« bo ■ «rp tchbI, the eae willcuntinuc tolwdieieudtxl 
vith, aad lo netiVB the dired impulse of, llie blond that 

■ drivea idIo it. Tho oatural reiitilt nf the ligature 
wlii be. iliervibre, to increase the tenidnn nf the tmc, 
bu, ■• Uoliniv pointH nul, the entar^menl of the eoU 
iMArml eirculatioo opeui^, ub il were, ".><iili>'Hhiices" to re- 
Srtc diii pranture, and cnnHiHiueritly aftt^r a few honrs or 
dm ibm «c k iMually found to be less t^-n^e thnn before 
iba npuatioa. HeDce the progreae of the aneuriFm may 
bt Tw lwi for a time, but it will often speedily inrreaae 
■fftiB, and may perhaps ereolunllr destroy the patieotby 
4Dp(«irmttAb and nhxi^hinif. Of ^ CA«e« io which this 
•prratiuD KB* pn*.-tL*r<l on llie carotid arlery. in US io- 
^ :- -.-• a iaial rrsuU tiior* or )ms Bpe«dily folloiwd the 

•Mrti : in the tr-inaiuioj; 13 caaw tb« palienU sur- 
mcil the ffffcU of Ibe ligature of the artery, Ihoiigli in 
(«« if any rmtm were they cured of the dtveaw for 
ictised. This o|>erfttion will 
H in speaking of the parlicu- 
"lioi'ii il ha- Uerii i-nn'tis*.-*! {ride Chnp. xliv. |. 
-Jits aod Contra-indicaUoiu of Ligattire. — Lie- 
<i artery lor aneurifiui. by the llunteriiin method, 
• ■eal in ihtiite caM« iu which tlie tumor ie uirvuni- 
oi Di - ,'e. »low in iia growth, having a 

try to 0.1 — 4.,...ui'a, and nnaecompanied by much 
of tba Qmb. When the antnriiim is undorgoing 
acvOi mrt. no »argical iDterfert.'uce should l>e em- 
rrd. b«t tbe cftM lefl to nature. In this way it ue<ra- 
li happeni, daring thi- prt-pamtory treauuent of the 
that tiit atieuri^ni bt-omitnt conAolirlaled. 
Beiorv tbe Sar;g«uo proceeds lo cut down upon an nr- 
ifry with tbe Tlinr of tying it, be shotild, ns tor an prac- 
tinblc. Hcrrtatn hy n cnrftiil «-xnrninntiT<n of it, ubether il Bppeare to he 
bft bottilby awl wiuml atnlc, at the pi>int at which he is about lo tie it. He 
AhwM U*i aJiiDg its coufM to a»c«ruia if it be tnuMiih, eaaily compresAihle. 
'ot. II —10 



Pig. <ss.- 
Art«r/ 



llsal«r*d 



fw I\>|iUt«*l Aa«a- 
riam. obltt*nt*4 
•1 «, tba lit* »( 
lb* Licftlvt*, an 4 
■t &. what* Uia 

TlUBI>T llft< kaCVBM 

euiKvliilulwl «ud 
■tMorbail; b«t«aaD 
ihcie i)«lnU Uia 
Artarjriiujiiii.aad 
MllaUralbfuidiM 
wn talk If ail. 



140 



ANEURISM. 



B gradual and careful inimuer.sn that the t^ntlency to tbo d«poiitaf laminattd 
fibrin mif^hl be- iiicr<>afied. ^'al5alvn eotJiiivorefl to carfjr out the first of 

then« iibjecu by suhjecting the patieut u> ainall and rapoAtM bt»o'liDgs, and 
by gradufttly reducing the qiiHtitity of food that wil» daily taltPD, until it waa 
lowered to nulf u pound of puddiu^ in ihe iiioruiiig, nod a quarter of s poand 
in theeTeniog. lii this way ihc parK^ut'DStreDgLh wa:i reduced antil beoosld 
scarcely be raised up in bed wiihuuc faintiug ; the quaotiir c( fuod ma then 

?raduallv augmented, so that the pioatieiiy of the bloud luigbl be rcscund. 
t is Mlaom that SurgeoDft carry (»ut Valsalva'^ plan of Lr«alin*?nt in the 
preciM manner indicated by him ; it is generally fuuud ti> be more cuvcuimiI 
to modify it somewhat according to the circa ituOau cm of the ca^>, Ibutigh 
the principles on which it in conduclm) are eateotially the nanii!. 

In aduptiii)^ aay ciiii-ilitutiiiiiiil irmttiieiit in caaea of nueurtmii.lhe 6rst and 
moot e>Kntinl {loiiit to be atlf;iidcd to U, to lc«ep th«i patiKnt [H>rfiH'tly <|uiet in 
bed and free from all mental, emotioiiH). or convenMitionnl excilritx-iit. Tlw 
diet should at the ^aiiie lime be very carefully re^ni latnl , Ininit umdualty 
reduced in rjuaniity, aud being made to consist priucipnlly uf fnriiiai'euua 
food, with but a very email ([uuutity of nicul, but little lii{uiil. niid a total 
abeeuec of uU stimulauta. Perbu|M tfaf beat regimen is tliac ruconimsodsd 
by Bvlliugham, uon!>Lstjng of two uuiiciw uf bread nud bull*tr f<ir broakfaal, 
two ounces uf bread and the same ijunutily of meat for dinner, and two 
tiuuotie of bread fur supper, with alhmt two ounces of tntllc or water with 
each meat, or ocr-asioniilly sippiKl in nmall quNiititiea. At the saicu Ume 
purgtttivts should bo admiiiiBtered, eB|wciHtly such ii£ give rise t^i wsl 
stoi)la, and remove obMructtoiiif of the p'lrUil bysteni : with this view a 8nru| 
of tbe oorapound jalap powder may W given twice a we«k. In some et 
if the heart's action be narticularly strong, reoounie may adnkatagooiudy 
had Ut small bleedings irom time tu time. 

Iodide of potassium, in doses vnrying fniiii five to thirty grains three t!l 
a day, has been tnrgoly used in onaesof ititrrithnmcicniidnlHlomioAl aneat 
especially by Chuokerbntly, G. W. Biilfoiir, ami W. RolM-rts. and Its ^ 
tmtcts lend sitme vvei(;ht to ihe 8op|H)m^l syphiltlic nrijiin of many Aneuriflf 
In a large propiirtion of the casts tliue treale<l, tin- i<uH^'riiigp of the pativQta 
have been relieved ; there has been diminotioa of the size of the ttw, and in 
several instances the cure has been apparently perfect. Tbe enfori^^^ment of 
the recumbent posture is, us Balfour rightly iosints, of high im[H>rtnnce as aa 
adjuvant in thii* treatment. There oertainly appears tube suffioirnt «?Tid<njOB 
to wammt a trial of the i'jdide in the cjustitutioiml treatment of noeurtsm. 

By judieiouitly carrying ou^ thiwc plans of trcntmeot aud modifying thvfB 
aeconling to the eircunisUinoQa of the case, ooDsolidatkm of the aoeurisi;'"'^ 
tumor may ocoa»ionally be produced ; or, if this be not attained, tbe | 
of the di&eaM> will bv very materially rclanled. 

When aneurism occurs in old./eMc eadieetie, or antBmif permms, a lower- 
ing; plan of treatment is ultirgetber iiiaduiLBsible ; here, the b1<.KHl being 
dftieient in tibrin, and the system in au irriuible slate fruni debility, the bast 
resului follow each a course aa will iniumve the plasticity of the blood, and 
regulate tbo action of the heart. Witn this view, cumplcte reet, tbe admin- 
istration of ihe preparations of iron, n dry but nourishing meat diet, aad 
the ocrasitiuttl employment uf upintm to relieve paiu and to quiet the syUeo^ 
will be atti?ndt-il by ihc U-st rcMulu. In aneurism occurring in etderlv people 
and nniongM the [Mwrer claiaea, this plan is, perhaps, more suecett^ul ibao 
any other. 

In tilt* LdosI Treatment of auf^urism but little ran b« done with the view 
of checking itji prog rr.-<)ii, except hy lite em|>loyni<-ut uf <limrt Rilrgicnl means. 
Tbe application of ico to Ihe surfbce of the tumor is Mid tu have avUal 



i 



ACCIDKXTS JLFTKR TitOATCKE. 



H7 



i-nds that llie lignliin> ehrmid be applied 



ob 



IT Uk 



botirvrr, mtitn 

K I cannnt but (l<iubl the pr«priely 01 mu auvioe. niiea m- 
Iku bren aol up io the oae. with a temlency in Huppuration of the 
; it ii a drbatshle quMtii^n whether the liigntiiro should be applied or 
Ib ibne outM I antte with H<(dK»<>n, that Iht- artery ah(>uld be tied : 
fcr tvmn Ulht uc eveaiually »ippitnit^, there will )h< lew risk to the patieot 
if tUt vVBlit f)r<.'ur after tlib Ajiplieation uf ihe lignture, than if It hap[>eQ 
r leailinj; iiilti ihi- Itimur i* pvr\-ioiiv. IT puppnmtiou have 
;ilac« aniuud thv sac, the upplieatioo uf the lit^ture ahovo the 
- nn the piiint uf bursting wuuld be worse than useleaa. Io 
_ ineiil' pmvttce must be deteriuined by the seat of the aneuriem. 

If Ibtt bv m the axilla, groiu, or oeck, it shuuhl be laid freely open, the 
eoagula MMopcil out, and the artery tied above and below the mouth of tJie 
a»e-— A iBa»t formiilnbte and doubtful operatioa. but the only ooe that Imlds 
o«t m obmnce n( tucoeoB. If the aneurism be iu the bam or calf.aiuputatioD 
«n«ld pnthably be thv beit course to pursue. 

Io aooie ioaUDon, there w do resource Icfl to the Surgeon but to amputate. 
1. Ampatatioa cnuet be performed when the uDcuriBm is ai«»ciaiea with 
^WMoa bcuM or a diseased joiot, as wheo a popliteal aucurism haa produced 
dUHractaon of the knee. 2. If the aneuriitiu \iave attained ao great u mugni- 
nim Uiat it has already interfered seriuusly with the circulation through the 
Kaib, mt iudii^ted by eoandcrable (Bdeiiia, Hvidit)*, and cotdne&i of the part, 
vitll diatCDtiua of the superficial veioA, it is a question whether the uppliea- 
lifla of ciw linture may not immediately induce ganffrene, and whether the 
WDoM not have the bmt cfaanee of recoverv by Kubtuiltiti;r to ampu* 
aioooe; this i« more particularly the ca«e when the aix^urism, whether 
preTi u osly \if£i or «mall, ha.s become difiuDe^I with impending K^^'^IIi^^e, 
«Sea Muuvaliiftlie limb nimil nut Im! delayed. U. If gangrene haveactiinlly 
* -i, and the patient's Btren^^h be sufficient to hear the ofieratiuu, 

»_.. ;.mu »hi^uld DC done without delay. 4. If a dilfuseil aneurism, 

■bcthrr suppurating ur Dot, in the lower extremity, hare been opened by 
■vtak-K fur an al*HTm, there tit no rvsource tcfl hut immediate amputation. 

Tbv niMrlalilv aHer ligniure« of the largvr arteries fur aueurism is very 
aoosidermlttv- ^bu», in I06 caam of ligature of the larger arteries fur 
amamntia, mWc'tni nml tabulated by Crifip, it would apt>car thai the mor- 
tKlity - ' ii 2'i per cent. And Porta tiniU thal.amoug 600 

asfs I >» fiir diseftsesanJ injuring of all kimU, the mortality 

•auu. iviiL, It muAt he btirne in mind, tluU Lbfwe are ivdlec- 

boM , >-<«. and that, iftlie unrecorded cases could be got at, Uie 

tait«<«fdaith would, io all prubabilityjH! fituod lo be much higher even than 
that alx^re •uicd. 

^FTKB Ln»ATt"iti: poit AsBlTKiflM. — The aecideuts tliHt may 

: iMi^n (if the lt)falure in a f-ascnf aneurism. are: I, Secondary 

I -rr'- :.npi»*^iii of ligature; 2, the CuiitiuuHnoe or the Reiiirauf 

-ill .:i .1. ...T .■>«o ; 3, the oecurrenee of Suppuraliou and Sloughing of 

Ti:ii..ir, with or without Hemorrhage from it ; and 4, Gangrene of the 

1. SMOoduT RemarrlMS^ from the seat of ligature presenU ooihing 
[. - ind has already Iwiii i)!hi-ii»("I 111 vt i. p, ■•04. 

CmtiMUtuu* or Return of Pahation iu nn aneuriamal sac after 
lb* li^s^J-in of the iirti'ry I>-iidiiii; to it, is nn intorcMliig phen»meni>n, and 
€■• thai dtwrrvfw murh attfnM->n. When the Iliiuterian o|>vriiticm is Mic- 
OMfally pfrfortDinl, th<-itgh the puliation in the sac be entirely arretted, a 
^Ptaia quantity of hl'xid contioues to be conveyeil into and through it b^ 
' g ebaMwla,uid it la from this that the lamiuated fibrin is 



( 
H 

P. 

■h. 



142 



ANBURISH, 



betwceo ibv eac aud Ibu livart, the lying the ynmel vttm nu lunger the oalj 
how uf cure iu tliU fomtiilahlt! Hitfeat^e. 

But tlie ireatniunt of Kiieiirism woe dfslioed bi lie sltll further ^hnplified, 
whua VanzeUi sliuwetl ttiBt, hy dis'wnlinf; ull itulrunietib u»l br the Hiruple 
presiure of the fin^r on the feeding; Krlery, a oon^lum mi^hl be funned, 
on the priMlucLion of which in the 8ac the uurv uf the Biipurixn eeseatialljr 
(lej)eD(l8. Aud in ndililion to thi^, the fnct was ettEnblii^eil, that in aame 
caeea adequnie oiapre-'^ioQ of the tcam;! and enc might be efftK^t^Hl br aimple 
flexion of the lifiib. ThuK, iheii, we have h»d n continuous and pntgrvMiTe 
proooa of siniplilioalioa in thu tr^atmeut of iiuc-urinru, u it hiia Im^^ti proved 
thmt itt»trum<-ntal cuniprcMioo raiiy bi\ submit iiut^.'d for the li?atur«, tbu 
prtiMure with the fitigor or Ilexi'in of tht- limb nufficw for the (reposition of 
thai ooflgulum on whit->h the cuiv of the diseuM! Hcptynda; nnd, lilill morti 
^•ct■ntly. the «[)ln'rt' of tht- ap|ilirabilitr of ooraprtssion hu been gn«tly 
extfodtNi by conducting it <luriug prolong<7«i anmlhcitia. 

Anotbcr »ub)iirliary m^^o* of treatnmnt in the management of touM of th«' 
Di<>r« iijtrnctable tbrinsofaneurifin, is eleclro-puocture, by which, m CiniMlti 
and others have sbowo, partial consolidation of the content* of no aneunwD 
may be effected to as to retard the progreea of tbe dueaie. if not to oorv U 
radicully. 

We will now proceed to oonaider in detail thne various method* of trat- 
mciil. They are as follows: 1. Laying open tbe hic; '2. Linrature of the 
artery on the cardiac nide; !i. Ligtilnre of liie artery on the diDlal side: 4. 
CompreBftion by iu^trumenla; 6. Di>;itAl <'ipm|irceeiiin : t!. Compreaaina by 
tbeelneiio tourniquet; 7. Flexion of the liinh; )*, Acupressure; *.K Mitnipula- 
tinn; lU. Galvano-puuclure; H. lujeotioa of the sac with coaguliuiii^'fluida. 
All tbt!$e varioua methods of treatment, howcvf^r tticy may diOvr ia their 
deutils, have, with tbe exception of the firsl. the »iriiiL- great priuciiik* in view, 
vii., tbe coQH'iliiialiou of tno aneurisinHl tumor by tbe depuuit ot L»agulum 
within iu When the prooem adunttil in of aurb a nature a» to load to the 
sluw depueit of enagtilum, ihia will bp found to br pale, firm, and laminated, 
the oeLtM clot of Hnicn. Wbeu the deposit in rapid, it will tie dark, soft, and 
hotnngeneouti, the pftMive cJoL 

LtOAniRF. — Til*? application of the Itfrature to tbe feeding nrU^ry on the 
canliac Eiido of the Hueuritim, was nhiuwt tbe only rocthml adopted by Sar> 

geoiiit fur the cure of ttie oiaeafla 
up to n recent dale. The maboaf 
in \t-hirb tbe ligature jihould be 
upplietl, uiid tbe vnrioui* cautinu 
rc«|»ecliug it« U9e, have l)««u ati^ 
ficieully dJscuwed (vol. i. p, 414 
ttffij.i. The (|UB!ti'»« as to tbe 
part of tbe v««vl ^l which it 
should be apftUed in aneurum. 
remains for consideration: and 
this invoWw some important 
|x>int». 

Situation.— There are thn* 
Bituationa in which the Itgatun 
may be npplied: 1 . above 9nd b&- 
low (he Mr, by the idd ojieratioa; 
2, on tbe wniiar firie of the iao, 
by Aoi'lV f Kig. -150 mr tlanter'a 
(Pig. 451 ) operation ; 3. on the dutat tide of" the sac, by Bnuiilur's «)r War- 
drop's operation ( Fig. -152). 



i h 



rif. i».— Anel'* Pif. U1 —linn- Pl|r. l&S.— M>. 
Op«talli>U. Ur'i Opvfatinn. lal Opwratlon. 



SBCOKUAHY ANEURISM. 149 

artkinlf of mora oornnino occurrence alVr tuieratioas for cnn^tM aoourUm 
fcr wBT oth«r form of the dUeaw. Tliiw, of ;il caw* in which tbe 



lerr WM lifil for aneurism, I floil that ptilMlioQ in iht* tiim<>r cou- 

! 1 returnt^I ill 9 ioMancM ; irhereaa of 92 caaes of iii;{uitial uueuriam, 

la «UK-It tlic> rxu-rual iliac artery was ligatur^H. the puUation recunvd ia 6 

rAK* oqIt ; am) iu Mveral of lbr«« it is int«re«tiii^ to iiot« tliut there were 

tvi> ftOT^rL-raal sacs iu the Mrite limb — one in Hu- ^min, llio uther ia the ham; 

xn i iliat til*' {>i]l«atiuD, tliuiigh jiennaiiently Hmvl^*'! iu the poplit^^iil, recurred 

'- in^tnal aticurUm. (n ihc ham anil axilla, pulautina occasionally 

--. v-ry rart^iy mcure. This dilTcrviice iu tbe frequency of the recurrence 

. u in ili0urvtit aueuristus, is evideutly uwiug to the ditTcreut degrees 

II) of [xtinmuDtcation that vxtst between the sno and the collateral 

la rariiias forms uf the discaae; thus in a carotid aneurism, the im- 

.'I tbe heart may at once Iw brought to bear upon the ooatents of the 

: tinugli the medium of tbe circle of Willis. UuL, in the cose of inguiuul, 

T fopliicaJ aneurism, tlu' luiustomosos, consi&iiii;^ rather of tbe 

< nfof irrmiQal branches than ofotieu cummuuiaili>jiid betwot^n laree 

' liable to irunsmit tbe blooiJ in a pulsatory stream. Fur the 

Ttic Treat fre«dom of the communieitlioti between tbe vcaecUof 

[lulMlion hfu more frequently been found to continue 

u , .. ii-l tllstinctly, though reduced in force, after the ligature of 

i^ artery iu carotid ancurisma. chan in thoM In any other utuation. Tb« 

Mhieh it return*) aft^r the oewation of a few hours only arc perhaps 

-it iu the groin and ham, a* in the neclt. In thuoe inatanceo in 

MP puUalion retumi within tbe first twenty-four houre after the li^a- 

', it UMially i-raMM a^in in a few day*, though it sonielimeH continue* a 

or two. Whtui it recunt at a later |)«rio<l, it U apt Ut la^t soioewliat 

Compreiwtion niitecetlent to the li^ture may m eniarj^^ the collateral 

»" ii t-'inttouance or return of pulsiLtion. I have once known 

iW palaa* iiiir, thuotfh rery nincb tessvufd, iu a pojvlitt^l aueuriflm, 

■ftir tiglUurti vf ibe MJfierficial fvmornl, iu a ca«o iu which treatiitvul by 

biwl unavoilingly becu triud for nearly three mouths. In another 




in which I lied iheexiprnal iliac artery fur popli(4>ul Hu^urittn. uwiug 
lo iIm fopcrfictal femoral beiu}; too diseased to admit of u lijiature, the pul- 
hUuo ccMed complftf ly for a time as I nas tij^bteuing tlio lifralure, but then 
nSawmed, ajid bocame vtry marked iu a few b<iurs. Iu this caae cumpiriBsiun 
hmi bam unavailiu^ly eiupUiyeti before tliv artery was tied. 

Tbe jinyiWMtf of tbe»e castM is on tbe whole favorable, but few of ihem 
baring evctttually pmvnt falal. Of 26 patients iu whom puliuilion occurrtNl, 
I tttd tbai thnw die<]: ttnd in all of thea*! the fatal Ksult was uccosiuued by 
taflsmatatiiin and •h'ii[:hing of the sue In all of the three in»tuuces, the 
pahMitMi murn^l Mithin the lir»t twenty-four honrs. When it returns at a 
awM ailrannnl itcri'vl, thfro ii litil« risk to the patient, us it is usually 
rtaililr amMiablf la progwr trcutment. 

A .Vf^nrffiry Aitrurlnt i« of esirL-mely rare occurrence ; indeed I believe 
thcr> twit mirnuiv>><-al in»tanrefl of lliis nrtoction upon record, both 

mt '*- h'ncr in the bam; the original tunmr having ilisapprnred 

mMi ition. the TCixiudary diM«w maile ita appeantuoe after a 

lifBL . ^ . '—in onu unae, and iu thr other aller tour years. It i« of 

ta|MirtMic« t" i^b bfliween a looondnry aueuriam and aecondary or 

noamait pulfo..- .. ..• an UMurLsmat sac. The t«rni " secondary aMiirisin" 
i^ool J b« rennirled to thow cmh only iu wbicb an aoeurismn) tumor ap- 
famn In xim *Ua of n former one, which hai uuderjronu consolidation and 
■bsnrpboo. The tjueatiou ouy be raieetl, whuiber nncuriMms of thin kind are 
1b realtty leenadary iir wbethtu- they may not originate in the dilatation of 



lAO 



ANSDBISM, 



' " of ihr nrlery coDligunus tx* tie tent of a fiirmtrr AitemM: It (■ 
^ iKil verr vnny to uniJc»tKi]il how ao HDCuntfiiiil hic (liat liait orm 
■v toiuolidutiun mid nlieorpti'Jii caii bijoid bccornv tjilnlctl inio s 
J iij hiiiiur; and I tliiuk it ainel probable Lfaot, althouuli the c<'OHrcv* 

ltTi< MtK'iirixRi inny hv liiuiid in the «anTu iiur):icijl regi<'u ax the primarjr um. 
it ill renlily takt-s tie ■>ri^tu fruiii a slightly higher part of thv arierr. wbtn 
the ^iinie Mnictunil chntige may have bvfn in protrrcM that dctcrmtDed tfao 
diivaee jii the limt intlunt^' at a tuwcr piihiL DiiuBle aoeuriiDi thuaariaiog 
is. imiecd, neciiniouBlly mt-t with in the ham uh u priiunry djteafe. 1 ban 
•ceil a rnoe in which mi uubiirioiiml tiinmr wuh eiiiiutfd ia the ham, mnd 
annlher at or imtnr<lialely iilmve the aperture in the adductor tniterle: if i1m 
artcnr in such a cnse ns thin had hecn tied hel'nre iht* Brntnd tumor had 
atlaiufd any mngnitudp, we can easily understand hnw. whpn ihii; beoima 
dilated, it might have been etinsidered to Iw a new rnlurjr»-mi'ni of tb« 
ori|tiual site, wnerena. in ffnltty, it vas nothing more thiin » new nneuritoi 
forming in the chiao vicinitv of the old one. 

Eniarfffwettt ofun nntunnrml mc uithmit ptifMiti(m,»f\trlhp Jipittirr nfthe 
artery Uadini; t'> it. i» hh intere»ttny phemmieuon, and ime that (i -•• 

thtf true nnlurv <if the tumor t-i he fiiiBuniiorBi>>ix|, as it ct'jwly r> - m 

it» &h>w nod gradual increat**^ the gruivlh uf » malignanl liiiiinr. it is ocra- 
aittned by the diMcution nf the sac hy regurgitant bhtiid hniugbl iotu jl 
tbruugh the dii^tal end of the venel, withuut snffieient l<jrc« to cau^e duIh- 
tion, thoujih with nuflicieol (irCMure to occHMua a gnidual increaw in Ui« 
Kiie of the swelling. 

Treatmetit of Itecumnt I'uUation. — In by far (he majority of csves of 
ee<»ndary pulimlion, this pheuouienoii censes of itself In the Lv^urse of a few 
days or weeks from consolidation of the hic, in the same way ne after liga- 
ture of the artery, by the deposition of laiQelliitrd fibrin. T}iii> lendenrr to 
ouQsolidntion of the tumor may be much nisifiled by means oiloulsled to 
leSKn the fVjrec of the tRipulM> of the blood into the hic, such as eum|>re»tna 
of the artery nbove the point lignturetl, rest, the elevated piwilion, and the 
cautious application of cold to the part; cold, however, must be carcfuIlT 
applied, left, the vilfllity of ihc limb being diminithed, gangrene be inHuwd. 
At the snme time, direct prefigure may be exereiited upon the nic, so ai to 
modomtr the flow of hlond into It j ihifl hnB in many ctat* tiuceeeded in pro- 
curing conaolidalion of the tumor, and may tnoat conveniently be nppliea by 
mean!) of a comprera and nnrr^iw roller. This plan is e«peeiAlly adaptrd to 
popliteal and inguinal nneuni>mfl, but cannot so well be fxcrrii^ed upon ihoa* 
•itunted in the neck. Care must be taken that the preMure be not at fim 
too powerful, ie»t gangrene re«iilt ; the object is not mi much to force out the 
coQienii of the tumor, <ir to etliic« tliiv. »h Minply to re«tmin ami modnntc 
•omewliat the flow of blood into it. Should the niieurivm \w ii.o (•itiiHti^l that 
pnMuro cnn Ih* exerci»e<l upon the arlery nhovc [lie point ligntured, Lhia 
•hould he had recoiiree li> eitlicr hy the finger or by iiiHtruioenl, and will be 
both safer and more likely to be eflectual than direct pressure. 1 succrrded 
[n lhi« way in coring a very renmrknblr cmm.' of recurrent pulNition in a 
popliteal nneuriKm. The patient, a mtm alHiut thirty-live yenm of ngr, was 
ailniittcil into I'nivenitty College Hot^pilal for an anetiriem, nlxiut the f\u> of 
an omnge. in the right ham. Treatment by com|»re$«)on wii.<) employed, 
witlioiii any etfcrl being pn>duerd in the. tumor, fur three months. During 
this period compn-wiim wan employed in all formB — bv Carte'i inrtrurnvnt, 
ibc weight, the finger, and llcxl»n. I then ligiitured tfie superficial femoral 
artery in Henrpa'is triangle. The puUntinn was armied in the tumor when 
the ligature vap lied, hut returned in n slight degree In about an honr. and 
■lowly inere&fted, never beroming at nil forcible, but being very diatineL 



TBXATMENT OF RECURRENT FULSATION. 151 

The ligature wparated od the fourteenth day. The limb was bandaged, and 
s pad applied over the aDeurisni without any effect; and the limb was 
laised, but still the pulsation continued. Carte's compressor was again ap- 
plied to the commoD femoral artery, and used fur about three hours in an 
iDtenuiltent manner, when the pulsation finally ceased. 

In the event of the pulsation not disappearing under the influence of pres- 
•nre. CDDJuined with rest, dietetic means, and the local application of cold, 
ibere are three courses open to the Surgeon : 1, To ligature the vessel higher 
op; 2, to perform the old operation of opening the sac ; and, 3, to amputate, 
if the aoeurism be situated in a limb. 

With r^^ard to ligaturing the artery at a higher point, I am not acquainted 
with any cases that throw much light on the probable success of such an 
operatim. We know that the ligature of an artery high up for secondary 
betnorrhage, after previous deligation of it, is a most disastrous procedure. 
But here the cooditions are by no means identical with, or even similar to, 
tbuae that accompany recurrent pulsation. In the case of secondary hemor- 
rhage, there has usually not been time for the full development of the coi- 
Ikleral circulation ; whereas, in the case of recurrent pulsation, many weeks 
woold probably have elapsed before the second operation would become 
■eoessary, so that ample time would be given for the enlargement of the 
mnaatoiDaees ; and, besides this, the very occurrence of the return of pulsation 
Bay be taken as evidence of an unusually free anastomosing circulation. I 
think, therefore, that if such a case were by any possibility to occur, in 
vhich recurrent pulsatioD could not be checked by the application of pres- 
■nre, digital or instrumental, to the artery above the point originally liga- 
tared. aided by the other appropriate local and constitutional means that 
have been mentioned above, the Surgeon would adopt the proper course by 
luatDriDg the artery higher up — tx. gr., the common femoral or external 
ihac, if the superficial femoral had been the one previously tied. In the 
errat of this not being thought advisable, he must choose between one or 
other of the two remaining operations, viz., amputation, or opening the sac. 
Of these measures, I shoula certainly prefer amputation, as offering the 
■est &Torable chance to the patienL The operation of opening the sac, 
taming out its contents, and ligaturing the vt-ssel supplying it, is in any 
drcumstances a procedure fraught with the greatest danger to the patient, 
and full of difficulty to the Surgeon, even when he knows in what situation 
to 8e«k the feeding vessel. How much greater then must the difficulty be, 
•h«D he is in uncertainty as to the point at wh»ch the artery enters the sac, 
and cannot know whether there be more than one arterial branch leading 
iatu it. In the event, therefore, of all other means failing, and of the pulsa- 
tion in the tumor continuing, amputation is the only resource left to the 
SorgeoD. 

In those situations in which this is impossible, the Burgeon may occasion- 
ally attempt the old operation. Siiiythe, of New Orleans, as a last resource, 
laid open a subclavian aneurism, for which he had successfully lied theinnomi- 
■ate sume years before, but faile<l to secure the artery, and the patient died. 
Morrie. however, has successfully adopted thia proceeding in a case of carotid 
aneurism after ligature of the comnion trunk htui failed ; and Berkeley Hill 
is a rase of axillary aneurism after ligature of the subclavian. 

^ncv the intn>durtion of absorbable ligatures into surgical practice, a 
return of pulsation has in a few cases l>een due to a restoration of the lumen of 
the artery after (he disappearance of tlic ligature. This is reeopiiized by the 
pmeD4-e of pulsation in the vessel at the point nt which it whs tied. These 
belong to a different class to those in which the vessel has been per- 
Jtly occluded, and require different treatment. The artery may be 



144 



AKEUniBK. 



BTtery boing mora rcmdily secured sl)i>ul(l niiv such arcMrnt happen. The 
fi>rc«uf the circulHliuu Iwii))^ llius l»k<fii I'll Irniii lliv Htiviirivrnal aac tb* 
cauae of the diM-ase wouM. in Mr. Huntvrs uj>iutoii, tw rt-movtHl; and bt 
thought it hiKhly |irobabl« th»t, it' the parlo were left to lh«niM<We0. lh« sac, 
with the Dosgulalwt blood cuulained iu it, might be abutibed. and thv uholv 
of the tuiDur remov«il by the actiun uf th« auirual ecuai^my, wbicb would 
coDve(]ueiilly render any upeniog iuto the mc uuiiecfuwiry." 

IluDter's linit uperatiou waa iterfuriiKxl in Ducerabvr, 17fS5. in a can of 
popliteal aneurism. The femtirnt art«ry waa ligatured rather b«low the mid- 
ale of the thigh, uiidercieatli the Mirtunu.-* iiiu8i*le; an<l from thiil time bii 
method was almiift cxclueivcty eni|ii<iyed bv •Surgt>«)ns in the treatxueot of 
■Mturism, tiiilil iho iiuriHlut^tion of votu|>r'es»i'<ri in 1412. 

The EffisctB produced upoa an aoeurLBmal tamor by the ligature nf the 
artery, accunlilig to the llunicrian [netliod, <l('M;rve furvt'ul atlvntion. The 
iramudinto ofTect, on <lriiwiug the lit^uiru ligbi, ronsii^u in a oi'^aliou uf pul* 
«atii>n and bruit in tho tumor, n-hich al tlic aami: timu gul)«tdc», beoi>tning 
partially e mptic«l of iu bl»od. Tho supply of blnofl to the limb being in a 
great meiuun:; cut ott', it becomoo numb and cold, with n diminuihm of inaa~ 
cular puwer. Tho more remote cSi^cu cnuaist in an increase of tho Acliviir 
of the collateral circulation, by which the vitality of the timh is mainuinv<i. 
At the Mime time, and, indeed, in eiinAe(|uence of this, tho temperature of 
the limh often riiios, until it becomes hi}(h<\r (ban that of its fellow. 

Tb« oonaolidation of the aneiirumnl tumor beginu M toon as the ligature 
is applied, and i* uanally completed in a few daya. by chang«a tAlcitig place 
within it simitar to ib<)»e thut Mccur iu the apontaououa cure of lUc ili>Mk». 
Thin itii|iortanl clmiige \» ed'tvted by the gmdual dvpoait of KlratiHed librin 
iu cuuL-eutric layers within the mlc, anil iH;c'H)<ii>nn)ly by the auddea coagula- 
tion gf it* c<int**ut«. For the uure to Iw aucoinpliitbe'l by the deposit of 
laiiiitiated librin, it ia oeoeBaary that, th'iugh the direct flow of bliKxl Ibroagb 
the tumor lie arrt»ted by the ligiiLuru of the ninin trunk, »4jme should yH 
be carried into it by collat«ral vhnniicU. This is a condlli'in very favorable 
tu the Buccvaa of the ligature ; for, if it happeus that all the flow uf blood 
through the tumor ia arretted, coagulation of that which happens to be (xui- 
lainea i» it will eiuue, »ud a ixifl yifihling clot Ix; formed, which ia mors 
likely to lead to uufuvomhle reaulta than the firm productJ! of slow coa^u- 
luti»n. It is of importaucu to tibaenri;, thut ihc |ini))«r conmdtdatioa of tba 
aneurinmni tumor, by thu df|Mwit of lamt»ut»l fibrin, will occur even thuugb 
A very coiuideralik i]unntity of btiHid continue to tiuw through it. la thm 
Muaeuni of University College there ia an excetxlingly intrreming prepanh- 
tiim that illuKtnites ibin point. It U one in which Srt'harles RoU ligatured 
the femornl nru-ry for popliteal aneurism. The [Mitlcnt di^d a wt^k after 
the operation, from erysipelas ; on examination, it was (oiind. and is ehown 
by the prtjuralion, that the femoral artery was double, and that, though 
only one pt>rti(>n of the vessel had been ligatured, the tumor, wbirb cod- 
tiaued to be supplied bv the other branen, was completely ciinsolidated. 
Ueooe it would appear tfmt, if one half imly of the influx of bloml be ar- 
retted, obliteratiun of the sac by depoeition of laminated fibrin may be ex- 
pected Vi occur. AAer the aueuriamal mc has been thus occlude*!, it pro- 
fnssively dinitnishce in siw, and is at last converte<l into a small maa» of 
brvid tinue. The artery that has bwn ligaturvd becomes clmeil si two 
poinU — nl the part deligati-d i Fit;. 453, oi, and where it communionlM with 
Uu> aae (Kig. 453. b). In iMith iIk^m; siluaUons, it will be f lund tu lie n»n- 
vertefl inti> fibroid tiuuv; while between thiMU (here ta an open space, 
tluvugh thu mediuju of whiuli the oullaivral uirculatiuD ia freely curried oib 



i 

I 

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ACOIDXNTS AFTKR T.IOATDRE. 



147 



ialiMdi 



, however, reo'imniends thnt the ligature should be appliec) in Buch 

lh«.iigh 1 cADH'tt but doubt the propriety of tbU adviiw. When in- 

fluDSHtioa hat be«D Kt up Id the wc, with a teodeoc)' m Hii|)|iunitioii of the 

iSHor. U Ua debatable question whether the ligature shouUl hv: applied or 

mC In Ume cases I *grm with Hiidg84jn, thai the arlvry eiuiuld he tied ; 

erea if the sac eventualt;r suppuraie, there will he Ivixt rii^k to the patient 

this event on-ur at'icr the appticatioo of the li)^turi>, tliaii If it hapjveo 

faitc the artery Icadinf; iuUi the tumor is perviuui^. Il' Huppunilion have 

It lakeu place anmnd th<- mc, the applloation of tlit-> llguiure ahovu the 

bflinwd lumiir on the piiiiiL of bunititig would Ih< wonut than useless. In 

■ek ca8eB,the lineof pruirtict- muxt Iw df.-Lvriiiin(Nl by the Heat of the aneuristn. 

Iflbit be in the axilla, gruiii, or nerk, it should be laid freely open, the 

nagula aoDU|>ed out, ami the artury lied abitve and below th<> mouth of the 

■r— • moet Ibrinithtble and doubtful o[K-ration, but the. uuly one ihuc hulds 

aal a chanee of sacoess. Jf ihe aneurism be in the ham or calf,anipuuitioQ 

vwuld prvihably be the l>eat ciiurse to pursue. 

lu »ome inslauces, there u no resource left to the 8urgefta but to amputate. 
1. Ainpulatton must be performed when the aneurism is a»fu>ciAte<l with 
eariuu* iKwie or a dUeaded joint, m when a {Kipliteal aneurism has produceid 
({(4tni(-t)on of the knee. ^. If the aaeurism have attained so great a niiij^ni- 
lodff that it )tai niready interfered fieriout>ly with the cirrtilatirm through the 
limli, a* iu'tictitfd br considerable iHtleuia, lividity, and coldne^ of the part, 

Iviih ilUb'ntion of the superficial veius, it tan ({uetttiuu whctlier the appiica* 
liint •>}' ciK^ ligature may uut immediately iuduLv gaiigrt':ue, and whether the 
paiifnt Houid nut havt- the Ijeot chance uf recovery by aubmitting to ampu- 
(itiuo at once ; tbin ia more jKirticularly (he case wbeu the aneurism, whether 
pTBriously large or small, bait become diSuaed with impending gangrene, 
vh«a removal uf the tinibmui-L not be delayed, '■i. If gangrene have actually 
MfierveiKd, and the patient's strength he ^iBcient to benr the operation, 
•npatauoQ should oe done without delay. 4, If n diffuecd aneurism, 
vbcihu* euppurmtiog or not, iu the lower extremity, have been opened by 
oiiftake fur «u absoeeti, there is uo resource leJl but immiidiaLe ampuiatioij. 

The m»rlalitran«r ligatures of the larger arteries fur aneuri^ni i« very 
eoDaiderable. Thus, lu '1-^G caan of ligature of the larger arteries for 
•Muriain. eollcctnl and tabuldti-d by CriKp, it would appear that the inor- 
taJrty MnouDted t<) about '22 per cent. And Porta fiuds that, nmoug GOO 
<aca of ligature of arl<'rioe for diseases ami injuries- of all kiiuU, the niortaUly 
wumoicd u> 27 per cent. It must Iw borne in mind, that ihcve are collec- 
riftM of reported caftes, and that, if the unrecorded ca&rs could be got at, the 
Mr of death would, in all probability, be found to be much higher even than 
dtal »h<>vf iitate«). 

ArctDEVTs fcFTRR Tjifj.vTt^BK FOR ANKfiii-HM. — The accident" that may 
fdl'jw tbe application of the ligature in a Ciueiif'aneurifim,arc : I, Secondary 
Bemi^rrliftge from the eeal of ligature; 2, the- Continuance or the Itcturti of 
Pulaatina in tbe Sac; 3, the t-KXsurreuoe of Suppuration and Sloughing of 
the Tumor, with ur without Hemorrhage from it : and 4, Gangrene of the 
Lhnb. 

1. 8e«ondar7 Heioorrhage from the #eat of ligature presenta nothlug 
|«culiiir, niid lia§ iiln-ady been discui«e<1 in vol. i. p. 40-1. 

2. TSl Continaance or Ketarn of Pulsation in an aneuHnmal nac aflcr 
the ligation uC the artery leiwliiig to it, is an interesting phenomenon, and 
One that dcscrvex much attention. When the Huuterian operation is suc- 
tMsfully performed, though the puliation in the sac be entirely arrested, a 
ovcain ijuunlily of blood couiinuea to be conveyed into and through it hy 
lk« aaaatooiosiiig ohanaels, and it is from this that the laminated fibrin is 



J 



146 



ANSUKiaH. 



and naturnl to the feel ; if it be hard, iDComprcMible, indicative of caLcifieatioB ; 
if it Ic-i^l lirouiliT than iiutural : if a. bruit be beard i» it on applyioe Uie 
■telhcBCOpe; if, in fine, there b« ovidvnee of dc};«iicratii>ii or ditutiiUoa of 
fu coaU, grtni cautiun jhouhi bo uu*l in uttfini[>ting to li^piiure. Should 
the deliffatiou of a diMiued artery become iiuuvoiiluble, the ADiiftopUe cat- 
gut, or the ux-auna Uguturf, would pmbubly be the beat mattirial for the 
purpose. The ends being cut short, and the wound eloaed over them, ibe 
cbanoe nf iih»ucbiiig and of unhealthy ulceratiou of the Teasel would be 
greatly lessened. 

It has occa«ir>nally, perhaps more frequently than the profeswitK) knowt 
happeiie<l to Surgeons tlial {hey have cut douu upon nn artery with the to- 
teutum of tyin>; it, and found it in »o dii»ea»ed a state tiiat the applicalinn of 
the lit!»ture was irupraeticable, and that it became oeceesary to close lb* 
Wound without winpieliugtbe op«rat)on. Listou and Aston Key have both 
bad the caudur to n-<:vni suc-h cases. In one case that hupi>entr<l to me in 
which it WHe thoiifjbt uocewary to tie the suiiernciul femoral lor popliteal 
Bneurism, I found, on cutting ch)wuun the artery, that tliemuae ii»mall autru- 
lifimal ililataiioi) just Iwluw tlie giving off of the profundu, and a tubular 
dilatation of the arLerv IkIow tliis, rendering the applirAtiou of ligature 
utterly imiiniclii-able. 1 aflerunrds tied the external iliae, but unsurcearulljr. 
It must be remembered that, lu such cases as tbeee, ooi only are the Hrterial 
coftts Boflened and incapable of beariug the strain of the ligature, but the 
vein is usually adherent, and cuDsequeuily liable to pttrforHiion in pasaiog 
the nnfunsni-ntcdle belweou it and tlic artery. And evea could the act m 
deligHlion be practised, secondary heniorrhngc wtmhl undoubtedly occur at 
an early period in an artery that ts incapable of healthy ohUtirration. 

All operation should be avoide<l when there is any si-rious iliMase of the 
heart, snd in cases of multiple aneurism where the second tutrntr is situated 
internally; but it has happt'neit that two aneuriitnis in one limb, ss of the 
popliteal and femoral arteries, Itnvc been cnrcid by one ligature applied ta 
the external iliac. Two aneurisms soAte^l in corrcapunding parts of oppo^te 
limbs, affecting, for iustance, the two popliteal arteries, may be sucoasfuUy 
operated upon. But, if two aneurisms be seated on dilTereut part* of toa 
body. n« the axilla and groin for instance, at the same lime, extensive disease 
of tne arteries would be indicated, and it certainly would not b« expedient 
to operate. 

In certain cases, the Hunterian operation seldom succeeds. This happens 
in thoee ioataooei in which it is necessary to apply the ligature very close to 
tlM MO, to oa iodeed rather lo perforin Anel's operation, as here there is Uw 
double dnngor of inflaming or wounding the sac, and of interfering with tha 
eiillaieral eirculatiou of the litub. Those coses, utst), iu which the aoeurism 
is %*ery acute in il» progreBS.iocreaiing rapidly with forcible pulsation, bavior 
rery iluid e<>nteuts, and a largo mouth lo Uie sue, into which the bluod ■ 
oome()ueiitly drivea at a full wave at each pulsiiiinu of ibe heart, are rartJy 
fitvorablc for the use of the ligature, inosinurb m stnititir'atiou tieldoui oceura. 
When the aneuriaui U situateil iu the midu of Iimkw and very yielding tissues, 
as In the axilla, where it readily expanthi to a large size, not being bonod 
down bv the surrounding parts, suppuration and sloughing of the asc are 
esp«>i;lally apt to occur after ligature. When it is ditfustxl widely through 
the limb, with coldiicu and a lendem^y to incipient gangrene, the circulation 
of blixid through the part ie so much choked that deligatioQ of the veatfl will 
iu all probnbility nrrc«t it entin-ly, und thus prixluce nmrttlicntinn. When 
artcricA ran be lelt to be calciHed, it \» a i^uestion wht^ther ihor <^sn Iw safety 
Itgatureil. as in all probability they will be cut or broken ttirougb by the 
noose, and the changes mcessary fur their occlusion will not take plaoe. 



t 



I 

I 



i 




more cnniiiit)a iK:currenc« after operations for oamtiJ anpiimm 

»y filb(!r tVirrii of the disease. 'Ihus, of 8] c&sea in which the 

silery vas tied for itiieuri.sm, [ Hud thnt pulaatiou in the Liinior cou- 

6a9»i or returned in 9 iustauc«t<; whereiuof til luisc^ uf tuguiniil an«>iirisna, 

!■ wbieb the external iliac artery was Manured, the pubukli-m recurred in 6 

amoDlT; and in ^veral of thc^e it ia iutero«tiiig to ante tbnt then? w^r« 

n» aiMiirtjniukl sacs in the same lirnh — ouc in the t^roiu, the- other in tli« hum ; 

udtluillM pulutioD, though pcriooneatly arrested iu the popliteal, reeurrvii 

m Iba inguinal aneurum. Iq the ham and axilla, pulButtuii oecuMimally 

Ihourb v«f7 rarely recuNL This differenoe in the fr«queary of the recurreuce 

of piiWlioQ in diflurent aneurisms, i» evidently uwiug to the different degrees 

of GmoImd of communication that ex\*t between the sac and (he colIat«ntl 

, bcaovhtt io variou* forms of the disease; thiia in a carotid aiietiri^in, tlie iiu- 

palwuf the heart nuiy iit ouce be broiiglit fi bear upon the contents of the 

ue, tiirougb the iiiediuiii of the circle ui Willis. Hut, in the cM»e of inguiual, 

Jsmonil, or poplite.al aneurism, ihe anaiitomo9«*i, coniii^liiiif rulher of the 

iiMieuUtioQsofieriuiual hrauehes tbuu of opeu ootuiuuuiuutiMUe lieiwi:eii lurj^e 

truiilu.are leas liable tu truusuiit the bhfou iu a pulisutory litreuiu. Fur the 

•uw Kasou — the great freedom of tlie comiuunicatiou bfcwi-mi ihu veiuels of 

oppMiM sides — the pulsatiou has more frequoutly l>ui->n found to continue 

unaterruptedly and diitioctly. though redueud iu furtv, after the ligature of 

Un artery iu carotid ancurbms. thau in thiuc iu any olher Hituatiou. The 

caw in which it returns uIUt the cessation <d' a lew hoiiro only are perlm|)e 

u frvqueat in the groin and ham, an iu llie neck. In those instaucee tn 

^B *l>icb the pulsatiou recunu wtlhin the first twenty-four hours after the liga- 

^Bturc, it usually oeasea again iu u few daya. though it tupmetime» contitiues a 

^■ttdt or two. \Ybeii it recurH at a later periml, it is apt to last aoruewhnt 

^B loof^. Coninreasion antecedent to the ligature may so enlarge the cotlat^-Tal 

I naiels a^ to favor h continuance or return nf puliation. I have once known 

Uw pulsation continue, lliough very much Ics^ued, in a po])1iteal aneuriiim, 

■Aer ligature of the superficial femoral, in n ctuio in which treatment liy 

tompreasion had uunvailiogly been tried for nearly three inontha. In another 

ease, Jo whioh I liwi the cxtenial iliac artery for popliteal aneurijtrn, owing 

Iu the supcrticial femordl btiug too diseased to admit of a ligature, the yaU 

lfttU>a oeaaed com|iletely for a time a* I uaa li(;hlening the ligature, but then 

muriMfl. and became very marked in a few hourb. In thi<i aute cumjireasion 

Wl been unavailiugly employed l>efore the artery was lied. 

Tb« ptognatU of these CMcit is on the whole favorable, but few of them 

eveucually proved fatai. Of 26 patieuts in wlioni puUation occurred, 

three died : and in all of these the fatal result was occaajouud by 

n and ifloiighiug of the sac. In nil of the three inBtaucije, the 

ioo recurre<i »itlim the first twenty -four hours. Wheu it n:lurue al u 

mure advanced peri-^l. there \s liule risk to the jmtiecit, us it is usually 

nadily ameuable to jiroper treatment. 

A Seenndary Aneuritm is of exiremely rare oucurrcuce ; indued I believe 

tliar«Ar« ooly two uueiiuivoeat in^tauebs of this allecliou upon record, both 

of wiiich took place in the ham: the original tumor having disapiH^ared 

enlirely after operation, the Kecnudary dtH-ase mudi' i\* apjiearancc alter a 

uf six monthe tu one (uur, anil in the other after liiiir yeans. It is uf 

poruitice to dii^tiuguitih between a ttecimdary aiieurthrii and Ki^condary or 

nl pulAution in an aneuri^^mal hac. The term " iter-tmdary anniriMn" 

Im reatrictei) to thnw caeca only in which an nneurismul lunuir up- 

in the site of a former one, which hnf< undergone ciuiaoliduLiou and 

abaorption. The qufation may be raised, whether Hneurism» of tbiH kind are 

is reality secondary or whether they mny not originate in the dilataiiuu uf 





148 AKEUBIBH. 

deposited by which the oonsoJidalion of the tumor b ultimately *fl<vted. 
This ulrturu of blood iurntslied by regurpilation, or by tniitfiniseion tlin>ugb 
th« enialler colliil«ral chaoDeU. i» cuDlinunu^, kd<I Dot pulMtor^; occmsino- 
ally, huwever, it » trausinitled iu gufficieot qiinDtity oy tome mure tiiui 
wimlty direct and opeu iiDBtiumociog branch, and thus gives rhv to a dod- 
tiouKDCe or lu n return of the pulsation. It is ioterestiDK' t^ observe thai, io 
tome of the ca«eB iu i^bicb ibis has faappeaed, there has htvu a rvturo nf Uir 
bruit, but in the miiJuriLy uo sound appears to havo bccu cmitlnl. 

Tbe period uf the rvlum uf the puleatimi iii the sac aller the ligature of 
the artery varit« greatly. In by fur the miijuriiy iil' cases, at least two- 
thirds of thoee in which' it ban hRpppnp<l, u rerlaiti rlejrree of thrill or of 
iiidi^tioel pulKutiiin han been ritiind in the sac shrtrtly nftrr the application of 
the liguLure: at all e%'enls, niihin the fin^'t twenty-four hinirs, Thin niav be 
lodkwl upon as l»eing rather a favoriiblp pign than oiIn'rwiH'. a» i( ifl inaic«- 
tive of the free state of the collateral cimilnttoii, and ^i-niraMy !UH>n diaappean 
BpoDtaneoUBty, the sac undergoing cmisolidatioti. Next in onier u( fre<|ueDcy 
are tho«» eases in which the pnleution returns in iibout a m<intb or «ix we^lu 
afWr tlie ligature of the artprr, the collateral circulation having been ftllly 
established, and, after continuing fur Minte lengtb of time, grndually oeMC*. 
It more rarely hapjiena that the pulsation n-tiinis Wtweeu ihew two per»ida: 
that is to say, about ten dH)-9 or a fortnight aHer the application of the liga- 
ture; thongh io some instaucea tbe slight vibratory thrill, scarcely amount- 
ing to a pulsation, which perhaps is perceptible a lew hours aller an artery 
has been tied, grHdiially litreDgthens at ihe end of a week or ten days iatv ai 
distinct and forcible a bi-at as had beea noticed before tbe operation. In 
some rare Instance* the pulsation bas reappeared aAer the lapse of aoDW 
months, the aDcurisinal tumor having in tnc meanwhile undergone absorp- 
tion ; liien, indeed, it may »ilh jii^iice be looked upon as constituting a 
tecondary annrruna, and a^ indicntiug a recurrence of tbe complaint. 

Tbe cavM of tlie eontinuauct^ or uf the reitirn of the pulsation in an 
aneorismal sac, luuet he looked for in too great a freedom of the collateral 
drcolation. Indeed, it is an e^ventinl reqatsiie for the manifestation of this 
[Aennmennn, thai there Hhould be so free and direct a eoDiniuDicalion hetwern 
the artery on the proximal side of the ligature, and that jMirtJon of the Tend 
situated between the lignttirc and the isar. or the sae itself, as to enable tka 
impulse of the heart to be tran^iinlted in a puleatory manner into tbe 
tumor. Ko regurgitant blood i-oming upwards from that portion of llw 
artery which in distal lothe sac, however free U may be, ran communicate en 
itnjiiilfie, ni> ii. uevcr flows j>rr ftitvm except in the fijM'cial case of a cooiino* 
ou» circle of Inrgc annstouioertf, euch us are met with between the arteries 
within the ekull. or iu the palmar and plantar archen. If any "f tbv direct 
cjllaleral or feeding vewelis liap|«en to Iw eofBcittitly large at the time i>f iha 
operntion to Iranemit the wave of blm<d. tbe puli<N(i<.>n in the »ac will Im^ cod* 
tinuous, or will return almost immediately after the applicalioii of tho Iik.>«- 
lure. If they be at first Uw small for tliiB. they may Itecome eulNrgrd aa 
part of the anasli>n)<.«ing circulation, and then tho pulsation wilt return ho 
soon as their calibre ia stifficient to transmit the heart's impulee. Btsidec 
these cfmdilions in ibesiie snd dii^tribntion nf the veeeels of the [mrt. it is not 
improbable, as has been ^iinpinie^l by Porter, that certain atalea of tbe blood iu 
some iodividuala may, from enuiw^ with which we are unaccguainted, render 
it less tinblfi to Coagulate than uxiinl, nnd thup diHpot^ to a retunt of tbe pul- 
sation iti ihr Mac. which remains tilled with Buid blood. 

The phenomenon under coneidcralion bns been noticed lo all pnrla of the 
b*Kly after the |>('rf<>miance ol the Ilnntorian ojieration, though it occurs with 
ditI«reot degret^ of fn^'juency afUr tite ligature of diAniit arteriea, an<l is 




SBCONDAKY ANEl'KISM. 



149 



t: ' '••'TTt cnminnn oecurreDce after operatJonf for carutid uueurism 

. ..ibvr furiii ul' ibe dit^aite. That, of 31 caaas iu whirh tbe 

tiil amuf was tied for sneurisai. I BoH that pulsatioo iu ttie Lutiior cnii- 
tioaad nrntmiKd in 9 instaocei; wherea«of 92 caecs of iuj^uiual uiiii(iri.stn, 
u vhJeh tlie cxieraaJ iliac artery H-aa li^tured, tbo pubali'iu n^rurnHt Iu 6 
CBMBoalT; and iu soveral of tlK'»« it is luteresiiDg lu auui lUat tUum were 
tvu aoetLmioal aac* io tbecaiae limb — onoiti tb« groiu, tbeolliur in the bam; 
and that tbe jJuUauuu. ihougb perinau«Qt.Iy arretted iu tbe puiilitiml, recurred 
in tke iDguiiud aucurt^u. !o tbi> ham aud axilla, pulsBlitiu oc(^i>nully 
tiidcirii vcrv ran-ir nvure. Tbie ditrvrvnuo iu the fnHjuvQoy uf the rBOtirreooe 
nf paWliua in different uiMiiriiiiii^, iH evidoolly owiug ti) the difieretit degrees 
af fraadiiai i>f commuutcatiuu tbut cx'in biitweuti Lhe enc aud the ci)llalcrnt 
fanadwi ia VKrious fortna of the diaeanv ; thus in a <'un>tid aneurism, the im- 
polaa of (be beait may at unci! I>e brou^rbt to iH-ar upim the cunlitnu of the 

thrangfa ih* medium nf the circle i}t' Willia Hut. in the caseof in|;uinal, 
~, or popliteal aneuriflin, the aniutommeioK, conHitilin^ rather of tbe 
f u 



loi t«TiiiinKl hraiieiies than of open oonimuniuationa Iwtween lar|>;e 

OUttlBlimre lew liable to trnn^mit the hlooti in a pnl^iitory stream. For tli6 
Mac rsMOO — thr i;r«at free<lo[ii of the coniinunicatioii helwt-en tbe vesaels of 
4MMn|e vdM — the pulaatioo ha« more frtiqueally been found U* coolinue 
oaiaUtmiptedly aD<l diatitictly, thout^h reduced iu force, afler the ligatui-e of 
ibe artery* in carotid aoeurUnis. thati in tboM iu any oth«r gituation. The 
eiB in which it rvturntt afWr tbu ceaaatiou of a few hm\rs only are perhaps 
a» fn^atal in the gmin and ham, as in tbe neck. In tbow instances in 
vlucii the pulaatiuo returns nitbiu tbe first tweuty-fuur hours atW the liga- 
Vac it uaually cvmam again iu a fuw days, tbou^^b it someCimes eootiuuea a 
«Mk or two. When it recurs at u later periwl, it is apt to last soraewbat 
laopf. CompreMtuQ autectNient to the ii^ture may so enlarge tlie collatJ^ral 
fwariv M to faror a uuotiuuauce or return of pulsation. I have once bnuwa 
iIm palMOioB cunliatw. tbou>!b very much lewened. iu a popliteal aucurism, 
*Jkv Upuan: of tiie tuperficial femoral, in a case in which treatiutut hy 
vmfrmAa bad unarailiot^ly been tribd for nearly three, months. In another 
can, ID wbirb I titil the external iliuc artery for popliteal aneurisro, owtoe 
ta tbt lupiTfirial fcmi)ral being imt dt»ea«ed to admit of a ligature, the pui- 
■ttiiia t^Mucd completely for a time a^ I was tightening the ligature, but then 
ntaracd. and '*■■ ■■"•—• very markird in a lew boun. In tliis com compre«ton 
kad bvwn unn - 'Oi ployed before the artery vraA tied, 

Tbt pr^jfui'tM M \t»-M' CHAM ia on tbe whole fa%'orable, but few of them 
kaviDf wvutimlly |iri*ved fatal. Of i!6 |Miiieni« In nhum pulwtion occurred, 



I 6ad ibal tbm« 
iDflammaiiiio unit 
paU>' 



'■ iu all of tbwe tbe futnl result wiu iK-o:i»iMued by 

_- of tlie sac. In all of tbe three innlaiici^, tbe 

li the t)r»L twentr-f<iur houhi. When it returu.'^ xt a 

then.' ti> little risk to tbn patient, »» it a iMuutly 

'\rvT ln'«t!iiftn, 

] on a nf i-xirt-iiiely rare occurrence; indeed 1 betie?e 

' ' two uiiNjuiviN-ul inatauce^ of this alfectiou upon ri-cord. both 

'. ulncK in the bam; tbe originai tumor having dlftap^ieared 

"I .. ration, the iwoundary di»euM< made it« apjwanuice afU<r ft 

lk|»i-. ■ . ..i. i....i..Ut itt one caae, and in the other alter iour yeura. It in of 

UBportancv Xi\ dtttiafatsh between a sec^mdary aneurifm and Httcoudary ur 

iweunrot pDlHUioo 10 an natarbmal sac The \Mrm " lerandaiy anettriam" 

afcaald be mtricled l» tbotse caMe only in whieh an nneuri^jmal tumor ap- 

pwn in ibe rite of a former one, wliich has undergone cousolidalion aud 

•fcaorptioo. Tbe qn«alion may b« rai«e<l, whether aneuriams of r.hi» kind are 

» Malhy •eciMAarr or whether ihcj luay not originate in the dilatation uf 



ISO 



A.'f BURISM. 



B p^irtion nf (h« nrtery contijfuotin to the BPat of » furnier ilturKW'. Il U 
certi'tnly Dot very oaisy to umlt-rHtaud linw «u niieumniHl cue itiut liie i«Dce 
uiiik'i-p<na confioltdiilii>n nii<l nL>»orpti^>n can again bvwme dilated into ■ 
piiUndnK tumor ; and 1 think it nj<<M prubable thai, altbuucb tlic cvuaero* 
live Riicuii^ui niny bt^ tuuntl in the »nnjc t^ur^iriil rt'^iiiii »» llie primary one, 
it in reality titki-v il8 itiigiu fW>m a slightly iii};lier |>iirt of the artery, where 
the suni(> i>iriictiinil rhnnge njuy liuvv bei-ii iu iintLTCM) that deterniiued tbc 
diacaec iu the tinsl inelunt*e at a luwer poiiil. IXiuVile aneurism thua ari>iDg 

~'l, indeed, oecusioiially iiit?t with in thu ham ajt a primary dieesse. I buva 
■een a eitMi in nhirh an anpurifnml liinior wan t>tiuult*d in thci ham, and 
uioiher »t iir tmmcdintely nl>nve the Hpcrinre In ihenddiirtormiisrle: iflbe 
artery in ttiich ii ciise as ihiK had he^n tied hcfiiro the arcoiid itimor had 
attHined Hny mnfrnitudo, ve. ran eflsily nnderstand how, whfn this h<Mama 
dilatfil. it might have been constderrd to be n new cnlarpenient of tb« 

'ori^'inal 911c, whereas, in rcftlity. It was nothing more thiin n new niieuri^m 
forming in the cinw vicliuiy of the old one, 

Euhryrmrnt uj an tnxuri'tiiol tac withovi ptilfaiion, after the ligature of ibt 

Plirtery Ivadinj; in il, is an inter«»tiiig pheuonM-non.nnd one that might caoM 
the lni»" nature of tho tunmr to be iHisiiiidFttiltKxI. as il rlo«plr resemble* in 
its »tow and gradunl incretun:' the growth of a iiinlignniil tumor. Il w ocra- 
eioneil by tlit- dintt>utiou of lh« sac by regurgilutit bjiHHl brought into it 
Uirutigh the di^uil end of lh« vesKl, without autlidcnt foree lo cau^e pulsa- 
tion, iliotigh with Huffitiienc preMur« to occasion a gradual incrvaae in tb« 
nze of the Bwelliug. 

TreaUneht 0/ lientmnt FitUQUim. ~~ In by far the majority of oiMs of 
8c<.*ondary pul»>ation, this phenomenon ee«s«s of itself in the eoune ofa few 
days or week)* fn>ni itinttolidation of the Mie, in the BBme way an after liga* 
ture of the artery, by llic deposition nf Inmellated tibrin. Thi^ leudi-ncr to 

l,iooittolidnllijii of the tumor may Ito mueh fiwi)>le<] by means calculated to 
leaieo the fon-v of the impulse of the bloiHl into the tae, eueh as comprcwinn 
of th« arlery nhov« the (xiint ligatured, rest, the elevated position, and ike 
caiiiioua appiioition of cold to the part: colil. however, murt he careAillr 
applied, let>t, the vitality of the limb beine dimiuifhcd, gangrene be induced. 
At the name lime, direct pro^^nre may be exercised upon the f»c, so aa lo 
moderale the flow of bliMwl into it ; tbia haa in many fatie* miceeeiled in nm- 
ctiring ronaolidation of the tumor, and mar most mnvcniently be applied by 
meanfl of a comprem and nnrrow ndler. Yhis plan is especially adapted lo 
popliteal and inguinal aneuri«m». but cannot bo well be ei*Tciitpd ujion tboM 
ailiiated in the neck. Care must be taken that the pre>«ure be not at tint 
too powerful, test gHugreue result ; the object in not no nuu-h Ui force out tb« 
oontente of the tuuior, or to elbco tlii», an ximply to rentrain and nMHlerato 
ettntewhnt thu Dow of bbKtd into it. Sb<>u]<l the Aiieiiri»ni be no «itun(eil that 
prtMuru can be exercised upon the artery nhove the |Miint ligHlun.-<(, Ihia 

,'ahould be had rocouroe li> either by the firi^'er or by inetnuiieiit, and will be 
both Mtfer and more likely to be ctlVclunI thao direct pr«i«ure. I succeeded 
in this way in ciiring a very rL-mnrknlde c»«v of rectirrenl puUtillon in a 
popliteal aneurism. The patient, u man almul lliirty-li\i* yeani nf age. wai 
admitted into University ColIc;re H>utpitni for nn nneuriKm. ab<ml the stan of 
an orange, in the right ham. Tnmtnient by cotiiprcfflion ivnt< emplojnl. 
without any elTeec being produced in the tumor, for three month?. During 
this period eompri-asion was employed in all forms — bv (.'arte's tn^trumcnt, 
the weight, the finger, and flexion. I then ligatured (he snperlieial femonU 
arierv in Scnrpti'it triangle. The i>ul«fltion was arnsted in the tumor when 
the ligature wa* lied, but returned in a alight degree in aboat an hour, and 
iluwiy tncrcaaed, never boooming at all forcible, but being very dticiooi. 



TRKATHENT OF RECURRENT PULSATION. 151 

Tfa« ligalDre separated on the fourteenth day. The limb was bandaged, and 
> imd applied over the aneurism without any effect; and the limb was 
raiMd, but still the pulsation continued. Carte's cunipressor was again ap- 
plied to the commoD femoral artery, and used for about three hours in an 
intemiitteDt niauoer, when the pulsation tinaliy ceased. 

In the event of the pulsation not disap|tearing under the influence of prea- 
■are, ooojoJDed with rest, dietetic means, and the local application of cold, 
there are three courses open to the Surgeon : 1, To ligature the vc^el higher 
ap ; 2. to perform the old operation of opening the sac ; and, 3, to amputate, 
if the aneurism be situated in a limb. 

With r^ard to ligaturing the artery at a higher point, I am not acquainted 
with aoT cases that throw much light on the probable euccees of such an 
operatioD. We know that the ligature of an artery high up for secondary 
hcoiorThage, afler previous deligation of it, is a most disastrous procedure. 
But here the conditions are by no means identical with, or even similar to, 
tbiiae that accompany recurrent pulsation. In the case of secondary hemor- 
rha^. there has usually not been time for the full development of the col- 
lateral circulation ; whereas, in the case of recurrent pulsation, many weeks 
woald probably have elapsed before the second operation would become 
■e c e s aary, so that ample time would be given for the enlargement of the 
■Dasbimoees ; and, besides this, the very occurrence of the return of pulsation 
Bay be taken as evidence of an unusually free an»9tum(»ing circulation. I 
think, therefore, that if such a case were by any possibility to occur, in 
which recurrent pulsation could not be checked by the application of pres- 
•are, digital or instrumental, to the artery above the point originally liga- 
tored, aided by the other appropriate local and constitutional means that 
have been mentioned above, the Surgeon would adopt the proper course by 
Ueataring the artery higher up — tx. gr., the common femoral or external 
iliac, if the superficial femoral had been the one previously tied. In the 
ev<eDt of this not being thought advisable, he must choose between one or 
other of the two remaining operations, viz., amputation, or opening the sac. 
Of these measures, I shoula certainly prefer amputation, as offering the 
OHM favorable chance to the patient. The operation of opening the sac, 
turning out its contents, and ligaturing the vessel supplying it, is in any 
circumstances a procedure fraught with the ^'reatest diingcr to the patient, 
and full of difficulty to the Surgeon, even when he knows in what situation 
to seek the feeding vessel. How much greater then must the difficulty be, 
wbeo he is in uncertainty as to the point at wh'ch the artery enters the sac, 
and cannot know whether there be more than one arterial branch leading 
intti it. In the event, therefore, of all other means fitiliug, and of the pulsa- 
tiua io the tumor continuing, amputation is the only resource left to the 
Surgeon. 

Id th««e situations in which this is impossible, the Surgeon may occasion- 
ally attempt the old operation. Siiivthe, i)f New Orleans, as a last resource, 
laid open a subclavian aneurism, for which he ha<l successfully lied theinnomi- 
■ate M>me years before, but failed to secure the artery, and the patient died. 
Morris, however, has successfully adopte<l this proceeding in a case of carotid 
atteuri«m after ligature of the common trunk hail fulled ; and Berkeley Hill 
in a case of axillary aneurism after ligature of the subclavian. 

Since the iutnKluction of abstirbable ligmures into surgical priicticc, a 
rHum ■>f pulsation has in a few cases been due to a restoration of the lumen tif 
the artt-ry after the clisappearance of the ligature. This is reeojriiizetl by the 
prvsenr*' of puiratlon in the vessel at the point at which it wits tied. These 
eases belont; to a different claifs to those in which the vessel ha.s been jwr- 
BancDtly occluded, and require (lifferent treatment. The artery may be 



162 



ANSLTKISH. 



ligatured ugaio at or near tb« eamo sp^it or at some other poinl. la a out 
of tills kiiiil tiiat iKHTurrvd uudvr llie v&tk uf CliruUi|tber H«utfa io Uuivenity 
Cjltfj^f H<ii«|)ilal, lilt! ffiotiral vaa wivxuxBi'uUy Lied in lluiiler's canal aAar 
liLmturt' orihf Hrtt-ry in Scarpa '» triaiiffte liad Ikili^d. The cauMB of failnn 
ol tlie lij,'!itiin' Imvi? iitrt'aity hfcii dt-mTilici (vipI, i. |>, 421 1. 

3. SapparatioD and Sloughing of the Sac— Wbfti, after the lif^iture of 

^ita eu|i[ilving artery, kii aiieuri^ui ii^ ahuul to 8iJ|i|><iriit>>. )ii»iii>ud t>t' diniinUb- 

fing iu hvie, it incn.iu<«i^. with )ieat, paiii, pul»ntii>ii, iiml some iiifluniiiiai'ir^ 

^diMSilurutiou of the tdiin I'overing it. This gradually lMH'tiiii<« ihintic^l, aud 
at liut gives wny; tho contents of the tumor, e<ifU:Q4--d and br<tk<'n down bjr 
iu&aininatioD and the admixture of pii8. are dJAcbarged through the upcrtur« 
in ita vra]l, in the form of a dark purpligb-bruwn or plum-culortril and oAea 
fetid fluid, intermixed with raamea of a »ufl dark coagula, or n( th«< drier 
laminated fibriu, which mav not iuaptlv be compared ia appearaooe to por- 
tioiM id' raisin* or dales. The e^oapc of^tbcse tnatten, variouaty altered, tnar 
be acoompanied or followed by the escape of florid arlfiial Mood. Thu 
iemorrbajre, which is the great eoiurce of danger in the sutipuratiou of an 
aueurisDial sac, may oerur in a sudden violent gush, by woich thi* patient 
juay at once be deatn^>ye<i, at the time of the rupture of the tumor ; or it 

iiua/ cuotiuue io email i{UHntitie«. which, alter ceasing, recur from time to 
tinM, ihuH gradually exliautiting the patient. It is thii (recurrence of see* 
uudary heiuurrhage that constituiea the principal danger oAer suppuratioo 
of aneurieoi, which ottierwieo ii not a source of any ver/ wrious riak to tba 
patient; ab<iut ooc-fourtb only of the cases in which the sac hasauppuraud 
naving had a fatal termination, and atmuU all tlinee in wbtt-h tiealh resullad 
having proved faul by licmorrbagc. Tbe naiienta in a few reiuuining in- 
8taac«) have been carrietl utt' by tiome special iiocidL-iit^, iiucb as tbv preasun 
of tbeaac on the pharynx ur uwiphaguti, or thu dtft(diargi> of ibe n»nli.>ata of 
the tumor into ibu pleura or bnmcbial lubea. Heraorrbage vt mun' liable to 
occur when tiuppuration lukex plB<*e a few Treeks after the ligature i if the 
artery, than wben a longer interval haa elapmxl. That hemorrhagt< dnes not 
happen more fret^uenllr after ^uppurutian of the «ar i« very renmrkahle, and 
must be owing pithrr to the sealing by ndhntion or plug;;i[ig by tvuigultim of 
tbe mouth of tbe nneiirii<ii), where it onmmnnicates niili [be interior itf tba 

{■-artary. It \* owing to tbi* plugging, also, that in many (-aM9 tbe lutal bleed- 
tng doM not occur at the moment of rupture, but only after a l«|w« of aoine 
days, or even week*, aixl then ni'»t ii«ually under tbe influencf of Mime 
incautious movemcut »{ the patient, by which tbe cimgulum or adhrfiitn is 
auddeuly dintiirlied. Th'jse eavvs are most dangerous in which pulMlion has 
returned in tbe oac alWr the ligature of Uie vessel, but before the superveo- 
tioo of Buppuratiou; as in thcev the tumor i» mi freely supplied wiili bluod 
ibat, if it burst, fatal hemorrhage will with certainty supervene. 

Thi« uccidcut is luucb more frfi^uvut iu some eituulious thau iu otbere, mud 
ii uorc liable Ui occur in aneurisms of tbe axilla or groin, than id those of 
the ham or of the neck. The pruximity of the ligature and tbe neocsHUT' 
iuierfureuei; with ibt> »ac iu iis appHcuiiuu, es|>eciully in largv axillarj' or 
inguinal atK^uriHtns. in undoubtedly a trnfuent crum' of it. The large aia_ 

;|mm tumura rapidly attain, in couMMjuence of the laxity td' their areolar < 
UMtiom. also favura it. Until retn-uily it was helievi^l that the occui 
of simple coagulation, inxkud of gradual deposit of laminated tibrin, wa« an 
important factor in the pnxlui'tion id' !<iippuratioti of tbe aac; but uur lale 
fiX)terieni'e of tbe treatment of aneuritun hy rapid compreseiuu cleaHy shova 
that the ilangor baa Im-n greatly exaggcratiii. In other cast's it would ap- 

ipaar that the fibrin, though pnifMrly dep««ited, acts as a fort-ign body, and 
l^vet riac to inflanimatiuu and suppuration in tbe wall of the sac and tae aur* 




fttrP^VHATION or &XC — TRBATHRNT. 



153 



artohu- tOBtte. Beaidev tbiB, il has been Tory justly roraarked hf 

tbe excneive hmidling and fr^Ufot cs&iuiDaLlou to wbivh an 

Itiaior oooirrinK in a hoepitnl patieat i« usually aubjceted. may 

TW Mrwd at which suppuration of tlio mc may occur after the ligature. 

mm a few dayii to as ninny months. In tbe majority of iiwtaiicea. it 

lid appear to take place bftweon iht! thini and t^ixfath weeks ; later than 

' il «Ndom happens, thou^b it may do i>u after the Upse of several inoulbs, 

■ a eaie recorded by Hir A. Cuuper, iii which a carotid nneurtsm sup- 

■TBicd al the eisbtb month. 

Tra^Mcat. — >\h^D an anvuri«m is suppuratinfc, and is on the poiat of 
pTiBg way, H will be better lo make An ittcintuti into it with aniiMptic 
aneaMMiA, so m to let out the brokeuMlnwn coiitcnta at once. It muat iKeit 
M treated like an unlinury absoeaa, witli a view ti> ilji filling up by gronula- 
tiOB; whirh, hiiwcvcr. will neceMorily be a hIow proceiw, in consequence of 
great t'lw and deptli uf the op^nint;. Durini^ the wlmk of thja time a 
init<|Det iihimid be kept looeely applied ujhiu ibe artery above llie sac. so 
M to be Ujfhtaaed at aoy moment it' blevUiug take place. If hemorrhage 
hmva alnady wperveaed, the cose is atti-oded with immixliate danger. In 
iodt a cmm as this, the firal iudicutioa is cliiirly u> arrest the flow uf blood, 
ill pnrvtDt thu pattrot from dyiug si uucc. This can beet be accom- 
by tumiog out tbe cimgula tiud plui^tug (he sue with Hot or com- 
apooga. retaiued in situ by a firm graduated compress, and well' 
ix»Ibr. The hemurrhacr having thus been arrived for a time, the 
ritoutd takn into coneTderatioo what 8t«]iH should be adopted per- 
Ij ta RBtrain it. In some cases, indeed, though these ar« exrcpiiunal, 
plog a«d ronpreflft may be sufficient to prevent a reeurrenceufibi' bleed- 
iar : bat b geuenl it will not do to trust tt> these meaas, unteaa the anau>mi- 
caT nrfarinw af the part be audi aa tu preclude the poaubility of adopting 
amy ■»» aetire maaMirfe. 

plana suMEcai theimelres to the Surveon for th<- permanent sup- 
win at tht bleMioK- The sac may he laid open, and nn attempt maae 
- that portion of ihf artery fn>tn which the blood iMiies. But this 
Ir (.. i-vi.M-tnl lofuccc^.ati, ill the majority of the cased, the roats 
:ii-ncd and pulpy, there would be tittle praepe«t of itJ 
11 if it were pamiblv to cx[>o«e it twfore the pnttent 
Indi'ol, ihoagh this plan has been s^vral times 
im D>>> :t«:tr>' ihat hy it the 8tirf^eoa has ever sucoeeded in arresting 
l^laaJiag fn;Di » »iippurating ani-uricmid sac. 

itioQ of tbe actual cauter>' t<i Ihi' bleedtufr orifice would, I think, 
'-ttar nbaocv. more particularly if (he hicod were puurvd out 
oeUaMfri rowel of a small size; In this way, ^[l>rri9ou, of Monte 
MBaaaili J ia arroatin^ the bleeding of no aneurism io the gruia that 
! ■opparatod. Should this mcoM. however, not lufii'.'e (and it is the only 
!■■ Inal GUI ba applied in many eituuiioos, ne in the groin and axilla), 
ttHW ii BO wwn leu but, in lhc«e Biiuatii>ns in which it can be done, either 
•a GfMOf* the aitery bigher up or to amputate. The application of n llga- 
tam aaarwr the ttotn of the cirruiation, oven though praoticnble, appears 
to Be lo be 0/ vrrr doubtful utility ; for tlie probability \s, that the circnla- 
tim ikracigb the llnb, emba r ra o a i d as it must have boen hy^the first lignlare, 
aad by the aahiKiueut distention and suppuration of the imlc. will be so mocb 
■Itffcffid with when tbe arti'rv ia tied a SM-ond time, that gangreDo will 
l«BiiIi;oreW ' ..-otlaierul circulation, if auffioiontly aetive to mainlaui 

tW ftiallt* i'< : will al«o knsp up the hemorrhage from the opening 

ID tb« artvT o.iiiiuuiuc»iing with tlic «ic. In tbeae eireumBtaneea, ika oolj 



Ti 



I 



164 



AN'KCniSM. 



coitrep Ipfl to thn Siirfft^n in amixiiatiirti of tli<? limb when the onenriMD hm 
BJltinUtl iliai il can in thj? nay lie rr-miivt^l. 

4, GaDgrene of the Limb. — Tins ^ticiivrnl wiliji-ct of gniipT^'nc i»f a limb, 
fullowiii;; iiijiiry ami li^iilnre of iIr- niniii arU'rv. Iium ulrfuily liec'U ilvscribvd 
( vol, i. [>. 44^1) ; Hiid we huvt- at |>riwi>r. t4i cunsiilvr iiiily those c— <■ in wfaidi 
it ucccum after the upemtion fur HneunHm. 

Oji>k#. — If ibe BDeummftl sac have attaineH a laTgf> aizc «it)i )pT«t 
rapidity, it may, by its preairure on the collateral ve«»el», or no the vcim in 
ito vicinity (Fig. V)4), produce such an araijunt of diiilurbaDc« in th* cirm* 
lotiou of tti« tiinb, preveutiDg the iuSux of arterini or obftnjcting the cfflox 

nf venous bl'.Kxl, iis to uccasioD n great liabUit; 
to the occurrence fif ^nngrenp. Uut perbapa tw 
prltK'ipn) Hource of duiij^r conaiBts in IM imanrfwi 
bfmmuit; tuddenfy md loidafy diffut^, more pw- 
ticiilarly in tboae oun m wfaich the auatumical 
rolnliutu of the collaicral ves^U are Hucti. u in 
tho haul, ihiit ihey may rcaililv and auiromlr 
hccoiai}ci>m|)r«f«o<l by tHeeffiiM^f blood. In than 
casfif ihc additional vmbarraseinieut induoMl in the 
circulatioit of the limb by the li^iiuireof it* main 
artery will readily induce gangrciie; and hence It 
is that, in difitiae aneurism of the lower cxtremitj, 
ligature of the artery ia so commonly followed 1^ 
inortiti cation. 

Ix>M of Uood,*ttix«r in conaequenceof Mcoudary 
heniorrhnge, or in any otber wav befortt or aA«r 
th« application of the ligature, u very npt lo bt 
((tllowed by gangrene i the more to, if it have bMB ^ 
nece«Mry to apply a ligature to a higher point i^^fl 
the trunk of itie veswlthau had previ>.>u9ly b«^^| 
tii-d. Tliis Bocvadary liiivture of » Urge artery 
iucasesof aoeurisni ha£, I believe, been invariably 
folluwod by gangrene of the limb, when dtme io 
tho lower extremity ; the interference with the 
collateraJ circulation by the second li^ture Iwing 
(IO great, that the Titaliiy of the part cannot be 
luainlHtned. 
BraMes these cauaei!. the ot-curretiL-e of rrynfpeiaa. exposure of tbe limb lo 
coid, or U) an undue ilegree of heat, or aubjcrting it to tbe ampreatien of a 
bAndage. mav lie attended by conaequeocen fatal to its vitality. 

Thc;)mW (lyn/iirrwnfMnnf gHOsmMof the limb is uenallv from the third 
to the t<-nth dav ; it seldom oocun bef>ire this peritKl, anieaa inoiptt^iit miirti' 
Scati'tn have nfready set in before the nrtery was linl. Gangrt-ne ustialljr 
follows tbe ligature of the external iliac al an earlier pori>>d than that of any 
other artery. In c'4i»es of anuurtsm, the gangrene it always of the dark and 
oiotst variety, owing to its being coninioitly depeudenl on prcasure upoa the 
l&rjce vcnrkUD trunks by the sMeurisniHl tumor. 

IVrrttmenL—'thii gi,'ueral preventive trentmvnt of gangrene followinr the 
ligaliirc nf the artery for aneuriam must be conductetl on the same princtnls 
■a when it nrioes after ligature of arteriev nnerally irol. i. p. 44.%). But 
•QiDfl apecini mod ificat ions of it arc require*!, so far as the ancuriaoi is oath' 
MTned. When the gangrene occun fnim the preasura of the aao npoa tke 
■ocom pa Dying vein, it has been proposed to lay the tumor open, and to torn 
oat its coulents, thus removing the compression exercised by iL The danger 
of tucb a pmeevdiDg oonsista in the probability of lb* ocewnno* of ' 



Vtf. IM.— Po|rhlMl Apflari*qi 
S*ai|««Mla( thu Vain, Kad 
ttin* wnrlni UHinna of 
tht Limb; a, Ariarj ; i. 
Vajti iMi«npr«M«d »t •!•, r, 
Aaaurlaai. 




VBBATllByT BV INSTRUMENTAL COMPABSfllON. 155 

'fton tht OMOiDtc matl? into Ifae ii»c, and in the risk atf^ndinct »uppu> 
up in Umc fc; yi-t it wouM iippcur thnUiii two CASce iu which tliU 
few bvcii aditpU'iJ, DO bad Ktulta fuMuMed. Tbufi, L^iwroiice liiu 
CMMof JiffiiHiliinciiri?>m of the p^>])li[eHl artery, in which ibtH plna 
wwm Ia4 HMWini Co witii the bwi reautta ; aa<l Benza has rcvordetl a cas« uf 
paipKtiKl UMtuiam in which the aame practice wae adopted iu twatequeuve 
•f gnat odemm anit incipient gaograoe of tlic ftxit; aAcr the extniutiou <ir 
aymntity of fleili-Uke nbrin frum the »ac. the pntieut iiiad« uti ext-vtlenl 
nui«u,i. Thtaa eaaaa wuuld cwrtaliily iuKtifv the Surgeon in adopting hucH 
■ evon* ■(■«» the dnoiivr of pinj^rone its iiiimincut, and <lL'pciid<'iit <m thg 
■w mai pna M u rw tif the tumor. Hhouhl, hnwcvur, thu gaiign-iiH tihow any 
AlpMMtlini In axtend, orshnnlfl them he h«mnrrhHg« fniiii ihe ni<- Hl\cr it has 
drat tMHB laid open, the Hiii'S'eon must hold himiti>lf in reiulinrHH to Minpulati^ 
■khiMt cMmt. When ^n^Trne has onre fairly set in. there is no rpn^inulile 
prMMci fif mvinf! ihf liinh; and the s^nnner nin(>iiialion is drtne, the better. 
Thtt limb mtua alvay^ ht- rrnioved hiffh up above the ear, and if pnaaible, 
■ol only Ml <nni^ r!i.<titir« from the pnii» that have niortifief), hut also above 
thepmrt t< ':>' t^-riMiK iiitiltnttiou that precedes mortifirntior) hns ex* 

iMMini. i "T L'Xirvinily iiUD't };envnilly be removed nl llic i^houJder- 

jflinc ; lh«< lowrr nbore Uiv middle of the thi^h. Id th<^^«e ca»e« there will 
ily be a c'>n4iJemble aoiuunt id' henjorrhage, and many veseela will 
Uk be ti«<d ID the atuiup. in ootttequence uf tbe eolargemeDt of Ihe 
' rirrulalion. 
Lonpitw*t'.'X uT iMTRintEyi*. — Id consequenee of the dangers and diffi- 
alteudaol u[>ui] the use of the ligature, Surguuiu have eodeavured to 
BBvantm by omi|ire»iou. The employmeal of direct preraurv uu the 
■• TCtt aimoM uatumlly 5ugpesied as a mesDa to counteract the ex> 
of the dlMue by the prewure of the b)o<>d from within, and bas 
Illy been applied from a very eiirly [wriod in tlie treatment of the 
Thb plaa uf treatment was first employed by Boiirdelot at Iho 
of the •eveateeiitfa century; afterwards by Gen(rn, Hei&ter, Guattani, 
aad ollwnk These ^urg:eoDs made the prcs^un.' directly upon the sac; and 
Gaaltaai ukI Klajani rtdnte several imres thiii they effected in this ivny ; 
Wu llie mrtluMl wis >» uncertain tn itit results, and so dangerous, fnttn irri- 
tatise and inlUtiitng the lae, ihut it fell into disuTc. The French Surgeons 
falf«aoerd a oi'wliliratiou of the pressure plan, by laying opt->n the sac, clear- 
tajc uat iu contents, and applying the pressure dircelTy over the opening 
iuo tbe Tnarl. r>rsebamii« cxprMcd the artery leading to the sac, and coni- 
mrm ti this arith an ttutninient which he teWcd the " nreiue-arttre." These 
larlMrvM modes of trrnlment, however, wt-re entirely M-t a-iide by the 
fceJHiy aail enaifamlivn fiucrew <-f the Iluaieriaii o[kfmlion; nn<l t-uinpres- 
tiii* in an* <* rspr'ly prHctuteil hy ^^ur^'t^)nM alter the great step made 

IrJWta ll ;h^ trt-stuifnl of iImk diHej^w. Vet we hm) that Juho 

Hnalar biiu»i<i l-l it. I. ami Freer nttemplvd. though without >iuccei«, to 
ail* tbisduea*" i'< j<i'u-ure on the arlery landing to the sac. Pelletan nud 
Itebnia apfwar to have been the fin<t who sitccratfully applied pn-vsorv to 
Iba artarr abiivr the aar. inslrad of to the nueuriein il«elf ; this was in l?tlO. 
After Uua period, ▼ari«Ds attempts were made methodically to treat uncu- 
n^ ia tUa way ; but tbe merit of having iiilnMluLvd the practice of mni- 
•raaaoB to tbe tnalmcot of aueurt»m into modem surgery, of hiiving given 
■I B defioiUi pifice in our an. and ni' having pitiahliHhe*! the true principles 
rhicfa it ads, iDctintnilahty lielongs m the Dublin Surgnms; amongst 
tbo aames uf Hutloo, Hellingham, TufocU, and (.'-arte dnerve especial 




fkiDdpla of CoBpTMiieiL — In the early iriaU of the cure of ■oeurisin 
fej aawpf— tng the artery on the cardiac side uf the tumor, the Surgeons 



156 



AKEUBI3M. 



who employed this method nctod od rd erroneous theory: and, the prindpie 

not being UD<lcrt)U>od. the practice uii« bad. It was eupp<Mcd ihM it wh 

ii«c««Mry, in urd^^r thut a ourv might tiik« pluce. (hat tlii.' whole flow of bUxii 

through the art«ry slioul'l b« arretted ; that inflarniiiHtiitn uf the veMcl at 

the piiint cumpreoevd sliuiild be set up; and tlmt the cixiB-ili-latioo uf |h« 

aa«umti) depended upuii the oltslructiuii vf the vessel <:'uuiK'|ueiit ufxto thii 

intlaiiiiiiutiuM. ThU l««l to the titnplnyiiieiit uf i^uvh violent and f'-rt-iblf 

cumpri^fum, with the view of excitiDK in6Aiiiiiiatton in tb« artery, thnt tli« 

pHtieiil oiild eelduiii b«ur it tor a Hufhcit-nt len^'th of time to «fl<«t k cure; 

iflou^hing <jf th« »kin coiuiuuoly rtsullin^ fn»in the severity uf tbe preaaurv 

to vrhiuh it nag eiihjected. To [he Dublin Surgeuns b<;k>ii|^ thts very graal 

merit not only of having pointed out the emir of this doctrine, but having 

diatinotly laicl down as tlio principle of the pmcticc, that, iu the loajority n 

coset), iho auisuriem wan cured, when tbe urtery leudin): to it waii conipn^aod, 

in precisely thv same way it^ whi'U a sjKiubioetiue eiiru tak«i^ place, or wbcB 

the Iluotertau operuti>m is iMTformed— vii:., br the dopueii of ^iraiified 

Bbrin in the hac, iiud by the t^niiU'quem uonitoltdiiLion nf this {,¥\g. 4>')d), 

aided by the contraction f>f the walh tit' the sac ; and thst. aji in the onie nf 

ligature of the v^>»«el, it was not ocrcMury that the vrhult 

of the eirrnlation through the artery i^hnuld Im< entiralj 

and ncrmnnenlly nrrf^ted. but merely tlmt it *hiiuld be !«• 

Denen in iiuanlity and f'ln-e to such tin exii-nt a* to be oota- 

[inliiile MJ[h the defnwiciiin of laminated tihrio in the me; 

and it WHB clearly nfiown by examination after death tltal. 

if tlie preMure w«ra properly conducted, the artery waa lo 

no way injured or oi.-ctuded at the part t-omprevevl. Tb« 

reeojfnition of the true principlea on which compreaMoa uf 

the artery leading ti> the eac cure* tbe aneori»ra, has lad lo 

iiiiptirtaut re»mlt* ; for a» the severe premuru that waa ft*- 

merly considered necefcjary n now known not only (o b# 

unuecewary, but oReu to be absolutely iujurious, no amouol 

<»f comprmeiun la exercised beyond what is re(iui«itij to n- 

atraiii and nuNivrate tbe flow nf hliKxi into the Kac : no a^ 

tempt living miule lo cninprvAK the artery bo severely aa to 

VIg. <»i.^»M of l*^'l '" i^ obiiLeruttiin by inflammation. 

AnaarlnaMrW I^u'- although, where the pn»iure is raixlenite or tiw 

by CvtapTM. anaiilomoi'ing circulation free, the cone^ilidation of the ooo- 

tiem: t>*|io*it leata of the ^ac taket< plnce in the way thnt has just bem 

of LauiiMud dmcrilwd, it would be an error to euppoee that tbia is tb« 

niMin. process hy which tbe aneurism beeoniM cured in all OMn 

in which recnarse ts had to compreeaioo. There can ba no 

doubt that in .lomr cnflea, where cunmlidation has taken place in a few hoan 

after tbe employment of pressure, coajtulalion of the contents of the aac has 

suddenly occurreil; and this sudden ctjofnilotion, which at one time was 

drpiulod hy .Surj^eons, ha^ been found by inerMMd experience to be in the 

highest degree advantageous, as loading to a more rapid and equally oertaia 

cure of ihe Riieoritin). 

In iIr' (ubulHr f<irm of nneuri»oi. which ia far less fre<^iient than llie mc- 
culKti>l in llie extmiiiliev, (he cure ai{>|>e«ra t" lake place, if it ucuun at all, 
ralbvr hv tlie i^mdual cKiitriii'iioii of the |mrtiHlly emptied aao Uuui eitber 
by the olow di'iiwit of lamiiiHU'*! liliriii, or by the rapid and alrawt Mdden 
Ooaguliition of ittt ci>nlenl«. The »ac graiinally Bhrinkit. nud eilmil* >>f fibrin 
only are f^>und adlierent lo iIm aide*. 13ul altbuuxli I Ix-lieve tiial llie cod- 
dilion of the aneurism, whether peculated or tubular, lias a oiuniiU'rablfr 
iDfluenct! upon the mode in which comprc»ion tu'tn in rfrcL-tinji: a rare, and 
also ujMiu tilt! time that u >x:oupiud in tlie irvutment, thta being much shorter 



TKKATIIEST BY IKSTRUUENTAI. OOMPRESSIOK^ 151 



ralatiHi thnu iu 1I113 tubular furiu of (lio tli8t;ii.^; vet then can he 
loubi Uist lliiB t6 malL'rially iiiQiienccti uleo by two other circutD«tjuice« 
' '., the ouDflitKBi uf ibe blund within the nc, aud the corapkteiieM of the 

WiMO the a»c B filled with flulil htoud, aod the compreseion ia not uoia- 
iptodly oumplt-tti, the sue appears to empty it«elf to a oon^identble ex- 
■ow, aftd eventually to txmaolKlate hv the ilopcwtt of Uininat«-<t Hbria. 
Bu. U* tbe wc already cfminio some solidified Urern, and (li« cuni[irv«eicia 
be PoaliaatNH aod coinplele. the ouagulutjou or t)ie rt'inaininK lt*iid part of 
km blood t« apt Lo lake place rnth^^r AiKliienly. But iu all c«m-» tlie cuutrac- 
tftw vt iht Mc, oiHurquf Dt upoti the nrre»t or re«lniiiiL vf Uiv current nf 
blood Ittio it, la an iiii[Mtrlnul t-U-nit-nt iu lh« cure. llluKtriUivv of this mode 
of ciif«, thrrv u a preparatiuu iu tbu Muxeuni of Uuiveraity CVIIege (Fig. 

Fnwa all tliiai then, it would appear that the consolidatioa aaj care of an 
aaMrWD bj euiuprMsi«n may uke plac« io thre« diHereot ways: 1. by the 
■Itf* tWn»it nf lamttialed hbriu: 2, by rapid coagu- 
labuo (j( thr coDt«nt« of the sac ; S, by cootractiou of 
lla aae. The paitioular inude of cure will depend 
tbe ootnpleteDeM of the comprUBioD aod the 
or len parftct armtof the blood iu tbe sac, the 
ibtlity of that blood, and the shape of the 



..<^ 




nmiitiiii III Indaencuig Succeai.— The success 
tf cIm traaiment by c>imprv»»i<ia depeuda vreatlv u\kh\ 
a SDVpsloafl atti'DtiuD Vt a oumbt^r of inioor circutii- 
■aaOB, which, ihoujrh oarh be triding in ilM'lf, he- 
osaa of imp-irtaocQ whpii takeu a^ a whole. Duriu); 
Ifcc wbcile of the treatlDMlt. also, the pati<?iit> ccncnil 
faaalth ahuald be atteoded lo in accordsncv with thiisi- 
dietetle and medical principles that have ulri'sdy 
Kms laid duwu io speakioff uf the coustitutionul 
malAeiu uf the disuue. The irritahility of the 
heart luutt aWt be subdued, and the irritatino of the 
^«etti Irarupd. by thv u*e of optAt£« nr of chloral ; 
Mid the potirul ih'auld he put into a comfortable bed, 
«ith Ar™ and well'SMured pillows and mattreoses, so 
tWih.. 

^. 

■a w lo rw" 
b— iagii « 

thoa be cnt 
4f Um NCC 



Pic. 4MU-«u of TuVulv 

AlMUrliM o«rai) bj 

CompraatioD ; Cmitrao* 

iIab of S««, aad Irrvgw* 

lar D»|.o«lt of FibriD. 

may nut be changpd. As it is prin- 

ii*ni uf ihf l.iwtT extremity that cotuprewiun can be em- 

-.Mrt-f-nl to ■ItT'cribf the tuulhoU vf iltj Hpplicatiun here. 

: the Compreasor. — Tlio llii;.'h should, if ntttwary. l>e ^liaved. 

lir. The elciu t^hnuld tbiru be powdcreil, and the limb 

r<'II':r : ii fwd U-iug Inid on the tumor. Pillows must 

: und<:<r it, lh« knee being isemiflexed. Much 

^utwill depeud u)mid the kind of inatrumeot 

The ordioary (KtricahDe, or Si^noriui'ii tourniquet, was the one first 

., BCd ihia will, in many cauv, amwer tbe purpose perfectly well ; 

ta ii VMBowhat difficult to rt-fnilale the pnwure with this itHtrunicnt, 

fe ii ool uorreqaently exen-tsftl too [Mwerf\illy, it has eenerallr piven 

at tbe pmeat <faiy U> the very inj^i'niouii aii|HiratU5 of Cnrte. wfiicli, ss 

IhtI '■■ cloMic force derivi>4l from vulcnnizMl India-rubber bnads 

thi- -ag preanire of tbe ncrew. nctiimuKMlntes itwif blotter to the 

ar»l w l*aii itKfly t<> pnwluiv iiijuriotifi comprewion. Thi^ ioiitniment, 

ell m» ihr <fthi-r iH)ttiriviiiicea whirb have at TBriotiB times hern invented 

iri»tia*Dl of aneurism by comprettino, are dcacribed by Belliogharo 





168 



I8M. 



mill TuHnell, tn their works <m this uibject, to wbic)> I must r«/er for t 
fViller awnmnl tlma I cap hen' give. 

[ |Io applviiig tbc cumprcseur, especial core tiiurt be takeu that it u »p1I 
paiMotI ja every part, so tut uot to gall the ekin. lo «oiue uf tbv early caaei 
ID which I Euw eoinpresaion erupluyed in Loodoa by menus of tbe hor au hoa 
tiiuniii]Ui>t, uiueli iiiiMuvenience nwullcd from uaut of attentitm tn thia p«r- 
Ucutar. The (eiiiK'nry to fretting of ihe skiu is mtieb letwene«l by ptmdpring 
tbe iiiiib; aaii tbe reiuoval of the bairs by sbaving rliniiiiiitbea matenally 



Vlg. U7'— C««|>r«r«ar lor ih* MI4d1i> af 
lb* thigk. 



tig. tM.— CWBprwMr fnr Ik* Urola. 



the irritation produced by the instrument. In order to keep up continuoufl 
preasure, and at tbe sniue Ume Ln prevent nor one part o( the skiu fron 
Deiop injuriously galled, it is of very great coaK-(|uence ttiat two iastrumesla 
alioufd be used at tbe same time, w tbat when ooe is screwed down tb« olfair 

may be loose; Iheee iiutramiisli 
O need not be placed cloaelv ti>- 

gclher. If Uie nneuriam m ia 
tbe ham, it will be sufficient for 
one (.f>^- 4AS) lo bo applied lo 
the gruin. whilst tbe other (Fig. 
4&7 ) is put u pen tbe middle of tu 
thigh (Fig. 459). In using tba 
instrument, tbe great point. ■• 
Tiifluell niiMft pn>)i<.-rlr ncmarhi^ 
id 1^) rnotrol the circulation irilh 
tbe minimum of prvMure. lo 
onler tn do this, the fimt iiutrtl- 
mrnl Hhnuld be screwed down le 
tbat all pultnlion cea^eA in the 
tiinxir, but i4till not 8>i ti^htlv aa 
comnleletv ti> nrmt all the ^»« 
of blood Uirougb it. As tbe pr«SMire exercised by tins become* painful, tbe 
•eoond one must be screwed tight, aod tbeo tbe firat comprovor may b« 



W\$. 4*9.— Two r«in|inMfDr* ajiplM far Pantvrv- 
puplilnl AnosrinB. 



70BMS or COHPHXSSORS. 



159 



la Udl w»^ ao nlKroatioD of presauro can be kept up without 
or iBcoavenienM!. Ifpimiblc', (he putit^nt sbiiuld be (aiicbt how 
BUikAx*^ the ittsuiiiDCUt hiiiisL'If. and will uft^'n find t»ccuptition und amuae- 
st in duing lo. If, htiwcvcr, it vxctten much pain nt irritnlion, as it does 
la mKue wibjcctA, it may be neccMary to give opiatcfl or chloral hydrate. 
^w prvBAure !«huu1d, if pAMible, 1>cooutinued duriiifi; sleep; bill if ic prevent 
tKr [Aiirnl fnttii taking )i'h tiaCural re«t, the augf^tton made by TulTndl, of 
voMivwiog the iii»trutupjit sli|;htly, and, when the patient t« asleep, ifently 
tWfct— litiif it again vrithont awnkening him, may advnntageou.iTy be 
MofMcd ; it b indved Burpri«iag how very little iioecrewin}; will relieve tJie 
■ua uf ibe cijiupre^iiiiu. A lar^e rradle should be placed over ibe jMttent's 
oody. o that the weight of the bed-clothes inny be l«l(eu off the HpjnLralue, 
sod thai the ivtieuc may mauaL'e It without risk of dti^turbance. Should 
tlMT* ■till b« inoch uueuintws, the iiMtrunicut might be tukeii oU* for ii lew 
boon, and oanpnwiuti kept ut> iu an iuttfriuitlcul ninnuer. Evvn in etich 
areaBHteOflea w tbcae, consul idatiou of the site luny ennue. 

la aoaw c—c in which, from thr situation of the aneurism, devp and 
itm pfMBUn it rei|tiirfd to rontrol the rirrulatioii, the pain hccomts to 
BBBadafaUe that the patient caimot niibmit to the 
tnaUaeat •uHIdenlly long for a gooil elTecl to tie 
pf-^'-— ' In aiichi-aaes opium or chloral liydrale 
r. ' ^D with advantage, so as tn enable the 

^Lirai in bear the prearare. But in eome iQ- 
MuflB more rorapk-te narcotism is necessary for 
kha tn eadure tt. In these circiimsljuicei. cfalo' 
ndarm heAi>mf» a m<Hit useful adjunct; nnd by 
■aia:: - 'icatuestbesia for several hours, the 

aaooi Uiratlun of pressure requisite to 

iAkx -ire ntny be maintained. In tbta 

way N\ I , of XewoiAtli'-on'Trne — t'l whom 

ii dtt* tar merit nf employing prolonrred NU»a- 
tfaMa aa an adjunct to c»nipr(;Mtou — cured an 
aaaariiai of thv ntxhiminal aorta by keepiug up 
pnaair* on that vevtel for 6ve hoars under 
cUunCiirai. Heath, of the tumt Viwn, cured on 
■— liiiii of tlie extVTDal ilinc by comprcninK 
IfaaalMlQauial aorta fiirMvctrhoure under chluro- 
fcna; llapotb«r.nf Dublin, treated on ili>.^femoral 
aaiariRBneoa*futly by coni|>res8ing therominon 
Biaffantrf7f<irroarand a half hours; and Lawsoo 
Inalad an tnniioal aneurism Bucceaifutly by prw- 
mn oa the suominal aorU fur four houre. Iu 
ttm anan of popliteal aoeuriani I kept up com- 
ly obrtnctiug prewure tm the common 

arterr. under chlumform, fur twelve hours. By the»e means the 
•eri-MU obiectioa to tbu employment of pn^eeeure, and the mmt common 
of Iu failure, may be prevented ; and it is clear that, under chI«ro- 
ftaa, praaauK may be applied to artcrie«, such oa tlie subclavian and camlid, 
Ml wilieti k could not olherwlie be niKd. The employment of a Htlffht may 
— irtiairj be advantajjetiu^ly !tubHtttnted for the clamp, and oflen oci^aaionB 
ima di>lr«aa Ui the patient For this purpo«e the upparatua (Fig. 4fl0) will 
b» (ittod xtry uflefbl. 

A ntfy smpU* cnmpreMKir in TuffnellV represented in Figs. 4fil, 402. It 
f^MMto »t( littl* mnm than a truM )*i>rin^, tvilh a pad to c«)nipreMi the artery, 
mmd ateap* U* Rx it to it* place, aud increaw, by bising lightened, the force of 
iha coaipuMiiin. 



Fig. *flO. — P- n. W«t»no'» 
Wrifht Comprvator. Tk| 
eircnlAT doUeil lins ibooi tit* 
pMltJoB of lb* II tub. 



X»0RAT]ON OF COUPRessION— TREATMENT. 

1. tbe aoattumotiog Tetsels enlarge, with a gotKl denl of burolDg pain 
ia the limb gmenlly, utd arterial puUatiuuB in siluuLiuoe ftlit-ic uhualh 
wmm an felt. Tbo aboormal pulpstioQ, in theee catei. ia alwajB fouud to 
is [Davli the aane litantioDe, the saoe veR!e)s appeario^ to undergo 
Thtu Tufnell hoii made a reuiark. which 1 have had aivte than 
•■• opportunity^ of Tcritring, that, iD the ireatiueDt of popliteal uueiimm hy 
CBMpnwoa, tarte irlerurs will he fbuod to be eQlarced. oii« of which pifsca 
•vcr Uw centre of the luiaor, another over the beau of the fibula, and the 
ikinl aioMit the uiDer ed^e of the patella ; he states aUo that the severe burn- 
tttg piin vhich u felt in dieae caeca ia oHiog to the artery aceompeDviD^ the 
c— Biupicii* pcruuei nerve being ealarged. After contplele sol idlfiva Lion 
of the tuuur baa takeu place, ibc comprcgsiou ought to be coDtioued for at 
kaat Ibrtj-eisbl boun>, m as to aceure agaiusl tbe occurrence of a relapse. 

TSa Intrauoii of tbe Treatment varir«i vory greatly. In eomc caee», as 

mbore atatrd. ihr tuuior hua U-rntue aoltdificd in n ft^w hours, or in two or 

ibrcc ilayai. In olhi-r inhlanriii, thi> tnalineot hae n-quired tu be pnttrarted 

ior toon ibao thret: HKintha l»efnr<>. a rur^^ has resulled. Of '2ti cam of fi-uiural 

or pnplitcal aneurism rtired hy conipresaion in the Ijondon hwpitats, tbo 

«Tcr«fr tituf, atrcnrdinK to FTulchinaon, was nineteen days. Barvell has col- 

Urtf r1 frttta American, Rritiiih, and Continental jnunmU all the recorded 

rsMra of fioiiliteal aneuriiitu cured iv comprefwinn in the ten yearn 1A70 to 

indtuife, and be ^ive« tbe followinfr statistics of the duration of the 

, ,^.-;^urDt. For iDStru mental cumpre«sioQ the longest period waa 7 weeks, the 

I tbortai 'i4 houra, the nieao of 19 caaes in which the lime was recorded, 12 

' ^"-- -. for diuital cunipre«*ion, the longwt period was 2X days, the shortest 

ura. and the nieau of 13 ca:»e« 0} daya ; for combined iiislrutoentnl and 

nipreeaioD the loogcat period was fix months, the shortest 44 hours, 

I I nm of 1*2 caacfl 44i days. Much, of counte, wilt depend, in this 

' ' > cvn-titutiou of ihv patient, and ou ihecouditiuu of the tumor; 

.-•ncva wliiL'h are most favorable to the Bpontaueous cure of the 

LdOi HiU al&o inilueucc the rapidilv of the euro by Ci>m{in>aiion. There 

uduubtedlr, ivrtain cuuditioua ul the bltHxl in which it is little dis- 

|D oo^u^le, and in tbese caaes tbe duration of tbe treatment will 

ily be prolonged. So alau, wbeo the aneurism ia tubular, we must 

opcct tbat tbe bl<NMl which paatieti freely through it in tlie direct current of 

iha drcalatioo will be alower in undergoing those changes tbat lead to ita 

■■■aiiliilaliiiii than when the diseaae h aaeculated, and thus contains a re^ 

•idaaoi of blood tbat ia not ao directly inBuenced by the curn>nt through tbe 

mc. lo tbe early daya of the com preaaion- treatment there was an indi»- 

pcattiao on tbe pan of Surgeons to apply it very effectually and firmly, and 

a Uager ttma waa exj^eoded over it tnan is now generally the case ; and the 

cSMDple ael by Murray, with regard to abdominal aneuri^im, has been fol* 

li«ca vitb snccrai in respeei to the femnral, popHti-al, and other forms of tbe 

Jfaaaa, lb« comprtMor being screwed down tight on the artery ao aa com- 

flMdy Itt ■rrat for the time all circulation through tbe aac, tbe patient kept 

■Bder cUoRkTorm, and tbe cure t-lTected in a fo w houra. 

AjpUMbOl^.— Of the great valui; of compression in the treatment of aneu- 
niB, tbcrv can b* do doobt; more apecially when the tumor is situated in 
ftbaaitanea of lb« lower txt/emily below tbe middle of tbe thigh. In uneu- 
nam oecarriDg in ibo vidniCy of tbe trunk, aa lu the iliac, tbe carotid, sub- 
daTtaa. and axillary arteriea, it is generally not ao applicable; although, as 
vt bavt abrcady hcd, aneuriama in the groin bare been cured by compree- 
mtn m( lb« abaaaioal aorta, or of the iliac artery. Spontaneous aneuriuo 
iaeiAfviDcIy ran in tbe upper extremity; and. as llie traumatic forme of the 
bJcb oerar b«re gcDcrally require tbat tbe aac tboald be laid open, 
tvt.- II— 1< 



16S 



ANBUKISH. 






it u Beldom fuund ncceaiary to ksve raeouree to U in IhU nart of Uie bodj. 
though it may be nod lias been Biioeceafblly applii^d ui the uruchiul nrt«ry. 

The great qucatluu with regiinl In coruprL-seioii nppeare, afite nil, Ut be 
whether it pue««0e8 any ^jtecinl udvantac;bs ov«r thfr ligAtiiR>, in thu truatmeat 
of th<«e nncuri^nia in which its omplornictit is pructieable. The friutipti 
obj<K!tiuufl that hnv<; hocn ur^'d aj^uinM <Mniiir(^£8ioti are, that tU em^ojnncM 
is more painful and tedious than the u.4cof the tip^atiiro; and thnt thnaa emm 
that are unpronmiiij; to the ligature, or that rrquire amputation rather than 
[delijration of the artery, n re equally iinfnvorable to corapreaaion, and cannot 
be Haveti by itn employment. 

Tothene objections it may with justice be anawered thnt the pain attendant 
on the employment of compiviMioD depetidi very j|{r«atly upon thf nkjll and 
care with which the apparatus is applied and mnna^rei) thmiiKhoul, m well aa 
upon tbe kind of inetruraent u»kI. hein^ certainly much diiniQittbe>^ when 
Ckrte's «la«tic cr>Dipre#«or is employ«<) ; and that, nx han already iK'on fthown, 
the pain may be uvercume by lhi< use uf an»-«th^aic8. With regard to tba 
relative Lcdioueuees uf the treatment under the two plans, it wuuld apEHiU 
that in reality tliere ie but little difTereuce ; fur althim^rh Bi>me t'.aMe, In wn 
oomprcnion la u»od, are prulungcd over a runsidenil)]!- »4|«cc of tima, yai 
do out occupy mure ihan is nflen iMinHumuil nhnn acidenta of varioi 
follow the UAC of the ligature; and it not unfreiguently happens in com, 
■ion, hut can never o(^•*ur aller the employmrnt of the ligature, that ih* 
patient is cured of hia diKease in a lew huura or day.'!. Taking, however, the 
ftvemges, we find that in tbe Dublin pai>efl the treatment lanted twenty-fira 
dam and in the Lunilon caaes collected by Hulchiu9>in but nineteen, and 
thw is nnt verj* different to what formerly hsppeocd when nilk Ugatnn*8 weje 
applied so as to cut through the artery and he finally wtthdrnwn from the 
wound : for of fifly-four cases recorded by Crisp in which the femornl artery 
was tied, tbe averaffo time for separation of the ligature waa eightei^n dnva. 
and if to this a week more were added for tJio closure of the woanil. and tnr 
.the treatment of the various iiccidcmj) thai ofU>D accompanied and followed 
I ligature, we should probably Ih> within ibe mark, and yet "nly brinj; thedura- 
>tJOD of the treatment by the two loetbudei to the same level. In the nretent 
|day, however, ligatureti which areeither abaorbable.or are inleud«d to uecoroe 
iMcloeed in the wound, are almoet unlveranlly eniploved ; and, as ««ilh tb« 
improved methods of trealinj: wounds, union by first intention, or within ten 
days, is tbe rule, the treatment by ligature han oorae to be the more apeedy 
mode of cure. 

Surgeons will, however, be eventually guided in tlieir entimate of the value 
of these two plans, not bo much by the question of Hubmitting their |>atiuotB 
to ■ slightly mure painful or tedious treatment, as bv the com[uLmtive risk 
of lift attendant upon one or other method, llpc^n tfils point suttHtta have 
yet to be made; jrartly because the uiisucoeesful came of iif^ture have not been 
[Saoomroouly nubUsbed as the succenfui ones, and partly because mifficiestt 
>tinie has hitnlly yet elapsed since the general adoption of nbetirbable Uga- 
turcfl and of antiseptic treotnienl to enaole us to form a current eoncluaJoBH 
to the diminution in the dealh-rnle that may be rfTecfeil by their use. Tla* 
folloa-ingstatiatios, however, mar bo quoted aa showing the average results 
of compression as oomimred with li^ure aihI tbe steady improvement that 
has taken pbicc in the latter operauon. 

In 1851, Bellingham published the results of 32 «im» of femoral and 
ponUt«al aneurism treated by comprmition in Dublin { Mfd.-tKir. TVoaa., 
Tot. 34), which may be contruted with 18K cases of ligature of the feroiuvl 
for tbe same disBBse collected by Norris in 1949. Of the 32 compreMiioa 
cases 26 were cnred; inl the ligature was applied after prtasura had failed; 



RESULTS OF INSTKUUEXTAL COMPRESSION. 163 

iD 2, smpntation was performed; in 1, death occurred from erysipelas ; in 1 
irom cfaest-diaease ; and in 1 case the pressure wns discontiDuea. Thus it 
vould appear that 6 out of the 32 failed, being in the proportion of 1 to 5.3 
cases, aod 2 died, being in the ratio of 1 to 16. Of the 188 cases in which 
tne artery was ligatured, 142 were cured, 46 died, 6 were amputated, in 10 
the sac suppurated, and in 2 gangrene of the foot occurred. Thus the 
deaths after ligature were in the proportion of 1 to 4, and the failures or 
serious accidents in that of 1 to 3, showing clearly a very considerable pre- 
|>ODderaDce in favor of the treatment by compression. Besides this, in 
many patients who recovered after the ligature, various accidents, such as 
gangrene, erysipelas, secondary hemorrhage, etc., resulted as the direct con- 
sequences of the treatment ; and these do not happen when pressure is em- 
plured. 

The perfect safety of the treatment hy compression was fully confirmed by 
the statistics collected by Holmes, and published in his lectures on the 
Surgical Treatment of Aneurism in 1874 ; but the proportion of success ia 
not so great aa in BcUingham's cases. Of 124 cases of compression for 
p>)plitear aneurism collected from the records of British hospitals for a period 
(if 10 years, t>6 succeeded and o8 failed. None died directly from the con- 
sequences of the operation. Of the 58 failures, 44 underwent ligature of the 
femoral, in 8 amputation was performed, one died of pleurisy, and the subse- 
quent history of the remainder was uncertain. The failures were, therefore, 
1 in 2.1. On the other hand, of 77 cases in which the femoral was tied 
directly, 11 died, or 1 in 7. In 1 gangrene occurred, butthe patient recovered, 
and in 1 seccmdary hemorrhage was successfully treated. The 11 deaths 
were caused as follows : pyaemia, 3 ; wound of vein and phlebitis, 2 ; second- 
ary hemorrhage, 2; gangrene, I; smallpox and disease of the kidneys, 1 
each, and I was uncertain. 

Lastly, in 1888, Harwell, in hia admirable article on Aneurism, in the 
ItUemational Eneyeiopxdta of Surgery, has collected 148 cases of popliteal 
aneurism treated by compression between 1870 and 1880. Of these, 68 were 
successful, while 80' ended in failure. Of the unsucces.'^ful cases. 57 submitted 
to li:;ature, 9 went away unrelieved, 4 sufl'cred amputation, and 6 rlied. Of 
the t> deaths, 2 i»ccurred from rupture of the sac, 2 fnim " thrombosis," 1 from 
^n::rene, and in one the cause was not stated. Durin<; the same period, 
'■>7 \-a^aof ligature occurred in six of the chief Lr)iiilun Ilnspitals. Of these, 
Indie*). If these are further subdivided, it will be found that out of 32 cases 
which occurrefl in the first half of the decade, 7 died and 2 underwent subse- 
•{Uf-ni amputation ; while from 1873 to 18TH inclusive, -So cases occurred, 
wiih ;> deaths aud no amputations. W'hetlicr this great ini|»rovement is 
merely accidental, <ir 13 the result of the improvement in the material used 
a^ the ligature and in the treatment of the wound, remains to be seen, but 
(hfrp i.-> great reason to believe the hitter is the true explanalion. 

If omipreA^ion fail, ligature may often be advantngcously applied ; in some 
rue* with a lx.-tter pnwpect of success than if C'lmpressioii had not proviou.-»ly 
l>wD Iricnl. that treatment having caused the collateral circulation to enlarge, 
aad thu.- lesM-ned the tendency to gangrene. If, liowever, we take tlie general 
averairc nf thfiee cases tiiat have been i-ubmitted to ligature after the failure 
"f ctHiprejfsion. we shall find that the result is not so satisfactory as when the 
ligature ha^ iR-en employed as the primary method of treatment. Thus I tind 
thai, out of -U) coBi'S in which the ligature wa,- employed after compresi-ion 
bad failfl, there were lt> deaths. This is probably not so nmeh due to the 
preTJiiu? employment of comjiression, as to tbe same caii.ses interfering with 
ihe consul idation of the tumor after the ligature that had prevented the sue- 
of the compression -treatment. With regard to the facility of ligaturing 



164 



ANKUBISK. 



uterysach ai Uio femoral, iilWconipn«Hi«n hna been tried and fklled, it 

itut be admitted tbiit tht- i)i6Scu)tiM are iocreueed. The aheath of tbeveHel* 

Ph apt to become tbick«Ded, lafiltnited, and tlie nrt«ry and vein perbapa Icae 

leasilT arpiirable tbun whea prewure tiai out previousljr been eniplovea. la 

fact, it must be said, tbat ia sucb cases tb« Surgeon bai Dot to uo with a 

TirKJu artery. 

It should bIs^' out be forgotten that io some cases, as nbeD ancuriiBl it 
ODuplicHlcd with heart diaeute. or occurs iu a very brokeu nud uiihealUi^ 
confitituliou, in v^hicU the operation oecesear; for ligature would scarce!]' or 
not at all bo odmiseible, compnvsion may be safely employed. 

Aflcr carefully ooDBideriDg the relative merita of iho two plans of tresl- 
nient, I think ve may eouclude diat, though iu some few caaea neither ligatiuv 
tipr comprewiim can be adopted, and ampoiatioii is the aole reaource, yet in 
others I'Drnpri'SMOQ can be employeii wbeu it would not be safe to have 
recourse Io the ute of thclignturc ; and that, in nil ordluar)' cam.ii of frmnrml 
and poplih'al ant-urism c^itecially, compniwion should h« prui'iTri'd to tbc 
ligittiirf, inniimnf-h as it is not a more lc<li<jU9. and is nn infinitely safer 
method of cure. At the name lime, it must not be forgotlcn that its Miccena 
depends very greatly on tho continuous care bestowed up<in the ca*e during 
the proprew of the treatment. 

Digital CoMPRi>i*ioN. — .Shortly after (he introduction of the treatment 
of nneiirum by inntrumental compression, the fingers wert^ used as an nrljtinct 
to lb« mochanira) means in ueo. Thus Grentrex,iu iMri, directed a pntimt 
to keep up comorenioD by means of the fingers, where ihc tourniquet had 
been used, atiit reijuired to be looeencd. In tbe fi.>llowing year 1 1K4S> 
Vanutli, Iheu Profei>wr of Burgvry at Charkoff, tried, lui uueuccesefully. to 
cure a lar].'e popliti;al iiucuri«in by compreesiou of the femomi »i(b the 
fingers only, ^-outiiiuod for two day». It was nut until seven years later. 
«liL>u I*rulL'»)H>r at PaUuu, that Vanzetli had an oi)[Kirt unity of putting ihia 
method Buccitefulty into prBrtict\ and to establish it as a ilistiuet meaaa of 
curing aoeurienis. liul allhungh tliia merit is undoubtedly dut; to Vonxetti. 
we roust cTi'dit Knight, uf New Haven (U. R A. >, with the firvl sucreseful 
cane — he having, in IMX. curtd a very large popliteal anearigm by digital 
e«mpret>Mon, maintaineil for forty houre. 

In thiii plan nf treating aneuritmis, no appiiratup uf any kind is used ; but 
the circulation through Uie artery leading to the luntor lit controlled by tbe 
preffiure of the finger. In order to carry tt out rffieientlv, there must be 
relays uf ni^t&tanls, each uf w hom comprewee the vessel for about ten minutra 
at a time. The preseiire should be applied in the way that is rcprf»ented in 
Fig. 1ft, vol. i. p. 78. The fatigue may he very malfrialty leascned by 
placing a 6 or 8 lb. veight on the t.*ompr(-«siDg finger. 'With Hucb aid each 
aaaislant may readily keep op ibe prewure for half an hour at a time. So 
■oon as bis fingera become fatigued, but before ho reln.\cs tbe prrmure. 
mnolher assistant compresses the vessel ; and thus the eirculiition through it 
may be uninterruptedly controlled. In this way aneurisms of the {Kiptiteal 
artery, in the orbit, at the bend of ihe arm, and in tbe groin, have been 
■uccecafully treated— thtr tumor hnving in aomc inetances become consolidated 
in a lew hour?. The effect of digital compression, and the rapidity uf cura, 
vould be increaicd by the application of direct prtsfure to the tumor, or by 
[iikaoipulatioD and by tbe previouo employment of proper eunelitutiuoal 
tsMUis; it mi^ht he very adviinlagcously conjoined with the irealment by 
I'Basioo. Ilut Its great aaranttpgc seems to he, that it is applicable to arteriis, 
ta IhoK at (be root of the neck, to wbiob it might be dtfficdt to apply any 
kind oi' compresor, and can be employed generally when no apparatus la 
obtainable. 



eshabch's clastic bandage. 165 

Esxabch's Elastic Bandaqe has been used with a certain amount of 
cueoett in the treatmeut of external aneuriBms. It was Brat employed in 
these caees by Staff-Surgeon Walter Reid. Pearce Gould, who has investi- 
^ted carefully thia method of treatmeut, has collected the details of 72 cases 
in which it has been employed. Of these he finds that 35 were cured, in 30 
the treatment was unsuccessful, in 5 death resulted, and in the remaining 2 
the result was douhtful. 

The treatment has been applied chiefly to aneurisms of the popliteal artery, 
hot in a few cases it has been successfully employed in other aittiations. The 
objects in view are, first, to empty the whole limb of blood as far as possible, 
with the exception of the sac and the part of the artery in immediate con- 
nection with It ; secondly, to keep the blood distending the sac at perfect 
rest until coagulation has taken place; and, thirdly, to protect the soft clot 
thus formed irom the influence of the arterial current until it has become 
Hifficiently tough and solid to resist it, by compression of the trunk leading 
to the aneurism. In the case of a popliteal aneurism, the treatment is thus 
carried out: The elastic bandage is first applied from the toes to the ham 
with sufficient force to render the limb bloodless; it is then carried loosely 
over the tumor, so as not to empty the sac, and again applied firmly as hi^ 
as tbe middle of the thigh ; the elastic tourniquet is then put on with suffi- 
cient force to arrest the circulation completely. The bandage is better left 
on tilt the tourniquet is removed. The average time required for the appli- 
cation of the bandage is one hour and a half. The time during which the 
limb may be kept bloodless with impunity is uncertain. Heath has kept 
ihe tourniquet on in one case for three hours, and in another for three 
and a quarter, without evil consequences ; and Barwell in one case retained 
tt for five hours. The limb must be wrapped in cotton<wool, and, if neces- 
aaiT, warm bottles, at a temperature of about 100° F., may be applied. The 
prenare causes severe pain, which may require the use of hypodermic injeo- 
tioQS of morphia ; but if tbe treatment is continued for more than one hour, 
il M usually necessary to administer an anaesthetic. Before the bandage is 
removed, a Carte's compressor may be applied, or arrangements made for 
keeping up digital compression, and this must be maintained for from two to 
six hours, even if all pulsation has ceased when the tourniquet is taken ofi*. 

The mode by which the elastic bandage effects a cure is by causing stasis 
of the blood in the aneurism and the adjoining part of the artery. This 
stagnant blood coagulates, the clot being formed first in the aneurismal sac, 
and then spreading to the artery. Gould is of opinion that the permanent 
■rure of the aneurism is effected cliiefiy by means of the portion of coagulum 
extending into the artery. This being in contact with the comparatively 
healthy walls of the vessel, undergoes the changes described in the chapter 
on Wounds of Arteries ("vol. i. p. 401); the vessel is thus permanently 
occluded. The clot in the aneurism, on the other hand, being in contact 
with the unhealthy walls of the sac, or with layers of laminated fibrin, 
nndergoes no process of organization, but tends to become friable, and to 
yield before the pressure of the blood, unlesa protected by the thrombus in 
the artery. If, however, the vessel he safely occluded, the sac and its con- 
tents gradually shrivel and are absorbed. Failure has in some cases appa- 
rently been due to the bandage having hoen applied too tightly over the 
tumor, so that the sac was but partly fille<l by the coagulum. In other 
cases it may have been due to a want of coagulability in the blood, and in 
order l« avoid the |>ossihility of this it is well to submit the paticct to a 
course of medical treatment and diet (p. lH!h befurc applying the bandage. 

If, on removal of the bandage, there is still distinct pulsation to be felt, 



I 



I 

I 

i 

I 



altliMUgh tti« liiniKr tK-^iii» pnrtinlly o'iit»)Ii<lnto<l,ti ctim may oftm bvoflfcctvl 
bjr cli^ititl <ir iiislruiitc-utiil ctiiii[-ri:Miou to a iv<x huun. 

Tbe clitof dnngvr to bo Bpim-litoded ewmt to be tpinsrcnr, which has 
oocarreil ill luurc tbaii uiie case. Jl a[»i>enr8 to Imrc lirvii due in thruttibotu 
lakiog |ilarc in Lbe vein, and powibty kImi in ibc rapillMrics of the patia In 
the DcighborbfHid of tbe aiieurUiii fnttii whirb th« uIuimI bad not been ex- 
pelled, TbiF, nitb ibc friuuiltaneuua ucrluFiou uf ihc arirry, wuuld offvr au 
MDouui i>f utifilniPliou lo tbc ciri-ulatiuii ubich auuld alnxat certainly end 
in gan^rcnei The only mraits nf avoiding it srpnis U) lie by ratryjni; I hi 
baoiloge ligbllr nvi>r ibc tumor, by wliiob Tbe veins may be eiuptieil «bil& 
ihe ftiloesB of ihe sac i« unt inlerfi-rMl with. The eX|mIfiion of 90 larte au 
amount nf blood fruni iht- limb uvccEsarily rai.trs tbe nnvrial tentlon la r* 
rest of the bixly ; contH-^iuiiilly the ti<ie »f the elastic bandage itt nol la 
recommendtHl in paiirnt.t nflicK'd milh nn inleinal aneurism which mil 
rupture Dndcr (he etrnin. I-'or tbc eaine reason it should be avoided wncs 
there is a 9li5|Mci(in of fatly benrt. 

Tht? eluvttc bandn^i^ h nio»t lil<cly Co incceed in eSecting a cure in aneu* 
ri8iD» that are Iteginnini; lo undergo con«'>lidati(in. It i* of little une in 
aneuriemg that are large, rapidly iucrcavitig, with Ihia 'niJIa and fluid 
coDtenta. 

Flkxiov. — Tbe treatment of aueurisra by flexioo of the contiguoui jotni 
is a methiiKl that u scarcely iipfilicnblf lo any othrr form of tbe dueBHthiKB' 
tbe pLiplilcal. Tbe history ot this )il»n ui' treating aneurismi ia iutoraitilif, 
aa no illustration of the grndunl ?te)>s by which Surgery umally arrives at ila 
ultimutt.' results. It bnd been long known to .Surgeon* that tbe pulse at lbe 
wriht luigbl be arretted by the forcible Bexi'^n of the forearm on the arm; and 
Matgaigue and Kichet had rccomn)cnde<l tbiii means for the itrn!»t of henior- 
rhago from the bmehiiLl arlory and Ihc nncrJE* ot the forearm when n ounded. 
I'ifurv — a <ltl^liugui^hed Frtnch mival Surgeon — baring succeeded in ouri 
a wound of tbc brachial artery by foroe^l flexion of the elbuw, aided 
direct rompn«Hiun, and one of the radial by flexion of ibo wrist, publish, 
in 1846 a memoir, in uhich he slated, as a conclusion from hia ohservattoiM, 
that auv aneurism of tbe forenriu ur leg might be treated by moatu of flextuo 
of the limb in which it was situated. To A. Tbierrv is due tlie honor of 
having been tbe Urn in curta trautuatio aucurisni of ite bend of the nrm by 
fleximi of the limb. This was in lH.'i2 i Uiehet, Diet de MM. rt de CMnayit^ 
vol. ii, p. ^I^^). In 1^ri7, Munnoir, of (tcnova, applicil tlie flexi<>D>tn» 
meut t'> a Inrge anonrlsm of the hnm. Forced flexion could not bi> Iwtrneoa 
account of the pniti it uccn^ionnl, and tbe pdtient v.-a». tbcrefore. nUowod U>' 
walk ou crntcbcv with the le^ tHoI, and supported in a kind of elirnip 
attaebed to Lbe op[Mj!>ite shoulder. In less tlmu three we^^k*) lbe cure wiu 
eSlKletl. which Maimoir liiund a year aftcrwiinbi to be {wrmaaeDt. In th« 
following year, Ib.li'!', Mart npplici) tbiu tnelhod of treatment vucocwfully ia 
a cii«c of popliteal aneurism, and to him is due tbc luerit of having been tbe 
lii»t Ut iutroUui-e it into this country. 

Flexion is iiecewarily applicable only to arlcritw situated at the bend uf 
joints, aa the elbow or ham. in which the circulation mn be directly cno- 
tmlled by Wnding ihe limb, or in tmuntalic ancurtcnid in the limbs below 
ihetM! jnintA. In which tiio flow of bhxKl through lbe fei-fUng artery eao 
be stopp«sl in the rame way. Its a[>plicalioD ia, therefore, snmewhat limiir>ilf 
and its use is still lurtber n't^tricled by ihe [win and tnt>uppon»M' ■ rinrt 

occasiomil in many raM*s by forced llexion of tbe limb, nece.- .is in 

Mnnnoir's rn.«e, a relnYiitinn of the method, which, hnwc-ver, vim Milt e 



Uv« in eunng tlir uneurisin. 




TBKATUEXT BY » ANIPrLATION. 



167 



JiotkinE cnn be uraplvr Lhau tbe details of this ptui. It conaute, in the 
ki«*r limb, in applyiDg a bnndagi; us high as the Knee and then gradually 
flcxiac thr k>i; upcm tno thieh, m that thp brat is bmuf^hl up towards the 
bwnock, when it is retained liy a etnip i.ir handiigt;. Ths patient ta at the 
■xtt tine ooBBntd to bfd, and put iiiuler pm[wr cotixtitutionnl treatment. 
Bf thii Btani, the popliteal artery being lient at an acute angle, the circula- 
tiga tkrosell it ts DMrlT. if not completelv arresled : and the oheiacte to tho 
lav of faiood it still further increased hv the comprft^ion of the tumor 
hrtWHa dM notterior flat surlaee of the femur and the upper part nf the calf. 
!■ tUa vmy the aneurism i^ moat favorably itituale<1 for the c-onM-lidntion of 
ilM floattnta, which, in the recorded caaes, has ofU-n taken place at ao early 
peiiod. 

Tbe prtoeipJe on ahich tho eure is tfTected in these caaea appcare to be, 
tlkftt liT flenoa tbe ancry leading to and from the eac, and the aneuritm 
kactf, mm an comprrwed that nit&rdalioD of the (Hrculation euaues, and depo- 
wiotm uf lamioaivd fibrin iako« place in the usaal way. 

Tbe couiproHioii by flexion, like every other nietliod of Creating aneurisnu, 
OceMHlsaUy faili'. It Ib nioet likely to be atteuded by succeed in those CSM* 
Id wUeh the aneuriBm is small, flitiiHted low in the popliteal space, and in a 
j«il»H or tuiddle-a{:ed subject, who cnn bear the continued tiexioD without 
■Bocfa ioooorenieDoe. 

WImb flexioo ia nut vufiicieDt of itself to cure au aneurum, it may very 
ilmifglillMlj be had recourse to in addition to other methods of treatment, 
■on Mpacially with that by digital eomprea^ion. 

TW sCMiatics of the trvalmeut by Hexiou retfuire ti) be carried down to the 
p fMi t tiac TfaoMS pablished by Fischer in 1^70. coraprit>ed -'>7 cases. Of 
tiMvB Sft wer* cum) — 20 being by flexion alone; and in 29 the melliod 

Tbe TmriouK methode nf employing cumpreexion, viz., by clamps, by weight, 
by flexiuB. and by the finger, may often m advnniugnously combinod iu the 
wmme ea*t>. Wbro the patit^nt tires of one, auother may Ih.- tiuhdtitutcd for it; 
■ttd tboa tbe good HiectK rontiuuounly kept up with le«e fatigue and irritation 
Ibftk woald oCherwiM be experientW. .Si alvi various moditictttions of th^ae 
dUNwftt methods may be practised to suit thf- requiremenlji of any particular 
liut for thme no special directions can be given ; the ingenuity of the 
BiiiBt supply tbe want in each fa>^. 

io!c RV ActTPRGBRVRR uf the main artery leading to the sac !e a 

that. I think, mi^'hi in certain csaea he lemporarily employed with ad- 

aud lh«- droMtlidntiou of the Arieurieii) thus obtatneil iu eases wher4 

tiion liT thworditiury methods, digital or instrumental, is not prao> 
Ic. With this view a long and otMng curvetl needle, such nn the slilet 
■fa ndtiiD-trocar, might be dipped dreply under the artery and vein — e.g^ 
tbt oonoMra femoral, and (he artery cumprusw*il agaiuet thia by means of a 
•Hk sml twiste«l suture kr sevvnU faoure — the vein iH'ing lell free. The 
palicM OHgfat bs kept under chloroform, if necessary. When cooKolidation 
■f thm moUota of tbe «c was ublainetl, the cimiprestiing means might 
henniBtid* Socb a method of treatment might |K»«iltty be advuntagmu^ly 
MMbbwrf ID certain extreme and exceptiotiHl caaet'. with tlie itijectiun of tiio 
•ae witb tbe perchloride nf iron, or the use of eleotrn-poncture. 

HasiPt' LATius. — Hir W. Kergnwon firoposed to treat some aneurisms by 
■ praoBdim which he termed manipiUation. This couisU in squeesing the 
aaaanMial taoor in such a way us to detach a portion of the congulum 
witbin it, whieb, being carried on with the current of hlood into the distjU 
artery, obstructs this; and thus, by impeding ibe drculatioo 



163 



tRlSM , 



through the tae, may lead to the gradufti coiuoHdatioii of the tumor: and U 
htt aUo been suggested b^ Oliver Peiuberton that the atteratiun nf the rela- 
tions of the lainiuated fibrio ia the cavity of the aocumm may bring aboat 
a further depoettion of fibrin on tho dbplaccd laiuimc. This pmcednre Imu 
as ret bceu cin^tloyed to loo limited an extent to enable us lo form aa 
estimate of its value, and can scarcely be coDBidered. uur is it intended lo be. 
of very gvDcral applicatiun. Tu aoeurisms, however, that are duI ameoaUt 
toordinsry surKicul treatnieuL, and thai raust necessarilv jjruve fatal if tt-ft, 
•a thoae situatuid ai the niol of the neck, murv pftrticulany of the snU'Iavian 
artery, it might pdaoibly be advaniageoitaly applied. It u sooroely neoe*- 
sary, hnwevcr, Ui point out the obvious danger of rupture of the sac, or of 
the diffusion of the aneurUra from the weakening of its walls by the sepai»' 
liun iif the coaj^lura. to make Siir^ins adopt due caution in carrying out 
this method of treatment. There is another daogerabo Mpedallv attendaat 
on tlii» procedure, when applied f * aiieurisnia about the seek ; viz., that the 
detached euiasulum may be carried by the circulation into the cerebral 
arteri«e, and oy obstructtDi; them occasion the (Ame kind of cerebral dti- 
turhance that occurs when Ineae venels become occluded by (Jbrinous plugi — 
embula. That this danger is a real and A great one, is evident from the faot 
that, in some cases in which manipulation of subclavian and carotid anco- 
risrae has been tried, the patient has beeu suddenly seite<I with svooopa 
aud hemiplegia. Teale has successfully cuujoined manipulation with com- 
presaioo in a case of poplitoal unuurism, in which the pressure od Ibe artery 
was slow in consolidating the tuumr; the detachment o^a portion of the 
ooaffulum almost at once Ted to the coosolidatioa of the tumnr. Sjmewhmt 
analogous to this method is one recommeodod in 164:2 by Blake, who pro- 
posed, by the ineroductiou of a cataract-needle into the sac, to deiadi at '^ 
of the laminated Qbrin. which might then be washed against, and ood 
the aperture of exit. 

Galvako ri'.Ncri'Bii. — The attempt to procure the conaolidntiun of ao 
aoeuriamal sac by the employment oi electricity ifl of oomparaiively recent 
date. It appears to have been Srat practiaod hy B. Phillips, abuut the year 
1832. Little attention, however, was given to this mode of treatment until 
a few years back, when it was revived by aorac of the French and linlisn 
Surwons, especially Ptiitrcquin, Burci, and Qnlselli. The object aiuiol at 
uis operation is the production of coagulation in the aneuriitiiuil wic by 

oompnsilion of the blood contained in it by means of the (;nlv«nir cur- 
rent. When two needles connected with the poles of a galvanic battery 
am tntrodiicod into u raasi of fluid blood, a firm Rolid coagulum is rapidly 
fiirmed muml that connected with the positive [Mile, while at the same time 
a large, »<>n, «\tonjfy ch't mixed with bubble* of g»s is seen at the negative 
needle, and n dark, tar>likt> fluid al80 mak«) its apjiearauce. If the needle 
used lie made of steel or any other rejtdily soluble metal, further change* 
occur ut tht> p<j8icive j>ote due tothe production of salts of iron with theacidi 
lilwrntt^l from the bloid. These changes are spoken of as secundary elec* 
trolysin. Th^ clot formed by electrolysis is. therefore, not compapcd simply 
of the tibrtu of tlio blood, but cimtains also a lar^ proportion of allHinHW 
coagulated bv the chemical action uf the currcut, and must be looked npoo 
as a foreign IkmIv around which we liopo onlinary coagulation will occur. 

The opcratiuu of galvauo-puucture is best performed am follows. Tare 
steel neiKlles, well iusutate<l with vulcanite or gum-elastic, are inserted into 
the sac uf the aiieuri-tih aud connected with the op|Hieite polea nf the bntterr. 
The neiMlIca should Ih> alxmt one inch apart, paretlel to each other, and so 
Inserted that n'> jiart of the iininsalitcd [Kirtion of the ueeillr shall touch 



TRKATMKNT BY OALVAKO-PnNOTtr BB. 



The bett h«tl#ry for ilie piirfHwe U one of the urdiiiury medical 
with nuBll L«cliuicb<i c«Uit. of which from tcu to Lweiily may be 
■nd for ■ lia)« var7iiig from twenty aiiuutes to half hii hour, <>r more — 
aeeordios V* the efi^cl produced. It' the tumor be suflineiitly nmr the eur- 
Im* Io b« clearly oiiierved, a« has Uvea tlic case ia tt;rcral of the aneiirisnis 
m iHudi U» tnaunvut liu ljii*a innpIuyL-d. it wilt he sbl-u to hecotnf mnra 
laaWBBd InBtUid tba expausilc usiturL- of the ptilHiition will b«cr>me dimin- 
Mbad aa IIm Dperalioti pmgrK»«. S<)ineiitmt< l)ul)bleR of ga5 escafte by the 
aida vt ika Degalirr nt'eiUp, and a littb; thick Urnwii fluid oozes up. Occs- 



lU 



to aot 



It tht tomor lim IjfOD ftxind to hwhII uiid ItecnniQ rmonant an jiercus* 
When a diMtnct rHi>L-t hait licen prodiice<l the needles may he with- 
I, and the small ptiitctures cloeeil with Mm iun\ c>>1lndion. Tho negative 
nill be found uimhered, while the positivn will be corroded directly 
rtfioo to tht! umount of el»:trolytic nclion that has taken place. In 
prerfnt thi« rorrosion of the positire neexlle, it has bc«n suf^gested 
Jonn DuDcnn that platimim may be used instead of i)teel. Thcrp- is 
ic*. huwirver, to prove thai the salts of iron produced give rJK to 
It particQlitr dnnger; in fat-t. It is pmbahl^ th«y aid cuii^denibly iu the 
fif th«^ firm cii]t|;uhmi Hurruundiuf; the aevdlr. The battvry need 
I opcntinn is of obfiderable iiiiportanci;. It has beeu pointed out by 
'll, that a current of high tension and somewhat low initrnBity i» le«8 
ftcnoae lb« production of undue beat (iuring the oiwration, aud cuo- 
1t lea prone to lead to inflammntiou and suppuratiou of the eac. A 
.therefore, oompoteti of a large number of email elements is superior 
<if s few lar^ elements. Some operators, and especially Basliau, 
hav* ailTucaled the iotroduction of the positive pole only, the negative being 
alUciiMl t^i a sponge or metal plate laid on the skin near the ancurltm. 
The only i«bjei;liou to this mode of treatment is the exceeirely small effect 
prodand. The eledrolrtic action which takes place is directly in propor- 
INC to tli« iDtcnwty of the purrent ; and by the introductiou of a considera- 
Ua mam of tbe tiamies of the patient in the circuit, the resistance is so greatly 
1 that electrulysia ia reduced to a scarcely appreciable amount, tbe 
DcedU appearing almoet unchaD^>d aAcr the opcraiinu. Othcni, 
■(BiBfliaTC Introduced the ucntivti needle onlv, but as thccoagulum formed 
aft thn negatiT* pole is soft and frothy, but little good can be cxpccicd from 
tikit owde of operating. Dr. Julius Allhauti. who baa etipcrinteudcd the 
ayecathM m fire caam. in strongly of opinion that "the most effeotire appli- 
mAm of the ciirrrnl is that where both polpa are insert*^ into the »ac." 
CWidb '•prratnl In thi« way, and Dr». Duiiciin niid Fnisfr. to whom we are 
iadalN;rd for ni.iny imjMirtant ohtiervationa on ga I vano- puncture and for the 
ion of ri-liahir insulated needle*, iupjtort the ."iamc view. The opera- 
ar>c<otiipjiiti«>'l by but little |>ain, and it ie only occaAionally that chloro- 
The effect of n single operation ia »eldoai nufHctent to cause 
improvement iu the condition of the ptUient. and it require* 
- ' - r>-peAtrd several times. 

ii*d ai the result of gal vano- puncture is somewhat soft and 
ana unltts supported by a luodcraiely firm aao aooo flatiem out or 
. and tba etmdition of thv aneurism baoomea mndi tbe tame as it 
' iha oprauioo. Little more than tbe most teiiip'jrury rclit^f t-au 
far ikk Maon be expeH'-d in many tmaea ; and whenever tlie am-urisui liaa 
hanBtdUHnir! ' u con only be productive of niiechtef by haa- 

kaiar Iha taSa- ngea on-urriug round the sac. It niisltt Iw Hup- 

pMM dhal ao aoft a clot would readily break up, an<l that the danger of 
lisBi wtHiU hr great in conKqucnoc; but expcrieuoe has shown that it 




ANKVHISM. 



IB nut, no sue)) nrridpiil liavhi^ liiip|H<ni-(l in any nf the raoofdad 
ocmsioiiiil 
tiiciit m\Q« the priiici] 



illv 



irrnl. hut its 



Iml 



puralton ot the sno has ocmsioiiullv orcui 

much \ct» frroiiciit HiDce the priiicipit^ of the opemti'm hnve Iwen moro fiillf 

Dodentoo^. ['ho torniatii^n of thrtighs round ine netdlt- puncture*, and coo- 

sequent hemnrrhngc, han not been iioiiced except when the ueedtcn hav* boM 

Imperfectly insulnlwl. In fiiol.it may be luiiil that in ainicxit every caar. 

er«n uheii the npcratiou has fniled to give rdief. it hnn at any ratA dooa Bo 

barm. 

Tho sifltUiicfl of the operation have not been f\illy compiled, but thm g«B' 
era) re3<iilt» of lh« jxibth^lied cnwi have not b««it iiufttvonible wbeo we coo- 
dider tbu lio|wl«s« Dittiiri.' of the caovti iu which it has hi^ii jMrfMrrnixl. Of 
13 cn&e* of un«iiri«m of the aorta Irx-alcd br Cini«Ili'» muthiHl, five urn 
cure*!, and no i'%'il (MnB^'quencvn followed iu noy ciuv. Of th« eaiup uuiuber 
whJcli hnve bcuti oirenit««l on iu thiti t-ouutry during tbc la«t few yean, noHr 
bavti bcuii curi^, out at least eix experienced more or Ikb rvlivf ; and in 
alinuet all, it may l>e said, the operation aimed only at relief, the iliaease 
being l(Hi ndvannnl Ui warrant any hope of ctir«. Alioul sixty other cbmk 
of aneurism iif vannus arterii.^ have been collectetl by Ciaiselli bm havi^ 
been njterated on Itrfore 1808; but iu these the melhiMla used were ao ' 
perfect, that they cnnnut be fairly coasidered ns bearing upon the qt 
at the prcH^nt time. 

When we compare galv-nno-puncture with ligature or Dompraanon in tha 
trentment of exiennil BneuriAni. it w, 1 think, imponible to heaitata fur a 
moment in giving a deciik-d prefcrenoc to the latter modes of treattmat, aa 
the results that hav*e hitliertu been obtained are not iuch as would justiff a 

f rodent .Surgeon in tHibniiltin^ his patid-oc to nu operation of ihia kind, when 
e poaiesaea such eerutu and comparatively safe modu of treatment aa dd^ 
Stum at ootnpmsion. In inu-rnal aoouriaiuB, or in thoae eases in which 
e disease is so siiuat^fd at the mot uf the neck, that the artery can neitlMr 
be ligatured with etaft-ty nor cumprt-aned, galvauo-puncture is certainly jiud- 
fiable, especinlty when conjoim-d with projjtir mtdical irt'flcniont, ft» we have 
ample pnM>f (but nilh the kuoirkilge uud mean* now at our dbpo«al we can 
perform the ojieration with scarcely any danger to the patient, and la favor- 
able caifes with some hope of relief. Much will depend upon the selectioD of 
the case. CHoiselli has piinted out that the conditions favorabte to jiucceat 
are, that the aneurism i>Iiall be sacculated nnd o[>euing into the ressel bv a 
narrow mouth, ofvluw growth and of medium size, and, when thoracic, »ita* 
at«<l eutirely within the thorax, aud that it shall not ia aajr aeritHis way 
have interfcrcMl with the general health nf the patient. Tbne conditions 
aeldom occur ; and when tficy are nh^>ut, the moat that caa be hopad fiir ia 
tempurary arrest of the ptogrcK' of the disease and some relief tu the patient^ 
aoAarings. 

IirjBtmoiT vrnr PRRmijrtHirp. or Irok. — ^The Injection of anrarismal 
aacB vith a soiuiiim of the perchloride of iron haa aim been practiwd. with 
the view of congulaling Uieir contents : such treatment, however, ia attended 
with great risk of embtdium, and is in every way vaitly inferior to the ligaUm 
or comprfssinn of the artery leading to or beyond the aac, and ahoald never 
be employed if theiu" ran he practise<l. 

Aneurium of the gluteal arterr has been soccesaftilly treated by injection 
of the perchloride of iron in at least one case. In eases, however, in which, 
either from the HttoAtion of the diseaiM'. its cnrnpliontion with oihfy ri- 

sive diseaxe nf thi" nrti'rial syntem, or its multiple ehnmcter, 1 .;id 

eomprf*i>on art' not upplirable, an t'luleavor might be nmde to priictirr the 
eluttiug of the hliMxi in the tumor by distal oompression of the artery, brf 



TREATMENT BY ACUPUNCTURE. 171 

attempting to coagulate its cunteots by injection of the perchloride ; and I 
cannot bat think that a satisfactory result might thus be obtained. 

Hypodermic Injection of Ebgotin. — Langenbeck advocated the hypo- 
dermic use of a watery extract of ergot in cases of aneuriBm, under the im- 
previon that it might act on the muscular fibres scattered over the sac of the 
aneurism in the same way as it acts on the muscular fibres of the uterus, and 
by causing cootraction might gradually diminish the size of the aneurism, if 
not cure it. He seems to have tried it in two cases only. One was an 
aneurism in the supraclavicular region (exact nature not mentioned), which 
had been previously treated with moxas, and almost cured. The symptoms 
having returned, hypodermic injections of ergot were tried. The quantity 
ioiected varied from about i gram to 3 grains of Bonjean's watery extract of 
ergot, dilnted with three times as much spirit and glycerine. The injections 
were repeated every three or four days. Decided improvement is said to 
hare occurred, but pulsation never quite ceased. The improvement com- 
menced after the second injection. Ko unpleasant symptoms occurred ailer 
Um injections. In the second case a man, aged 42, had a sacculated aneu- 
rian of the radial artery of the size of a hazelnut. An injection of two 
nniiis and a half of the watery extract cured it in one day, as the next day 
It coold not be felt. The injection gave rise to some inflammation of the 
mrrounding cellular tissue which disappeared in a week. 

Tbifl accident I have seen happen in one case in which I tried it, but no 
good resulted from the treatment, which cannot, indeed, on pathological 
grounds, be considered to be of a hopeful character. 

IjiTEODrCTios OF FOREIGN BoDiES. — The intn)duction of foreign bodies 
otf' various kinds into the sac has been attempted in a considerable number of 
GHca with the view of producing an artificial coagulum in the aneurism. 
Thus coils of horsehair, catgut, or iron wire have been thrust into and left in 
the aac, through a puncture made in it. The results of these operations have 
nol been such as to justify a repetition of the treatment. 

AcTPrscTfRE with very fine needles has, however, been performed with 
some benefit in a few cases, and if carefully carried out, can hardly be pro- 
ductive of any injury. It was first suggested by Velpeau,and practised with- 
out success bv Dunville and Agnew. ^Marshall has in more than one case 
obtained in this way some cousolidation in aortic aneurisms, and MacEwen 
succeeded in curing a j)opliteal aneurism by the introduction of a fine needle 
while the femoral artery was compressed. Heath attempted the same trcat- 
meni in a case of subclavian aneurism in University College Hospital after 
be had unsuccessfullyamputated at the shoulder-joint. Six fine needles were 
intn>duced into the sac in such a way as to cross each other, and were left in 
for fuur days, at the end of which time the tumor was much firmer. The 
patieut dietl about twelve days afler from causes uneoimected with the treat- 
ment, and a considerable amount of f^rm clot was found in the sac. This 
treatment seems worthy of further trial in otherwise hopeless cases as a sub- 
stitute for galvaoo-pUDcture. The smallest sowing needles with heads made 
of sealing-wax may be useil, as iu Heath's case ; or better still, the fine pins 
known a? entumological pins, which i-hould be gilded. They may be Ictl in 
for from fuur to five days, and it is perhaps ^nfer to <'over them with some 
umple antiseptic dressing to diminish the risk of ulcenitiuu. After they are 
mnxved the punctures must be covered with culKxlion. 



172 ANEURISM. 



ARTERIOVENOUS^ ANKURISH. 

Preternatural communication betweea arteries and veins, though uBuallf 
the result of wounds, occasionally happens from disease; ulceration taking 
place between the vessels, and thus causing an aperture Lo lead from one iDto 
the other. When such communications are of a traumatic origin, they may, 
as has already been stated, constitute either an Aneuritmal Varix or a Vari- 
cose Aneurism. As the result of disease, aneuriamal varix only can occur, 
varicose aneurism never happening except as a consequence of wound. Then 
spontaneous communications have been met with between the aorta and the 
vena cava, and between the iliac, temoral, carotid, and subclavian arteriei 
and their accompanying veins, in nature, symptoms, course, and treatment, 
they so closely resemble traumatic aQeurisma) varix, described at p. 450, 
vol. i., that their consideration need not detain us here. 



SPECIAL ANEURISMS. 



CHAPTER XLIV. 

ANEURISMS OF THE THOKAX, HEAD AND NECK, AND UPPER 

EXTREMITY. 

ANEURISM OF THE THORACIC AORTA. 

t?YMPTOM;*. — The symptoma of Intrathoracic Aortic Aneurism are of two 
kiode : autcuHatory and ratUmaL 

The Anieiiltetory Bigni vary greatly in dietioctness, and may even be 
wanting. In some cases, more especially in fusiform aneurisms, they are 
slniost from the first of a very marked and obvious character; in others, 
especially in sacculated aneurisms, they may be absent throughout, the uneu- 
nni terminating fatally without its existence having been determined by 
Uie stethoscope. They consist in murmurs of various kinds and degrees of 
mtensitr — bellows, rasping, or whizzing; in the second sound of the heart 
bring audible over a greater space than normal. At the same time there 
nwy be dulness on percussion. These various signs may often be heard 
more distinctly upon or to the left side of the spine, than at the anterior part 
<^ the chest; when occurring anteriorly, they are chiefly met with on the 
rifiht side. 

The value of the auscultatory signs in the diagnosis of aneurism within the 
che-t is not perhaps so great as in many other thoracic diseases, in the early 
tiA^v^ of the affection, and in those cases in which the nneuriem continues 
small and sacculated throughout, or is so deeply seated as not to approach 
the (>arietes of the chest. This need not be a matter of surprise, when we 
r«fl(rct huw deeply the ascending portion of the aorta and the arch are situ- 
aterj : h-iw they are covered in front by the lungs and loose areolar tissue, 
tlirnu;:h which sound is with difficulty transmitted ; aud how they are cov- 
«r«*l in l>ehiDd by the apine and its muscles. When, in addition to this, it 
■ V^ime in mind that aneurisms of the arch often prove fatal by bursting 
in^■ runliguous cavities and canals before they have attained a size greater 
than that uf a walnut or a pigeon's egg, and thus are incapable of furnishing 
a murmur of any very marked kind, it can be easily understood that the 
value of auscultation is but small in many cases of thoracic aneurism. 

The Rational SigHB of intrathoracic aortic aneurism are of three kinds : 
Prwvure-effecis ; Pulsation ; and Tumor. 

Pressnre-eflfecU may be exercised on any of the contiguous structures; 
and a glance at the anatomical relations of the thoracic aorta, more particu- 
larly the arch, will enable the Surgeon to judge of their complexity and 
inportanco. They will necessarily vary according to the size of the aneu- 
ritm and the portion of the aorta affected by it ; more according to (he latter 
than t<> the former condition. When the aneuri.-'ni arises from the root of the 
oerta, Bn<i more especially when it is intrapericardinl, it i." usually of small 



174 



HPXOIAI. ANKUBISM8. 



size, oad iu pressurc'cffecto will be liuJo obvioue. Wbeo tbe aDearins ktim* 
f'roR) tlie tmniniitioH of the nreh, ur thf ilesc.mting aorta, it may often stlaio 
a cuiuiderable develupDivnt witliuui causing anv vi>ry <ibvitiu» preaaofv-eflMMi. 
AaeurisDii ibaC are nituatetl ui'Mm the wnairitg uj Ou itrrh nepcwrily ^t» 
rise to very severe effects, by itx; ct>ui|im«i><ii tlit-y uium cxcrr-isp upoo mom 
one or ottier of the vtry iTii|M)rtant atruriun-A tlml are induiUtl withio tlw 
anrtir urrli, Wtipn tlii> aiUerktr jxirf nf the noria bt afieoled, tbu aseurlMn 
tnay HLtaiii a vi>ry ctio^iJuritblf bulk, even coining furwari] »u as to prq^Mt 
aod pulsate between the iritprcoatal Ppaces, without any vury aoticcablu pn»- 



t. _sr»iJ 



!;■ 



>«' 



r-s--. 






Fig. 4fiX.— Broaioa of tniarv*n»bral Fig. 4IVI. — AcmHini nf Dii«ara4lliig Aort*, krattag 

Subftmeoa bj a •mall AKontiim of an^l IravciilBg Vatt«fan*. 

[IfttceiMlitig Aurl* |iT«MJiig b»ck> 
atanlB. 

■ure-*fll;ct» Iwing inHticed. But when the potfrrinr will <if Uk arUry U the 
seat of the disease, then Bcvere Byrnptome aw early rvl "p by tlic cnmpmMinn 
aad emsion of the »truoturc» lying D>Dtit;uoti0 to lh« artery anil nlung the 
•pine (Fig. 463). When the upper pari of the wirtie rrrrh is the sent of an«o* 
min. a peculiar train of cerebral aymptonift, tiucb ae vertig<», iiw-nsibilitr, (W 
defective vi«oD, may be ioduced by ita interference with the circulatioa 
thraugh the carotids. 

The preefiure-offeots that need chiefly engage our attention, are: I, Fain, 
2. Oy9pna>ii; :{, Dyaphagia; and, -1, OCilema. 

I. Fain is ueuallv ono of the earliest syniptonu of intrnthnracic aneurifm, 
and tif freqiieiuly o^ ^'rcat value in a diagnostic point of view, ns it Is often 
moat marked when the other syniptoras are the lenst developed. It is gen- 
erally inori' M-'vere in Baceuliiied than in I'u^ifurm aneuriBim. and when the 
jjHMtitrinr rather than the antcrinr o^inecl of the vewel i» the cent of di i'o — c. 
The pain \» of twn dtstim-t kindft. Tne finit kind to IinciDatlng. intermitiniti 
and iiounU>rlc in ita charaelcr, cridentlr dependent upon prneure on tbe 
BpinnI or Ryinpalhvtic nerves. Thin pain is Mated chiefly on the left ride, 
and iibontA up the ilide of the head and face, nlonff the upper arm to tbe dbov, 
nKiU}! the tntenvnto-hutneral ner%'t?,thn)Ugh the ent^t, orWtweeti theseapaUa. 
Tlir M-(^ttld Tirm uf [uiin ncrurs usually al a latf-r nlAge of tbe disease, it ooa- 
ciauoim, mid of » horiii);, Imt, or biirniug chararler. It seems to depend 
upon the pcrluratiou uf tb« ti«»ue», more expvtriiilly the honet, bv the anea* 
nsntal tumor, and occurs chiefly on the right xide of the cheat (rig. 464). 



PRESSURE-EFFECTS OP THORACIC ANEURISM. 



175 



2. DyipouM is of very frequent occurrence in intrathoracic aneuriain ; in 
all probability it is more uniformly met with than any other single aymp' 
torn. It may arise fnitn five distinct conditions, and its characters vary 
with its cause. 

s. From dire^ preamre on the trachea. In these cases the dyspnoea is at- 
tcodied by much wheezing cough, and often by whistling sounds in the cheat 
and tubular respiration, and by slow expansion of that cavity. There is 
Qsuallv expectoration of thick tenacious mucus. 

J. Prom dirtet presture on a bronehtu (Fig. 465). In these cases there are 
wheeling, cough, and some degree of expectoration, with, perhaps, dimioished 
respiratory murmur in the side 
aflected, and puerile respiration in 
the opposite lung, as has been 
poioted out by Stoxes. 

:. From prtwurt upon the lung. 
In theee cases the respiration is 
companuively little interfered with, 
the spODgy tissue of the lung ac- 
oMDmodatiogJtaelf and yielding to 
the pressure of the tumor. Atler 
a time, the pulmonic tissue will 
become incorporated with the wall 
of the sac ; and then more serious 
difficulty in breathing, with btemop- 
trais, will supervene. 

f. Dyspnt^a is very commonly 
induced by irritation, eompreaaion, 
«r ttretehing of the left pneumo- 
ytutrie and recurrent laryngeal 
merrtK by the pressure of the 
tumor. In these cases the muscles 
that are supplied by the left re- 
current laryngeal nerve may be 
paralyzed, 8» as to occasion attacks 
of iDlense difficulty of breathing. 
In many cased spasm occurs from 
irritation of the nerve before it is 
preej>e<] on sufficiently to cause 
paralyi-is. 

It is the erico-arytenoideus posticus muscle that is chiefly affected by the 
roniprefeioD of the recurrent laryngeal. As its action is to open the glottis, 
it» paralysi.« cause's an imjiediment to the entrance of the air by the collapse 
of ihe left side of the rima [^luttidis — henco the dyspuo'-a and struggle for 
breathing under exertion. The Vi>ice becomes hoarse, croupy, or on)aking; 
the cough has a loud croupy or metallic sound, and it attended by the ex- 
pectoration of thin frothy mucus. The laryngciil stridor oflen does not 
occur in ordinary respiration, but is pnidueed under exertion, or on making 
the patient inspire fully and deeply. The hiryngeal symptoms are some- 
time* so much more prominent than any of the other ^igns of intrutliurucic 
aneurism, and so closely resemble chronic or even acute hiryngiti-^, with 
inpending a.aphyxia, that there are not a few cases on rcconi in which Sur- 
geons have performed traclieotomv, on the supposilion that they had to do 
with cases *if pure and uncomplicated liiryufjea! disease; and, in nther 
iafUmx*, this operation has been performed with a view of pridonging life. 




Fig. 4B5. — Aneurism nf Areh of A'jrta, of the 
Hiie of An almonil, rprinftiDg from bctow left 
Subclnvian Artorv. nnil burgtiDg into left 
BroDchu!. 



176 



SPZ01A.L ANEUBIbXS. 



wreo wheo the depeodeDoo of the latrnK^al spurn oo aaeurUni of tlic aoru 
baa been nicogniMd. 

Dr. Oeorgc Joliosuo has made sqidu iDifioriutii ub«ervaU*otts oo the 
the laryii{;flsoi)|i« iu thu diatf uosia of ibt- uiium- uC ilyspoifa io aortic i 
He Bfl^a iliut, ID ciusvs whvru tlie cauto ia prvasurc on the recurreui larysj^ 
Qervi>, tbt' larynx Ik aeuu to l>u healiby.and the BpMta may be aeeti to oooor. 
If tli» pri'^urt.' tu: suniciciiL lu ttbolieh ibt: fuaclion of th« dbttc, uailat«ra] 
[winilysii* will occur, wbirh i»ii be easily auoerlaiufil by laryDgU8O0|iic ^xani- 
Datioii. TliB voice in such caeCK ii: neak and liunky ; wbpruan, ia cskb ia 
which the [treasure i^ oq the trachea, itfl character is unchaoged. When a 
thoracic aneurism nreoMs the trachea a^inst the apitie, the Lracheal stridor 
and tJie voice-stiund are heard with remarkable diatiiictm-ss on appIyiDg th* 
atetboBcipe over the upper dorsal vertcbne — the »ound being ouoducted 
through the bonea. 

I. Dyapnopa may be depepdent nn compression of tlie puimonary vein by the 
aueuriBiual tumor. In cases of this kind there wuiild be cwwiderable Uvidity 
of surface, anti signs of pulmonary coDgcstion. 

The dy!tpii<i<'tt of intrathoracic nncuri^tii will uOvn be eiilficiently intenae 
to occa»iou dfuth. It may be mistaken for onlniary itsthma ; bitt the dij 
nosiif can usually be etfected by ob»erviug that iu aoeurisni the pnroxj 
of dyspncea oflea come on in tht^ day &» well as at ni^ht, and are gn 
inctvHsed by change of po«itiou, as by pluciug the patient either upright or 
recumbent, th« tumor thus shifliue it* jwinl of prenure. It is, as Bellioff- 
blim has pointe^l uut, not iolluenceu by atniuspheric cbungcs, mid is genorsUy 
aaaociatcd with laryngeal etridor or ajiasm. When such symptoms aa these 
are Maociated vith pain and dysphagia, they poJat very strongly, even id 
Uic absence of all auscultatory rigus, to the prennoe of on aneunuoal 
tumor. 

Aneurisms situated within the concavity or springiDg from the , . 
porta of the aortic arch are those which, either directly by their pr 
on the air-tubcfi or the pulmonary veins, or indirecilv by tbe influent 
they excrciae on tbe recurrent laryu|c:eal nerve, are chiefly lUBociattd uith 
dyapofca. 

3. Bysphaffia ih a symptom of sufficiently fVequent oocurreoce in aiieD< 
risms of tne thoracic aorta. Eaton has dciermined ita existence in nine out 
of twelve cases. It seldom occurs, however, in the earlier sta^ea of ihc 
diseaae, or when tbe aneurism h small, and hence is of iimch leM diaj;- 
nostic value than dyspuuA. When, however, it is aaaociatcd with that 
symptom, the combination becomes important; as the coexistence of tbe 
two onditiooa clearly points to the compreMiion of the <ecK>phagus and Ui« 
atr-tubeit by a tumor, which other diagnostic iiignH may prove to be aittni- 
rianiat. 

It ia of importance to bear in mind that In some aneuriitras, npeciallr of 
tbe iJeaeenrliug thoracic aorta, dysplia>;iii may be one of tbe most nutrluHl 
aigna. In «ucb caaes as these, stncturt; of the weophagus baa erroneoualy 
been suppoaetl to exist, and tbe patient has even be«a treated by the iutn>- 
dnction of bougies uo ibis ^upposiiiuo — an error of praclicL- that haa termi- 
nated fatally frum porforaiiou of the aneurisoiBl sac, where it projected 
against the a«'jpli»guii, by tbe point of the iustrument. 

Tbe difficulty in deglutition, in cases of ooBpreaaioo of the cewphaguij 
aortic aneurism, is almust iuvuriubly referred to tha et^Mennl notch. T _ 
dysphagia is commonly awocialed with [miu, or with tne Mnaution of a cord 
drawn tightly around the body. 

4. (Edema, with muru or less livldiiy of the upper extremitfet and head 
Mid neck, occaaiuoally but rarely ocriire. It is ge-nenttly moat marked on ibc 



aUKOIOAL TKKATMKNT OT ANSCItlSM OF ARCB. 



■ad sriscB fmtn th« cimprcwion of the superior cava or the innomi- 
M bj uwumrTu itprtnging from the fore or upp^r part of the *rcfa. 
uk) Tnioor, ohwrvablp externally, ar^ alwayg ab^ont in th« 
rMrlrMaMof intratborftctc aortic anetiristn, and v^rr frequently cr>ntinoe 
1^ tnrcognoBt the proercDa of the affection ; indeed, in anenriems npringing 
~ llic int^aperifftn^lflI aorta or the concavity of the arch, death usually 
I pUor, cither hy niptiire into one of the wroua eavilie* or the air-tube, 
■r by tb« exhaustion indaccd by dyspiKm, long before the aneuri».ii> has 
■I nil 111 a MiAdfm flit« to be reco^izahle externally. Tlierti ar«, however, 
ihm portion* of the tburacic aorta nhich, when afTeclfd by aii«uriisin, vield 
atental evidenoe by the vxb!leiie« of pulMitiuu or tumor of ihv true uaUire 
of tW dfaaiw, These are — 1, the aut«rior a«pect of the ascendiou aorln; % 
ifca MEmmit of tbe arch ; and, 3, the p<wterior aspect of the deeceudiug aorta. 

1. WheJi tlie aneuritfiD is nlualed on the anlvricr atptct of the itKcnding 
avHb and tvmmn*crm(nt o/ the arch, puleutioD may be detevttHl by presure 
been MB the tDterc<«Ul ifpacve on thu right side of the eternuni, ami a thrill, 
tm voU u d)stiui>t impulee, may often 1h> felt over that side of the chest, 
biAtaaiiy external tumor becnmee visible; thus eimulatiiig the beat of tfae 
iMSft, ia aiiditiuu aad opjKieite to the seat of the true canliac impulse. Afl 
lbs atMuriam increases an external lumor appeant, the wall of the cbeet 
baeooiw absorbed aod perforated cppoeite the point of greatei^t impuUe. 

2. WCeo an anenfinn spriogs from (At; nimmii of tiif. arch, a pulsatinff 
iMBer a]^wan al the rwA of the neck, behind or even above the margin of 
ibe etcranni, mn^l commouly toward? the right side, aod occnaionnlly rises 

Ugh oot of the thomx. and ta so distinctly felt in the neck, as to run tbc 
of bring cdofounijed wilb aneurism of the bmchio-cephalic or carotid 
Tj (Vig. 470, n. 160). This error, Khtefa has fi^uently been committed, 
■pd vbj«b has Ira to operations on the arteries at the root of the neck, may 
IJy be avoided, except in the case of the bmehio-cepbnlic, by the impo» 
of tracing vith tiie finger the lover boundary of the tumor, and th« 
«aof difCiDciduIneM oD percitseion.aDd poBsibly of impulse or of au»* 
ritalory eridvnce of aoeorism, below the level of the upper^ margin of tha 
inai or clavicle. 

Wbm aoeuriem springs from the potttrior wait in the detemding aoTia,m 

sting (umor tuay gradually develop to one side of the spiue or under the 

iMla. cosmoDly on ihe leftside; and it may attain an excessive size, fully 

imixat as the bead ( Fig. A^), before the patient is destroyed by the rupture 

lb« tumor exierually. 

Txzjtmr^tT — lo tbe great majority of aneurisms of the thoracic aorta 

■ i-e is impoceible, and our sole reliance must be placed 

. nst. it he admi nut ration of iodide of potasstam (see p. 140). 

Svgical IieatBcnt of Anetuum of the Aortic Arcb. — Tlie ioen of treat* 

saeoriim ef ibe noriie arch bv ligature of one or two of tbe main arteriea 

(b«r ruot of the seek, Drigiuate'd in tbe results of an operation perforated 

Cbrvtopfa^r Ileatb in 18(^ lor the cure of a suppoeei) innominate aneurism 

tbe »in)uliBOe<>u» ligature of the right carotid and ^ohclavian arteries. 

patient, a Wf^man of intemperate habits, survived the operation tor four 

rear*. sp[<«'ariog for a lime to have been benefited by it. Cn her death 

luand ibal the nneurtsm irae not one ef tbe innominate but of 

I aarindipgaorta, and that it had bees practically cured by or atUr the 

■*"" Dr. (Vrltle about the same Ume waa engaged in a ecries of 

oWervntirn* on I he itpontaneoDS coDtolldation of anenrisms of tbe 

at' ' :ind that in »onie of these cases the left carotid artery had 

»tid be interred frf>m this pathological fact that ligature of 

ri Blight be of use in tlie treatment of certain forms of aneurism of 

t II — I'J 



178 BPKCIAL ANBURI81IS. 

th« urcli. This eu^^gestion watt acted od br C Heath, who, ia I'ST'i. tied tbt 
Icll i-Arotid artery in a patieDt of Dr. Cockle's aflected with aDcurism of tin 
woending and traiitfvcrce portions of tlie arch. The patieot was bciM)fit«d by 
the operation. Harwell has operated in two cases, in one with Bdvantiig& 
In the other, lu which the left aubclavian was also tied, the patient died, 
apparently uninfluenced for eood or ill by the operation. Ucath s Bcoond caM 
of ligature of the left carotid provoil fatal by syncope. In all, the operation 
appears to have been done 13 timeaCA^hhurst) — in six ouce with mareorles 
mnefit. In at least four of these eaaes the artery was ligatured on the nip- 
position that the anouriflm ytts situated at the root of the carotid, when, u 
reality, it uccupietl the aro.li. IlArwell iitates that, in thoae aneurisnu which 
■lirin^ from the aorta beyond the left curotid, tiir&ture of this veMi;! will do 
mure harm than good, and that th<> operation nhmild t>o confined to thtwc in 
which the tumor appeura on the lefl Mide, hut not far from the median lion. 
anil Tige^ into the epiiitemal notch or under tlie lelt tiU^rtio-niaftloid. 

The Simultaneous Ligature of ^e Right Carotid and S.ight Subolariaa 
Arteries lur nuvunsm of the aortic arch iiait, acc^rdiug to BurwL-ll, been dou* 
in throe cimb only for aneurisin diagnoBed as aortic before IJm operBtton. Id 
Bomo utlier caMs. aa the ona referred to ubovc, diagnoeod errooeousiT a> 
innomiDate, hut pruriug in reality to be aortic ouvurisin, it has bIm Mto 
done. In the Uiree cases of reooenizod nortic aneurism the operations wm* 
done by Harwell, Lediurd, and Wyclh. lu all, the "ox-aorta ligatura** waa 
ttsed, and the paticnu lived 15 months, di months, and 1 year respectively 
afler the o])«rHlion (Barwt^ll). 

The ligature of one or more of the main arteries at the n>ot of the nedl 
for the cure of aneurii^m uf the aorlic arrh involves a new principle in the 
treatment of that diseaAe; ont^ that differs in all reeneols from that in which 
tbe cure of nn onltnary external aneurism is ei^tea. By whatever way the 
Surgeon nets, whether hy the Hunterian or the distal ligature, by oompra- 
aion with iostrnmrnt or linger, he seeks one common result, riz., the arraitor 
retardation of the circnlntion through the sac so aa to facilitate the depotiit of 
laminHtwl fibrin or firm clot. He usually acts directly uiMm th»t artery that 
is the «eal of thi- di^a^te, and in all oases of the Hnntennn o|M.>nt(ion, or of 
arterial couprcssiiin, the supply of blood sent into the hsc ix mmt niateriallv 
diminished, if not altogetWr arrested. But In the treatment of anrtlc 
aneurisuis by ligature of the left carotid only, or by that of tbe right 
carotid at its root, and of the right Bubclavian in the third [uirt of id 
courK, he not only doca not diminish or retard tbe flow of bltod throacb 
tbe aorta or leoseu the qusntity »ent into the aneurismal sac, but as tlie 
Tolume of blood ejected from the letl ventricle at eaoh systole continues un- 
changed, a larger blood-slreum muat actually be tfarowo into the aorta b»- 
youd the point at which tbe deligate<l vessel is given off, equal in amount 
to what would nornially have passed into the artery that has been tied. Dy 
thus innmasing tbe volume of btood in that portion of the arch of the aorta 
beyond tbe giving off of the ligatured arterj'. an increased pressure will be 
tbrowu upon the whole interior of the vessel and of any aneurismal sac that 
•prings from it. Thus, the very reverse of what happcna in the Uunteriaa 
or ordinary distal operation, takes place when one or more of tbe primarr 
branches of the aortic arch is tied. And if a cure of an aneurism in this 
situation be thus effected, it must be on a new principle, different from auj 
that hna yt^t guided the Surgeon in the treatraoot of this disease. 

That some benefit appears to have followed these operations in a few of 
the casM is undoubted ; but how much of tins may be fidrly attriboted to 
tbe direct inSuenoe of the ODoratiou appears to ms to be very UDoertaiD. For 
it cannot be doubted that the oonflneQient to bed af^r tlie operation, aod 






eUBOICAL TRSATHENT OF ANEUHI8M OF AKCH. 179 

the more careful and regulated life that would be led by those who had been 
subjected to so serioua a procedure, must exercise a very directly beueficial 
iaflueDce upon aoy ioteraal aoeurism ; aud it may fairly be a question 
vbetberan aneurismal patient, Bubjected to ao operation that would require 
eoD6DeineDt to bed or at least absolute quietude for several weeks and sub- 
•eqaeotly necessitate a quiet and carefully regulated life, would not derive 
aa mach benefit as have the patients in whose necks large arteries have been 
(ied for the care of aortic or even of most innominate aneurisms. 

The oeceaaity for hesitation in the adoption of these operations for the 
cure of aortic aneurism appears to me to be strengthened by the acknowl- 
edged difficulty in effecting a correct diagnosis, in many cases, of the exact 
seat of the aneurism, whether it be innominate or aortic, or both, or, if aortic, 
froBi what part of the arch it springs ; and also in determining with abso- 
lute certainty whether a given intrathoracic tumor be an aneurism or not 

The immediate danger of these operations, whether done for aortic or in- 
Domloate aneurism, is also very considerable. A very large proportion of 
cbe patients so operated on died within a fortnight, and in some cases death 
resulted immediately or within a few hours consequent on the disturbance 
of ihe circulation through the brain by the ligature of one of the greater 
arteries springing from the arch. 

Another &ct of much importance that cannot be ignored in considering 
tb« advisability of subjecting a patient with supposed aortic aneurism to the 
operation of ligature of the carotid and subclavian arteries bthe undoubted 
very slow progress and prolonged duration of many of these aneurisms, and 
tbc possibility of a spontaneous cure in some. Patients with aortic aneu- 
risms frequently live for several years after the disease has been recognized. 
Under proper constitutional treatment the severity of the symptoms may be 
greatly mitigated, and in all probability the chances of cure would be about 
equal under the two modes of treatment — the strictly surgical and the medi- 
cal — whilst that of speedy or of sudden death would be more likely to occur 
to those subjected to the operation. 

Some Surgeons have tried to obtain consolidation of the tumor by coagu- 
lating its contents by thrusting coils of iron-wire or catgut into its interior, 
but it need scarcely be said that in no case has any permanent success at- 
tended such procedures. 

The rapid solidification of a large dortic aneurism is not unattended by 
danger; so lung as the contents are fluid the patient goes on fairly well, but 
if they rapidly solidify the pressure of the tuniur leads to great distress and 
rapidly hastens the patient's death. 

The mode of treatment which has been more frequently adopted in aortic 
aneurism than any other is galvano-pnncture ; and in well-selected cases 
this may be productive of considerable good, or even occasionally lead to a 
cumplete cure. In 27 cases of aortic aneurism thus treated, which have 
been collected bv John Duncan, 5 were cured, 10 relieved, 9 unrelieved, and 
^ died. Experience has shown that with the latest improvements in the 
Mperatiou — well-insulated needles and a suitable battery^there is scarcely 
any danger to life, aud that, even where it does no good, it does no harm. 
It ba^ been applied in all stages of the disease, from the time when the tumor 
becomes eutficiently superficial to allow the safe introduction of the needles, 
to the time when it has perforated the chest-wall, and is on the point of 
bursting. In one of John Duncan's cases, the lite of the patient wiis un- 
d'Aibiedly prolonged for nearly three months after the time »t which, if letl 
to it«elf, the aneurism would have burst p.\ternftlly. The ca.-*es best suited 
for galvaoo-puDCture, and in which even a cure may be oeeasionully hoped 



x&o 



SPKCIAL ANKt'BlSHS. 



for, are thueu io wbich the tumur u of slow gruwth, bas not ^vt perfonilcd 
tlic di(«t-wull, mil) in which it rati lie iliagiiospd iik nac'cutHU^ and romna- 
tiiicalirig with ilie aorta hy a rDinparativel)- small upi'iiinp. It » intpmUBi 
kIbo Ihnt the giaticntV health ehiiukl not be too much broken hj saffering or 
viflceral dii«aM>-. When the lunmr projectn through the parietn af Um 
thorax, forming a sccon<isry sac outaide, the pnwpect of run; is iniiBiUii- 
InaJljr vmall ; but even then, progreni may be delayed, ami much rvlipf givo) 
to th« patient. If the tumor have become ditTuBed, as may occur when it 
poiuis in the back, gal vano-punc lure can only do tiarm by increasing the 
tendeacy to JDflnmmation and suppuration alre&dj ezuting. For lb« del^ 
of the opcratioD, see page 168. 

There is ijdc point in the treatment of ume forms of aortic aneuriAU. thai 
folia within the province of the 8urgeon, and oo wbich hi« opioiuu may be 
j^ht. I mean the advi^obility of opening the windpipe, lo rdi»VL> the 
iticDi from iho didtrcM uctUBioucd by tin- laryngeal spa^m that Lviuinoniy 
attends many of thcae caacA. The deciaiuu of this qumiiia i* alwaya an 
anxious one ; for it must be born« in mind that, lu) tb« disease that itccaaJODf 
tbe nMsme iif the lar^'ox is neceaearily and inevitably fatal, the i>|Mrralion 
eao be ex]iected to give only temporary relief, and at mod but a brid* pru- 
lungaliou of life. 

lu determining this question, the Surgeon must bear in mind that sinple 
laryngeal spasm la rarely, if ever, the cause of death in aortic aneurisa ; 
that, allhough the patient may suQer greatly froiu this complication, he dot* 
[not die of it : but that the ultimate cause of death is ueuallv intrathurmciu 
IfkreMure, rupture of the sac internally or exleroolly, or exhnu^tiou. The 
j^peratJon, therefore, would be justifiable iu those cases oulv in vrbich it ooold 
M determined that the spasmodic dyspuma was purely iHryngcftl, and was 
not dependent on comprei«ion of the air>MueBgca withiu the chest by the 
aneuriHmal tumor, but simply on the irrilatioD pntducixl by the ittiplicatioa 
of till' left recurrent laryuin^iil iivrve. Such cilm:« are very rare patbdlugiraJly, 
and ueceeearily moi^t ditticult of accuruu- iliagno(>is. As the &ui^-4iu will 
usnally get the credit of having kilU-d the patient if he be induced to perform 
the o]>erntion, and the relief be not immediate and great, 1 would advise him 
not to operate unless the diaguoeis be most clear, or in circumslancfS of 
imminent ileath from uncomplicated laryngeal Rpaum, with the view of alKkrd- 
iog immediate, even if it be temporary, relief If any operution be dace. It 
should certainly be laryngotomy, and not trnvbeolomy. 



ASKUBtBH or TRB INXOHIKATK ARTCRY. 

Aneurisms of ibis artery are very frequently accompanied by dilatation or 
actual nnrurisni of the aorta. Inuomioute aneurUii>s may he eiUier of the 
tubular ur the sacculuteil kind, and usually give rise to » train of senosv 
id dnDgeruus sytuptonis, Irom their pressure upon important [nirts in their 
nghboroood. luoeed, a glance at the relations of tliis arterj' will show the 
laportmnt effects that must be tinxluced by the pressure of a tumor spring* 
iBg fVom it. Before it Iim tlie led innominate vein, U> the outer side are the 
lower cv^rviml tmrdiav branch of the pneumogatitric the right inDoaueate 
rein, the ngbt paeumogastric and the pleura; behind it and to its inner ude 
is the limchea. An aneuriatnal tutuor of the innominate artery may eixtend 
backwards so as to come into relation with the vet^hagus, aod upwards so ae 
to pres on the Hgbt recurrent larynginl. 

SmFTOKs, — ^Ine geoeral symptoms of an aneurism of this ftrterr an 
exiilenoe of a pulsacing tumor of a globular shape bebind the right 




or THE tKKOMINATX — SYMPTOMS. 



181 



dftvicutftr KrtimUti>iD. atleoilexl with pain, and perlmps ledema of tlie right 
mIkoCUm fiue and arm. \Tiih nomo difficutty in respiration, Inryngijal cougb, 
■ad djrapbafts. Ttie tumor ij usually soft and oompredsible, Siting up more 
nr Ihi <»m^lelv Lbe hollow above iKe sternum, and cveu rising fie fiigh io 
thm Boek aa tha luwer margia of the cricoid cartilage; it poshes forwards, 
Am thm aUenad, and afterwards the olavicutnr purtiou of tho Bteruo-nicutoid 
■aaala, and haa occasionallT beeu accn to extend into the posterior inferior 
iif the neck ; and, indeed, is generally mo«t ilistinully dcfiucd to- 
Ha braahial anpect. In anme cases no Uiinor rbefl into the neck, but 
tbaMBrnnm, clavirle, and cmtal i-»rtilng« uf tbe firat rib, uir found to be 
tbly [lu^bnl formint.'^ I>^y<md cheir natural Icvul. In the space 
thpri^ht Ktcnirr-rlnviciilnr articulation, and about the upjior piirt of 
■Boroam, tbrre vrill l>e dnliim on percussion, and marked pttluntion is 
Ml in tbe first inlercoatal npace. In very many in^tannes then' is no 
bat menty a strong impulse with the heart'H sounds, as distinct ae in 
I omtiac region, or creo more so ; but in other cases there may be every 

of broil. 
Prtasttre-effiwts. — The mo«t importaot symptoms are occasioned perhaps 
r Iba preaMrD-oflecta of the tumor upon the neighboring parts afiectiog tne 
llatt tbe Tenoua drcnlation. the nerTes, respiration, and oeglutttion. 
Tbe Pvlae 19 uMially iutlueoc*^!, h«)ng mtich smaller and feebler io the 
t»dtai aii^rr uf tli<^ sBected thxn of the sound side, and in some instaacce 
c<impW<ly arrested ; owio>;. doubilees, to pressure ou or occlusion of 
lanbdaviKo. The pnUatiou in the right carotid and its braaohea \a also 
inottly macb leas powerful than in the opposite veosel. Tbese signs corn- 
ier orenr before any external tumor is neeu or can be felt, and hence oon- 
ttitUbt aa imp->ruiot element in the early diagnosis of the disease. 

At&krfOMiit of tite Soperficial Yeiiia uf tbe neck and right upper ex- 
tremily is of frequent occurrence, the external jugulnr being the vemel that 
m MoaUy BfaC evideotly dilated ; at a more advanced period the superficial 
laeoos veins of the upper part of the right side of the chest often 
turtonuB and form a dense plexus in this Mtuatton. while manvanas- 
with the r^phalio and thoracic veins abnvft, and the superficial epi* 
below^ As the pressure incrcaaes, (nlemB commences in the right 
: aad band, and may speedily extend to tbe whole of the head, fiice, 
ana, wbidi bemme hard and hrawnv in ciin^aenoe of wrous infiltra- 
!■ ooetnauuire I have bc«o the lefV arm hcconiewddenly nDdetnatous, 
riM lift faiBoraioate vein being preaaed upon. In these cams tbe eyes become 
Marfaic and pmaioent. and the lipa, nose, and featum livid and torgid with 
blood, as w«U as odematoos, ao aa to alt«r greatly the expreasion of the 

VlalB of a dull aching character in experienced in tbe situation of tha 
Uuftor, froo) ihr oomprnwlon of the neighboring structure*. But in the 
atacea of tbe difteaae tbe patient oflen experience* sharp shooting pains. 
■pparMiuy of a rbeiimatic or neuralgic character, in the arm and the side 
m iW bead and fiiee. arising from prcasure upon, and irritation of. nerves 
' A* MffTical and brachial pie xu9r>>. Tnking the ooune of tbe ascending 
' daOMkdniff filamenta of tho cvrvicnl nlexun. the pain shoots up the side 
''iW band and neck, and over tbe shoulder and upper partof ihechnt; or. 
pnanra upon the brachial plexus, it radiates down tbe hand and arni, 
■Boally «mdalW atrare about the elbow and finger*. The muscular 
of tbe ripit arai ako commonly b«ooniea impaired. Persistent dilaia- 
of lbs nsaala, with swcatioo' of one nde of the face, occasionally occurs 
pnaaurr em tba synpathetie. 




183 



SPKCIJLL ANKURISUS. 



) 



Vt(. 4M.— ABMlritn <X lb* Innonitiiat* 
Arwrr oMBprflwInc fta4 itrttahlDit tb« 
Awartani LftrjngMl ^arT•, and pit»btiic 
ih« TrwbM i« Uie Un Sid*. (Buk 

VUw.) 



Oysposa i» or vt.>ry c'4>iiiiii<m occurrence, noii of vpnr v&ryiD^ dcvraaaf 
iuujuity, fruni fllighc <lifficuUy iu breathing up to faul a^ByzM. It may 

proc^d eitber fntm corapnaiioD of thie 
recurrent iicrve. or f^ftn prmura on 
the trnchoA. When tt dfr|»«'ndii on iW 
former coudiEtnn, the voice ia hoftn*. 
husky, or whup(>ring; and thera k a 
dr)', cmupr, oud paroxjmnal eomcli, 
iMually ftccofnpanied by expeecotmnn 
ot'litn Trttthy niuouft. fa thMo lanw, 
:ili. I ili'ath, (lit right r«curf«itt ocrra 
will \w fouixl In he 8tretc)»etl out and 
^reHlly ftiingnt^ \*y the prcMure of 
the tumor (Fijr. -l(Wj). OoinprMainai 
the trachea, which l>ecume« tial 
and curTe<I over V\ the left eidc bj 
the prolrusiou of the tumur, ia a com- 
mon cause of tlsypnogi. and is nnt 
unfreqncntly aaeuciatMl with prwura 
iin the reeurreut nerve. 

The luryngcal iiynpn'i'a in tlwac 

Rasee iw auulitgiiun tn that which oocnr* 

in ayrlic aneurisms i p. I7-'> i ; the odIt 

ditTerencc liein^. that in one case it » 

due to presiure opoti and paralTsi* of 

the muscles supplied by the riplit; in 

the other, of those to which the l«ft 

rccnrrcDt nerve is distributed. It ta the paralysis of the enco-arytencndaas 

■ticus musel« that is so espocinlly distreseing nnd daoKTous; for by h» 

ral^is ih« oorresponding side of the glottis is clowd. More mrrly by far, 

the right bronchua u oompreMed by the extennon of tbe tumor downaantt. 

Dysphapa \» of sufticiently frequent occurrence, and vAri«« from slight 

uneMdinvNi in deglutition to an impoeeibility of swallowing anylbiuu except 

fluids. I have never Men it occur without having been preceded oy dysp- 

[lltea; and, in everv instance that has fallen un<ler my ubeervation, it baa 

I BStociated wjih ]arj-tt};eHl <lyripna-a. The voinciiitjuce of these two aymp- 

_9nu if readily explained by the anatomy of the parts; the recurrent nerve. 

lying between tbe sac and owphagus. must sufler compression before the 

Flnticous canal be inlerlered with. 

PitOtiNOi^iH. — The prognnsis of brachiocephalic aneorisni is in the higbeat 
degree iinfuvorahlo, though tbe disease fre(|ueutly does not run a rapid coune. 
If it extend upwards and outwards, tbe tumor may nciuire a very large itia 
before any very important urgan or part is implicated ; but if it pnsa bactk- 
Ja and inwards, it may prove fatal at an early jteriiK). I know of but 
1 CB«e of spontaneous cure (rt')>orted by J. O^le j, and but few instances In 
which the rupture rif the sac has taken place. Tbe must frajuoit csose of 
death is BHphyxia. from apaflmodic closure or paralysis of the larynx Induced 
by prcMUre on ihc recurrent nerve; or from preaurc on the trachea. 

DiAiiMMttH. — The diagnosis of iriDominotc aneurism is uaoally euffleiently 
l«uty, if niK^ntlnn he paid to the dymptoras that have just been d«tait<^t. Hut 
U times the ditliculty i:i ho grrnt na to halUc the most sngacious Phy»iriatu 
and most cxperirm^d Surtrcnns ; ihnl whirh has during life hern considered 
* be an anirurisni of the innominate nrti^ry, hnving, atler death, prowl tO' 
one of the vummit of ihc H»r(ic arch rising up into the rotil of the nrdc 
behind th« right »temo-matito(d, or overlapping tbe brachioK-ephnlic trunk. 



TRKATMCNT Or INNOHIirATS ANRb'Riail. 



Tbe twk of overcoruitig this difficulty iti diaguo«U muet, he kfl to t)ie laot 
of tbe Surgeon. But it is impoa^ible tu uvercetimalc lU inipurtaiice, when 
the quntioD of li^aturiog the arteries at tlic n>ot uf the neck for a BUppused 
tDDotDlnalc aoeuriiiia it contciuptatutj; for, in ut tciift three c^sve in which 
thia operation bae been done, the an;h of thu aorta hint l>een funiul tn be the 
HAt of di»eR8c*. tlio iunoiuiimle in two of the eufm being unaflected by aneu- 
ram. I am aojnaiuttd nbo with a faiirlh vase, in which thn (ipemtion was 
eomateQced, bnt waa abandoned, an the oiiliclavian con Id not he renchpd ; the 
^HUient dyiof^ a fi-w iIuvm afterwardu, the iinciiriHni wag fonnd to he aortic, 
lieiu)^ up iulo thii root of ihe neck, the innomtnatf lifting sound. 

Treatmest, — Thi^re are several InHtant-PH on recunl in which a properly 
^Oonducit'd ivMirBe of riin.'>litnlii)nnl treatment has cured the patient; thus a 
'vase of Luke's waH permanently cnreil hv flmall and repeated bleedings, con- 
joinLtl «ith the adniinistnition of digitnlis. In connection with such treat- 
ment, diutal preoHure might be employed, as in a ca^e that derived benefit 
from this plan in ^^ynie't^ hands. 

In aneoriam uf tiie iunondnate, the v««wl is so short, and the sac so situ- 
ated, that it b impossible to attempt (o apply a ligature on the cardiac aide 
of the tumor. What resource, then, docs eui^ry offer in tlie*e cane* beyond 
tbe employment of coustitulional and dietetic means T It may be answered 
to this, that, if these measures fail in arnwtiug thv diseaw, our choice must 
lie between two alternatives; leaving tbe patient to his fate, or having re- 
ConrBe to tbe application of the ligature on the distal nide of the tumor. On 
Jookiog at tbe innominate artery with reference to the distal operation, we 
are struck by two peculiarities in the vcuel, which must necessarily rnoclify 
to a coosiderabie extent not only the s«at of the operation, but the principle 
i>u which it is c(inducte<l. The first pecuHnrltv to which I allude is the 
shortness of the trunk, which makes if impog^ible to apply the lic;ulure to 
the vet«el itself, but renders it oeceaaarv to dcligate one or both of its tcnni- 
nal branches. The olhei* peculiarity is, that in no circumstances can these 
Tcsels be so ligatured as to arrest the whole of tbe blood sent into the artery ; 
lor, altliougli the circuliiiioD through the carotid may be eotii-elv stopped, 
yet it is impossible, from the seat and extent of the disease, to tie the sub- 
clavian at any point except Iteyond the sealeni ; hence that blnod which ts 
deetlned for the supply of the branches of thJa vessel — the vertebral, the 
tfayr«iid axis, the iuUTnal mainmiiry, and the Rrst intercostal — must continue 
to be pro|)elled inui and thnuigh the ^ac. Throe distinct mii<lii!catioiis of 
llie distal "peraiion have been propKised and rc^^orted to for the cure of aneu- 
ntnm in thiHailnnlinn: 1, Ligature nf the Subrliivian alone; 2, Ligature of tbe 
Oarotid alone; and, ^, Ligature of Both Vessels with an interval of greater 
or leas extent. 

1. Ligature of the Subclavian only (Kip. 467) haa been practised by Du- 
puyiren, Wardrop, Ijangior, and Ilroca. Dupuytren's and I^ngicr's cases 
were soon fatal, and Broca'A experienced no relief, and died in six months. 
Id Wardmp's caiie the tumor diminished and the patient purvivcd for two 
years. This partial succeM may fairly he attributed in a great measure 
to the accident of the carotid having been occluded by the disease. The 
results of this pmctice have certainly not been suffiricntly favorable to 
jostify tlie Surgeon in repeating an atlempt of this kind, opposed as it is to 
Ibe known priucipl«« on which the dislal operation efipcts a cure.' For, 
soppoeing. as we may safely do, with Wardrop, that only one-third of tiie 

' TbP Tnhles of 0|)efationB for InnominaW ADcuriem given in fomiBr cdiilon^ have 
not beeD rvjitixlucnl, lu ll>c nutuWr liui m> Kt^utly iiii'n.-used 'jf l«U- }'<-»n m m msks it 
linpoMltile lo rvcord nil without uecup^ing too much tpiic«. 




JlL 



1S4 



SPECIAL ANKURISUS. 



, blood that ia Beut iatu the iDDotniDiite Bads its wav thivugh tlie cxtn- 
'tcaloniLl portion of tlie nubclaviiin, the rerimin<Ier being tla-ttiiiHii for iu 
brttuch«4 mid Uio carotid in eciual proportions, what &ot eao be ftdduoad or 
j}riociple laid dowD from which we cao expect to obUlD the cure »f an 
raoeurifim in otoe« proximity to the hoart, by cutting off for a short tliiw oolf 
•0 Bmall a proportion m one-third of the supply of blood sent into it!* Aa 
■oon as the oolliktoral Vfaacls have dilated, tnc flow of blood through tbt 
artery will bo the Aamc aa before the operation, as the supply of blood to 



.s-l 



2' 






.^^/ 



\ 



r^ 



Vig. 467.— Biiiohio-wpliallit 
AKaniitin; Llgilnrsaf lln 
SabetkrUn ooljr. 



Fig. Ill-il.— Br»ehiu-i<*phalia 
AoMBiUn: Llgatar* ii( tin 
CWtttid on I/. 



Pig. leU.— l;r>c]hliM<a|ibaaa 
Anoarttni; I.lgalmvnf Iti* 
S<ib0k*iMi N»4 C<nitt4. 



the upper limb Id maintained by means of the amutumoBea of the bnuirhea 
of the first and aecond part uf the sabclavian with Uioae of the azilfary 
artery. 

2. Xigratnre of the Carotid only ( Pig. 468) for innominate aneurism waa 
first p4Tfoni)ed by KrariH. in 182^4. The tumor diminished for a few dan 
afler operation, but ni the end of seven days ioflammatioo of the sac set ta« 
fi)llowed by obliteration of the arteries of toe right arm nod the branohM of 
the carotid. At the end of a year tumor still exiated, with oon^unt pulution. 
Next year the anc suppurated, and discharged much pua. iSinoe that tima 
the operation hai been repented by Mott, Aston Key, Ferguaeon. Huichin- 

laoa, Pirogoff, and tniUT othen, nmoanling in all, according lo llolniea, to 
iunet«en casei. In onlr one oue, that openuod on by Erans. does tha 
l^iseaK! appear to haro Wo matM-ially beoofit«d ; and in that inatADoe tbt 
[nod effects can tcnroety be attributed to the operation, bat most rather ba 
looked upon aa the result of suppuration of the sac and e>>u«equent oblitera- 
tion of the arteries of the arm and bead of the aflect^t) aide. Key's patient 
died in oonwqueooe of the left carotid becuming occluded and the brain 
being depriviHl uf ita profier supply of blood; and in several olber oaaea 
death is refi-'rrvd t>j hviiiipleiria an<l other cerebral diaeasea. 

3. Thu Carotid and Subclavian Arteries (Fig. 4439) were tied simultane- 
oufly for Ibe relief <}f iiinnuiinale aneuriitm for the first tinif bv Rnwi, in 
\SA'i, but there is some doubt as Ui the partuf the artery to whicli ihe liga- 

Iture was applied. -Since that time the o[M!nition has been perforoied ny 



TREATMENT OF INNOHINATK AKBURISH. 



185 



DurhAm, Hulinm, MoCarlhy, Weir, Liaiie, FVIlijck, Stiiiiaon, Littl«, Lnngley 
Browue, Harwell, Berjj;inHiii), iiiitl ullien. According to Holrne!;. the toUll 
aumher of caxea up t» 1S82 iimounted to iwcnly, tij which Bergmunn'e caee 
must be mMed. In seven vtmets murked improveinvnl foljovred the riperntion. 
^timson's patient survived the operuliim tweuty-oae montha. Four in'>nth3 
«ft«r the aperatifiD he was Huddealy attackixl by left homiplegia and itpliasiit, 
after whicfi the tuomr diminished in sice rapidly. He partiuIlT recovered 
m the p«ralysls. After death the third part nt' the subclavian and the 
id were aficertaioed to be obliternted ; the eac of the nDeuru'>m was 
■lioat tbe»ize of a hea's egg, and commijuic^atcd with the eubclavinii. nil the 
braacfaes of which, except the ioternai nianiniary (which could Del be found), 
were patent. Little's ca&e lived three and h half years, dyin^; at tuet of 
pleunsT. The aneurism was prnctically cured, but u channel exited through 
It to the tnbelavinn. Of Barwell's four cases, one died from the aniesthetic, 
and three were auccc^ful. One died three months aAer the operation of 
broDchilie, and the second died two vears after at^o of bi-onchitie, and id 
both of theec the disease wns practicallv cured. The third remains well up 
to the present time. In Browne's nnd Bcrgraann's cases the improvement 
eoDtiDued up to the last report. Of the fatal cases, four died from rupture 
of the sac, one from hemorrhage from the ligatured arteries, one from shock, 
<one from hemorrhage from the sac, one from cxhatitation.oTte from uaphyxta, 
e frum the anawthctic, two from the unrelieved progress nf the ani-unsm, 
and in two the caDM of death was doubtful. The operation wan attem|iled 
in another caoe b]^ Cheveni, hut the subclavian vein waa wounded, and the 
patient died in two liouRi. 

The carotid and subclavian have alan been tie-d conoecucivelj at intervals 
varving from two years to one month, in six coAeia, bj Fefirn, Wiekham, 
Malgaigoe, Mott, Bickersteth, aud Admue aud Treves. lu nl) cmw the 
carotid was tied BnL lu Feuru's i;aee two years elapsed between tli« opero- 
lionij, and the patient died four tiiuuths after the eubcLuviau was ti«d, of 
pleurisy. The aneuriam wa« found to be C'>u8<didated, with the exception of 
a channel leading to the subclavian. In Wiokhum's case relief fullowed the 
ligature of the carotid, but syuptoms soon returued, und the subclaviau waa 
tied about six weeks afterwards, but without eflect, thu patient dying iu two 
and a half months from rupture of the sac. In Mott's case a practical cure 
reralted, the patient dying <jf phtliiijiH tbree yeam alter the secoud operation. 
Is Adams and Trevea's case the aueiiriem wa« coaeolldated, but death took 
place 108 days after the second operation from rupture of the sac of an 
aortic aneurisoi. In the remaining ca»ee no bencnt was derived from the 
flpefatioo. 

A r^jnmi of the oases of aneurism of the innomioate, in which the opera- 
CioD of ligaturing one or both arteries beyond the sac has been performed, 
having thus been given, the question arii<es whether tliesu operatione), or any 
of them, should retain a place in surgery. This question niny be examined 
from two points of view: 1. A^ to the principle on which these operations 
are performed ; and, 2. As to their results in practice. For the auocess of 
the distal operation, it is requisite that there be no branch given off, either 
from the Hic or between it and the ligature; or that the current of blood 
tbpMigh the sac be at least so far dimiiU!<hed as to admit of the deposition of 
laminated fibrin iu sufficient quantity to fill it up, by o process similar to 
that which hBp{>ens in a case of ititeurLtm treated by the Hunterian method. 
In order that thi^ may be accomplished, it is certainly neceasary that the 
^^breater f>orti'in of the blood paAsing through the sac be arrested ; for. if the 
^^^arrent that i^ still kept up be too free, the tumor will continue to incrPA«c, 
W ta vn have seen happen in ctaen of inguinal aneurism in which the femoral 



^ 




from the brftchii>cenbalic, as tb« subcIaviMi] beyoud the MCftl^iii, be tiot), and 
btit a third of the olood circuiAtiiig ibruu^h Ihu msiii iirtt-ry hv iirru»l««1, 
»r« we jusliGud in hopia^ that the uirtiulutiuu tbruugh the sac will be 80 
intliienced by tho dtveratou of this stunll ^uHutity, IbuL liiu rvniaiuing inu- 
Cbird« of tht> bluod, which wiJl elili piuus thruuuh fur ihu supply ut' Lh« 
canitiil uud ihu Liraucht» oi' tht; subolaviua, will gradually depueit tbueu 
fibriuuus latuiosu by which uhltterucioa of the lumor is tu be ofTected ? 
Should we nut ruther eipect that the larger current will be too twwerful to 
allow the rormatioQ of these layers, aud will continue W distend the sac in 
aucb u way aa to prevent ita coatractiou? Surely, if the comparalively 
auiall nud feeble streams of blood that pass through the epigHstric aud otrcuni- 
Qex ilii, are sufficient to interfere with the cure of an inguinal aneuritiui al\er 
the distal ligature o( the feiuoral. theetroug current that sweeps through the 
carotid and the lar^'c braDches epriiigiog from the «ubclnTiao, with the full 
force derived from chise proximity to the heart, will nvoet probably be suffi- 
cieoC to prevent all lamiDation 10 au aneurism of the innomiunte. That the 
arrest of tlie circulation through one of these ve^els only is not sufUcierit to 
iuSuencc materially tho growth of the aneurism, is evident likewise from 
what is not unfroqucntly observed after death in ensc^ of thU kind — one or 
other of tho vcoscla being fu^ind compressed and oblitc-rated by the pressure 
of ihc aac, or pluggefl by fibrin, and yet no alteration in the tumor resulting. 
Theae cmtt, which arc tolerably numt^nms, would of themselves have been 
sufficient to prove that aomeching more than tbiji amount of obstruction is 
required, in order to effect proper stratification of fibrin in the sac; and if 
w« turn to the result of the twenty-three ciisex in which either the carotid or 
the 8u))vlaviaD has been ligatured, we shall tiiid that in one cuHe only, that 
ojiernted on by Kvans, of Belper, has a cure been e fleeted ; and in this 
iDStauce how was it accomplished? Acconling to (be principle on which ic 
WAS attempted to be establiiibed? Certainly nut; but, ae will be seen by 
attenlinu to the details of the cnae, Mid as has already been pointed out with 
much acuteoo^s by Oulhrie, by tb« accideotiil eetling up of ioHammatiou, 
which extended to the »ac, and thus obliterated it. 

In the c««e (that of Mrs. DeumMrlt)iu which Wardrop tied thesuliclaviao 
for the cure of nneurisui of the brachio-cephalic, there is eouie reason to 
doubt whether the iuTi.«t of the pmgreiss of the tumor w»a owing to ihe liga- 
ture of the subiOuvian artery, or whether it was nut much iulluenced by uie 
ob«lruction which exiittcd iu the caruUd for uin? days utU-r tho Q)icralioa, 
during which time so abundant u de|Hit;it uf laminated librin might have 
occurred an to arm;t the progrtiis of tbu dtaeaMj for Home leuglh of time. In 
ihia cuire, aliro, Guthrie t^uppoeis it probable tliat the intlamnmtiou of the 
tumor niiiiht have IhI to it^ obliteration. 

From a careful considenilinu of all the circumstances of the cases in whirh 
ligature of one ve(«el only, either subclavian or carotid, bat) been employed 
fur brachio-ceplmlic aneurism, we arc, I think, fully jn^titieil iu vuncluding 
that in sixteen of the ca^es the fatal rei^nlt vas Hccelenited, occurring as a 
oonsequence of the ligature of the vessel; in three the progrees of the uisGue 
WH8 not materially interfered with ; in two it was arreatetl, tiie patients living 
for iweniy months and two years respectively; jn one the result wa3 uncer- 
tain, and in one case only the disease was cured. The improvement in two of 
the case» was the result of accidental cireumstnDCCs, which were unexpected, 
and unconnected in any way with the principles on which the operation was 
undertaken. These results would n<it, in my opinion, justify eny Burgeon iu 




INNOMINATE— RESULTS OF TBBATllliNT. 



187 



•gain miikios bh attempt to cure an innominnte aaeurism by tbc iif^ature of 
eitb«r the BUOclavJRD or the camiid arttrv aloue, tlic patieot liaviuji; been 
dirTWtIv killed by ttie operatiou id two-tltirilfl of llie ciiBe«. Of tlic rumniaiDg 
tliinl, iQ uo«>balf the patieuu reojvered from the operalioo, but lUc <iisc-uw 
nn it* coune as if ouauch procedure had been adopted; aud iu tbo rctuaia* 
ing aleader perceuuige of cases the improvcnictit tliut took place tu two, and 
Uw cure ID the ooe Holiinry iusiAQce, were due to accidcatal drcutnitlaucee 
unconnecieil with th& operatiuQ, and which ooD^ueolly might have devel- 
oped equally if none bad been performed. 

We have yet to cnoHtdcr the opcmlion io whieh both arteries are ligatured. 
ThU double operaiioti may cithur he performed with an itUen'ai between the 
opptitntion of the ttoa (igalurei, suflicicnt for the i-stablishmcut of collateral 
ctrrulauon ; or the two vceuels may be licatured Hioiullauuouxly. The former 
plaa baa beeo ado]ite<l in »ix cases ; the latter in twenty-one; not a sufficient 
luimher for any eufe deduction. Of the eiz cases in which au interval inter* 

med b(>iwei->n the iwo o|ieration9 the tumor s^^ems to have been ]>mctica]]y 

red in three, in two cnnea do relief was obtained, nnd one died directly from 
the operalioD. In the twenty-one cflKe* in which the vesAela were ligatured 
simultaneouHly, dfiith took place directly from the operation in four; the 
iliaease waa nnrelieved, and terminated talAlly in eiRht; in two the cause of 
death isaoroewhat uncertain, and in ^ven K'^at benefit oi- a praclicnl cure 
ll«d. It is intercf'tin); to note that the later cn^es have been the most sue* 
iful, and it w reasonable to hope that this i« due to modem improvements 
iSb the methods uf tying arteries and dre«»ing wounds. The case-i, however, 
are not yet euflicieutly uum«rous or fre« from modifying circnniittAncea 
tu enable as tu draw any certain inferetice from them : we muat, therefore, 
rrvert to (be prinriplu <iii which thia o[>eration should \m uiiJer[ak''n. This 
will ditfcr materially, ucconlinp to whether the two ortcritx are ligatured 
■multaneously. or with a sufiicicDt interval for the reeiitahliHiiment of 

llateral circulalioo. 

If an interval of two yearti, as in the lir^t oaae, or even ot two and a half 
Lho, as in the second instance, be alloweil to elapse between the llgiiture 
of tiiD carotid and that of the subclavian, the opemtion reduces itself essen- 
tially to that of the ligature of a ^iu^le artery, which, an has already been 
fehowo, is iusufficicDt to induce those changes in the sac that are neceti&ary for 
the accomplish men t nf a cure. If [he pulient survive the effect of the liga- 
ture of the carotid for a few weeks, sulbeieDt time will have been afforded for 
the proximal end uf the subclavian, the vertebral artery, and the thyroid axis 
to lake upon tbemaelvcoa great increase of development — the collatemi cir- 
caUtion bcinj; rarried on by them and not hy the \ei\ carotid ; so that, by the 
time that the subclavian comes to he li(;atureil hevond ibc soaleni, the sac will 
rtill continue to be traversed hy a current of blood for the supply of the 
branches of the wihclavuin, dilated beyond their nnrnml size, in consequence 
of the iftjik nf Kupplyin^ the ripht side of the neck, face, head, and brain 
heiof; priacipally thrown upon thpm. This current through the proximal 
end (if the subclavian, increased a^i it will have been hy the whole of that 
blond which is destiiiC'l lo supply the place of that which should pnw by the 
tarotid, will pince the sac in nearly the same condition as it wiis before the 
Ujpiiure; nnd will consetpiently, for the reawn that has already been givoHt 
b« too powerful for a cure to lake place in the course nf it* atream. 

It now remains only for ue to consider the »itnuttanrouM ligature of both 
Tcswl« — an operation' that has been performed for innominate nneurism 
twenty-one timeo. Iu rensouiii}.' ujkiu the simuItanetHts ligature of the twr> 
vaiteU. we must consider two points; 1, !n what coiuiitiou do we place the 
2, Is the danger of the patient much increased t 



188 



SPXCIAt. ANEURISMS. 



fta for u the MO is ooncemed, it is impoanhlc to plue it in a hector oaodt 
tion for th« d«poiit of Uminited fibrin; two-tbira« of the blood flitwiag 

tlirouffl) it b«ing iirn?«t«d, iind that only tnivemn); il which ii •!' ^'^ 

tb« »U|>{ily of the Ijnincbo^ of the siibclavina. It is hy uu mttat.-^ •»- 

ble thill even this strfum miiy yet bi? too large and furcihli" to nliow thv |tro- 
ocm iif nccliision in tnk« pliic«, v«l it is intpoteible sLill further In <)imini>b 
it ; ami if tb(> unuurium be uicculati'd, ani] project fmm one niiJe of th« in- 
nominate arlery, pHrticularly to it^ inteninl or mesiial aspect, it il by do 
means imponible that it may be sufficiently removed from the atroftm to 
allow ooosolidatioi] of its cootenbi. 

Dooa it add to the danger of the patient to ligature these two roHels sim- 
□Itaneously rather than separately 7 I think noL If the risk of a douUa 
operation is to be incurred, 1 caanot think that it would be poaitiTely ia- 
oreased by the two being performed at oni-e. instead of at separate intervals j 
the whole of tbe ves^elii that serve to maincaio the oollat^ral circulatioa id 
the head and upper cxtri-niity being lcl\ without iotorferenoc. And tlw in- 
sult that has followed the limited number of these operations corroboralci 
the justice of tbis opinion, for we find that the paiicDts reooTered from tba 
opcralions in fiileeo ool of the twenty-one cases. 

The result of these fifteen caaes, so far as the a&earinn itaelf waa wa* 
corned, vm not altoeetber iinoatiufkctory when tbe othervise hoprieat natars 
of the disease is taken into consideration. In acvcn the pauent derived 
fpreat and unmistakable benefit, and in the remaining eight there is no rea* 
son to believe that the operation hastened the progress of the cose towartb 
death. .^ far, then, as actual results go, it it evident that the ehane«a are 
decidedly against the patient's deriving any benefit from tbe operation, and 
at the same time it must not be forgotten that aneuri-ima of the innominate 
artery have been cured by palliative and oonfltitutional treiiimenl. It does 
not seem ju)iti6able, therefore, to reaort to the dixlat ligature till thnse meaaa 
have bad a fuir trial. If, however, rest, diet, and ineilical treatnient fail to 
arr«^t the progrew of the disease, tbe amount of sucoess obtained from oper- 
ative iuierlereuce has been quite sufficient to enoourge a repetition of it ia 
weU-celected com*. 



I 



ANBOSIBH OP THE CABOTID AUTUKY. 

Aneorismal Tarix of the Carotid Artery and of the Jngnlor Taiii,] 
the rt-iiuU i^f punctures and stabs in the nrck. has b>ecn iiii^t »itb in a st 
cient number of instances to establish the Higns and treatment of such a 
condition ; and au instance is retate<l by Mackniurtlo, in which a communi- 
cation WHS e«tablii^hed bvlween tl>e«>e ve»«eU a« the result of disease; but I 
am not aci|uainteii with any case of Varicate Afieuri«m uf lbi«e vcfksels having 
been recorded. The Sigyu of aueurismal vorix in this situation prtwnt uo- 
ihiug (leculiar ; and the Trmtmcnt must be entirely of a hygienic- cbanu'trr, 
no o|>enilive interference being likely to be alteude*^! by any but a fatal 
rteult- It is the more d««irable not to interfere in these coses, a» the disaiM 
does not ap)icar to thorten life. 

Spontaoeoas Anearism of the Carotid is oot of very unlrequrot oooiu^ 
n-ucc: ill i'rmp's Uiblu ut' 0^1 uiifunHms, 25 were of tbe carotid; aad It 
ranks in unler ui frequency between those of the abdominal aorta aad of 
the subclavian. It occurs more frequently in the female than any other as- 
ternal aneurism : thus, of tho 'Zo cases alluded to, 12 were in women, owing 
probably to it soldom being the rwutt of violence, but geuiiraihr ariiiiag 
mm diaeaae of tbe coaOi of the venwi. In Hnlmes'a table of S87 anea- 
rlsms, 11 were of the common canitid, 10 being spontaneous, and 1 trnu- 



riA 



mi COMMON CA] 



189 




Bfttic. Three of the former were in women. This aneurism in alMmnuk- 
kble OS occurrinfi; at efirlicr sta^i^ than nii^sl others ; thus, TIodf>90il ItaiMta 
it in a girl of ten ; Sykes, of Philadelphia, iti one of eij»hteen ; C. Tltrath, 
in A woman aged twenty-three (external carotid), who was suffering from 
eiteiiBive dtACAM of the cardiac valves. The right carotid is much mure 
commonly atiect«d than th« litft, and the upper purLiuo of tfa« ve«»el than 
the lower; indeed, th« bit'urculion i« iJie most couinjon wat of aiieuriHiial 
dilatatiou. The root of the right carotid not iincumnionly is dilated ; but I 
have never seen or hwird of a caeu iu which the left carutid, before emerg- 
iti|! friim thf vh««t, lin» l>ecu atlected. 

SvMVToMg, — A carolid aneurism io the early stage presents ileelf as a 
uiiall. ovoid, t>iiiuutb tumor, with distinct puleatiou and bruit, and n well-cir- 
cumscribed outline It is communly soil uiul ciuuprviwible, dimiutHliin^ lu 
•is»t>a prtwur«, aud expanding again with the ii*ual aueurisuial dilal^itiun. 
As it iDcreaaev io size, it becunieB more solid, uucaaiuue sbootiug paii>s iu the 
ikMd ami UL'ck. and, by its pressure ou the pbnrynx, ccsopbagus, aud larynx, 
{noduoca diUJL-ulty in deglutition and rcRpiraciciu ; Kuuctimeit lIi6 Hilivary 
glantis are much irritated. Ailer a time, the cerebral circulation bbcouiea 
inlerfered with, giving rise to giddineos, Impaired vision of the curres)K>uil- 
ing eye, nt^ses in the ear, aod a tendency to xtupor. These fiympt«)iD& may 
be oving to compreaaion of the jugular, to diHiculcy iu the tranFmiiviou of 
the bluod thrvugh the tumor, or to irrilation of the cervical ganglia of tlie 
pathetic. The ^ixe that the^ ancurisme may attain varies greatly; 

-illy tbey are coufined to the epnce under the angle of the jaw, but not 
,_ .fimuently they occupy the greater pnrt of the side of the neck. If they 
he allowed to iocreoiie without inlerferenoe, 
death may happen, either by rupture cxtero- 
allj, or into ttte pharyn^c or <i«i>phagUH; by 
Mphyxia, from prcasure on llie larynx or reeiir- 
RDt nerve ; or by fttarvatiou from compreseion 
of the ceeopbagus. 

ADCUrianis of the carotid are uttually of oloir 
growth, and may aometimeti exiflt for a consider- 
able number of years without giving ri»e to 
any special inoonveuience ; thiti iii more particu* 
tarty the cane when they are seated at the 
bifurcation of the arterj-. I have, however. 
teen a ipontaneoun aneuritmi in this eitualiim 
attain tbesiieof a)>mall orange iu a few weeks. 
When at the root of the ucek, tlicy are more 
likely to be attended by iujurioutt pritu^ure- 
etlecis at an early pericKl. 

DlAUKOsit;. — The diaguoeis of ciirutiii aueu- 
risoi is without doubt laoni dilUculL than that 
of auy other form of external aueurieui ; the 
best proof that this is so, may be found in the 
ibet tuatfOf the cases in which Liie carotid artery 
bM been ligatured fiw suppoeed ancuriHtn of 

it or its bmncbee, in several iat^tanrce no t^uch disease existed — solid cysts, 
or otliCJ tumors of the neck having been mifliakcii for iineurism.and this by 
Sorgeons of great ami acknowledged repute. 

The diagnoeis of aneurij-m of the lower part of the carotid from timilar 
dueoM of iriher arteries at the nxit of the neck, as of the Buhclaviaii, verte- 
bral, and brach to-cephalic, aod the arch of the aorta, is surrounded by diffi- 
oukiea, which can be cleared up only by a careful istethoscopic examioatioD 




Fife- ITO.-'Anouritinof tU«8uiD- 
■nil <if 111* Aruh of Ik* A»rtii, 
■iinnlKticif 0*iiiUd ADeurUin. 



190 



aPBOIAli ANKUUISHS. 



of the pan. In some ftueurl^uiA of thu arch of the aorta, the aae riMi up 
iaio till- m-rk, so as closely to aiitmlatc a raruUd aneuruin, as Id the anpccwe 
cut (.Fig. 470); and this greatly ioereases the (HBiniltTof tb<> dingnocJa. la 
mich ca«M, Halmes suggests that the effect pnnlurcd by carnfuTly applied 
difttal pnwitiro may aid in the diagnoBiB. If, aflfir a i'evr Iiouni, whrn tn« cnl- 
laiernl circtilation nhouM he commencing Co onlarg^, the aac shows no pigas 
of diminished tetiMon, the case in very prohnhty one of aorlin aneurism. Tbt 
principal atfections of the neck, however, with which aneurt«ni of tb« carotid 
may be confounded, are varix of the internal jugular vein, fiolarged lyiDptuitic 
glands, ah«c«m, tuniore, cvstt in (he neck, and pulsating bniocnoc^lc. 

A diUiUd oTtrry doubted u;wn iU/tif may oUisefy rc*«ml>l« an aneurism wbcft 
situaltxl at the runt of tliv n^k. tMich a ca»e i« r««urd««l hy C<>ulsuo, It 
occurred in woinau of ISti. Nu treatment whs adopted, and aflt-r di-mth tl>s 
supposed aucuriiini vras found to be a reduplieatiuD of tb« commoa carotid 
flurruundt-d by iutliiratcd c«ltulnr linsuv. _ 

From ran> the diagnueis niny rcndily bv made by attenliou to lh« fulU^^A 
ing circu mdlunctw ; that in varix Lhc tumor is always eoll, does not puIH^^H 
expanMTcly, and diinini^hts in size during a deep URpiraLina, and ua 
prcffiing tht' vein on iu distal »ide. 

Glawuiar tumor* of Uie neei: are ollnn very difficult to distinguish fi 
aneariun, more particularly when the ariery paHHes through and ia embracad 
by the tumor, so that the whole mns^ di-tlinctly riovh at each puli^utiim. In 
these coMti also there may be an apparent diminution in the hixc of the tumor 
on compreasion, by the artery within iL being emptied, or by the growth ra- 
ceding luto some of the interspaces of the neck. But in the great majivity 
of insUnoes, attention to the globular, oval, and nodulated fed of glandular 
swellings, and the nossibilitr of raising them up and pushing them awar 
tfom the vessel — which may Iwst be done by feeling the cnri>tid with the hkh 
of tbo fingers of one hand, and then pressing upon the tumor with tha 
—will claar up the true nalurc of the case. 

From ab*K$te4 of the ntek the diagnosis must be made on general princi 
The coexistence of ill-defiued har^luess and (;ulargen>ent of the gtatids, _ 
inflaraod state of the skin, the ready detection of fluctuntion, and Lhv nbseoet 
of expansile pulmtiou iu the tumor, will show thai it is not Hm'urismal, how- 
ever nimiUr ita other ch»ractera may be. It is ofimportaDceto obaer w alts 
that an aneurisoi that tiucluatea is always forcibly distended with stnM 
pulsation, and can be materially diminished by pressure, neither of wbicii 
circumiitances can pouibly occur in abscess, liut if abscess may be mis- 
takea for aneurism, the conveive also holds good ; and au aoeniwn may, 
unless ciLre l>e taken, be mistaken for abscess — a far more fatal error. Am 
there is one variety of false aneurism, that to which T^iston has invited speOal 
atleutioD, against which the Surgeon muiit be carefully on his guard, oo 
account of the many points of resemblance between it and aneurism ; I mean 
tha case iu which an artery has given way into the mc of an absce*. In ihit 
ciMi fluctuation and pulsati^m will exisi, ultbough not perhaps of a dii>tesd- 
ing kind. An important diaguoslio mark will be, however, that Uie nuUioa 
of an nneuri^m is di^tiueily ileHnul and limited, whilu that of an aheeeM 
never is. Aneurism of the intamal carotid has been found hy 8yma to 
nmulatc very cIomIt (Ateeu of the tontiU. 

J\tflUfn of various kinds — (!a^t';illomatou^ fatty, and fibrous — m»occar lo 
the neck, and rtiuse Hume little cmbarrassmmt in the dtsgnnais Iron anen- 
rlsm; thus Li»frBnc.O'Rcillv, and Kerr, ofAberdMD, hav« rvcorded csMifai 
which the artery* has been tignturcd in such case* bv mistakfi for aneoTiBm. 
Tile diagoosla of such tumors as these muiit be efiecte^l on ordinary pHndplca. 
1 have in several instauce* met with a small, bard, distinctly circumscnbed 



eHKM 

Meoet V 



LIOATURK OF TUB COMMON UAROTID. 



191 



tnnior lying ilir*cily upun the carolici artery, and apparently ooDaected with 
it, and rt^ct^ivin^ pulmitiun from it, imually prottuced by a fit of cougtiing or 
Iftugbiag. TbU tumor, with the true nature of vih\ea I nm unacquaiatcd, 
nouiins stationary, and doe« imi require any operative iuterfereuce. 

The thyroid Uxly is not uufrequentl; the seat of eDlurgenienls, that hnvo 
b«ea mLitakea Jbr aneurism. These cotwtst chiefly in a circuit] acribiid enlarge- 
ment of one lobe of the gland, which extendi laterally over the conioinD 
carotid, and receives pulHition from it. This kind of broDchoccle luay he 
dtagoofted from aiieiirieni hy the communicated pulsation in it ceosini' when 
it IB raised from the artery. The most puzzling cascg, however, and tnoBc in 
which mistaken mar most ea^ilr he mndc, are instances of pul»'ding bnncho- 
^eie, in which these tumors have an at-tive anrl indepcnrlent pulsaiiuii or thrill. 
Id these iostance*, however, there are three ]poinu that will almu^t invurr- 
ably enable the Surgeon to eflc-ct the diaguosia. Thus the tumor, aUhrnigh 
principally cuntincd to one lateral lobe, ulwayi* aifi-'cte the i^^thinua more or 
MB. Then again, in brou(':ho4-t;lt>, tfiat portion of the tiniior ie luo^t tirinly 
flxad which stretches towards the rawiiftl line; whilst rn cnrotid nncuri*mihe 
fimest altachmtnt is undftr the uterno-majitoid muscle. The third point of 
dlflference is that, on dt^iring the pati("nt to make an effort at deglutition, the 
eatargcd thyroid body movps with the larytix and trachea. Ckfstt iV. the thy- 
-raid body are of more common occurrence than pulsating bronchoc(^te«, and 
«OBWCime« equally Hiriicult of diagnrv9iii. Dupuytren ha.4 pointed out that, 
when these cy3t« are tapped, the pulsation often ber^omeo stronger, and the 
duid, which on first flowing is serous, may at ln<)t herame pure arterial blood, 
•u that the Surgeon may snsppot that he has punctured an aneurinm. 

TREATtarsT. — Digitid Compression ha* of late ypars b(vn siirreiwfally 
«lDpb>yed for the treatment iit' carotid «ne«ri«m. A cai^ of aneurism of the 
401110100 carolid arterv, cured by iulcrnilLlvnt digital cumprerwiuu, has been 
recorded by Routce, ot Lausanne. The imtieut wu8 n male, aged 68. Com- 
prcBsioo was nunJe by placing the Ihuruu against tbb anterior «<lge of th« 
sterDo-maatoid and the next three tingere under the ponterior edge ut' the 
muscle; the artery was thus seized and i,-oiupn»Bed. This avoided any preo* 
core on the pneumogastric nerve, which waa supposed to he the cause of the 
paio usually produced by attempts to compress the carotid. The compres- 
noo was applied for seventeen days during seven or eight hours each day; 
sjid at the end of the time the man was cured. In addition to this, Uolmes 
haa Qollecte<l four successful cases by Sheppard, Kerr, Humphry, and Gay, 
and two uosuccecvftil by De Castro and Delore. The pressure should, if 
pogeible.beapptiedabovcthe transverse proccm of the eixth cervical vertebra, 
80 as to avoid oomprea^ng the vertebral artery at the same time. 

Li^tnre. — Since the time when Sir A. Cooper first ligutured the carotid, 
in 1805, the mettns on which tbei^urgcitn alnK»taIwaye relie.^ for the cure of 
&neurii?m of this vessel ia dcligation of the arl^ry at a dislnnce from the sac. 

When the aneuriitm is w situated that a sufficient extent of he4ilthy vessel 
•ntB betwt^n the etcrnum and the ba>>oof the tumor to admit of the applica- 
of a ligature, the Hunterinn operation may be prnctieed. If, however, 
root or lower portion of the artery be so involved that there is no room 
Uo apply the ligature between the heart and tbeaeatof the diseaw, the distal 
'aperatinn may he performed. 

Ligature oif the Carotid. — The patient must be placed upon his hack with 

B shoulders supporte^l by a pillow, and the head allowed to fall bnckwardi 

as to put the aterno-mnstoid slightly on the stretch. In the later stages 

the operation, the head musi be bnmght a little more forwards to allow 

lite muaele to be drawn outnardH. If brought too much forwards the artery 

ima* relaxed, and the difficulty in paining the needle is increased. When 



lfl:i 



SPBCIAL ANSURISM8. 




thfi 8urgeoD can choose the scat at which to ligature the artery, he oiiiallT 
BolecU uie part ot' thv vemel which biKct£ the angle formed hy tbr aulrriur 
edge of the slerno-mBHtoiil with ihe omo-hroid niueele at the level of the 
cricoid canilage. The course of the nrtcry is markod hy a liue tlmirD fintn 
Cho ftAmo-clnvieular nrticulatioD to a point midway betwe«D the mmgUiii 
proocH and the angle of the jaw. The practical gnidlog line during the 
opcraliou 18 the anterior border of the itcmo- mastoid, which forms the fim 
rallying point. The artery U reached by making an iocieion about ifam 
Lnchee in length in this line, the middle of the wound being opponte the 
cricoid cartilage. After dividing the akin, aupcrBcial fascia, and platyitoa, 
with the branches of the superficial cervical nerve, and the deep ecrirical 
fascia, the fibres of the stcmo-matttoid come into view ; the inner border l» 
easily found, and the muscle turned outwards. The second rallying point it 
the upper border of the anterior belty of the omo-hyoid. To bring this into 
view, tne layer of cervical fnacia forming; the posterior part of the sheath of 
the alerDo>mHhtoid ntuet be di>«8ectcd through, taking care not to wound the 
desccndeQi! uoni nerve, which usually lies imucdiatvly beneath iL Wben tlM 
muscle ie found, its upper bonier iapuatieddoMUHardji with the baodlaof t^ 
scalpel, and held out of the wav with a blunt hook, and the abesth of t h» 
veaeela then corais intuTicw. The Surgeon now prwseihia finger 
towards the bodice and iransverec proc«aaes of the cervical vertebne. and 
artery will h« felt rolling under the finger over llii.- Ikjuc. and iu exact 
lion i£ thus easily aj>cvrtaiiivd. The vtisscl is eucliHHnl in u shrath of cer 
liiscia ouaiuiun Iu it, tlie intoroal jugular vmu, and the puuumogaalrii; nem. 
This fiheuth is dividtil into three com[>artnienla by dbilinct libruua aepla, and 
it is imporlant to ojivn the mwt intcninl of those, in which the artery liea, if 
poaHibte without dii'turbing ihc others. To do thie, the common sheath muA 
be openm] well t^) the tracheal side, aa the oonipnnment for the vein is mud) 
larger than that for the artery, and occupies the greater part of the anterior 
aspect of the shejith which is expoeed in the operation. AlUr opening the 
common aheath, the special sheath of areolar ttasue surrounding the arleiy 
mu&t be cjireliilly divided until the white external coat ootnes into riev. 
The needle is ttien passed from without inwards (Fig. 471), U-iwetn the 
special sheath and the external coat, through lb« looae areolar ti»»ue naturally 
iound in this situation. If the veeacl be properly cleaucd. it is iilm<«t im- 
possible to wound the vein or pick up the nerve* If, however, the wroog 
oonipurlnient of the common sfavnth be opened, or (he special sheath not 
properly divided, either of thv^ accidents may h«ppen. Almoet all the 
accidenis which may liapt>en in ligature of the carotid arise from one of two 
causes, either drifting too Jar outwards in the deeper part of the inciaioo, or 
not cleaning the veeael sufficiently before paaiing the needle. In ca ia of 
aneurism the dilhculty is ofleu increased by the proximity of the sac. nad 
■ometimL-B bv iuOuuimutory thickuuing of the sheath. In femalea tbe tdgt 
of the tliyruid body may overlap the artery, and precent a somewhat pui '" 
appearance when exposed. Iu performing the operationsnlKtatiuieiju» vi 
are occasionally wounded, which may bleed ratlier freely ; if so. they sbonl 
be ligatured. If theoulerconiparlmentof theeheath is accidentally u[>ened, 
the jugiilar vein swellei up so as to obacure the artery, but all difficultr firota 
this source will cease if it he drawn oride by a rclnicirir, or repressed ny the 
■Mistant'e finger. When this happens, it must not be Auvolten that the 
proper compartment of the common sheath, and tbe special ahcflth of th« 
urter^ , have both to ho opened before luuung the needle. Tbe MMuno 
gaatnc nerve should never be seen, as it lie* deeply behind the TcaMia. 

After the operation the patient should be propped up in bed with the bead 
forwards, in order to prevent any strain upon the artery. Beat eao be Kill 



XIOATUBK OP THK COUUON CABOTin. 



198 



perftctly obtained by applying a Iciither uplint nioHl{ie(l bHore tbu 
itian Ui reach fruni the loins lo xhc-. back of the li<?a<i, and lo ovt^rJap ihe 
■BnulHcrs. It ran be put od iminediatcty after the operation, and worn for 
the ttrst two weeks. 

Ligature of the Carotid below the Omo-ht/oid becomee Deceeeary if the aneu- 
ram have attAined a very considerable size, extending low in the neck, aiiJ 
Dot leaving p«rhaps more than one inch of clear apace above the claviBle, 
Thf oj>er«lioii i» Wi^t performed by dividing the Bternal head nf the sieruo- 
mastuid cloM to it« origin. A V-flhaped iucision must be made, one limb of 




.^l 



Vlf. 471. — [ndfloo for Litttare wf tbe Carotid Artetj. 



rig. 4;2.— Di&grkm Af tht Right 
CotniBsn CAnlld ArUry «t Iba 
ivatof Ligaturt.p.t. platjima; 
«.•). itsmo-usMuU, (Irnwa to 
<iDa*lil«i D.I.viiKi-b7ciiJ,<lnwii 
dnvmrarili aod Inward*; (.A, 
wlornn- byoid ; n. tb« trim J ; 
f . laiamal JogvlAr fdn ; d.n.u. 
dMc«n<l«iii noni oarTa. Tba 
pDAumuEiutHi! Ua«t >e«D, a* it 
ll*( bablad tlia vaxaU, 



which correapondfl to the lower two inchee of tbe inner border of the stemo- 
mastoid, and the other to the inner two inches of the clavicle. The inclsiona 
ire deepened till the muscle comes into view, the inner head is then divided 
and turned up in the V'hnped flap. The second rallying point is (he edge 
of the sterno-hyoid. White searching for this, care must be taken not to 
wound the anterior jugular vein, which cromffa th« niuvcle transversely on 
iU way to join the external jugnlnr. When the edge of the muscle is found, 
H amy be drawn on one avlv uith a 'jwtula, or, if necessary, notched. The 
•temo>thyroid acarcely rvquires division. The eheath of the vessels now 
cocDea inlu view, and must be cuutiously opene<l, the Burgeiin keeping care- 
fiilly lo tbe tracheal side, sn as to avoid the vein. There is uaually a wide 
interval between the artery and the vein and nerve on the right side; oq 
the left side more care is required, as the vein moat commonly overlaps the 
artery. 

Alter ligature of the common carotid, it is interesting to observe that the 
collateral supply is not afforded by any of tbe branches of the corresponding 
meel of the opposite side, but by tbe subclaviuQ artt^ry of the same side. 
Id a case relale<l by i'<^rter, in w)iich tbe right carotid had been tied, the 
nbdavian and vertebral arteries on the same side vere enlarged to at least 

TOI- IL— IS 



194 



SPBGIAL ANEURIflKa. 



double th«ir iiniural iliBUietere, and the chief mmmiiiiicAliiMu oulAide the 
skoll tiMik placv lictwet-a the superior uixl iuterinr thynvid nrlrriw, whiefa 
vere cnlArgod ; KhiUt insidi; the craniuni the verl^hral t»uk ihf \t\nct of titt 
intrrnnl cnroiir). I m lup^hutcly alter ihc nptralJon the bhxNl infty bo to 
{rtely coDVevcct to the dutiil tiide of the vf«Ael, by the tr(« rtininiiiuirAtioa 
•ubsUliDg between the artcrJoi of op|M«iiit« side«, both within and wiih<iut tiir 
er*oiuro, that a cfmlinuanre or a f[>eedy rc-tiirn of piiI»alion in Lbc mi iBof 
coDimoD occurrence. Thifl conditiou, however, usually diMi|>|>eAn afUr a 
tiino by the grftdual conimtidatioD of the tumor, »nd iodet-d iiiav genmlly 
be ItMiked upon a» & favorable gijfii ; l>ein^ very avMoiu luswicialcu nitb Unm 
uervbral leyiuyUnns that, a« will immediately b« explniued, comnxmly pmrc 
fatal nRer luis "{lernliiia. Occaniitnaliy llie pulmlii'ii cnutiuurs, una Un 
tumur gradually itK-rea«e« in siu in ipit** uf ihv ueolueion uf the main tniok. 

iSiippur<Uion uf thr mc is nut of very uncuiuiiii>u iK-currunw after the Ib 
turv >jt thv caruUil lor aneuriniu — ^omelimvs even otter ho ctia»idembl«1 
interval as fight inuiilli*. a» happened in u caM.> related by Pout. In 
majority of tlieee iu«lnuces, the paLit'Ul eventually dotv well ; hut death msj 
reeult by the tumur prcesing upuu tbo pharynx and larynx, or by the (Kvur- 
reoff- of sernmlary hemorrhage, which may lake plaoe t-ilber from the part 
to which thit ligaturu hae bevu appiit-d.ur from the ^uppuraliilf isc In lh« 
fir^t ini<iani.-e, it nBually •jiH!ur» about the period of the aepuKtiua of tbe 
tifrnlure; in the seoouu, it may happeji at a ron«i<lerBh]v later period, even 
after many weeks. In a cusu under the ejtre of 11. Murris, euppuralion look 
place round the twc Gftetrn weekii after the lif^nture wag applied to the main 
trunk. Pu» vns let out hy an incision, after which the tumor rapidly in- 
creased, with return of pnltfalion. The ?ae was then laid open. Tne anea- 
nam whm found to have iipntng from the external carotid, and the recurrettl 
•trcam of blood was deriveil entirely fr<im the brancbes of that vflMel. Tht 
trunk aboTO the snc, the facial, and the superior thyroid were ligatured, and 
the patient made a good recovery. As the suppuration il often due in all 
probability to the proximitjr of the wound and the ligature to the (irn-uriam. 
It bae been sugx<:-rted that, in such cases, it might be B«fer tu antici)>jite itbjr 
laving «f>t;n the mc after ibe application of the ligature on the proximal 
eifle, and Iyiu^ the vessel again on the distAl eide. thus perfurniing a com- 
bination uf AueTn and the old o[»«nitJi^4i, It would appear, however, •■ if 
this were only subslltuiing, with certainty, one evil for another that umj 
vcrv powibly be uroided. Besides iheee, which may he loukeil upon as the 
ordinary accidenU followin;; the uppiicHtiuu ofa ligature fur aneurism, d«U- 
jintion of the carotid artery ooc»«iuually gives riae to serious and ensi fiuol 
dismrlmnce of the iir^-ulHtion within the erauium. 

SffecU on the Brain of Ligmtnre of one or both C&rotida.— Many expui- 
meuts have been made hy Mey^T, Joberl, atnl ittbcrv, upon the Inwer anioioK 
with the view uf determining the effect pnKluticdoo the bruin by the li){aiara 
of the cnrotiil arierim. But the deiluctiou5 from tlteaD arc of no value what- 
ever when Bp|ilied to the human Mjhjeet. tor the sim)^ rcme-iu (wbicfa 
aptiears U> have bien atnuigely uverlcHikvd', UiaL in many of the low 
animals on which the ohaervattotut were made, as the dog and rabbit, (at 
UMtance, tlie comniou cumtid art4>rieH are of secondary i(up>irtanoe *o tuits 
the cerehnil circulntinn is t'oncerned, iK'ing di-^tincd principallv for the 
supply uf the exiernal parts of the head — I he hraiii rleHving il» rhief KUppty 
fr»m the verlchrals ; whiliit in other animals, as the horse, the bruin dvrivca 
m>arly the whole of its lihwid (n>m the rarntids, and hut a very small i|uaB- 
tity from the vertebrals. Hence, in one case the carotids may be ligatured 
witboDl danger, whilst in the other their deligation i» ioeviiably fnul. The 



LIGATURE OF BOTH CAROTIDS — RESULTS. 



196 



statistics of ligature of tbe carotid in the human subject have been collected 
by Noma, Ehrmann, and others; and more recently by Pilz, of Breslau, 
(Ar^iv fur KUnische Chirurgie, 1868), who has collected 600 cases of the 
operation, including 27 in which the artery was tied on both sides. The 
causes which led to the operation were, hemorrhage, in 228 cases ; aneurism, 
in 87 ; erectile and other tumors, 142 ; extirpation of tumors, 71 ; cerebral 
sffectinns (epilepsy, etc.)* 34; and in 38 instances the distal operation was 
performed for aneurisms of the aorta and innominate artery. In the 228 
cases of ligature for hemorrhage, the presence of cerebral symptoms is noted 
in 69 out of 167 — no information being given in regard to 61 ; and, in these 
69 casee, death took place in 40. Excluding, however, these from calcula- 
tiou, inasmuch as the brain disorder may have been in many due to the 
hemorrhage rather than to the operation, we derive from Filz'a statistics the 
following table showing the proportionate frequency of tbe occurrence of 
cerebral disease and of deaths from this cause. 

TABLE OF LIGATURE OF CAROTID FOLLOWED BY 
CEREBRAL DISEASE. 



CATSK OPOPBBATION. 


NUMBBB 
OP 

CARES. 


CAIEH IN 

WBICB 

CEREBRAL 

APPCCTIOK 

RKSrBD. 


DEATHS 

FROH 

CRREBRAL 

DISEASE. 


DKATOS 
FROH ALL 

Ckl'ttKH. 


NO RECORD 
HKOARniHfi 
CEREBRAL 
SVHPTOHa. 


Aneurism .... 
£r«ctile and other Tumors . 
Extirpation nf Tumors 
Cerebral Affections. 
Diaul OperKtion . 


87 
142 
71 
34 
38 


32 
32 
13 

8 
U 


16 
20 

8 

... 
7 


31 

49 

•i5 

1 

25 


5 

8 
8 
3 





872 


HC 


51 


131 


19 



By this it will be seen that the most common cause of death after ligature 
of the carotid is cerebral disease induced by the operation (as was, I believe, 
firet pointed out by Clievers) ; and this result appears to have been rela- 
tively more frequent after the distal than after the Hunterian operation If 
tu these cases we add 14 in which the brachio-cephalic artery was ligatured, 
we get a total of 386 cases, of which 96 were attended by cerebral symp- 
toms ; or, as nearly as possible, 2-5 per cent. 

We should necessarily expect that, in those cases in which both vessels 
had been ligatured, there would be a greater tendency to cerebral disturb- 
ance than in those in which only one had been deligated. It would how- 
ever appear, as is shown by the following table, that of twenty-seven in- 
stances in which the double operation has been performed, death is recorded 
to have happened but in two cases from this cause ; while in another, in 
which convulsions took place, a fatal result did not occur, and three other 
eases were attended by mere temporary disturbance of vision. In the only 
case (that of Mott, No. 16) in which both camtids were ligatured simulta- 
neously, with an interval of only a few minutes between the operations, coma 
and death resulted. 





SPECIAL ^^^^^^^^H 


^^^^^ CASES OF LIOATURB OF BOTH CAKOTIIIS, 1 


^^H^ IH-KatTOM. 


•OK. iMSKiM. ' iiATasnrLMATiiKK. 1 MUtitn. I 


^^1 t Dttl'trTTHBll 


•>. 


An«tiruni b^ Kt](bt ranaidllkd brll>t|r»f- Delinum.hMU- ■ 


^^^L^^ 




fttiMtomnai* of 1 Ir»ninl819; l«n by R»tM-rt . |>let:M uf Ul | 


^^^^L Robert. 




tcftlp. 


for vxtcoaioo of dtMAW, la •ldtt,At>dd«tk. ■ 

1!<..57. ■ 

IntorvBl of A tnoath. B»m»>frf. 1 


^^^^^ 3. lIxcaiLl. 




Tun goal tumor 






of b<>th orbiu. 


I 


^H s. Uluamk. 


30 1 £rMii)« tunur 


Un IM tint, 18S3; Hgttt Dmib uo tUid ■ 






of orbit. 


une f««r «(torw«rds. 


il«v by h«nar> 

rhii^ 


^1 A Hdvet. 


» 


An«iiri«iD by 

MiHtomuiM of 


Lanmrolid, S^>l 20; right 
varoUd, Uct. 3, 18:^7. 


RMu«er«d. 


^H 6. lIAtLn. 


*i 


SrectllA luRtor. 


8Mtt. 18, 18S1, Abd Jkn. 38, 
1882. 


BccotatmL 


^H 0. Pkinoit. 


M 


EpiWn«> ; 1 RJcIti ck,rotid, tied Aii|t. 28; 
IIeini|< r;;iii. tv-n (-nroiid, >'i<v. 14, 1881. 


BMMnvd. 


^^M T. Pekbtox. 


S4 


P»rti»l piirBlv- RiRbt (•■rotlij, S«rt 7; Uft, 
•it And hcmil- Ud. 10, 1831. 


Baotvond. 


^H 8. PmEaroH. 


■ II 


Bpll^^. Tied At iularrtl of month. 


Racovand. 


^H B. Kont. 


C8 


AneurliDi b; i Left Mfottd, May '2*, IKS4; 


BActirierttl:«0»- 






»nti»iijmo*'w of ' right ou Aug. 4, miuq jeur 


vuhtoa* Ataf 






•caIi). 


eAf-h>t|«rAd^H 


^B 10. r. 11. Ham. 


18 


Epfltpa;. 


Bicbt <!»rolid, Ang. 1838; 


K«cu«*t«^^^| 


^^M ILTOtl. 






left, JklKrcb, 1H3V. 


^^* 


^^M 11. Vklfead. 


20 


Anflorinn hj 
AiiAMamoib of 


Riicht canitid firii, Aufiusl, 

18^1)) left, itb<iiil Ihnw 
niuntht Art«r«tHrd». 


]iccov«r«d. 


^^^^ 12. PiBiraonr, 


20 


Heatoirbt^ 


Left cftrAiid, Jar. Ifl, 1M8{ 


BeadArlw aad 






from AneuHtm 


riRbt, jAfi. B, 184A 


ininiitln^ Aflar 






bj aDAilooiosli ' 


«Ark opirrE- 






of MAlp. 




UtiBirecoiAty. 


^V 18. Sllik. 


21 


SeoondAi-y 
lieiDorrh«gefo1< 
lowing gun»hot 

wtiuitd of 

tonpu«. 

Rrcctila Uitoor 


InlATVAl of four And a half 


Curad. 


^H 14. J .U. Wae- 


28 


Tied left, Ootobcr S ; rigbt. 


Ound. 


^^m 




of f»c«. 


Nov. 7, 1846. 




^^L^ 16. ROBKET. 


••» 


Anearlitn hy 


L«n on J>ia* 6, 18481 rlgbt 


BMdwbR ta»* 






tiuutitmoil* of 


oo PAb. 23, 1847. 


(KtrArj-dlUurk 






fonbaad. 




EiiC«"f vtitoci 


^m 10, Mm. 


•t* 


C»rdooniA of 


IntervAl of Ilftean miaulaa. 


recotny. 
CutUAandd«B|b 






rarulid. 

Entlepij'. Intf>rvalor halfA vear. 
« FiinKiii of RiKi>l fl'*t^( ^fl< llirw wmIu 
tiAial HMi»." I«l«r. 


ill 34 biwn. 


^H 17. Morr. 


«•• 


It»-c-iTer«l 


^^^r 18. BLArKMAy. 


1ft 


Tnnlinniry b«i 






oi vtti'itiofMk 










T-M ii. 


^^^^ 19. HUWBT. 


19 


EraoUl* 


l^ti 8nt ; rigbt, ona tDonth 






tumor*. 


after. 


t. ..f 
VI'i.Pii irvwlf* 


^H 20. RXTKOLIM 




AnwHim bjr 


Kl|;bt cATotid tied W B«t. 
nold* in 1844; Utt bj Vaa 


BacovMy. 


^^H 




EAAitotncaiB. 




^H Vax BuHEjr. 






Buna in t8d0. 




^H XL pAHKjm. 


46 


OkrcinoRiA of 
nnirum. 


iDtervAl of thlrtf-two dAjr*. 


UMtk. 





LIOATUBK OF BOTH CAROTIDS — RE3UL1S. 



197 



CASES OF LIGATURE OF BOTH CA'ROTIDS— Continued. 



fiWooD. 



a G.C.E W«- 

BKR. 

K Cakxocbax. 



ft. BiLLSOTB. 



ST. BUENOEK. 



DATIR OF MOATUHB. 



&J I Encephkluid of 
antrum. 



RiKhtctiriitid, July 18; left, , Afiersecondop' 



34 



Dec. 26, 1856. 



20 Epilepsy. 

Lar^e morbid I 

growth of face , 

(elephantiasii). i 

Ounibot I 

wound. 

27 Ulceration of , 

carotid from | 

syphilitic caries 

of petrous bone; [ 

Hemorrhage. ' 



Left carotid, Dec. 2; right, 

Dec. 19, 1857. 
Right carotid tied, Nov. 

1866; left, June, 1859. 

Rieht, May 12, 1868; left, 

May 18. 
Right carotid, Dec. 13; left, 

Dec. 20, 1864. 



Aneurism by 
anastomosis 
and wound. 



Left tied for the aneurism ; 
five years afterwards the 
right, for a suicidal wound. 



eratioo the tu- 
mor diminish- 
ed : then diar- 
rh(ea, rigors, 
delirium, ex- 
haustion, and 
death on six- 
tieth day. 
Recovered. 

Cured. 



Death in thirty- 
eight hours. 

Return of hem- 
orrhageonBix- 
teenth day; 
death from ez- 
hauEtjon : no 
cerebral iym|>- 
toms. 

Disorganiza- 
tion of right 
eye: recovery. 



AAer & careful examinatioD of this subject, I think we are warranted in 
oomiDg to the following conclusions. 1. Ligature of one carotid artery is 
followed br cerebral disturbance in more than one-fourth of the cases, above 
ooe-half which are fatal, 2. When the two carotids are ligatured tnUh an 
mUrval of •ome days or weeks, the operation is not more frequently followed 
br cerebral disturbance than when only one ie tied. 3. Pathological inves- 
tigation has shown that, if the vessels be gradually and successively oblit- 
erated, the patient may live, although one carotid and one of the vertebral 
aneries have been occluded by disease and the other carotid ligatured, as in 
a caae related by Rossi. 4. As in a case recorded by Davy, an individual 
nay even live for a considerable time, though both carotids and both verte- 
braU be occluded — the cerebral circulation being mainteined through the 
Boedium of the anastomoses of the inferior and superior thyroids and the 
deep cervical with the occipital artery. 5. The reason why more or less ex- 
iCDMVe ohiitructiim by disease of the arteries leading to the brain may, as 
appear* from pathological records, be unattended by cerebral disturbaoce, 
while this so frequently follows ligature, lies (as has been pointed out by 
Pllzi, that in the former case the obstruction is gradual, so that the coltat- 
cfftl circulation has time to be established, while in the latter the interrup- 
Aoa is sudden. 

The cause of these cerebral ajpnptoma is certainly the disturbance of the 
cerebral circulation, induced by the ligature of the carotid. When a cun- 
oderabte portion of the supply of bloo<l to the brain is suddenly cut otT, two 
HU tff symptoms may ensue — one immediatr, the other remote. The imme- 
diate symptoms are those that generally result from ftuictional tlistiirbauceof 
tbc brain, consequent upon too small a supply of arterial blood. They con- 
■■t of Bvocope, trembling, twitehes, giddiness, and impairment of sight. 



198 



SPECIAL AKK0U1BU3. 



Aflor thi^i condition hna Itrpii iiinintaintMl for a few days, the nulritinn ilf ft* 
urffnn becomes nialerially averted. Ami sufUuing of ihi.- ci-rebral Auhtiaon 
ULKiH place ; givioK rbe lo a new and more serinUH set uf sympUifns iodict* 
five nf thia pathulo^^ieul condition, such oa niuvuU\i>UB, bemiplt^ia, ud 
death. In oUior oases congestion may come on, Mther by the inicrfrrMflP 
witl) the return of bluud ihmugb the jugular vein, or as a c4iaaec)U^-iiii- uf that 
Tenous turgidity which we commonly oUacrve after tliu tifruture uf a nun 
arterial trunk ; or pcrhaiM coma may be induced by apoplcctie elTuMoD iMm 
ft itnt^ened portion of the orgnn. 

Effects on the Lnn^. — Benidea the brain, the lnng» are not uncommunly 
Kcundarily aHt-cted after ligature of the oirotitl. To |hi* roinlilii^a •pedal 
attention liaa bwn <)irccle<l hy Johert and Miller. The ItiiigM ap|iear tu 
become greatly cunge>te<l, ami thin condition hsH a tendency to rtin intii a 
BuUiiciite form of iiiHammnlion. The cause of thii)coii^e»tioM of tlie liint^ b 
extreniely inUresling. It tannot be owing to the simple ofwruction nf lh« 
pawage of tJie hlood through lhi3 airotid enusing a di»>tUTh«itc« in th« 
twJaQce of the circulation, and thus a tendency to iulernul cougeelinn ; Ivr. 
if this were the cauite. we ought tu niei-t uiih it generally after ligtiturv 
of the arleries of the tirst cloM. Nor c-nu it be owing to any injury BUc-taio<nl 
by the eighth nerve during tfa« dcligation of ilie artery ; as in many uf lbs 
instauceu iu which it is stated to have occ^urred. there was no cvideoce uf 
that nerve having bevu cxpoiMxl or daiuagcd, and uvery reason, frnm ll» 
known ekill of the o|>crulon), tu believe the contrary. 1 am rather incDonl 
tu look upon the unuDiiully frequent occurrence of pulmonic (Hiugwtion aftrr 
ligature of the rarf>tiil, a» a setxindary condition cnnBe<)uent U|htn a JeraniEe- 
ment in the fiinctiitmi of the br»in and meilulla oblongaia, primarily iniiuced 
by the diittufhed ctiate of the circulation through that ofgau: for we know 
that any cause which deprewce the activity of the nervous rentrea tmds to 
diminiHh propctrtionaiely the freedom of the reapinitory moveneDte, and ihoi^ 
by interfering with the due {>erfornianre of the act of respiration. dieposMto 
congestion of the lungs, aaseen in injuries of the bend, in apoplexy, and is 
the uperaiioQ of the sedative ptisnns. It would app4^r from the df<>taiU of 
Some of the nn-orde^l caMs, as well as from Joltert's experiment, that blttod* 
letting ii* of consiiK-rable Mrvice in the reotioval of this condition, and should 
euuMf>}U«utly nut be omitted. 

Ligftttire'of the Carotid on the IMstal Bide of the 8ae. — Anmrism of ibe 
carotid artery, occurring low in the neck, does not admit th« upplicatiim of a 
ligature ou the csniinc side of th« tumor. What, theu, i» to !>«• done in sucli 
a caw as this? Should it be leA to tbe remote chance of a spootane^ms cure, 
or should it be subjected to surgical inlcrfvrcoce? ■SjionLaneous cure in 
carotid aueuriem has never yet, I believe, been met with. The Suriwio, 
tberefon;, niui^t endeavor Ui treat the disciase by ligature. Two plans of 
tnatmeDt are oricn to bim — to tie either the innominate artery, or the 
aarolid on the distal side of the tumor. The lirvt alternative may fairly be 
Ht aside; for not only are the easm in which it is puKible to tind room 
bet w o n the sternum and the sac extremely rare, but, even were pucb an 
ioBlanoa to present imtf. few Surgeons wouM. I Lhink. Iw ju.'4titi»l in under- 
taking an opemtion which hna only once euooeedetl. even (p. IVi) in lb<> 
most skilful nands : we are consequentlv reduced to the allcmntivc of lin- 
lurlog the artery on the distal side of ttie sao. But although this apevrnMU 
is tbe onlv alternative that presents itself, yet its appHcaUon in practice is 
att4.'ude«l t»y serious difficulties and perplexities; for the 8ur^r«y>n must he 
able to satisfy himself that it is actually an aneuritim of the root of the 
earotld with which he ha^ to do, and that It ii not the trunk of tbe innomi- 
nate or the arch of the aorta that is affected. The difficulty in doing this is 



DISTAL LIGATtTRK OP CAROTID. 



199 



&r grater thaD would at first appear; for, od examining the details of eight 
oMn ID which the distal operatiou has beea performed fur supposed carotid 
aaeiirism, three must be excluded; as, after death, the tumor was fouud to 
frum the aortic arch. Iq the annexed table will be found the result of 
ues, ia which the carotid artery has been tied fur aneurism of its root 
OB the disul aide of the sac. I have excluded an eighth case, as there 
is reasoD to believe that io it the artery was not ligatured, but a portion of 
Uie abeath accidentallv tied instead — an accident, by the way, which S^dillot 
has witnevetl, which Korris states also to have occurred at the New York 
HtiSpttal. aod which I have known happen to a most excellent Surgeon 
ia the caae of ligature of the femoral artery. 

AXEITRISMS OP ROOT OF CAROTID TREATED BY LIGATURE 
ON DIriTAL SIDE. 



OTEVATOK. 


SWX 


*«E 


REiH-LT, 


CAIISEOFDKATH. 


1. Wabdkuf. 


r. 


63 


Recovered, 




19-M. 










1 Lambkkt. 


f. 


49 


Successful 


Uemotrbai^e 


1827. 






to far a.s 
, Mneuriana 

w&s 
concerned. 


from uppt^r 

portiiin of 

■rtery. 


t Bush. 


r. 


3G 


Recuse red. 


1 


1827. 1 

! 








; 


4.3Io!rr- 


m. 


30 


Died. 


1 Sac suppu- 


ooMaar. 








rated. 


1928. 










a COLTEM DE 


f. 


• C3 


! Kecovered. 




NoTop. 










1*4«» 










«. Wood, J. R. 






Recovered. 




ISL4n. 










7. Dkmhc 


m. 


38 


Died. 


Suppiirttlion 

of S8C : 
heitiorrliage. 


« La!ce. 


m. 


:;6 


Died. 


Inflammiitiim 


I«a2 






QSlii d»y. 


of lungs. 



RKMARKH. 



Tumor diminished until fifth 
; day: tben inflamed, suppura- 
ted, and burst. The patient 
recovered, and was alive three 
, vears after operation. 
I l^umor diminished after opera- 
' tion, and became consolidated ; 
»ac filled with firm coagulum, 
and lowerpartof artery closed; 
ulceration into artery, just 
above part ligatured ; vessel 
dilated where ligatured. 
Suffocation was imminent before 
operation ; tumor rapidly di- 
minished after ligature. Alive 
three weeks afterwards. 
Aneurism of arch also. Left 
carotid tied. 

Tumor and pulsation dimin- 
ished. Alive and well three 
years afterward«. 

Armurism cured. 

Aneurism of arch : double aneu- 
rism of carotid. 

Tumor Hlled with layers of 
coagulum. Ulcerated opening 
communicating; with a|)ex ')f 
left lung. Left carotid tied. 



On analyzing the cases in which the trunk of the common carotid has been 
i^tured on the distal side of an aneurism of the root of that vessel, there 
are several points of interest that arrest our attention. Thus we find that 
ia every case the tumor, immediately on the ligature being tightened, under- 
west a ooDsiderable diminution in its bulk, with corrugation of the integu* 
■ests covering it, and considerable subsidence in the force of its pulsations. 
Ia ooe ease — that of Bush — respiration, which before the operation had been 
aOeoded with great difficulty, became easy ; and in two others iuSammaticm 
of the sac took place; being in one (that of Wardrop) unattended by bud 
aaoseqaeoces, and in the other (Demme's case) followed by death. It is not 
Mfe to deduce any general conclusion from so small a numher of cases ; yet 



200 



8PB0IAL AKECBISMS. 



the result of Uieee is so uoifonn, thai I have do heeiiatioQ in sUtiDg tl u mj 

'opinion, that, whether we reganl ilip prinrijile iiii nhicb thi* u|icniU(«i la 
founded, the amount ofBUCoeaa which li:i9 hiliivrlu aUfiiileU it. the neos- 
aarily fuUil reuitt of these CHwa if Icil l^i ihvmw'lv<«. t>r the nhoinice of aor 

|.othor means thai bold mil a reneoiitihlc hnjie of bi-iittil, th« Surgiwa is joau- 

*fied io resorting In the ligiiture ut' the trunk of the LNiromou canilitl oa the 
dietal side of the sac, in vastA of oneuHwo limibMl to iho nxil of that viwel. 
The IrunL of the External Qeratid is so short tliat it eeldom becomes the 
seat nf anetirism without iuTolviiic at the »inie time the eod of the cotumon 
artery at Its bifurcation. It may, however, liecomc aocummal. Tbo tumor, 
prcaeutluK the usual signs of uncurism, will be foand situated under tbe 
ADglc of Uie jaw and ab«>ve the level of the cricoid cartilage. From the im- 

'__ ircant nature and close proximity of tho parts surrounding it, the pmMure> 
effects ore serious and early. By pressure on the hypi>gliiual nerve tbs 
muscles of the corresponding Aide of the tongue may be pamlvze^l, so that 

I when protruded the tongue is turned towards the atfectod aitfe. Aphonia 

■ aod dysphagia have been met with a? early symptoms. 

The treatmeot consiets io ligature of the commoo enrotid above the omo- 
hyoid. AHcr this operation it may happeu that puUntion cootiBUca faintly, 

ror speedily returue to the &ac. owitig to the freedom of enlarged aDastoOMMi. 

ilt has. therefore, beeu proposed by Morris to ligature as well the prilttuy 

[bnuiclies of the exterool carotid — a project certainly diffioult tn execution 

ruid probably of doubtful utility. 



AKECaUM OP TU£ LXTlOtXAl. tXkXOTW. 

The Internal Carotid Artery may be the subject of aneurism before or 
after it haa passed through the carotid canal and entered the cavity of tbs 
skull. The symptomn of these two classes of cases differ neoe^nrily in almost 
erery respect, as likewise do the termination and the susocptibiliiy of the 

,ease lo ?iirfrii'Bl intcrfi-r'^ncc. 

Extracranial Aneurism,— When nn aneuriim a^U the trunk of the in- 

^lemal cnrotii! U-fore it» enlranct; into the skull, the symptoms prwiented by 
thi« diwKwdonot mnterlally dilfer from those of aneurism at Ibe bifurcation, 
or of the upper part of the commou carotid, except in onv important respect, 
which WHS, I believe, first pointed out by Porter, ot iJublio — vis., the t«s* 
dency of the tumor to extend iuwards towards the pharynx, aud to protrude 
into ibal cavity. The leawm of this is obvious ; when we cuiuuder the 

iBnatoraical relations of the internal carotid artery, we at once see that its 
pharyngeal aspect is that which, if one may so term it, is the most superficial, 
aod that between it aud the surface the smallest amount of soft parls inter- 
venes — nothing lying between the vessel and the rauoous membraoe except 
the thin piiper-like constrictor, some lax areolar tissue, and tbe snperiar 
laryngeal uerre ; whilst externally there are inlerpo^ l>t>iween it and 

liDteKOmeDt tbe layers of the cervical fn^ciu, the margin nf the ^tcrno-niaat 

'the oigastrio t<tylo-hyoid and ^lylo-jfharyngeus, and the styloid prooem, 
ibove the digiiiftric the |)onttid ^land. 

When, thert-foro, dilatation ot* the vesjiel tnke& place, it necrssarily has a 
tendency to puah forwards that f»art ol'tts covering where it meets wriih leaA 

riflHStaBce ; and, this being to the pharyngeal ride, more or less promineaea 

'will oonsequently be found in this cavity. In a rase that occurred toftyraa, 
this was especially well marked, the aneurism uf the intrmal ramtid nimn- 
lating doeoty an ahscesa nf the tonsil. In two cases related by Porter ia 
tbeaevcDtecnth volume nf the Dublin Jaumnl o/ Mtdiral Srienet-, thb waa 
one of tbe most marked features: the "appearances of tlie tumor (as seta 



IADSES OF IKTRACBANIAL ANBUBISM. 



201 



bv ihe mouth) were most alarming; tlic pulsation could be di^inctly Men, 
*Kiid the blocrtJ alrnti6t felt iiudor the mucous inctulimuc; it ticcmcd ready to 
give way and burst into the uioulh every nionient." 

Tkeatme.vt. — The ireatmeot of lhei«L* ciitM« ihtn not differ from that of 
Boeuramfl connected with tlie carotid nrtcricn, and iu^tod at the upper part 
of th« neck ; but we arc not in poweuioo of a Auffjcieot ouoiber of iacta to 
eaable uk to determine with any degree of precision wliat the reftult of fur- 
gical interfereDoc in them U likely to be. If we could give an opinion from 
the limited number of cnaed at pn-5eut before the prufewiion, we should firal 
• ^poaed not to entertain a very favorable opinion of ibe re«uk of tb« 
[anteriaa operatiui), as applied to aneurism of the internal ramtid outside 
'Uie skull. This is doubtless owing to the situation of th« aneurUm againat 
the mucous membrane of the mouth, being i^ut-h that the Hurrouiidiug tisMies 
do Dot exercise a sutUoient amount of preiwut'e a>;ainHt the sac after the 
ligatiireof the vessel to allow the efficient <le|>nsilionof lameilated coaguluin, 
and consequent occlusion of the ariery leading into it. which, in Rccordanoe 
with the principles that have been laid down m speaking of the liuuleruit 
openitioo, are oeceHury to succen. 



ISTBACKASIAL ASEUUIBll. 

ADeurisms within the ekull may arise from any nf the arteries that arc 

tSiel with in this Fitualioo, though some EU'e much mure liable than others to 

fUbe vc-currcncnof ihisdiscBse. Of 62 caeea noted by Kir W. Uull. thebatfilar 

mrtery was the «rat of disease in 20 cases, no <1 the middle cerebral in 15. 

Id S of the remaining cased, the intcronl carotid wbs allected as it lay by the 

11a Turcica; and in others the anterior cerebral artery was the seat of 
neurum. The vcrttbral arteries and their branches were alTeeted in 28 
CMea, and the carotids and their brnuchM in 34. 

OAt'SES. — The cauiw-s of intracranial ancuriftra arc verr obacure. It micbt 
be mppiiud that the compflralivclv timall diameter of the arteries wittiin 
tbe skull would reader them little liable to the occurrence of spontaneous 
aaeunsm, were it not that the anatomical characters and phyaiologicai rela- 
tions of these vcs^la predispose considerably to the occurreuce of tbio affeo 
tioo ; there being no other net of arteries in the body of the game size as 
those within the skull in which spuutaneouA aneuriitto ko frequently occurs. 
Tbifl can be accounted for only by the thinner nf their coats ami want of 
an external Rbroua sheath rendering them uii:ihle to aupport the increaited 
IcDsioD, to which they are occasionally subjected in coasequcnce of the alter- 
atioD io pressure of the cerebral circuialiaa at diDbrent periods, the result 
of aoiue variation in the relative i^uautiticfi of the dilfert'Ul tluid» witbiu the 
•kull. or of dcU-'rminatiou of bhiod to the brain. This would be the case 
iDore particularly if their uatunil cla«licity had already been impaired by 
the occurrence i>f dt^^'cneration of tbair coats. As Ihesc clmagcs are the 
aatural «!ODeequence!t of advauco in afrs. «o shall find the tendency to the 
oceurreoce of ihie diiteuse increases with advancing yeans. Thus, accurding 
10 Sir WUIiau Gull, of 58 casea iu which the patient's age ie given, only 12 
ama occurred in persons undor twenty -live, live of the patients being under 
twenty ; of tho reiDaiuing 40 cases, 13 occurred in persons under forty ; of 
tlio remaining 83, 2^ wern met with between iiirty and «ixty, and 4 in per- 
soDfl above sixty. Of (he 58 cases. •i<'> nen> malcH, and 2:1 fetiinlea. Church 
bultevea that, in the young, intracranial annurism Ik duo tu enibi)liam. 

The immediate exciting cause of thu disease is mo»t coromnnly involved 
ta ubectirity ; somelimes it may be traced to a blow on the head, to a fall or 
1, or to excess in drinking; but more frequently the symptoms 



202 



SPECIAL AKBURI3M3. 



^M^ 



>> 



/* 



K 



.( 



l^ 



?. 



mAnifeBt thcmwlra ntddeoly, without being in any way attributable to n^ 
extornnl influsnces, sod occtir in vi>^>raus kdcI RppHrenily bealtlir p«n<ifit. 
Fatuoukiv. — Intracraninl anturismu are ulm>«t alwity^ furinff<t by the 
utiifiirm ili!nU(ion of the whole of the calibre of the artery — the mcriilBtni 
TRrit-ty beinK rHrely met with. Id the museum of Uoiveraly (V>tte^ ib«» 
are, however, two speeintetis of sacculated UDCiiriBnie of the cercbml ortrriM. 
The coal* of the arterin in this situation beiug very Ibin, and unprovided 
with any exleraal fibrous sheath that would eupport the iiupetiix nf tbi 
blood, rupture of the ve!>Ael would oncur rsibrr than partial dilalntinn. if 
one portion only of the eirouinferenee wcr^dUcased. Occasinnallr, ihedili- 
tatjou ut fuBiform, exicn4lin<; over itomc length of the artery: tfiis furm b 
probttblv CTinfinetl to tho baftiliir artery (Fig. 473). 
The iiiteaea would apfHsar to be of hIow growth, and ihe sac sometinieA b^ 

conius Ailed with laminated onagula » 
completely an to ocrludr the orifice of the 
an^ry fr)ni which it flprtnjff. 

Thf .«{»■ that nnfiiriAn) in thla nituftt 
attainii bffor'' death mullii i* soinf 
considerable; thuB. in a «i»e of aoeui 
of the basilar artery, that oocurre<l unat 
years ajjto at Uiiirer»ity G>llege Ilii*nital, 
the tumor wa»i nearly bh large as a walnoi : 
in aiiotht-r carte, in the Mine hovpital, H 
»o»)cwliat exceeded t)ii» eixe. K. W. 
Smith, in tb« Ihibiin Jmimat of Mr^imt 
•Sctenor, vol. xxv., meutioDtt a case of mul- 
tilueular nneurijfin of the left pnelerior 
cerebml iirlvry us large aa a Broall apple; 
and Sem-», one as larj^ a» n brni's pgg. 
On the other hand, they occa»iooaily pmve 
fatal by rupture whilst atill of very «wUI 
sire — not larger than a pea or a nut. 

It is iteldom that more than one nf the 
arteries of the brain aufTer ancoriamal di- 
latation. In the Mueeiim of the College of Hurgeons. however, are prr- 
pAj-otJonii (\o8. 16H7 and I&S8) of aoeurismal dilatation of both iatrmal 
carotid arieriMi, reumbling "two bulbs about five-eijihths of an inch in 
diameter, filling up the hollow on cmcb side the sella Tiireica. nhirb wnv 
evidently dilatations of the cAn>tiil arierics; and from their bein^ filled witb 
laniinie of coagulated blood, there eimid be little doubt of their being anni* 
risDu uf these arteriea. The one on the \tfi side wus the largcM: l^ai no 
the right aide communicated with the cavity of ibe artery, which waa doc 
the eaae with the other." 

A case occtirrol in University College Hospital many yean agn. under 
the eare of A. T. Thotusuiu, in whirh a somewhat similar condition existed. 
A mat), forty-uine years of age. had fallen on his head some months before 
admission into the hospital. Since tlieu be had b<%u KBrmloUB. silly, and 
very irritable — becoming readily inloJiicale^I. He sudilenly became ooma- 
I'lse, witb voniitiutr and laborious breathing ; he could cl<»e both ey«a. hut 
the ri^ht pupil was dilated ; the left side was paralyr^il. He was treated 
fiir apoplexy, and beennie slightly better, but die<l lo ten ibis's from the flrat 
atlacK. Ou exiimioation, an iiucurism a little larger than a hazelnut was 
found on the trunk "f ihe right carotid, where it gave off the middle 
bral artery, and luiother »niafl one on tlic omree of that artery. There 
a globular aoenrism on the corre«|ioDding artery of the opposite side : 



n«- 



Vit. — Pufiferu Anciirliui o( Bk^- 
■Har AHafJ Ikli ■>[»■. 



STMFTOHS OF INTRACRANIAL ANBDRISH. 203 

banlar uterj wu thickened, white, and opaque, as were also the other 
larger uteries or the brato ; there was sofieoing of both anterior cerebral 
lobn, cflpecially the right ooe. 

The arteries of the braio are very commonly healthy in these cases. Out 
of Umw instances of iDtracraolal aneurism that have fallen under ray obser- 
TatioD, the other vessels of the brain have been healthy in three cases, and 
atbemmatiius in but one. In one case I have seen aneurism within the skuU 
avnciated with aoeurism elsewhere — in the thoracic aorta. 

pREvURE-RfFECTS. — The pressure exercised by an aneurismal sac situ- 
ated within the ekull is always chiefly directed against the yielding cerebral 
■nbetance, which ie oAen extensively disorganized. The bones of the skull, 
however close their proximity to the sac may be, frequently escape, and sel- 
dom Bufier much. This peculiarity in the eAects of aneurism in this situa- 
tioD may be partly owing to the very dense itnd compact character of the 
inner layer of the skull, but is doubtless principally due to the very soft 
and yielding nature of the contents of the cavity. Absorption of the sub- 
jaoeot bone, however, sometimes takes place to a limited extent; thus in 
one case (Moore's) the body of the sphenoid bone was indented and partially 
^wnrbed. 

The parts c^tmpreaaed in each case will vary according to the situation of 
the tumor. But the structures that principally suffer are necessarily those 
seated at the base of the brain, and forming the floor of the lateral ven- 
triclca. In Moore's case, one of the optic nerves was flattened by the pres- 
•are of the substance of the anterior lobe; the laraina perforata, the roots 
ot the olfactory tract, the anterior part of the corpus striatum, and a con- 
■derable quantity of the neighboring white matter of the anterior lobe, were 
remored. In a case recorded by Lager, the portio dura of the right side was 
paralyzed from this cause. In R. W. Smith's case, the floor of the third 
Tcntricle. the tuber ctQereum, and the origins of the optic and olfactory 
■erves, suffered; the optic nerve of the opp:)dite side was flattened and 
aoftened. 

Beaidea the changes that take place in the cerebral substance as the result 
of preoMire, important lesions may be met with ns the effect of the interrup- 
tion which the presence of the aneurism ofTcrs to the circulation in and 
BntritioD of the cerebral hemispheres. Thus, in the case of aneurism of both 
tDtcraal carotids that has already been referred to as occurring at University 
dllege Hospital, there was white sofleuing of both the anterior cerebral 
lobei : and this lesion was most marked on the side that corresponded to the 
largest aneurism, and where con^quently, it may be supposed, the greatest 
amount of obstruction to the circulation existed. 

SviCPTOMs. — The symptoms of aneurism within the skull are e.itremely 
equivocal ; and, indeed, aneurism of large size may exist at the base of the 
brain without occasioning any symptoms whatever. An interesting Instance 
of this occurred at University 0)llege Hospital in 1848. A nmu, thirty- 
seven vears of age, died of pulmonary apoplexy and chronic pncutiionia of 
the left lung, consequent upon the pressure of an aneurism of the cimimence- 
meot of the descending aorta on the }Miluniiiary vt'iiH of that .-iiii'. On 
examining the head afler death, an aneuri-im of the basilar artery n?< large as 
a basetnut was met with, of which no suspicion had been entertained during 
ble. there having been no head symptoms whatever; the sac <:f the aneurism 
wu very thin, and there was much atheromatous degeneration in the verte- 
bral arteries. 

The only symptoms that are of constant occurrence, when this disease gtH-s 
4a lo a fatal termination, are those of hemipleiria and apoplexy. These may 
oDOie on suddenly without any previous warning; or they may be preceded 



204 



dfECIAL ANKUHISM3. 



br B train of ptinnomeaa indicative of the extstenoe of ohroDie diaeue witlua 
tfie oninial cavity. 

The nxvit coiitCAiit of (ht^> iilicnnmeiiA is pain ; viUich alTMU, bow««*r. 
great VAriely, butli in nxWrU aixl clinnict«r. ft may l>e tliffuaei], or ta»y 
occupy a tixetl point; it m«y )»e criritiouima or inl'-nnilllii;; ; it may he ia- 
crcasfti liy iiiDVAmenU or ncCk>mpiini«il l>y peuullnr smisaiiiuis, a» af piilaatioo 
or iif opening and tiliiittitijL; ihc tup of tb« craoiiim. 

Tlie tight niid )R-aring urv urieo impaired, DimneM of sigbl, <1ilalatioa of 
oue or lioth punils, ptiutopliobia. diplopia, and lusa of vieiun bavv been mHioad 
in e«veml of the cwm» recurded. (Juwere Btatt^o that iatrucraniol uieurtsnM 
evoD (jf luore size are pot. ae a rule, accompaoied by uuy awociatod ocular 
cfaaug«fl. Nor do tbey odtiu cause coasecutive thaog«e, uiileas (beir pnsitioo 
is sucli a» to preoe upoo the npdc oervcs; tliere is then losi of vision vith 
atrophy of the aerve recognizable by the ophtbalnioscope. If the aDoariMi 

Crew on tli^ caveraoUH aiaua, there may be some fulnew of ibe retinal vno*, 
ut tbia is u&ually only temporary, the pressure beinf^ relieve<l by ib« free 
oomniunicaliou between tlii' uphthalmic and tnrial veins. Opiic neiiriiU is 
ire OK the muU of intracraDla! nneuriBius. Ptosis has been met with fiooi 



^preSBUre od the third nerve by aneuriein of the poeterior comtiiuDicat 
artery. BuzKiag DtMsea in the €nn>, and dt^afucsi, are not uncommoo i^ 
toitis ; doifocRB, more perticularly, appears to be ■ phenomenon of freqi 
occurrence. 

The patient rareW looea the power of arLtculnlion and of d^latition; iin- 
pairnient of these functions, howci'er, has been inet with. 

Ther« may be paralysis of the «de of the face, shalcina palsy, or oompleU 
hemipl^ia; or fits of an epileptic nature may occur. The ntental oontUtim 
may underf^ chanuM indicative of chronic disease nf the brain. There m&f 
be depression of spiritK, IbttlpMUc-ss, or, aa was nolicetl in the case abttve r^ 
laled, the lempor may become irritable, and the patient be garruluui or silly. 
Insanity has oeen noticed in one case. As is always the case In eercbrw 
atfections, the gastric function* are often impaired. 

In 8<irae casea the presence of aneurism has been detected by a loud rough 
or "wbixzint;" uoisc heard on the application of a stethuacope over no« aim 
of the bt-u*l, and, pcrhups, audible to the paiienl. This sign, however, exu^B 
in but few cases ; but when it docs occur, it is unquestionably' the iixiet paibii^^H 
noraooic of all. I am not aware that it has been nioi with in nay form 4^ 
cerebral dbeasc except intracranial aneurism. 

Thus it will be aevn by a reference to ibis llfll of symptoms that, with tbe 

-exceiKJon of Uio whisziuf; noise, no special signs are atfoniml hy anrurisma 

within the bIcmII. which will enable us to distinguish betwueo the symptrtma 

oocuinued by their presence and tboee of other tumors of the brain, and of 

organic cerebral diaeaw. 

Very frequently no premooitory ayroptoms manifest thomselvea; the patieu 
being suddenly seized when apparently in good health, with apojilexy, wbieh 
terminate} rapidly in death. 

CUtmia OP Dbatu. — The &tal termination may occur from one of font 
caoaea. 

1. The tumor may <<xerciiw such pretmrf ufton the vJwtt MrArat nwus •• 
lo occasion denih. Thin mode of leniHOatioii is rare. 1 am acquainted with 
one caMi of this de«crintii^n, which t» re|>ijrt«d by UuMhenherger. The symf^ 
Innis were very renmrKnble. CiMtststing of complete hi?miptegia nf the led flid«, 
wilh involuntary unl^n'-piiflterlor vibration of the bend and body, and paral* 
rsis agilans of ibo right leg. Th« patient slept heavily, with loud snoring; 
n« ate voraciously, but oo^naionally hatl considerable difficulty In degluttttoD 
aodurticulutiun; hisinlelleot was clear, but very alow. After death, an aoeo* 



IVTBACRANIAL — CAUSBa OP DEATU rROH, 

Af tlM bwiliir Brterr u Inive ns a picoon'o tg^. coQtaioiDff an irregular, 
my hard, dry el»t of blood wus rouna pressing on tiie pou? varolii. The 
wme bad givvQ nay at 'luc p»int, i;xini\-a«ali(iD ukinu jilaitf inla Lhesiilwtaoco 
of tbe piitu, wbifli was eotlcnpil, and ul' a bluifib color. 

2. Td« moM frequcul mote m wbicb dvatb takes place iu these casee is by 
lh» a m d i l $ m rmplurv of the tac and extravaaatiiin of bli»>d into the cavity of 
dwmnMtbnoid and toe mahcB of the \»a mai«r at Lh« base of the brain, or 
iBla tbe hu«fml rentrioles — elllier rrom thu aiieiirisin projecting inl4) them 
iBd iWregiviog war, ur rupturing iuui the»> cnt-ilip» bv breaking down the 
iBMrraaiiv oer^rd'aubstance iilff. 474, 475). When this mode of termi- 



V- 



r 



rX 



\ 



V\g. O*. — AMarlaai of Iba L«n iDtnnd 

lri«l«. Vi«« *r AkMruu (roM &b«««, 
pn^MliBf UU VMIrtcle. 



Fi)[. 1*5— Vi*« at lb« ujBo AB*iiriin 
(root b«lo«, «(iilt*4iieil la «iibei*De« 
»f IlMniiphor*. 



aatW' --~— "• thpfy are occasionally no wflrning or premonitory symplnms 
of ir 'UnKer; tbe pnlient, when apparently in gootl ht^alih, n«^tng 

alrad^ 'i<>nn or an attack of n|toplexy, nhich is sp«>dilr fatal. More fire- 
•DeDtiy a KrW of thn^o »ymiili>iii9 that bavc already Dcen mentioned as 
■ttadlMC muiy ovm of tblD diM«M>, precede the fatal event for a longer or 
■iMtter tIBM. Wh<>tt rupture itf tbe sac and ejctravasalion of bbiod tnke 
IImb. <le«lb ie in^vitablv; at lea^t, T am not ae«{uaint«(t wilh any case in 
•Meh ibc BppeArancv found nftor ii<:-nl.b couvertetl m** to th>> belief that tbe 
pBtkal had even t<rropurarUy nrcovertrt] from thi^ ci>tidiii<>n. 

Dmtb ftvm ninturv of the tnc «p|)earR to be nio»t frt-i)ti«nt in yotingvr 
•riyecta. In tbe later peric^Nj uf life, an«uri«m ix cuniiuotity tL^t»oci»tiH) with 
•thwoMtuiu diaeiuc uf the vesseU gvn«rnlly, which may cau»e dealb by 
tohmaAng and effufinu of bitiod. According to Gidt, of 'iUcn«^e« occurriug la 
piianna undvr ibirty-fivu yeare of ag«, lli (or fit) per cent.) were fatal from 
rvplure of the Mr ; while in ^7 OUM over thirty-five, dealii occurred from 
ikm eaoar in only 14, or 38 per cent. 

3. Demlfa may rmilt from another cauM than tbo prreaure of the aneu- 
riiBal aae or ita rupture ami ibn extravaeution of ila contenln, vi&., from 
m0m)ii^ af Om mh^atiM o/the bntin to a greater or lvf» extent, in coneequencu 
■ tW iKiiiln]n)''n oflbreii ti> the paaeage uf the blood through the nueiirisinHl 
vohfL fn the <-ii«* nf aneurism of botb ean)tid», alrcwiy mculioiivtl as 
WnV r-,ivt-rriiiv Cotlegc liiwpital, tlm was the case: bcAb 

aatorr wrn- nM-cieil wlih whiu- soUening, and this oondiiioa 

. «pacnlly ohprrvable oD tbat side on which the aneurism was larger. 



SPECIAL AMKUttlSHS. 

4. LiHtly, doeth msy be produced by the mere irntofion f)caidoa«<d br 
tb« pmaure of one or more Aiieurismitl tuniurs within tho r.maiuro. OftliB 
ao interesting pxiiniplo 18 ufltirded )iv l)ie history of a, ciwr of anenrnm of 
both inlerual oumtiila, contniDod in Hio Mii»ciiiii of tho College of Surgwm, 
ftod related bj Hir <i. BUdc in the 7*raHMriioii8 of tM« Soeietjf for tJte In^mm- 
meni of Medical and (htrurpical Knotciedge, vol. ii. p. 192. In this caap ihr 
patient, a lady aged tii), had suffered for four years from attacks of giddi- 
uesB, beodoohe, and irap«rfc€l vUinn ; about eixtocn moaths before her dealb 
she beoflmo ineaoo, recovered, and then relapsed twioe into the oariie mate. 
After havin|{ regained her Booses fur some months, iho became aSeoied with 
giddint^at, r^nciu of the «ytd, and violent maniacal delirium, which, eoa* 
tinning fur sumo wv«>kB, caiued her death. 

Ailer duath the fullowing appearance* were found : " Upon exaroininK Uw 
body, there wan no appcarauc^ iu the br»>n itwlf that ouuld in any way 
acouuiit for the tymptonu. There was, ttidet-d, a greater quaDtiiy of fluid 
thau conniion io the ventrirtes, atxl the Hurfuc-c of it waa moitter than it fa 
usually found iu a M>und i>tate ; hut in all other cases wbicb have occurred 
to me of otvanio affections of the brain proving fatal, except Ihove wbicb are 
sudden, sucli as apoplexy, there lis9 been a preternatural quantity of fluid 
in its vvulrictcs. There were also spicula of bone in the menibmue furniiug 
the falx. The inner substance of the crura cerebri was of » brown color, 
aud more tcudcr than natural. The optic nerves were smaller ibnu ualnral. 
He if they bad been wasted. The septum lucidum was more than usually 

" But tlie morbid appearance in this <'flso, which was so singular, and lo 
which the symptoms of complaint seemed chit-fly referable, was two bulba, 
about Hve-ei^htlis of ud inch in dianietiT, lilling up tho hollow on each side 
of the sella Turcica, which were evidcmly dihitaliuue of the carotid nrterin, 
and, fniiii their hcinj^ tilled with Inminie orcua^fuliiled hl«HHl, there could be 
no douht of their lH>itig uneuriHrns of thi^^; nrierii-ii. The dissoctiou was 
madc! by Mr. Hunter, a«i»t<il by Mr. Home, in tlie priawncc of Dr. .Tenner 
and nivHolf, and all concurred in the o|iiinon that thr«c tumors were aoru- 
risnut. The one on the left nidr^ wait the Inrjirpst. That on tho right nde 
coromnnicated with the cavity of tbe artery, which was not the case with the 
other." 

TRE.iTMKST.— In th* irentmMii of intracranial flneuriara iber« la oaually 
little to be done, th« nature of the eatw- not beinj: sufficiently obvious in tbe 
majority of instances to justify active meanures. Should, however, the lood. 
rough whir. I>e dutincUy audible over one side of the head, more especially 
about the bane of the skull, or by application of the »telht>sc<>|>e l«) the 
BMstoid |iroce«8, and i^hoiihl KvniptoriM of cervbral tx>iinpret«iitu beKia to 
Quiniftwt thetti»(dves, ligalurv <>t the cnnitid artery on the »l1e4-teil Hide may 
with projiriely I)** practiiwHi. Thia Iihh lieer> done succvwfully in a mutt 
inlerestiii)^ and iuDtnivtive c-atu- of iulrNcrnninl aneurism by Cop, of Bristol: 
and uiwoci'twtully iu one at Univemily C'ollvgi! ]I<w|itlal, by Barkuley Hill, 
in which death took placo from hemorrhage from the seat of ligatore. 



IXTRAOltniTAL AHBUKISH. 

" Inirnftrbilnl Aneuriniim" were for a loiifj time. con»identl hy Rurgeotw in 
b^ of the nntiire of trectibr tumnn: ; but the ermr of lhi» npinioii viiw pointed 
out by Bu>k, and fiitb»e>|uent]y hy Xuiuietcy, who (inclusively eliowed Uiat 
except in lhi»e very rare ca>w* in which a pulsating tumor of the i>rbil i* 
congvoiial. or has ap[>eitre4l slmrily after hirtb, or is assiKriatcd with ntcvoid 
tissue developed in thu eyelids, it iuust Iw luolted upoo as beiug due io the 



INTRAORBITAL — STUPTOUS OF. 



207 



rity of c»»e* to the preneace of no eneuriam or nueumiual vnrix at 
.h« orbit. These views have becu fully cuiiUriuvl by liivingtoo 
in hi? exhaufriive paper fuUDded on l-i recorded caaeg of [iLil»ntiu^ liiinur uf 
the orbit collecteu from various sources, nad iucluiliu^ ouc \vvy iiiCcnrHliiig 
cMe of bis uwu. The vessel iiffecled appetirv to be lu sotue iiiBUiitree the 
ophthalniic artery iiaelf ; ia other iiigtauces it wmild &p|)ear that tliti tiiitior 
ii devoloiiod wilJiiii tlie crauium, sprin^iDg from iho camlid artery, the 
ophihatimc bdaa but aecuDdarily atfeclod. Di^leiis. of Parin, hnt; rwordeil 
three cases verinod by pn«i-monem examination, Ju which the Fymptoni? 
arwo from an nrterio<vcuouB aneurism afltiuiiag the cnrctid artfry in tbe 
cavernous ^ioua. 

Cacsek. — The causes of JDtraorbilal aneuriatu arc iii twinn vMAe» very oh- 
ftdJtv : ID otbois, it cvidiiriUy luid diruclly has uri}:iiint4Ml fnini ii blow upon 
the beat}. lu the firxt cbiKi oi' case*, where the dleeaise htm hei-u nf ttponla- 
oeoue origin, the putieui bus Huddeoly f(;lt u crack or luiap in the nrbil, lilie 
the "crack of a whip," or tbe "nnap of a gun," and llie dit^fUH- hati then 
developed gradually. In the traumatic cum-", the blow upon the head han 
omally bren aeverc, attended in .4tinie instance!! with oymplom!) of frncture of 
the anterior part of the ba.ie of the skull. In several cases it has arisen from 
peoetxating wounds of the orbit, a.« from fttickg or small »bot. 

Of tbe T3 cases collected by Uivington, 32 were idiopathic and 41 trau- 
matic. Of tbe idiopathic ca^e^ two were con^nltal, probably ^nnine 
ftpeciroeaa of cireoid aneurism; the mean n^ of the rest wa« 43, the oMe«t 
JtteiDg ()!>. The mean ajge of the traumalic case^ wa^ between SO aud 31, the 
< extremes being 11 ana 72. Tbe sjionteneou^ case* were most coirmion)y 
ill women: thus, of 30 caaes io which ttie »ex ii reconled, 21 were females. 
Tbf traumatic form ii must coumiou iu men, the number being 31 nialea to 
10 females. Amongst thu iiliopathic auKs, lo occurred uu the right side, 13 
C'U tbe left, and 2 on both sidot; of 40 traumatic cuees, 10 were oo the right, 
27 OD the letl, and 3 ou itiub. 

Symitomj*. — Tbe first seusutiou experienced is, in uponlaueoua caues, that 
of a loud imapor crack iu the orbit or head. This U lollowcd by cougestiou 
of the coujuDclivu, difficutty in opening thu eyeli<hi, a feeling of tcQ!<tiin, and 
.in gome instaDcee severe pain in aud aruiiud the orbit. Loud whizzing, 
jvrildering uolses are experienced in the bead, and are mueb increased oq 
iping or lying down. In traumatic cases, a persiflteace of congestioo of 
conjunctiva with redness and some a?demH ot tbe eyelids, and tlie occur- 
reoce of noises in the bend, are imuiilly the first iudJcatinns of the mischief 
that boa uceiirrc-d. In all cjises, after a lime, the eyeball becomes unduly 
pfuntiucnt, and pulsation of a thrilling vibratory character can be felt in tbe 
itrbit: uD the application uf the ear, n loud whizzing bruit is discernible, 
licJi extpods uidcly over the side of tbe head. Tbe eyeball itself eventu- 
lly falls into a state of chronic c<iti|i^-3tion; ebeit)L>sis occurs, the cornea 
iface opalcsccut, the aqueous humor turbid, and si)^bt is impaired or lost. 
bfuit and pulsation arc diminished or cense on compressing the carotid 
ortfiry of the side afTccted. 

pRonNosiH. — I thinlt it is still doubtful what wouM bHp|>en in a large 
number of these cases, if the disease were left to itself without ojieration. It 
mifthl be supposed that it would prnbably have a fatal terminatloti ; that 
rupture would take place either into the cranial cavity or cxternallv, and 
that auddeo death would occur. That this has oceasirinally tsken pfnco is 
]>ruv«d by rec*»rded cases, but it ts by no means a necessary consequence of 
the disease. I was coiuiittcd at the end of 1865 by a genlleninn about 
44 y<^r« of age, who, in couHcquence of a fall on the head a few months pre- 
viously, had been attacked with symptoms of aneurism of the left orbit in the 




SOS 



SPECIAL ANBtJBISHS. 



mnft tnnrkod manner. The bruit and the pul)>ntiou were very load aad dit- 
tiuct. The eyebflll wiis greiitlv protni<i«(l. the coiijuaotiva aad eyeUdfl ven 
oongeeted nud bwoIIcd. Greavce, of iliiriuD, with whom 1 mw the euL 
' Hgned with mo in urging HgEture of thr caralii) anory ba the odIt meuii «f 
cure. Td this the ntitieDt would not ct>u^nt,and preferred taluog bboboDM!. 
Bj attcntioD to habita of life, Bbfltinciia; frum Bcimulaata, and ordiiuuy BwA* 
cal treauncDty the tumor subsided, the eye retreated within the orbit, uid the 
armptoma diminiithed grcAtly; so that, at the axd af {ounetn muntba fVea 
ike lime when I first saw bim, I uudcrstaod that they had tu a very gratf 
exteut diaapp«flr«d. 

But there b reason U> believe that all the cigiM uf iDimorbrLal aoeuriia 
may entirely disappear, the diaeaie undergoing a t[)ootuneiius cure. Oulbud 
relat«^ the coK^xil'a man 41 ye&raof age:, who. in oi>nMttjutfUi-« of a (all tin the 
back of hJH head by which he wad rendered iii»«nHtble, vtns i^nulitully r-v'md 
with ttymptotiiH of aneurinm of the lutl orbit ; brtiit, jiuUation, <li|ilii)ii&, uA 
protrusion of the eyeball, toi^ether with con|{«stiuii of tli^ evelidH, l)«>inu 
marked. After the diwaM oad cootinued fur a coosiderable k-ti^lh uf tt 
the patieut vas put upon a course of purgattvex, with a eulomer and bell*' 
donniL pill daitv. and cold lotions to the furuhead. Under tbts treatraeut tin 
Bymptumis grmiuallv subsided, and io three yean and a half from the cam- 
nMDoemeut uf the (futcase had entirely disappeared. Cullanl liuliovoe thai in 
this case there was a dilalutioii uf the ophthalmic artery and ite braucba, 
arising fnmi and maintained by u morbid stale of the uphthHlmlc gaagliua, 
whii^b furnish^ vawHuotnr fitument^ to the art«rie« of the eye. Tfaia^aa- 
glion he helievee h) hBve b«en injurrd hy eonirc-fmtp, and to have rcmaiaeil io 
an abnormal state, which pru4lu(«d dilatation of the wall of the ophthaltnie 
art«ry and itx branches, increwe of the piilsntions and the other aymptoBn 
which have lieen dencribed above It ix H%-idenl from thCK casea that a grave 
prognueis should ni>t lie hiuttily given, aa it is only by watching the caoe thai 
a correct ooncluriion can l>e arrived at If the protrusion of the eyeball ooft- 
tiiiuei^ to increase, and the globe itself begins to PofTer, and vision is lost, the 
pn^noais become* grave and the case taone requiring surgical trfatmfnt. 1/ 
there is no increiue of the symptoms after imiiii- months' observation, the 
patient may be led to nature unlms the annoyance of the disease is so great 
that an attempt l<> give relief beoomee neccswiry, 

Patboixwv. — ^The esKnlial features of stM^lIrd intraorbital aneurism or 

Sulsatitig tumur of the orbit, may arise from more than one )mthidiigical con- 
itioo. Hiviugtoii has ollvcted 1^ fatal cases in which thv iliseiuKH] parts 
were examined hIWp dttith. In one only (^Outhrie) was an anennam (ouIkI 
in the urbit. lu this cnHc tliu disease was double, and there was a circoat- 
scribed aneurism on each ophthalmic artery. In three cases no arterial dis- 
ease was found: in one of these (U:Itlingeu) there wba ubliteratinn "f some of 
the veins nf the orbit frum old iuQammau>ry mischief, in the other two (Bow* 
.man and Anbrey^ there was ohetruction to the passage of blood from tbe 
orbit through thrombosis of the inimcnmial »iQU»es. Id one (NuDuoley) 
there was a circumscribed aneurism of the onhlhntmic artery before it 
entered the orbit; in three (Baron, Gendrin. ana Nunneleyj ruptare of aa 
UMtlrismal internal carotid into the cavernous unus was f<iuod; to «■• 
(Wecker) aimplo dilatation of the parotid in tho eaveruoud sinuA was tlw 
cause of tho discdw. and in the remaining three, recorded by iVIens, aa 
aneuriemal varlz of tho carotid artery and cavernous sinus was fouad. 
Thews three were all the result of injury, one arising from a direct woaod 
from the p<tinl of an umbrella thrust into the opposite orbit, and the ollnr 
two frtim severe blows on the bead, probably aceorapanied by fracturei. No 
CSS6 of aneurijju by anastomosis of the orbit has bsoD demonstraled by past- 



TREATMENT OP tNTK JLOR»lTAi. ANBURI9V. 

luortcui i-xaiTiiiiatiui], but there is BtrouK rcawiii to Iwlieve that two cabm 
which have hvvu ructirilcd uf oui))cvnilal nri^in were of ihia nntun?. The 
earlier uUwrvurs etup^KiKeil all case» u> iw tlue lo aneurwm hy anti«lomoste. 
Th« Ikllnc^ lit' ihifl upinton wus fifvt piiiiURtI oiic by fiuak, who r«ibrred 
the eTuiptiittitf Ui a rupture of the nplithulniic artery and the developnieDt of 
a inrcutuBcriliwi tr«iimatic anciirUm of that vessel ; this also hna not.b«Mi 
di'iDuuHLratul hy post-mortem observation. Niioneley doubted the correci- 
tiew uf thia vifw, and referred the syinptomR, iu some cases, to a peculiflr 
vmcular Cfniilitiiin of the partii. de|M:-iident more upon an affection of the 
reini* than the arceriee, and somewhnt analogous to what Uitcea place in the 
exophtliiilmofl nf br4^>Dcho<!e]e. He pointed out also that in other ciiso:i an 
iineiiridm exic't.';, hut that it is not in the orbit, but behind it in theenveimoua 
rinoH. In thette latter eases he showed thiit the pn^imluence of the eyeball is 
due to distention of the veins of the orbit from obstruction to the return of 
blood, and the pulsation ia commimieated to these distended veins by iho 
Boeurism in ihc cavemoii^ tinns. This view is fully confirmed by the pusl- 
murlem records quoted above. In cbo»e c-a«;s in which nothing lieyoud 
ob«tructiiMi to the returu of blood through the cavernous sinus and conse- 
qu<;4it ililatAtion uf (he orbital veiue has been Ibund, the cause of the pulxa- 
tioo is not Ml evident. Iti other cases, it is perha{i8 possible that sutne 
derajigemeut of the vsso-motor inBuent^e uf the sympathetic may really 
Dccuiuu ibo syniptfiniB of increased vascular activity that are et> chnrac- 
terislic of the divvaae. 

The Mc»udary phennniena that are observed in the«e cases, such as con- 
gestion of the eyeli'ls, of the palpebral and ocular eoiijuoctivfe, amounting 
even Iu ehemosis in aiaoy cases, and the muddinesA of tlie a<)ueous humor 
and leoB. are doubtless due to an interference with the return of blood from 
tbne fiarts Ihrougli the ophthaliuic rein, to the coiuteijueut conf^lion of the 
BouUler vessels, and to etTuaion of scrum into thii 8ubconJtiD<-tival areolar 
tUBue. Tbc protrusion ni' the eyeball ia due to the vascular tumor, what- 
ever its preeJiHL- nature may be, and the dirrangement in viyiun to an altera- 
Unn in tuc axis of the eye conseuuent on this oxtrusinn. It te remarkable 
that the Imtit in ifaeee cns4« Khouul bo ko loud, not nnlv to the [latieut's own 
•mses, but to the car of the Kurj^on ; and thi^ ran be aecoutited for onlv 
by the proximity of the cranial bones, which may act as conductora of sound. 

DiA«JS<i»»iK. — The DiafpioaU of pnlnitin): tumor is Hiiflicieiitly easy, but it 
ie just an difficult to detennine accurau-ly the cuitiDe of the disease. It is 
probable that nearly all the traumatic casea nn^ due to aneurismak varix of 
the carotid artery and oflvcmons sinua. The sLidden onset of the dinea-te, 
with ft crack or snap in idiopnihic casei), would lead to a presumption that a 
Mnall aneurism of the carotid had f^ven way into the sinna. O^n^enital 
ca«K>a are probably aneurisms by ai)Hj>tomiwii<i, Beyond thii*, accurate diag- 
Dosia of the palhologitaxl conditiun iit hardly possible. The di.'»ease most 
likely to be mistaken for an intraorbilnl aneurism is a pulsating sarcoma of 
the booeii of the orbit. In this, however, the pulsation is less expansile and 
the peculiar, harsh bruit is wanting. 

Trkatmknt. — The results of the esses that have been referred to above, 
ihv tmrertainty in which we otleu are as to the real pathology of this 
disease, and the certainly that in umiv iustanees at least there is no true 
ascurbmal tumor, wvuld justify the -Surgeon iu having recourse to medical 
treatment, aided by digital compressiHU of the carotid, and, perhaps, the 
■ppltcation uf Ice to the forehead, before proceeding to operate. TlnU these 
naaws are occasionally eucces«fiiL there can he no doubt. Giuppi, of I'ndua, 
baa recorded a oiee in which au intraorbital aueurieui of great severity was 
cared )iy intermittent digital compresvion. The compre^iun WA8 kept up 

TOL. 11. — 14 



3 



SPBCIAt. ANEDRiaUS. 

for periods of a oiuiiite or two wiLb fre<)uent iDtervals ; preaurv coiitinmd 
for more than one minute chu»^ fainting. It was cured io four liajrt. 
VuDzetli and r^arraiuuszii hnve published another caae, in which inlomtl' 
lent digital cuBkprcasion waa kept up for five minutes at a time. The out 
VBS complet«lv cured at tlie end of compreaeioD during KVen huun and 
twenty minutes, spread over eighteen dajB. 

Ri\'iugtoM lias L'ullccted 16 cases, including thoac juitt nwutioued, in which 
digital eompmeion has been iidopU*d. Of tbcse, 5 were idiopaibic and 11 
traunintic. Two idiopathic and one tmumalic were cored, in the rut no 
benefit resulted from the treatmeoL In«trumcota) compreMion baa beta 
tried in four l-sm-s without result. Galvanopunoture has been triod twice, 
once it failed and once it wan fatal. Coagulating iojectionf have been und 
four times. In all the disease woj traumatic. The Bubetance tiaed was 
perchloride of iron in three caseo, two of which wen^ eornl and one derivid 
no hcnetit. In the fourth case a sohilinn of lactate of iron waa injected ai^ 
the patient was cured. In sptte of this succeaB the injection of coagula^^^f 
fluids into a dilated vein in which it is impoesible tcmporarilT to arreat flP 
flow of blood, can hardir be regarded as a safe proceeding. When medioal 
treatment and compression have failed in producing a decided impreanoa, 
the only course lell for the successful trealmeot of the disease is ibe ap[4ie^ 
tiou of a ligature to the common caiotid of the side atfected. This oparatioo 
baa been highly successful. Bivingion has collected 44 caaes in which it 
has been performed, 18 idiopathic and 26 traumuLic. Of the idiopathic 
cases 3 diet! and 15 recovered; of these 15, 12 were cured, in 8 vision aai 
restored, in 3 it was nut regained, and in 1 the cllect in this respect Is otA 
mentioned. The remaining 8 cases wi^re bvueJUed bv the operatioti. Of 
the 2tj tmuraaiiit ea^ee, .'1 died and 23 recovered. Of the 'l\i, 14 were nired, 
1 by ouhtKeiiuunt injection. Vision wna not nrgained In 4. In 5 the opera- 
tion failed, 2 of tliei4(' were subsequently cured by ligature of the opposite 
artery. Four were tianiully curcvi and one relnfwed after appan>nl cure. 

In a vi'ry iuteresling caw which 1 saw in V'elpeau's wanls in 1839, both 
orbits we^e aAcctml ; and.a-t pressure on the right carotid arresliMi the putaa* 
tion and bruit in both, ihnl artery was tied. But ihnogh the di^eiwc ws* 
cured in the left orbit by lhi.1 operation, and temporarily arre»tMl in the 
right, it reappoared in the latter siltintion, and was eventually cured here by 
the ligature of the lef^ carotid. 



ANEL'KISU OP TUG BUBCIAVIAR AHTEBV 

AneuristDs of the i?ubclaviau occur in order of fretiuency between those of 
the carotid and of the bracbii>-cephalic arteries. They are must frequeatl? 
met with on the right side, in the proportion of about three to one ; and thM 
w>mld (ip|K'ar to be lu a great measure dependent on tlieir being uccasloaed 
by direct violence, or by repeated or prolonged exertion of the arm ; Iboa 
tbey caramouly occur from falls, blows upon theshoulder, or exceanve fatigoc 
of this extremity. From the fact of the aneariflms arising from esteroal Tio> 
lenoe, we should eipect to meet with them most frequentlv in malea, aad 
this we do in a remarkable manner. Of 120 cases collected by Poland, oaly 
11 occurred to fetunles, and in 4 of these instancca the disease resulted froa 
injury; in 2 eaacs, both arteries were aAct«d. The disease may- be seated 
in any pari nftlie vi.-8»el on the right side, though most commooly it is not 
dilated until afler It has pn^sc^l beyond the anterior si-alenos. On the left 
side aneurism never occurs bdnrc the arterv has emerged from the thomx ; 
and then, as on the right, it most commuuly happens io the third [lart uf the 
course of the veaeeL Subclavian aueuriam may occur at any ago abi>T< 31. 



•rVOLATIAN — SYMPTOStS — DIAGNOSIS — TREATMENT. 211 



!■ arm eotumoa in raiildle life ; and, according to Poland, U three timet 
- 'r iieot to England than in any other cxjuntrjr. 

■US. — Ad aneumm ol^ the ^ubcUvinn arlvry ia characteriMd br a 

ii-aiin^ oooipraMible tunuir of an elongittM or ovoid ahape. nituated at the 

•«■ i>( the poK«rior ioferior triangle of the neck, immwiiately abuve the 
«lsiriel«. If U be sinall, it wilt duuippear bebiml this bone on tbe shoulder 
Wac niMd: aait iocrt>a>>e« in fixe, it fills u|i the whole uf the space between 
tb« cMViele and th« tra|>eziii». otlun nttaioing a very considerable bulk. In 
CBMtn«e«et of the prtwure which it exercivea on the brachial plexiu of 
■uvu tberi! » pain, oAen attended by oumbu^w, and ext«<nding down tbe 
•na and fiugere, OBuallr with Bome weaknesis of those parls. In some in- 
■liaca there m a apKAOiodic afiecLiun of the diaphragm, owing to irritation 
of tike pbrraie nerve. Thet^xtt^rnal jugular vein is commonly distended and 
rmritsmt ; (Bdema of the linad and arm may be present. The tumur does not 
iaere—B rapidly in size, oiving to ila being tightly compressed by the aurround- 
iiw parts ; and, as the disease never extends inwards, it does not interfere 
wah ibe trachea or asophugus. In mme cases it hna been known to extend 
donnmrda and backwards, so as to implicate tbe pleura and the summit of 
tWlitfl^ 

DlAOSOBls. — The diagnosis of subclavian nneuri^ni U usually easy, and 
proMia no point of a jptcial chuniclcr. Mayo, however, mentions a ca*c 
B which aa exoatoeis of the Grst rib pushed forward the anbclavton artery in 
■aeh a wn* as la cause it to simulate an aneurism, and eventually to arrest 
tk* pabation io it. 

RncCLta. — As a subclavian aneuriam incrvflsea in size, it may become 
£Amc«1, and bant either oxiemally or into the pleural sac. A spontaneous 
IT* baa iDoro fre^juently occurred in this than in any other external nneu- 

TKBATMnrr. — The treatment of subclavian aneurism is in tbe highest 
qoaatiafactory. Gumutr^mon on tht enirdtac «ide can be employed only 
IIm artery is so irregularly distributed that it rises sufficiently high in 
ht admit of praaure being applied between tbe scnleuus and ibesac. 
8*eA a oowbinaiiuu uf irregular anatomies] distributioua with aneurism 
■at of BMHasilj be excessively rare : but in one case in which it iXM^urred, 
JMasd luooneded in effecting a cure by digital euiuprcssion. kept up for 
MMiV-au houn. Tbe tumor tbeu was smaller and harder, but still pulHuted. 
Tba BatMol leA the llospiul. and. nt tbe cud of a mouth, tbe tumor was 
lb«M to have baoome aolid. and to have ceaaed to pulsate. The uumbcr of 
aaas in which eonprenion is pcxisible, may perhaps he increased by |ierforin- 
ia^ tbe opBtmtiua under prolooged animtheMa. 

Ointt I^tmurt on the rac has lucceedcd. It has been tried In three cases, 
aftdia aJlsucetvifuny. Warren, of R(>etj)n.roiult) the pressure by mtmns of a 
aaimb l ; and <'omi-r, of I'oplar, by means of n leatlu>ni cup moulded to the 
•■■InBg. The allfrmpls at id)Uiining couHilidalioti of the tumor by eotulitu- 
ISmtmi SMViw or by ffo/watw-pwuiure, have hilhcrio failed, except in wmic very 
ran* [a«laB<v«L A ease is report^l hy Vontman of the cure of !>iib<-iuvinn 
V-ilaalva'n plan in eighteen months. Oaloano-puneture has been 
- )iui only on o«* with success — in a chbo under the cJtre of 
!-•« hftvo bfni sucreMfully treflte*! by I*i»ngpnbeck, i>f 
■■ Dilloit, oC Bern, hy the tuhntlanrottJi injniion of trffoUn 
its over the tumor. MaHipulntian, as recommendeit by 
'. 11 irtrd tiv« timm iTIolmc^ ' ; r-ncc in the bands of Little 
fMeeneAiIly. ooce by Kcreuason with partial success, and in the three remain- 
i^ caaaa wilbuul any advantage. Tbv tr^-atmeiit undoubtedly deserves a 




SPKCJAL ANKITRISMS. 

further trial in Uiese oasn, wheo ve consider the extreme danger nf tlM 
dbraso and lUt. great want of succcsn that atteudi other meant of cttr«. 

Ligaturt of tM bnichio-cephoHc, and of the juMbvmui •(•eVf. iaterBal to, 
hehind, and nevciml the Kuteuus HDticun, has b«eo pimotiaed n>r the von of 
this form ol' aiieurMm; it hu likewiM beeo propOMd to apply the diital 
0|H!niti<jn to the treatment of this dtsesoe. and to atupatat? at the tboul4kh 
joint. 

WhtfD an anetirisni i» vituuted oo the right eubclaviiiD artery on tkt 
tracheal vide nf the siaileQue. there is nu war in wbioh llic flow of blood 
thruugh it can be arrested, except by the ligature of the bruehio-ecplMlic 
unery. Wlirn it i^ situated bevond tbo HcaIoaui,or even bcliiod it, ligaturr 
of the vewel basheeo practised m ibe fifM pwrt of its courta befor* it raufati 
tbU muticle. Fur mbc)a¥iaD aiieiiriazD on the leA side, ia thcM rituaUoaa, 
no operation coDducted on the Uiinlerian priuciple would b« practicable. 

Let m DOW proceed to examiue the rcsuiU that have atieoded ihew opera- 
lire propedurt'fl. 

Liffatnre of the Braohio-oepholic — Tho brochlo-cephallc artery, at tnar 
be Kcn by the aecompoDying ubie, hod boen ligatured MxtfK^n timu, and lo 

OASEA OP MOATFRE OF BRACHIO-CEPHALIC ARTEHY.' 



w 


lATITRK 


» 




Afmm»nm. ■■». 


"**■ Of PHSAII. 


aa«rLT. 




1. MoTT. m. 


67 


SiibcUrlsn 


IHed on 'ifllh 


Ti«d an ini-h t>rhiw tiirnn-atliW. 


■ 




■no u rum. 


do-y. 


Liga(im> Mpatalf<il Id fiHiiiwn 
imyt- QcDitirrbaga oa Sfah 
day, ttopptd b; praMure: r*- 










1 


eurrrd on 91th. 


S. UOATX. 


— 


■ »■ 


Subclavitn 


Died on CTlh 


Llgiluni H'paralod in fourtMB 








■ rifriiriitn. 


dny. 


day*. Died or hei»iirrh«|;R. 


S. IIalu 


«n 


• ■■ 


SuIk-IkvUr 


Died >'» 5ih 


Artery waa dii»a*«(l and r««a 
way. lll^«diii< arreaiHl bj 








ntteufiitiu. 


d>,v. 












plug: dralh h^xnnthvf cawN. 
Ckh refermd tt> as itrrurriBf ta 


4. Durrt- 


__ 


m >> 


•■• an 


I>i«d. 


TMKR. 










lbopraclip«iir Du[Mi)ru«a. 


6. XaoMAV. 


m. 


... 


SitbcUvian 
Bneumtn. 


Died. 


Dicdof pflrintrditlifltty bvai» 
an«r oiiifrnlion. 
HtnwrrliaE:^ i-aiiip on cm Iki 


0. BUKD. 


tn. 


81 


SubcUvian 


Died oil IBtk 


V 






iin«iir)tni. 


A»y. 17th and iKlhdajt. Upilurv 
a|i|iUo() tu upfwr porttan nf 
■rl«r>-. 


t. LtXAOD. 


• •• 


*«* 


Sii)wlHvI«n 


Dim) un 2ht I^»tBr*MpK»tedo(il7uiu^. 
dav. H«[norrha(;p on Itfih. 








■ineiirisiii. 


B. UCTIV. 


n. 


se 


llROuirrliaKfl 


Diud m 12 Puiicliirtd wouml in aiilU, be 
boun. 1 which ■iilMUvian «« iMi 








fefler li);ftture 








ufMibclavlui. 


Iben bracliii>c«|ihBlie~~ti«tL 



* Tbw arv all tb« casw of I1f;«tur» of lb« braebicHcephalk arttry th» dvUlt* «r 
which I hav4> bw>n ab)* lo nolleL-t. Tfaia artery b al*)i >aid Iv bave bMn vtvm UgmUmi 
hy Vin-gi-tr, and twuo by KiiBahitt — all thre» paw I fatal : but, m I can Hud nn datalk 
lba>*op«niliun*, 1 h«Vr- . ■ ■ > ■' r— in Um abtivn Uilil*-. (lurK, in hi* It*pnft A 
trftty ("Arehi> fur K ^i«," vvl. iil , l^Ctij, uni*. In ipatklof at 

ii|Mr'*MC»nd raM»: "'J Ij; '-^ cai* of ligatiirf i>f lh« lnn>i|Rtiiaie «rMy : 

lid •varj' Dfiv t'i ibrni ba> |ir«v«<J laial." In Ibv Ind*t ralalogncor lb* Lib^vry at 
iSurcpon-nrnTar* Offir^, 'Watbinrtcti, » ■ r«rn-VDce !•• a pa|*«r by D. L. RfiMf, 
on *■ A ra«a of tucc-Mifiil lij;ail>in of ide innomlaatAartorj," AmarUmn Mttttfml tCmta, 
N«w Torlc, 1^4. I ruunut And a rvfutvimv ii> iln> ck>*> vliMwhoro, and baT« oof ' 
abl* tu luok u|> tb« iirlglnat f*ptr bafora tbau thttu wtal u> pr 



LIOATURE OF THE IKNOUINATE ARTERY. 213 

t. A<E.< OF LIGATURE OF BRACHIO-CEPHALIC ARTERY— Cfanimwed. 



.lATcaa 

or PIRBASK. 



',• A«SDT. 
111. OHtpRlt. 

Sail Fran- 
ti-o«j. • 

II. C.«P««. 
IK>.. 



I:!. <;oRi. 

Bath.) 



.■.2 



; >KTTH. 

. N*w Or- 

'■<«ni. . 



:i-2 



Subclavian 
aneurism. 
Subclavian 
and carotid 
aneurigm. 

Subclavian 
and carotid 
aneurism. 



Subclavian 

Hnd axillary 

aneurism. 



Sutictavian 
aneurism. 



Died on 8tli 

day. 
Died on 9th 

duv. 



Died on -Hih 
dav. 



Died on ITili 
day. 



Recoverv. 



14. BlCEKK- 


Ul 


41 » 


Subclavian 


Died on tith 


*TCTB. 

LiTerjKsil.l 






HDeunsm. 


day. 


Itublii). 1 
I'. \V Tn.i»|. 


ni. 


1!' 


Subclavian 
iinGurism. 
Subclavian 


1 

Di-alh no\l 

dnv. 
Died <i"ri 4ii 


Djbiin.' 






aneurism. 


dxv. 



Inllammation of lung, pleura, 
and aneurismal sac. 

Uppcrondcifsterniim and inner 
end of clavicle remnvcd. Dya- 
pnnptt and retention of urine: 
|iiig in the right kidney. 

Hones removed a« in previouB 
oatte. Patient was apparently 
doing well, when secondary 
hemorrhage appeared. Imme- 
diate cause of death, hemor- 
rhage, in coni>equence of re- 
moval of bandages by patient. 

Artery cut through by ligature. 
Cardiac extremity not con- 
tracted, but partially plugged 
with dark congulum. Inflam- 
mation of subclavian vein 
I left). Pus in anterior medias- 
tinum. Aneurism coiitmctad 
iind filled with eoaguliim. 

Ligature applied to brachio- 
[-ephalic a quarter of an inch 
below bifurcation, and at same 
time to carotid one inch above 
origin. Hemorrhage on l&tb, 
'■)3<1, and olst days, arrested by 
pouring thot into the wound. 
Ligature of right vertebral on 
.')4thday. Tumor returned ten 
yean afterwards and proved 
fatal. 

Direct comprcisinn tried on the 
nrlery fortwodays. Thenliga- 
iiired above and below the spot 
where comprfs^inn had been 
H|>p1ied. Death frum hemor- 
1 liage. 

(iirutid also tied. Apoplectic 

^y1rlpl^)nlS. 

Sirnndiiry hemorrhage 80th 
and ^il'lh davs. 



N B — The artrry was out down upon, but not actually ligatured, by Porter, Post, 
AttL-D Key, and Hoffmann. 

rrerr imtance but one with a fatal result. la four other instances the opera- 
tion bAibeen comtueQced, but abandoned owing to unforeseen difficulties, and 
till* br some of the most skilful operators that their respective countries can 
hmtt'nf. 

Althou^ch, ID reasoning on the propriety of performing an operation, it is 
BOt io general worth while to take into consideration the difficulties that a 
snrgfm may encounter, provided the operation be at last applicable ; yet, 
wlieii we coosider the fact of the ligature of the brachio-cephalic having been 
axt«ffipted. ami in consequence of unforeseen and insiirmnuntablc difficulties 
left ODCoDcluded in so large a proportion as one-fifth of the cases, and these 
in tb« hands of Burgeons who were as well able as any to accomplish what- 



S14 



SriCIAL AXKtrSISHB. 



evrr 



til 



• pomr of •pwmliTC mrgerr to do, 



.r wM hcrftBU npoo 



uubt bnei ibe oawtjon iUelf. befcra pracnedJng Ia ijk« 



tht ibaea] 



aUaa* 



ui mberl 
kf be fiMittd 



vhieli 
Divrvlv in ttir puuliuB ud ABmunicAl relatirmi of the TtsaeJ, 
ihr oi<n<lilii>ti in vKtr): tkc utcTT and tlit^ adjacent ■Croctara 
aflvr tlir i-vta^l '• --^oim^. Tlius. in ^•^npr'« raje, thtt aDearam. ulilcli 
a Inip} (tiiis I' ''>' wbiilv of ih« tnfrririr {VMterinr tiian^Ir u( (be DCck, 

being nearly ;»)> •i>mm.'« broad; a^ no pulmticn wa* trai<cable in tb^ Tcsaek 
beyood ibf Kueuriau, it wa> tuirlc** t» attempt ligslurv no tbv tli»ul nde. 
Oti expoaUi|[ ihv bracfakvcMWic. Uiat vn»«l was Touod ia b» dncafcd, aoi 
it ima act tlH>u|;fat dtMrabW to ftm ihv ti),'atur« round ii- la cooMifttraet 
of the cx]x«urr uf ibr artcrr. bowercr. tbc pulsation ui tb« tiUKir paduall/ 
(Umiuirlml, and at laM cwi e d coUrvIr. its bulk also beovmiog Icsa. 

In K«v'b i'nse. in whicb it 'K*a impnicLicablo to paw tbe n^liin;. tt was 
found allcr dcialb thai lb« bracluocvphalio vaa disrased. banc dilated ud* 
mediat«lv after i(» ori^D iotn an oblong tuttior. which '>crupi«rth« wlMlcirf 
the arterr. It ts rrmarkablr that in ibis caw, as io rurirrV inflamaMlka 

I Menu to bavt.' taken plaM in thv arta7 in cooaeqiience of ibe oeoMMiy 

I handling io nhirb it waa Mibjertcd. and that the pulaatiuu to Um «Ht vam^ 

[■Murnilv dtniinL*>b«4t. 

Tbe i{iifii>ulttrft of the c^MtmiiOD are in themiwlvfs of aeriotw aagniiad*; 
arising fnim tbe depth of tbe mael, ftmn its proximity to tbe centn of tbi 
tniTulation, and (ntm the netfi^hortiood of large veiriB. which may bvconM 
turgid, ntid a wound nf whiob n>»t onlv obsmree the line of ind^on witli 
TeuouB blkHK), bnt inditcvs a risk of tbe'e&traooe nf nir into the rirralatioB. 
The trunk of the artery lies bebind tbe acejDo>«Uvicu!ar articulatioo and tbe 
upper part of the »tenium, and biftimtea at the level of the u; I'-r 

oi tbc clavicle. In fmnt of it ard tbe ateroo-hyoid and Mcmo-lli . m- 

dea, and it JBaoMed near in tipper part by the rigbr inferior lh>roi.l vam, 
and Inwer down by the let) iDnnniinale. To the right side is the rijd;bt innomi- 
ttate vein. The pneumogastric nerve i^ bebiod and to tbe outer aide, not 
being in clow relation with tbe artery. Behind tbe vessel are, at fint the 
tracbea, theu tbe pleura, the trachea being dow internal to the arlerv. Tbe 
artery may be reachei] in the deRd body by an iocbion starting Irom the 
■terno-clavicu Is r artinilntion, and carried upwards for nboiil threw incbe* 
between the twu beadn of tbe vtemo-mastoid, but this would not be jiistifisble 
in tbe living subject, as it does not give Mifficient space. The eorlT <lt«ps of 
tbe operaliun shutild In! the same as in ligatatvof tbe lower part (.if the camtid 
(aee Ligature uf the Can*tid, n. 193). Tbe stemo-faycHd and 8tem»-tbyrc<id 
moBcIca must be frvely divi(lv«i, and the c&rolid expoenl as low down aa pos- 
sible. This vissel K?rv<« ns th« guide to llie iunominnte, tbe linger b^ng 
paased along it till the bifiircntion of tbe main trunk can be lelt. The 
needle is then guidnl by the linger, and pannl round the artery Irom tbe 
outer nde. Jl in iniilrnt that tne ve«el cannot be dearly exposed in this 
node of operating, and the nc>edle u tba«fbre pMnd aomcwluit in the 
dark. To ovdrcome (lii* tlilliciilty. Cooper removed the inner end (^ the 
davide and port of the sternum in both bid ouea, and shonld tbe openujoa 
be repeated it t* probublt- that ibis would bo the aafnt plan of expoBuig lM» 
p| ; at any rate the operator should be prepared to adopt it at an exien- 

imm of the jirooeeding (irat described if neccwu-y. Even when the difficnl* 
ties iif exposing the artery have been surmonnted. and it has been expoaed, 
its Cfialii may be found m ilisrasrd, or it«, calibre so increased, that it may be 
undiwirablc ur im]>uiwible to paea a ligature round it. Tbe failure in deth 
*i>i2 tbe arlerr would, however, aa wo shall immerllatcly tee. appear to be 
iMitraus in its consequences than succeaa in tbe attempt; for of 1^ 



LIGATURE OF THE INNOMINATE ART£RV. 21$ 

Atm CHOI that have jtut been referred to, in which tbis attempt v.tui niadu 
■■d did Dot Micoved, ooe was cared of the (Iim'sh.-, tin- artury lining ublilfy 
rBMd by tbrombosU, cousequeoi upoQ iotiftiunmtiuu of its coiiti). »vl uji by 
lb* naaipvUtlan during tbc op«ralit>ri ; ond iu auoiher, Key's [mtient, ao 
aHanpi loaeC up thi» finici-a> a|>{rears to have b«eu maik', tbe tumor Ijvvom* 
iag wwid and ocwing w pulsate : nbi'reaa. in every cn»e but one in which 
tW vcBsl was ligatuml, a fatal nxiilt aiwetlily eiiiiiie<l. 

TW rbqIis oi' tbe ligature of Uie vnsel arc tb^ii in the highest d^ree 

di— mgiag ; far uf the oixteeo cases iu ib<} table in which it has beea done, 

salf <aie hM rvoovered. The only sucoesaAil cnse, that in whicb Hmrth, of 

Stm Orleans, was the operator, is one of tbe most remarkable on record, but 

■ raUlty aflbrds no evidpuce as to the possibility of safely ligaturing the 

hnwlii*>«ephaUc trunk. For in thifl case the caMiid was also tied so as to 

*)p tbe regiugitont flaw of blood : yet, not withstanding tht^ prei'aution, on 

■he foortrenth day seTere hemorrhai^ to syncope occurred. This henior- 

ftiajr recurred at iniervala for a period of thirty-seven days, and xraa tern- 

fotAiilT arrested by lilltog the womid with shot, till, on the filty-lirvt day 

•ft«T th« operation, a " lerrifie " bemorrhn^ie took place, stopped by syui-ope. 

A» th* bl««<lin]; came from the distal »iite and from the etibctuvian artery, 

thft wrtebral was tied, with [wrlect Hiccess — no bleeding recurring. Tliis 

bet ■» of lite utnireCsnr^gical value; it shows thnt the secoudary hemorrhage, 

«Wck may be ltM>k«d opoti almost as the necessary sequence of the ligature 

•f ibf ionominal*? ar1<.Tr, may Ite arrested antl the patient's 1if« saved by 

tW ligature of tbe priuciual arterial branch that oominuuicates with nud 

iknl carries reguniitant blood into the distal end of the artery which was 

•rigiaalir ItgatureJ. This fact is entirely new iu operutife surgery; and 

Am ■tabusfaacnt of it, as well as the skill' and courage that were displayed 

m dwooenttiTe procedures required in, and tbe general manageraent «t'thie 

MM, tVMGt the highest credit on .Smyth. I am indebted to him for tbe 

Itutfaar Ustarr of Uits unioue case. After ten years of gt»od health, in wbich 

tha falirat wu able to follow bis employment as a ship's steward, the puba- 

lioa rabtmed and tbe tumor reached a nize larger than before. Thinking it 

■Mu be fed br the Internal inammar^'. i^myth ligatured that ressel, but 

vjnuHit any reHit. About six months aJFler an absraffi formed over tbe sac. 

•■d the aneurism became diffused into it, and as a la^t elTiirt to snvc the 

HdoH's life, Smyth performed the heroic opemtion of laying open the sac 

TbahesKmfaage was profuse, and the openings of the vessel into the sso 

e— M BOC be sseil.aa that the operator had to cmntent hini««lf with plugging 

Am vMiad. Th* patient died a few days aAer. Thn post'raortem examina- 

tiaa ahdved thu ine eireniation bad beien carried on cbicBy by means of t)ie 

iiiaaliMiiTS between the aonit^ intereostals and tbe branches of the axillary 

aftcry. In three tnore eaaca the operation of ligature of the innominate is 

•ud to have been cried with apeediiy filial results ; and in four oases, after 

baiMf aoaunenced, it was abauJooed. Death occurred fp^m secondary bemor* 

rfeay* in Mffai cases; fWim intlamination of the lungs or pleura \n one; 

fnm pericarditi* in one; from di9en»eil kidney in one; from phlebitis and 

«app»Btion in one ; from " apoplectic syuiptunis" iu one ; and iu three from 

mmmm thai are ool raenlioned. 

la ooe case, that of Hall, the arterr was transfixed by the aneurism-needle; 
laaajfrfcag* occurred ut the time, wliicU was arrested bv plugging, and did 
aol. raear, the patient dying from other causes. In tlirec cases, tlt»«e of 
Uatk, BSaad. and Kizars, tbe hemorrbnge cane on shortly after the lepara- 
IMl 9I the Hgnturr ; hut iu Grtfe's it did not occur for fifty-one davB aller 
thil^ iJm cicatrix in the artery having then probably given way under the 
of noie imprudent movement on the part of ibo patient. In 



i 



SI6 



SPECIAL AKECRISMB. 



Cooper'* aeoQud caw, the patient appeared to be Koiog an well for 

weeks, when seoondarjr bemorrbage appeared. Learaiug that uuIUm 

ifurtber could be dune. I lie pmicut [ore oil' the bandafiea wbeji alone, an 

^blcd CO death. lu Bickcn^tiub't! ouse. tin- urtt-ry had beeu injured by tha 

prt.-viouB coiiiprt-frjiittu applml by lui-uus of a leadeti wire. The li^tur« wat 

applied ou «ach Hidt uf Uiv bruisvd epot ; but secciiuliiry hetmjrrhagv pr^Tod 

fatal oil the (■ix.tb 'lay. With euch mBults as th<!He, thure can 1m but ooa 

opiuiou as to Uiu extreme danger of auvU aii oiwration. Atr its perforoiaace 

liiia hitburtt) iu evury itii-taiict;, (!x<%iiL in HniytbV, 4>ntuiled dt.>nth, and |;eoar- 

ally a ajienly death, it should without doubt be undertakoji with tnuirh httJh 

talion ; anil it could only be wt a last reaouroe that a SurKeon would hava 

reconree to such a procedure, in the face of the conaequeooea thm hare 

hitherto luvanably t'ollnwml the application of a ligature to thp hraohio- 

cephnltP artery for Hubciaviao aneurisTO, Thommn's case ia the oulr oni 

in which a ligature not intcniled to cut through the coaia of the artery hai 

rbeeo applied, In hia case the nmtcrial uaed wu the ox-aorta lif^tnre rfr 

'cooinitruded by Biirwell. Althou^di the patient died iVom socondarr hfimtr^ 

rhage i»u the forty-second diiy, ihe rveult waa lo eome denree fii<' 

for the blood had e8ca|>ed from au ulcerated opening at the bifun : ri<l 

not from the aeat uf ligature. The opening seems to bav« been the result 

of ulceration fr<»m a amull carily lefk aHer partial healing of tlie <ro4iod, 

jAod it seems probable that the blood was supplied by a recurrcDt etreaai 

through the verlehral. 

Ligature of the SabclaTiUL— Polaad collected tweDty-<«e catee io wbicfa 

thia arlery has been tied iu the third part uf lis course fur aubclaviao or 

[lubdavio^xiltary aneuriam. Of thnie iiiue recovered. The sac waa puite- 

[lured in two cn-tes — by J.,i9toa and Travers. The majority of the duatht 

'Were frt>m hemorrhage. Warren relatee n remarkable caae occurring lu a 

lady aged thirty, wbo was afHicted by an aneurism just above the cla%'icle. 

The patient was exceanvely dcfurnted from club-foot and curvature of the 

Bpiue, ao that the lint two hbs nwe above the clavicle, poaaog obliquelv 

acroH the neck and carrying the artery upwanls and bacKwnnu, so thai it 

tlay pnnillcl tu, and about nn inch from, tlie external borter of the irapa* 

xiuB. This peculiarity of position enabled Warren tn tiv the artery on the 

cardiac side of the tumor, and the caae hud u succcaaful iiwue. For aiinu- 

risnia situated on the right subclavian artery, behind or beyond the acalenua, 

that veasel has been Ligatured on tfte Traehtal aide of these miHclea : on the 

left side this operation ia acarccly practicable, on account of the dopth at 

which the Artery is situated. It has, however, been performed in one caao 

by Dr. J. U. Itodgera, of New York ; and it was attempted onM by Sir 

lAalley I'onjter, who failed to secure the vessel, and i» aaid to h«v« wotHKbd 

the thi>rfti.-i(; duct. In another caae McOill exposed the arter}*, and tempiv 

rarily *-i)mpr*'w#d it with a |uiirof forcenu The pleunt wa* wounded in lh« 

|0(>eration, and tite piitient die*l on the xixth day of plenriny, When we ron- 

rider the anatoniicnl reltilious of that (H>rtion of the right subulaviHii which 

llerveoes between the braohi'>.cephalic arterv and the trncheal etlgetif tba 

Jeotia amicus luusclc, we nro at once Htruck with the great difGculliea of 

thia underlakiog ; and whcu wo rcdect on the poaition iu which the ligatnr* 

'will be placed between the onward current of olood in the bracbio-e^>halie 

ou the one aide, and the regurgitant streaiu conveyed by the vertebral, lb* 

thyroid axis, the internal mammary and superior iotercoetal, into the aab- 

~ iviaii, immediately beyond the iieat of dvligatioD oa the other side. w« earn 

rcnly, iu uecordauce with thuaa principlea uu which the lunualion uf ■ 

ilum within a ligatured vesael l&kee plane, auti<-ipali> Hny hut the moat 

itroua rceults. 



LIOATUKE OF FIBST FART OF SUBCLATTAN. 217 

In reference to the mere difficulties of the operation, Fergusaon justly 
diaracteriies it m the most serious in Surgery; the proximity of the common 
<sroti(i anenr on ooe side, the internal jugular vein on the other, the vena 
innomioata below, the vagus and numerous small venous trunks in front, 
tbr recarrent laryngeal nerve and pleura behind, constitute relations of 
Hifficient importance to justify Fergussoo's opinion. But supposing these 
difficulties overcome, and the ligature applied, this must be situated, as hag 
just been stated, in such a position, with a strong current of blood flowing 
npon laicb side of it, as to render the formation of itn internal coagulum im- 
pcwnble, and thus up to the present time secondary hemorrhage has invariably 
uccurred when the ligature separated. Whether the application of an ab- 
sorbable ligature without division of the coats of the artery will be more 
•occcKful remains to be seen. Besides the danger of secondary hemorrhage 
from these causes, there would be the additional risk of the coats of the 
arttry being diseased, as we commonly iind them to be in a more or less 
BorlHd stale in the immediate vicinity of aneurisms; and, thus being 
tendered insusceptible of healthy repair, ulceration and sloughing would 
take place along the track of the ligature, causing the probability of a re- 
currence of hemorrhage. Thus, in Colles's case it was seen, on exposing the 
subclavian artery, that the aneurism had extended in such a way towards 
the carotid, that it was doubtful whether any part of the affected vessel 
continued sound. On exposing fully, it was found that only a space of the 
vessel three tines in length remained free between the sac and the bifurca- 
ti>-«i of the brachio-cephalic, and it was in this narrow space that the ligature 
was applied. 

The subclavian has been ligatured on the tracheal side of the scaleuus in 
fourteen cases, all of which proved fatal : twelve from hemorrhage, one from 
inflammation of the pericardiumand pleura, aud one from pysemia. 

The cases are as follows : 



vrasBa!*, 


HRX. 


AOB. 


F'ATK or PB«TH. 


1'4L'!1R lir lIKtTI). 


CrtLLtv 


■II. 


3.1 


4th dHV. 


Ileniorrhsge. 


M..]-:. 


f. 


•21 


18ih ddv. 


Ilomorrhape. 


IltVIiC.N. 


i". 


•>7 


]2ihdav. 


Hemorrbage. 


• ' Rkilly. 


m. 


:itP 


14th day. 


Hemorrhage. 


P&aTKin>>E. 


in. 


HS 


4th tliiV. 


PiTicarditis and pliMirisy, 


I.:-T > ' 


II). 




i:{ih(la,v. 


Hi'itiorrha^. 


L:»T-'Sf ' 


III. 


.P. 


:it:thdnV. 


Ili'iiiiirrhnyp. 


•(.TJLLllR.* 


in. 




101 h daV. 


Hemorrhage. 


a^-tiOZK-. 


ni. 


4^ 


14th da'v. 


Hemorrhage. 


ArTKBT.' 


... 




Illhdav. 


Hcinurrhage. 


Ar» KKT.- 


... 




2-J.id«y. 


ili-morrhagc. 


AlTtT 


III. 


;V4 


>'ilh duy. 


V\!vm\». 


lt*rsR. 


ni. 


•_'l 


24 hiitirs. 


Ht'uiorrhagp. 


H'HART * 


f. 


... 


HUhdny. 


Hcmorrliage from the carotEd. 



Thus it will be wen that, while the operation is had iu priofipli', it is most 
aofortunate in practice. This appalling Ttible needs no coiiuiH-iit. It is, to 
DT niiml, couclu^ive as to the merits of the operation, the putivnt having, in 
•■very ia,-*e but two, been carried ofi'by secondary hemorrhage from the distal 
tide ijf the ligature, in conwqucnre of the L-l<»st; proximity of numerous col- 

' Ir. ihi* ca*" the '.arotid wni> aho tii'd. but Iho h<-ii>>>Trliai;t.- caino from thi.' ^uh- 
rlaiian Fi(. 477 . 
* Fic 47'"., ' Carotid b1<«i tifd. * Itofirn-d t" hy .1. H. Tower. 

' R*f*rreO Iu hv J. II. I'-iwer. * ( iir>>liil h]^i> tied. 



218 



SPECIAL ANEUBISM8. 



lateral branoliei (Fig. 47G); and iu tlic t«ocxoeptioo&l cues 
ftllhougb performed skillutty. prov(;<i f&ial jd one intUinM from pvrik-nnliiw 
nnd pleuri^v, and in th« other frntii pyivmin, betbre (be periix] Kt «hidi 
Kcondsry hemorrhage might have heea expected. Listoo, in cioe cii*e, ii|[»* 
ttircd the root of the conimoD C3rv>tid, at well as that of the vobcUviu, 
doping io thi« vay tu diminish the rivk of seoomJary hctnorrhitge. by nrrot' 
Li)i; the curreol of bUwd which, by sweeping iotn the camtid putt thr mutrtb 
ntthu tubcluviao, would aecestnrily waab away any congulum thiit mi^ht 
be formed io ihia artery. But hi» expectationa were not realise<j : heoior' 
rhage bmk place ta usnal, aad from that portion of the artery which lay do 
the dialal side nf tha lignture, the blood having been carried into Lbii> end uf 
tbe veawl in a ralrofcmde course, through the connection exiitiog betivna 
ebo vcMels arlaiog IVom it at this point, and thtwo on tbe opposite aide of tfaa 
haad and nertt, ax tllustrAte*! bv the anncxeil cut (Fig- 47 1), taken from ibt 
prapnmtioii of (he eiutt; iu tbe \Tnivcreity C-<ilte^c Museum. Indeed, ibtf ■ 
tJto prt'At diinp'r u> be upprehendetl (ine'r lij^Lur<> of tbe aubclarbuj uriery 
nn I he li-Mi'ht^nl side of tne scalenus, dej>cndiDg as it doca on the aoatumieat 



(W\- 



TIf. 4rA.--|jgM«r»«rth«SiilMUTtulnth*nnt 

Put nf lU CVMfM, bj> LIltOK. 




Pi(. 177.— LifMMr«brtb«S«l 
CuoUil (or SiWlAtUa Ai 
LiMoB. 



rtlatiotta und contivctiotiti of the veswl. which un .-ikill uu the |)art of tb* 
Aperatur cnii in nny wny ieweu. aud which, in my opiniuD. oogbt certataly 
to vaufK the t>]M?ntliua of litiaturo of the BuhclaTmn in the firat part nf iti 
counw Iti 1k' bKuiBbt'd from stirgical practice, unless further expiirieDoe ebova 
that alMorbnble liKnluri-s cuu be applied wtth certainty in such a way a« to 
ucclmlo the artery wilhtiut diviiiun uf ila ooala. 

Thu niclliod of operatini; that hat) been meet commonly adopted k tbt 
•aow aa that alrca<ly drat-ribed for lijfature of the root of Iho carotid. Wbea 
the vneelfl are ex|MiM>d, the juffulnr vein i^ drawn ouiwardi with a copper 
fl[>ttluln, nnd the Buhciaviaa is tnus brought into view. The needle {« poaaad 
from bvlon upwards. 

When mi uiiruriFm la situated <m the aubclavian arterr, in tbe |Kialerior 
inferior triangU' of tbi* neck, it is neccmarily impn««ible to ligmcun* that 
xtmel beyond tbe HcaleuuB. ax there would not be sufflcient room fr.r the rt- 
poture of tbe artery, which, even if laid bare, would in all nrohability be 
found in t^Hi diwased a condition to bear tbe application of a lijrature. 

Thna it will Iw seen that, in every ««e, except t^mytbV, in whicfa •■ 
"iam of the Rubtlavian artery liaa been >ubjecte<t Uj operation, wbathir 



90BCLATIAN— OTBEB MODES Ul 



TM8XT. 



219 



|Blm« of ihv brachio c«phRlio or of the aubclaviaii lUelf inttmul tn the 
ri. xh* rntilt bsf> b«vii r fats) one. As ibis unfortuonte tenniuiitioD is 
Ta fK) wmr lo b« KUrjbut«d U* w»Dt of vkill on the part uf the operator 
s^^^Te lw«ii. nttboul exception, men greatly ttntiuijuiaheU for the pof*e»>< 
^^^B this rvrr quality — but li He|M-n(lenl solely on certain Hnatomical 
yBHvttie* in the Brninjirnieut of these vasaeh, liy which their succenfiil 
Tinutre Ua» bwn rvacterei) rM but iniponible, a repetition of lliese attempts. 
■ttieb niRT faaiiien the patient 'a death, can at present ecnrcely be considered 
JMiiSBble. What, then, an- ve to do? Are we to leave patienia laboring 
•Deari«n of the aubctavian artrry to inevitable dc«(h, without luakinj; 
I cflbrt tn Mve them? Or di.«i! Surgery oRer other modes of treatnieoi 
tfauae just mentioned, by which we may hope to arrive at mure suc- 
eavAil nsoli*? 

Wkhout mentinnine direct pressure, manipulntion, or galvnno-punclure, 
■Ucfa m certaialv deserving of furtbt-r triak in i-oinbination with ap- 
fnpriaCa eoaMhalKinal trcauneut, three modes of ircftiuieot present ihem- 

OMBpnaaion of the ArUrr where it panea over the First Rib, and 
tly no the Distal Side of the Tumor. 
tg»tare of it on the Distal Side, alK>vp nr hrlow the Clavicle. 
Amputiiiino at llie Shfttt!d<^r■j(li^t. and Distal I,i(:aturc of the Artery. 
Campretsion of the Artery on the Distal Side of the Sao could 'be 
ooly wbf-re it crossea the 6rst rib, and conM^iuenlly would b*^ appli- 
Mtty to anruriniw of the first part of thin ve**<'i. Thin plan has never 
trivd : partly. [>erba)w, on acmimt of the dithculty in Applying pressure 
i* thta Mtuation. aD<l partly, probnblv, oo accnnnl of the want of huccp«> 
tkal baa aUanded procedures of this kind when applied to Teasels in other 
■taarioca. 

Tb« ilificully in applying the compreaaion might, I think, be overcome 
bf fW OM of an instrument of which a representation is given by B<>urg«ry. 
1m aftcinicy uf the i.i>mpret«ion would he materially incr^«e«l by the 
■■|iliiji limit of direct pressure on the tumor, or of galvano-puucture or 
acapBDolurv &t the same lime, and in this way a coagulum might be formed 
m U« Mc AJlbuugh tiHi much ought not tu be expected from tins m<.>de of 
tgmXmtMy 7«t. I think, it might with propriety be tried in casca uf the kiud 
that have been menljuocd. 
:^ Distal tigature of the Sabclavian Artery in the Third Fart of ita 
beru euggetted, and niav, j><.-rhu)JM. hold nut sonic pnutpeot uf 
in Man of aneurism situated iM'hind nr inlemal tn the M-alfiut.^. In 
ihI uc springing from ihf arterv in this niluatton, lht> prineipul 
il of blood vould. in all prohnhiiity, i)c thai which i» dcfitrneil for the 
mtpfij at the tipppr extremity. Bnme of the brancbeo arising from the 
■iHvj b«lDre h haa pastied beyond the flcidenns nniioUR would, dunbtleR), be. 
■an or Icai mmpreaHd, and thuH obliterated, by the itimor ; or they might 
k obKrvelad br an exten^inn nf the laminated Jihrin over their orihcea. If, 
IhMUfiiii. the mpply to the upper extremity could be cut nfl*. there might be 
ililT tifthim- changes taking place within the sac which are necessary 
lotditeraiinD of it* cavity. TfiP principal obMacles to this desimble 
luuld n<!cnwnrily be the transverse cervica). and suprncapttilar 
which, ticinK the two voseeU lliat arc more particulnrly destined to 
the rircuUliou io the uppi^r extremity alter the ligHtur« of the 
iviaa. would nrc'.'««anly, if not otcliidetl, undergo dilatation, nnd thus 
iiaitianii to draw ton large a current of bl(ja>d through the sac for strntiBca- 
of it> eoat«Dl» to lalie place: and, if they were occlufied. there nuutd ba 
of gangrene of tbe arm from insufficient vascular supply. 






BiiptijtreQ lifiraiur^d the axittnrr artery linger the pectoral mnsclM fur a 
cue of dtibclitviAn aueiimni, two arterial branches being <l!vi<le() in th« 
incixiftns thniiigh the fat and arcjlnr tissue; aiid thu patiout dJeil on Che 
ninth Jwy. This operation could nut l>c cxpwtcd to succeed; for between 
the licnturu and the sac are ihe larj^e and nunieroua slur, acromial, and 
thoraciu brnnchi<«s uf (hu uxillury nrlory. which wouM cuatiauu lo be r«d by 
a ctirretit soul through the tutuur, uml llius i>rt!clu<le the poaaibility of it« 
cuntuuls being sufficiently stationary f»r ultimate contraction and uure to 
result. Luugier pertornied the diiilal operation in a supposed ease dl' sul>> 
cUviau aueuriain, which auerwanU turneit out In be oat; ot* the bracbio- 
ceplinlic artery. Iti addition to Dupuytreu's ease, the operation haa been 
done by P6tre<juia, Schul>, and Canton, lu all instances without benefit. 

3. The above-mentioned diftirultiea are met by a plan <•( procedure origi- 
nally auffgcteUid, 1 believe, by 1-Vri;u9s<>n. It in Amputation of the Arm at 
ttie ^houder-joittt, Iblluwed'by Distal LigatnTe of the Artery — a dei<perate 
UDdcrUikin^, truly, but for a desperate disease, it rou^t be reineaibered, ami 
one that under oniinary surjrical treatnieut it* almost incurablo. 

The aritry mi^ht he liyatiired before the ampiitatiou. " II is known," 
Bays Fcra:us.*au, "that tiniput-iitinn at the shoulder-joint ie gt>nerally a very 
8UP0i«af(ir operation ; 90 far as this wound is concerned, then, there mi^ht 
be little to apprehend, but the effect on the tiiinur is not so eneily foretold. 
Ligature- of the axillary arl^ry on the tiice of the atuinp rai;jht here be reek- 
oned like Brasdor's operation ; yet there is a vast ditlerenee. lor in the latter 
caae the same amount of blood which previously passed towards the upper 
extremity would still find iia way di>wn, and probably part of it would run 
through the aac; whereas, were the member removed, m the aaroc quantity 
would DO longer be r©t|uircd in this direction, the tumor might powibly be 
much more under ch<* control of prcMurf^. The vnlue of such a mgumtictn 
remains yet to be tested, however, and it would he futile to reason 11 pun it at 
present. It might be ajudicioiitt venture firm to tie the axillary under the 
clavicle: and then, if it were found that the aneurism »till increased, ampu- 
tation might be performed, either immediately before or after the aeparation 
of the ligature." 

Were a ca«e of aneuriara of the tubclavian artery internal to the scalenus 
to [ireseut itaeif to me, the plan that I should adopt would be, first, the 
emph'vmeut of pre«8ur« on the veK*iel at (he di»Uil »ide of the tumor, if prac- 
ticable ; should this not succeed, I wouhl, if the distiiae were aituat^rd behind 
or iutvrnal to the scalenus, ligature the artery in the third part of its cuunie; 
and. did that nut succeed iu checking the increase of the aneurism. I would 
perform ampulation at the shouldcr-joiut, m rcconimetidud by Ferg'usson. 
Should the aneurieui occupy the artery al\cr it has pa»ii^d the ttcnlenus, direct 

freasuR! on the sac holds out the bc8t prospeia of succi:tu>. Shouhl that fail, 
would not allcmpt the ligature of the artery below the criavicle ; aii it in an 
operation the nsiilt of whii^h is moat un satis furtury, and would not prevent 
a large current through the sac fur the supply of the eolhtleral circultition of 
the arm; hut 1 would at unce have recourse to anipiitatlon at the shoulder, 
and then ligature the vessel as near as posjtible to the (iac. It is true that, 
even in thin rasie. the ligature would be below the hranchea that are given off 
under th«.< perUiraE mubck>a ; but, at the arm would be removeil, they could 
nut undergo any dilatation fur the supply of the collateral circulation of the 
upper extremity. 

The firat case tn which thia nperatiun was performed, vra.11 hv Spene^ in 
1864. The patient lived for four years; and. although the aneurism was 
not curetl, ihe rMoll affiirded gnod promieo of surce^w for the future. For 
the 6rst ten days after the operation, the pulsation waa scarcely to be felt; 



I 



I 



AXS0BISH OF THE AZILLAKT ARTERY. 221 

and when the patieot left the hoepital the tumor had diminished to one-third 
of its fi>rnier size. The artery was tied in two places — where it waa cut, and 
mibo Just berond the tumor. Before the patient's death — which probably 
nrcmc from ioteniBl aneurism — tlie aneurism had increased somewhat towards 
tbe chest. 

Since this Holden and Heath have performed the operation, but without 
•occeae. In both cases, however, the aneurism was traumatic in its origin, 
aad had attained a large size before amputation was practised. Hence the 
chances uf consolidation and cure were mBtenuUy lessened. 

Ligature of tbe Vertebral Artery. — This bold and difficult operation was 
fir«t performed on the living body by Smyth, of New Orleans, who had re- 
coune to it to check regurgitant hemorrhage after ligature of the innominate 
for subclavian aneurism (p. 215). I will give the details of the operation 
in the words of Smyth : "The head of the patient being thrown back and 
tligfatly turned to the left, an incision two inches in length was made along 
tbe poateriur border of the sterno-niastotd muscle, cummencing at the point 
where the external jugular vein crosses this muscle and terminating a little 
above the clavicle; the edge of tbe muscle being exposed and drawn to the 
inner aide, the prominent anterior tubercle of tbe transverse process of the sixth 
oerrical vertebra was readily felt and taken ibr a guide. Immediately before 
tbia and in a vertical line with it lies the artery. A layer of fascia was now 
diTided ; some louse cellular tissue with lymphatics and tbe ascending cer- 
▼icml artery were pulled to the inner side ; ana a separation was made between 
tbe scalenus anticus and longus colli muscles just below their insertion into 
tbe tubercle, when the artery and vein became visible ; the latter was drawn 
to tbe outer side (this is important), and the needle passed around the former 
from without inwards." 

In 18^1, W. Alexander, of Liverpool, suggested ligature of the vertebral 
■B a means of curing or relieving epilepsy. He performed the operation in 
Kveral cases at first with apparent bienefit, but subsequent observation showed 
tbat the improvement was merely temporary. The operation was repeated 
in two cases by Watson Clieyne. The method of 0|>erating was that above 
dewribed, and the results so far as the operation was concerned were satisfac- 
turv in the great majority of the cases. 

ASEVEISM OF THE AXILLAllY AltTERY. 

Thi? artery, though less commonly the seat uf aneurism than other large 
T^^«r«;ls, iiuch a« those of the ham, the groin, and tlie neck, yet Ik sufficiently 
fre<)uently diseased. This is due chiefly to its situation, its proximity to the 
Moulder-Joint causing it to be subjected to the very varied, extensive, and 
oftrn forcible movements, uf which that articulation is the scat. Amongst 
the m^att frequent causes of axillary aneuri-sm, may be mentioned falls upon 
the shoulder or upon the outstretched bandit, and in many ca^-es tlie eflbrts 
matle at reducing old-standing dislooationii, inslitnces of which are recorded 
bv Felletan, Flaulwrt, Warren, and (iibsun, the liea<l of tlie bone in these 
CUM having probably contracted adhesions to the artery, in consequence of 
which the vessel was torn during the efiort« at reduction. Axillary, like 
subclavian aneurism, occurs more commonly on the right than on the left 
nde, anil i» met with in especial frequency amount men; of 37 c»^e!>, onlv 
•t 'locurred in women. I am acquainted with one case only in which both 
axillarv arteries became aneurismal; it occurred to Furiicr, of Brighton. In 
this remarkable case both axillary arteries became afrt'cte<l, an interval of 
about fifteen months intervening between the formiition of the two aneurisinal 
lamon; and the subclavian was ligatured on both aidoa successfully. 



222 



SPSOIAL ANIUBISMS. 



Symitomh. — III axttlnry anetiriBm there are three aeta of afmitDni^i 
tion to wliich Kill uhiiaIIt enable the Surjreoii to rvco|n)>u Wt Atummi 
ar«, the exislenre of a tiimnr in llie axilla, the puju that It oocauattti, aod 
t))« afTecUori^ to vrhtoh it gives nae in tliv limb. 

Th« precise situation at wliich an an«unaai of the axillary artery pn9«ot« 
exttTually. will depend upon whether it epriag* froDi that portiou oflbe 
that Iic8 above, beneAth, nr below the l««»er fwctoral muscle. If fr»ni abn 
it will appear M a tumor seated immediately below tJie clavttle and occiipri _ 
the triHUguiar space between the upper margiu of the ieaacr pectoral and thai 
buae; if it be lower dowu, it will raise the aoterior fold of tbe axilla. Itvin^ 
prevented from exteudint; much out of this space by the deiue fascia diai 
airetcbee acnMn from oue eidi* to the other. The tumor, which is ai ijntt »(>ft 
and comproBsible, linn a whizzing bruit, and iUs pulj^alioDP, which an- cx|iai)' 
gilu, may 1»> arrested hy pressure upou the subtTtaviaii artery. wfa«re it paaa* 
over the fin>t rib. It usually iooreases with greut rapidity, owing to the lUtk 
reuMAuce opposed by tbe looM areolar liaue in this utuaUoa. aod BOtt 
commonly extends downwards and forwarda, causing the hollow of tbe axilla 
to disappear. In some rare iiietaiioes, however, the J,un)or has bean koowo 
to take a direction upwards under the lesser pectoral, and into lb« areolar 
intenral above thai muscle, or even undcmeatn the clavicle into tbe acmmial 
angle between it and the trapezius. It is fortunately rare for an aneurtsto 
to take auch a course, as it would present serious diificully in tbe eonipra»' 
itton or lifraturc of the subclavian ; and there is more than one instance oo 
record, in which the sac has been punctured in the attempt to pasa tbe n«MU» 
n>uiid this ve«iel. Whtn the aneurism is soaie<) high up, it not unfraquesfly 
happeus that the clavicle is pushed upwiirds by the pressure of tiio tumor 
btfueath it — » cum plication of considerable monunt in reference tn th« optn- 
tioQ, the diQiculties of which are greatly increased by iL The pnttun of 
the tuTiKjr upon iieighborin}; parts may give rise to »eriout cooaequcttcvi; 
thus it may pruduce a carious state uf the first and second rib*, and ifc* 
compression of the brachial plexus of nervea will occasion pain and numtt- 
neai in tbe upper extremity. Tbe o^fcfiotwof the limb ocoasioued bv the 
aneurium are diminution or extinction of tbe radial puUe, trdema. coliIneM. 
and loM of muscular power. In soiue cnsoa the brachial artery bevond tbe 
tumor would appear to be obstructed, no pulsation being perceptible in it 
Compreniou of the axillary vein may occasion (edema of tbe band and am. 
with (Kime diminution in the tompirraiurc <i( the limb; and tbwe lympbioifk 
if tlic tumor attatu a very large eize, may amount even to indioatWOB of 
impending gaugn^uc. 

DiAONOrttH. — The diugnnaU of uxillury aneurism is usually readilv made; 
there Itcing but two diaeases with which it can well be confiMiuued, vix.. 
chronic enlargement and Mippuniiiori in thi? glaudsof tbe axilla, and pulsM- 
iog tumor of th^ houeA in thin region. From glantluiaror other aiaeamet, tbe 
diagn-jAis ih generally ca^y; hut I have Be»D aome oasv iit which, pnbatlon 
being eommiuiicated to their eontentH by tbe subjaoiint artury, it was sodw- 
whiit difficult to distinguish the nature of the tumors. Here, hawerer, tbe 
hidlory of the case and tt8 speedy progress to pointing will indioalv ita true 
nature. From nu^uUitry tumor, or osteo-aneurwm of OtK hrad of Ou Aiunimu. 
the diagnosis is not alwaY«> so easy ; and there are at least two in"*--' 
record in which the subdavinu artery has been ligatured tor \\'»r. 
kind OD the t>up|N>Aition of it» lieiiig an aneurism. In thr»e instam-t-* 
huwevi-r, generally lK-<<n olt^-rved that the tumor first made its apf 
uu the fi>r<'part nl' the KlmuMer, and not in the usual sitwaLiun of aXfl 
aneurism; that it was from the tint tirm, smooth, (.'lastic, but urarty ioc 
prcaeible; and that, although it presented distioot pulsation, there was no 



k. 




beUuWMKMind, but radier a tliritlJog bruit perceptittle in it. Tho tnosl 
It dwgnusLic mark, j>erlmpf^, i^ tlib J«cL of these tumors forming a 
Bcv ID tiitu8tiuii0 io wbieli anpurtsms of the axillary urt^'r}* would 
Ant liiuw thdiuMlvrs, as at Uie upper, outer, or anterior part of the 
dwlJw. In mort! sdranwd stages, when the substance of the hone hns 
mdarpRM abaurptiDO, and its shell has become thin and expanded by the 
MrtWf J pt MBu rf of the tumor, there le often a dry crac-kling or rufitling 
aoand pensered on pressure, which ie never met with iii ca^es of anourium. 

TUATMXirT. — 1 am not acquainted with any instance in which an aneu- 
CHa of the axillary artery, nul arising from wound or injury, ban uuder- 
MBS cpontancous cure, ur been oonsulidatcd by constitutional trentmenU 
OiMprsMioD or ligature of the subclavian in the third part of its course is 
ika oqIt meuis of cure. 

Alillaiy aneurisms arc favorably situated fur the employment of digital 
mmptemon. Vtj this means the oubclarian can easily be comraanded as it 
{■Maaa over the first rib. And the success of this treatment is likely to be 
Bvai ; 6rst, bf«aute, the mc being usuiilly lar;^, a considerable cjuantiiy of 
Iw eootaiDed btood is well out of the current of the circulation, readily 
■uoKOod may thus easily coagulate; and, secondly, because the cur 
. of blood lhr<nigfa the sac u proportionately small, and thus, if coagula- 
' begin, may easily be completely arrested. Digital eompr(.>ssiou. 
, in my opinion, should always be had recourse to in the tin^l in- 
By this means, aided by rest and constitutional treatment, the prog- 
n^ of the tumor may be stayed, and possibly a consolidaiiun of iu con- 
tma Bad cure bo eflbcted. This occurred at University College Hospital in 
ft prtisnl ■evfntjT'ODO yean of age. in whom an axillary aneurism as large 
^ » dMddodt *od of an actively progressing character was cured by inter- 
■ttl^t diktat DKMun ooottnued at intervals for between two and three 
' .dorti^ wnidi dae compretsioa was kept up in all about twenty-three 
. tba eonaolUatioo oorameocing on the third dny of treatment after 
bdBrs of preasure had been tried. Holmes nientiom eight cases in which 
^mib] (nnprneiou has been cried. Three of these, under the care of Cini- 
aJs mad DuLoJl. and another Surgeon wfaoee name is not mentioned, were of 
uaamati£ ursia. and of these two were cured. The remaining five were 
idiapatfaic- Three of thew, under Cooper Forater, Peataon, and Riuoli, 
were aired. Two, undrr Turet and Vanz«tti, failed. In Cooper Forster's 
OMe th« oomprnMun wa^ nppli<>d twice under chloroform ; on one occanon 
$1^ ihrtm oBii a quartpr lu^txr* and on the other for eight hours. In Peatson's 
case iW prr^wMr** uus upplit^l at intervalji for a period of nearly lliree mootfas. 
la lit JLX! the treatment lasted i-ven longt^r, the cure not being com- 

plttr iy *>x months. let this casti the arlt-ry was so dilated and dis- 

SMad tbst ligature was impo«sible. !□ Dutoit's case the comprcnion was 
^plini for six houn a day for six dayn. Lund has also recorded a case 
«>f«l by digital ciinipressitm in two pen«)ds. the 6nt of ten and the second 
4^ aarm osd half boiirv, 

I« aoocbcr CM« under the rare of S. Jones, compreesion was combined 
wiilt tfas application of ICsmarcb's lnoudage to the arm, but without success. 
CoCBpfwaaao by instrumeula on tho CMdiac side cnu seldom be maiU* a\y 
ytoobla lo aaeuiisnu in this situation; inasmuch as the pressure that is 
MvaglK to baar upon the subclavian must m*<.'i:MSunly at the earoe time in- 
Caeaor Um greater port or the brachial plexus of nerves to such an extent 
as to be usradnrahU' by the patient. Vet it is nut impracticable, and neaiiB 
■Mk bedevt- rotime this tltffimilty. 

LifMure ei' i . y b. however. Mill the Surgeon's ofakf resource in the 

oftbcM tmm*. The part of the vessel uDivcrsAlly selects] for the 



SS4 



SPXOIAI. ABTKUKlSlfS. 



application of the Lignlurc is, in aocordnnce with the Huntariftn dft<>triliw.lllii 
«rtiicii lies on the fint rib beyuii«l the BC«)eDU« aQticw maclfl; thh pwt|R» 
KQling tli« udt'antagM of btjiag aufficienlly r«iiiuv«^l front the ii«iil uf diMaw 
lo iuBure the prulnthilitr of the co«(i^ of the arlvry bvin^ iti a vouad 9ta[«, of 
being by far the mo«t accessible, and, wh(;u ijeligalvd, oi' allowing the colUl- 
eral cjrculaliun by which thv Tilality of the arm is to be maiutaiD»l u> nuntta 
uoiiijured. Notwithstanding these oliviouB advantage preacnled by the lica- 
ture of the iiibclaTian over that of the aiillarv artery, in other wnniislijf 
perlorioing Hunter's instead of Aael's operation for ibe cure of »(>>mtaDeuia 
axillary aneurieni, there would appear to be a leDdciicy in tfae mindeorMm 
Surgeons to advocate the latter instead of the former ot these openUiotii; ud 
lu subatiuile for one thaL oSere the udvantaces that have Jun be«n mrntioaeii, 
a procedure that i« not only tuiu:h more dinicull in its performance, and thai 
inierfiTes with the collateral cireulutii^n, but that U practised upaa a riJaeawd 
part of the veeevl, in dangcmu^ pri>xin>iiy to the »c. 

Ltgature of the Subclavian in the Third Fart of its Conrie. — In order lo 
apply a ligature to that tHirtion of the «ubciuviun artery which iDterveMt 
between the outer edge nf the scalenus onticux and the lower border of the 
fif«t rib, the patiejit should be placed in the recumbent poAition, the am 
deprened as much a« nosaible, and the bead turned somewhat to the opponlr 
aide. The tltaation <if the external jugular vein should then be atc^rtatiMd, 
if poisible, before commencing the inciaioD. It may lie nt any point belwwo 
the posterior border of the Memomastoid and the erige of the trapMiua; tncil 
commonly it is close to the former muacle. Ooeaaiooally it la wanting. Tlw 
opemtiou h coiumeiived by drawiu^ the integument* of tlie lower mrt oriW 
uin;k dowowurda over the cUvicU- uud lunkiiig au incision about lour ioobta 
in Iviigtb upon tlu* bone, dividing the i^kin, auperficisl fascia, platyema. 
the aupra-clavicular bruuches ol thu i.'ervical plexus. Wbeu the teoi 
takeu utf the |Kirc, this incis'un will be found to traverw tfaa bttae 
posterior triangle of the neck. The chief object of drawing tbs akin 
wards in this way is to avoid any risk of wounding the external jugular t*u, 
for as thb veanel perforates the deep cervical fiLiria about one finger's bmndtk 
above the clavicle, it cannot l>e tlrawri duwDwitnls with the integnmenta. la 
some rare cases the cephalic vein croseett the; davicle and joins ibe exlenal 
Jugular. It would then nece^siirily be divided in the ftrst inciaioD. The next 
step in the operation ia to tiod the external jugular vein. In order lo do Ihii 
the deep cervical fascia miigt be carefully diaeected through close to the 
olavioie; immediately beneath the fascia a rjuantitT of loose areolar tiawek 
aipOMd, in which the lower end of the extomal jugular will conuBonlf ha 
found, As soon aa the daep cervical fascia is dividwl great caution mtut be 
used, the anxilsr time being picked up in small pieces with the forcc|«aiid 
Lacratched through with the pome of the scalpel or torn with a blunt pmbeer 
rneel director. When the exiornal jugular vein conk* inu> view it must be 
treated according to iu jxiMtion ; if at cither end of the woand, it mar 
be drawn a^ide with a blunt hook; if in the middle, a doable ligature wu»t b«> 
paaaed and the vein lied in two places and divided between them. Occasion' 
ally the transvetae cervical and supra-scapular veins form a plexus witb tbt 
external jugiilar imtuediately above the clavicle, and the difficulty of exposing 
tti« artery is then greatly inrreaaed. The transverse cervical artery \\m 
normally above the wound, and the supra-scapular is cuucealcd behind tbc 
clavicle, hut in exceptional cases they may be found in tfanspaocs expoaedia 
tlw operutioti. They niunt tlien be urawu out of the way witJb blunt boota, 
Dr combinetl culling and scratching through the areolar lieaun, t' ' ttsi 

edge of the sualenus antiuus ia reni'lied ; tliitt ta the "dirvcUag < nn 

which tlio fiugvr ia run until the tubercle of the Srat rib ia felt. Hits i* the 



- inobea 



LIOATUBS OF THIRD PART OP SUBCLAVIAN. 



226 



^ide to the artery, which will be found immediately above and a little behind 
n, covered, however, and bound down by a dense faacia. Immediately above 
the arterr, and in cloee contact with it, is the lowest cord of the brachial 
plezos, that formed by the last cervical and first dorsal nerves ; beneath the 
arterj is the first rib, upon which it can be felt rolling under the finger when 
firm prcasure is made. At the same time pulBation will be felt, but this must 
Dot be taken as a proof that the structure beneath the finger ie the vessel, for 
tfw lowest cord of the brachial plexus lies so close to the subclavian artery 
that it receives a communicated pulsation from it. On firm pressure the 
Dore ctill retaiiu its round form, while the artery flattens out, and its surface 




Fig. 4TP. — Ltgatare ot the SubcIftTiBH in tb« Third Part of it« ConriB. 

hecnmes slightly concave. The thick fascia covering the artery having been . 
cartfullj opened with the edge of the knife, the needle is pne^ed from the' 
nerrr. as low down as possible, so as to avoid any risk of injuring the pleura 
by Flipping over the upper border of the first rib. The subclavian vein is so 
fiu- below the clavicle that there is no possibility of wounding it. In a con- 
fkierable pniportion of cases the posterior scapular artery will be found 
fpringing from the artery in this part of itp course. In 296 arteries. 
ezamiDe<l by Quain, it arose from the third part as n.«eparftte branch in 101, 
r« as nearly as possible one in three cases. If this conilitiim is met with, the 
ligature must be applied as far as possible to the proximal ^ide of the branch. 
If Dc«efleitT obliges the ligature to be apjilied oliitfc to the brnnoh, it is porhitps 
■aftr til tie this also, as the anastomosis of the vessels in this region i^ i<u 
abondant that the risk of gangrene from the obliteration of a single brunch 
would be very small. 

VOL. It. — I't 



226 



SPBOtATi ANEDBISIiS. 



The opcratiuD just i)e»cribeil is that oommntily aduplcd. In ortlvr lli*l rt 
should be ensily cnrried out, it is in the fimt place nec M t nr v that Uw 
Bliuulder should be depressed as far hs pnssible, bo aa lo bring l}i» clavidc 
down. This is a niatlor of much importance ; for, if the claviulu bv thriM 
unwnnlii by the pressure of a lar^ nneurisiu, or if tl lie hi^h in cinieqoeDee 
of emphysema of thp lunes, the i^urgcun will have to find the artery at ihe 
bottom of a deep wound, mstead of on n eomnaratively placu; ^urAiFe. It 
iherefore. the clavicle cnunot be thoroughly deprc«cd, more room moat h» 
providivl to the miperBcial partx of the wound. Thia h done by makhiKft 
vertifal incininn upvranls, cither along the border of the rtemo-maaloiaor 
fVom the middle of the wound for about two inches. Ai theart«ry u in time 
ca«ea apnruarheil mther from ahiive than trom the front, the 9tni<-Lumi mvl 
with differ Aomewliat from th<we already deicribed. The ponterlor MU of 
the nmo-hyr>id i* alvrnyg expnoed, and forms »n important rallyinf,' [tuiiit in 
,the operation, aod the tmosvene cerricnl artery and rein will inoKt cobh 



rif. 470.— iJiacraui of fti|tht 6ab<il«Ti» 
Aitarj In Thir4 fart of In Cmin*, 
iwMMd bf irRiuDvrmlli vollt »n*rja*i 
V«tB. n, SubaUriaa ttrtatj. t. Iti* 
terakl JugulM rvaaiitng ItmniTmali* 
aolll T«ln«. n. BnuibUI pt«(U> of 
MTTM. M. Omo-kfaid mntelk. 



Tig. 4«0,— Iii«gT»ia of lb* RaUlloni af lk« Tblf4 
pari of ilifl Sntiotadu Arlarj': f, u»fmimi 
». i. aina>b;otil i s- a. ■a«l«nai anUoaaj *, ■. 
i(Bn)<i>mMlatil ; *. ■lUrud JugnlM ••tk; k. 
brarlilal |>lezu*; «. »tUrj. 



moaly come Into view. The danger of including tbe lowest cord in the 
brachial plexus is greater the more the artery is approached froai obor*. 
Tbe vertical iiicUiou Bhrmid always be made in fat ■ubjocta. 

In some cases the clavicle mar lie so high that tbe artwy cannot b« «x> 
poied oven with the help of the vertical iucision. A com occurred to Sir 
A. Cuuper. iu which the attempt to liirature the flubclavian ortery for a 
large aocurisra of the axilla vioa foroed l\} be abandoned, in conse({iiena* of 
the elaviclu bulng thrust up to too great a height to enable bim to reach ibe 
Tttsel. The extent of the ditHi^uTty oecasioned by this olovatiun of tlu 
elaTiole mnat necessarily depend in a great meooure upon the baijtbt ol 
which the subclavian artery happentt in any particular eaae to be lituoied 
in the ueok. It is not uncommi>n t>) 6ad it uulsaliug so high iu tbe Beak, 
that no amount of eleration of the clavicle ny a subjacent axillary aneu- 
rism conid raise that hnno iibovo the level of tbe vaaffif. In the majority uf 
oases, however (in seventeen out of twenty-five, as shown by Qusin in his 
work on the Aricriet). it IS either below the level of tbe hnne, or but slightly 
roioad above it ; so that, if the clavicle were thrust upwardii and forward^ 
tbe veosel would be buried in a deep pit behind iC Dupuytrcn was of 
opinion that thv artery c»ur4ed hi>;h in persons who were tbin, with slender, 
hmsi oeck-i; whcnMW, in thick, Bii>jrt-neck(«l peranm, with mu^rutar sho«I- 
dern, it whji deeply svated. I havu nfii-n vcrim^l fb^ truth of ibis obeerr** 
lion, both iu dtssuclion and in cxamiaiug tbe pulwtiuns of the vass«l duciac^ 
lift. 



ACCIDENTS DURING LIGATURE OF. THIRD PART. 227 

In order to obviate the difBculty that has occasionally been experienced in 
rcacbiag the arterr when thus buried behind an elevated clavicle, it has 
be«n propoeed by Hargrave to saw through the bone. The most serious 
ttbjection than can be raised against this practice, is the fact of the clavicle 
bemg sometimes a part of the wall of the aneurlsni ; but, supposing the 
Surgeon could satisfy himself that this was not the case, I cannot see any 
objectioD to thy procedure, provided any very great and insurmountable 
difficultv presented itself Id passing the tignture round the vessel without it. 

Aeeidenti during Ligature of the Third Fart of the Sabclavian.— Wound 
t^ the ElxtenuU Jugular Vein is a must serious accident, as entrance of air is 
very likely to take place, and may cause immediate death. This accident 
is avoided by careful dissection, and if the vein is so situated as to be exposed 
to the risk of injury, it must be divided between a couple of ligatures. 

Profuse renouf kemorrkage from wound of some of the numerous veins in 
ibe neighborhood has more than once prevented the. completion of the 
operation. Should this accident happen, the wound must be plugged and 
the operation attempted again at some later period. 

Wtmnd of the Sae is a somewhat rare accident. In some cases, as has 
already been stated, the sac passes upwards below the clavicle into the 
inferior posterior triangle of the neck ; when this is the case, the Surgeon 
incurs the risk of puncturing it from its close proximity to the artery, as it 
lie* on the first rib. This accident happened to Cusack while ligaturing the 
nbclavian in the third part of its course, for a diffused aneurism of the 
Axillarr artery. An alarming gush of blood took place, which was arrested 
by plugging the wound ; but the hemorrhage recurred on the tenth day, and 
the patient died. In a case related by Travers, in which the sac was punc- 
tared by the needle, which was being passed round the artery, the Blood, 
which was arterial, did not flow per saltum, but in a continuous stream. 
*• The hemorrhage," Travers says, " was more terrific and uncontrollable 
than I have ever witnessed," and was not commanded by drawing the liga- 
tare tight. It was so great that it was doubtful whether the patient would 
leave the theatre alive, and was arrested only by plugging the wound with 
aponge-tents. The patient died of inflammation of the pleura. On exami- 
nation, the aneurismal sac was found to have a pouch-like enlargement 
upvards, ovt-rlying the artery, where it had bi.ien punctured. 

InrlasioH of the lowest cord of the brachial plexus in the noose of the ligature 
ifl a more common accident; indeed, the mistake has more than once been 
committed of tying these nervous trunks instead of the vessel. Thus, Liston, 
in the first successful case of ligature of the subclavian in this country, 
pa.««ed the thread round the lower nervous cord ; but immediately perceiving 
hi- «-rri>r, turned it to account by drawing aside the included nerve, and thus 
more readily exporting the artery. Dupuytren, in a case of ancuri.im of 
K>me years' duration, succcedt'ci, after an operation that lasti'd one hour and 
forty-eight miniitef), and which he desorll)es as the most tedious and diflicult 
be rver attempted, in passing u ligature round the vessel, iis he believed. 
Af^r the death of the patient, which occurred fn>m hemorrhage on the 
Btolb day, thf artery was found to have been pcrfurated by the needle, and 
ooe-half the veswl and the lower cord of the brachial plexus included in the 
aonee. In a case related by Porter, it is statfd that tlie artery comniuni- 
cmlcd i>uch distinct pulsation to the inferior ucrvnus trunk, that there was 
■o mean> of ase«Tlaining whether it was the ves.-ol or tint, except by passing 
the nectlle under it. 

PunH are of the pleura in passinj^ the needle i:* not usually recognized as 
•■«e of the dangers of ligature of the third part of the artery. It may, 
however, take place, especially if the nee<lle is pa^ed close tu the scalenus 



SFECIAL ANKURISVS. 



uiticus and from above, u oiuat often bo the case when the clavicle ii much 
raised. 

Id conoectioD with the ligature of the »ul>claviAn in thia 8ituati<iii it la 
impoasibie to oaas over in sileuoe the Inct-, that in lonie itutancn th« >rt»rv 
tnkea a remarkably high course in the neck, aQ<l that to some nf thnv in- 
flluoces iii»tmd of pawing over (tie Bnl dorral rib, it hat been «ippor(«d i<o 
a bupefDumerary cervical rib, the annloinicul reliitioni being thui aenoutly 
diaturbed. Ana flgaiii, if this 8U|H:ruumerHry cervical rib be UDUMudly short, 
the vessel may be found to lie between it and the hral doraal. Anotovr ftb- 
normality of great rarity \s the paaugQ of the Bubclaviau vein behind iht 
scalenus nniicue with the artery. This would add greatly lu the difficulty uf 
the op(.-ralion. 

Ligature behind the Scalenus Antioas. — If the eac eucroadi apoo the 
nc«k. rising above the clavicle, or the artery he not sound in the third part 
of its LMurse, it may bo necessary to ligature it behind ilie scalenus juiticns, 
dividing the outer half or twu-thirds of the muscle. This ODeration should 
I not he considered as distinct from ligature of the vessel in toe third part itt 
llts course, hnt rather as an extension of that proceeding, if it be found, for 
the reAsonn just mentioned, unadvinuble to tie the artery on the fir^t rfb; in 
this way it haa been practised hy Diipuytrcn and I^iatim. In its fintt steps, 
far an the exposure of the scalcnun amicus, it i» the fuimi- as that for the 

tligation of the veasel in the third part of its course. Whi^n this muscle 
haa oeen exposed, a director rau.it be pushed under it, upon which it is to be 
divided to the extent of half or twiwthirds its breadth, nlien it retracts. 

iposinu the vesael. During thi:i pari of the of>eralii>n. «ume dimger may be 

icurreu by the phrenic uerve.and the tmnsvenMtle« colli and humeri arteriaa; 
but if ordinary care he taken, this will uot be very greaU The phreuic nirrve 
lies altogether to the tracheal aide of th« incision, if that be not carried 
beyond one-half the breadth of the muscle; and should it apj>«ar to be in 
lh« way, it may readily be pushed inwards towards th« mesial line, iNnng 
only loowly invested by areolar tinue. I have, however, seen uq« instanoa 
in which the right subclavian artery was ligatured fur a spuutaueoua eylis- 
driform aneurism of the axilla, anil the patient died, on the eighth day* of 
pneumonia; <•□ examination alWr death, the edge of the scalenua waa found 
cut, ami the phrenic nerve divideit. Had the injury to the nerve in this 
[Saae anything to do with I lie pneumoniti? I do out think it improbable; aa 
''division of one phrenic nerve, by pandywng to a certain eilfiit tlie dia- 
phragm, and so Tar interfering witli the rtspiratury movemeutB. must neoea- 
earily have a tendency to induce congestion of the lung, which would readily 
tnio on til inflammation of ihal ot^n. I have Hkeuiw! hean) of noe caae in 
which incessant hiccough followed this operation, and aAer death the [rftreftie 
nerve was found reddened and inflamed, having prohuhly in some way been 
hiterfereil with during the exposure of the vesael. The iraiuversales ooIU 
and humeri arteries may be avoided by keeping the incision in tlu^ musetc 
between and {mrallcl lo these v^-sscls. 

Another imj^oriant point in roferenoe to the ligature of the vnael in tUs 
part of its course is, that in tive cases out of six on the right aide and in 
one>hatf on the lell, the superior intercostal arises from the subclavian 
srj- between the scaleni. When this is the case, there w-Hild probablv 
but a slender chance of the occlusion of the artery by ligature in th» 
irilaation. 

Ono principal danger in ligaturing tbo subclavian artenr at aay point 

Eftbove tne tint rib, certainly ariMi from intcafaratce with the Ascia which 

lia between it and the scaleni aiitaclcs, aniftrattng it irom tb« pleura, and 

which ia eontinuoua with the areolar tisaoe of the anlarior meduistinum, bving. 



BSS0LT8 OF LIGATURE OF SUBCLAVIAN. 229 

uit]e«d, the deep portion of the ascendiDg layer of what Sir A. Cooper has 
described as the "thoracic fascia," and which helps to form the superior 
boaodary of the chest, being continuous in the neck with the deep cervical 
fiwcia. After the deeper layers of the cervical fascia have been opened, this 
fine areolar tissue presents itself; and, if septic inflammation be excited in 
it. the morbid process will readily extend by continuity of tissue into the 
thorax by the anterior mediastinum, invading ultimately the pleura and peri- 
cardium. Hence, whenever it is practicable, the Surgeon should keep the 
piint of the needle close to that part of the artery which lies upon the first 
rib. as there is less risk here of opening into the deep areolar tissue of the 
Deck. 

Keanlto of lagatnre of the Sabolavian, — The general results of ligature 
of the subclavian in the third part of its course for spontaneous aneurism in 
the axillary are by no means satisfactory. Thus of 48 cases of aneurism of 
the axillary artery, not dependent upon any external wound, tu which the 
artery was ligatured above the clavicle, I found 23 cures against 25 deaths. 
This result was so unfavorable, and so ditlerent, indeed, from what I antici- 
pated. that I was led to analyze carefully the causes of death. I found them 
as follows : 

Infiftmmation within the cheit, etc., .... 10 cases. 

Suppuration of the mc, 6 " 

Suppurative phlebitis, 1 " 

Hemoirhage, 3 " 

GsDgrene of the Iwnd and arm I " 

Ctenf^ne of both arms and le^, ] " 

yol (toted, 3 " 

25 <■ 

Thus it will be seen that the two most frequent causes of a fatal result 
following the operation for axillary aneurism, are not those that are usually 
■net with after the ligature of the larger vessels. It would therefore appear 
to be owing to some special condition, dependent either upon the application 
of a ligature to the subclavian artery in the third part of its course, or upon 
the situation and nature of the disease for which that operation is had recourse 
Vi : and the important point to be determined is, whether these conditions 
art: the accidental or the necessary consequeuces of the applicatioD of a liga- 
ture in this situation for the cure of aneurism in th(t axilla. 

JnjiamtneUion of the Contents of the J^oraj- proved fatal in 10 out of 25 cases, 
•■r 1 in 2.5, and is the most frequent cause of death, though not, I believe, the 
m'«t frequent untoward complication of this operulion. It might at first 
he supposed that, iu this rt'^pect, the operations on the subclavian artery 
ruemuled other of the greater operatiims, after which pytcmlc pneumonia is 
»'jC>mmon a sequela; but, on closer examination. It will be found that this is 
o-ft the caite. Inflammatiim, when attacking the thorax or it-s contents after 
ligature of this artery for axillary aneurism, is not cuTifiueil to thu Innjrs, but 
Tfri- cummonly affects the pifiira and prricanlium iw wc-ll as, or even in 
j>r>:-fen::nce to, these urgans. It wi>ultt, thertf'ore, apptar probable that it 
ar<v« from cau.«e3 that are e:*sontially conncctoil tither with this operation or 
wiih the aneurism itself. These arc rftorable to three heads. 

1. Septic inflammation of the deep areolar ti&Jue at the root of tlie neck 
loav extend to the anterior mediastinum, the pleura, and perioardiuiii. This 
wouM appear to have been the cau«' of death in a patient in whom Kuy tied 
tht: i-ubclavian, and hofi been especially adverted to by that cxeelleiit Surgeon 
in his relation of the case. 



230 



SrVCIAL ANEUBISHB. 



3. Tbc sac may. by ite precEure iowordfl, eocroacli opoo uid (nve liie to 
ioflaiumatioii uf that ))<)rlii)[i gf the pleuru wliicti oorn>i>i>uDdB U> Ue [Heitj'iur 
aspect. Tbie occurrct] in » case io v.-))icb Mnyci, of Winchfvtcr. (.i)H'rste<d, 
and is more liable tu liap{M;u il' BUppiirHtinn have litkcii iila<v in tlif nr; 
when this occim, ailbcgion may tnke plnr o between it and llie pleuru. nr eveji 
the tiwue of the adjuceui luti^ ; and the coiitentfl of the Buppurulin;* !:tm'>r 
TDDV be discharged idIo the pleural cavity or air-tubes, ant) au c'< 
01' thi^ curioua mode of lerminatioii there arc nt least two eases <^ i; 

one by Hullen, in which the patient recovered ; the other by Grnes, iti which 
the patient died from the escape of the contcntA of the sac into the cavity of 
"le pleura. 
3. Division of the phrenic nerve would neceatarilj, by tnteHVHog: wltb 
lie reepirniory moveracuts, induce a teDdcncy to cungmtioD and inHnnitna- 
of tbc lungs ; and, although such an ttccident must ho a very rare ooe 
in eases of ligature of the i>uhclavian for axillary nneurisni, yet it undoubt- 
edly baa occurred, as I have myttelf witnessed in one case. 
I Suppuration of the Sac is the most common, though not the ino«t faUl, 
accio^ol after ligature of the Bubctavion for spoDtaDenus axillary nneurina. 
it waa the immediate cause of deatli in six cases, and occurred in two of tfao 
iti«Dts that died of inflammatiDu of the chest ; it took place in six casw 
that recovered ; io all. founeen cases out of forty-five, or nearly oat io 
thre« — a much higher proportion Chan is geuenilly observed in catea of lig»- 
ture for aneurism. 

What occaaioDS tbis greater frequency of suppuration of tbc »ae in axillanr 
.aueuriaias than in those in other eituationer The chief cause to wbicb it 
kppeare to bo attributable is Ihc great laxity of the areolar membrane in the 
kxillfi, vhich allows the tumor to increase so rapidly in Bine as to exrita 
inflammatory action in ilie surrounding liraues, ubieb may speedily run ioto 
ippuration. in) long ax the cuntcutK of the tumor eontinue fluid, they will 
lecraearily excite le»t irnlalion on surrounding structures; but wbeii odm 
~ ey have become rioltdifitd. whether by the gradual depoell of latni 
flhrin during the progre!>!i of the disease, or, more sudilenly, in c<inBM| 

thoM^ changes that take place in the contents of an onenriamal aae after 
fie lifTfttiire ot the artery leading to it, the indurnred ninM, acting like any 
other forei;:ri body, sets up inflammation in the areolar tiMiie that ts \u im- 
mediate c^inlnrt with it, and thus diiipoiies it to run into Auppumlion. The 
more s|>eeHily the JKilidiAcstJon takes nlnce, the more di»pn!4iti<io will there be 
the occurrence of ihis stcidcnt; tlie neigbhuring twirls heiug unable In 
immodalc themselves to the sudden extension and compre*»ii-n they are 
ipelled to undergo. It is probable, also, that the prnxiniily of the wrtund, 
and perhaps acluiil injury done to the aucurisiunl eac during tb« ojicratiua, 
are, in many cases, the iminediate causes of tbc inflanimntion and suppura- 
tion. The etntiiftics col]c<.-letl by Koch ehuw a much grviitrr mortality in 
c«H« iu which the aubclaviaii artery hua been tied for spoiilaneoiia 
leurisms extending above the tipper border of Ihe ftectoniiis minor, than io 
lose below that point. Of 17 oif the former I'i were fatal, of 23 of llie 
Uter only 10 died. 
The iieri(xl nt whirh suppuration of the sac may be expect*^ to oecar in 
FcBiea of axillary aueuri»in. aOt-r the llf^tun.' of the subdarian. must nem- 
sarity iu a great measure he depi'ndent on the state of the sac at the time of 
the o|ieratiuii. If inflammation have been already set np amund it. it may 
happen a few days after the arterr hne been tied. But if this ntorhid pro- 
Jen have iHil already oummeDcetf. ihc period at vhich sunpuralion may 
moat pniliahly he ex'pecleil is between the flrsC and second month. The 
period at winch suppuration nnd rupture of the sac take place doca not 



RESULTS OP LIGATURE OF SUBCLAVIAN. 231 

influence llie probable tenniD&tion of the case to any material extent; ae, 
in tbe cases that prove fatal, death occurrfd at vanoue periods between the 
serenth day and the second month ; in Aston Key's case, on the ninth day ; 
io Mayo'ff, on the twelilh ; in Belardini's and Grafe's, at the end of the firet 
month ; in Rigaud'a, at the sixth week ; in B. Cooper's, in the second 
month. The recoveries, likewise, took place at all periods after the ligature 
of the Teasel, between a few days, as io Porter's, and six weeks, as in 
HaJk>n's case. 

Ad axillary aneurism that has suppurated may burst either externally, or 
into the lungs or pleura, or both. It is luoat usual for it to burst externally ; 
the tumor eulai^es, with much pain and tension ; a part of the akin covering 
it becomes inflamed ; fluctuation can be here felt, and, if an incision be not 
made, the tumor will give way, discharging most usually a quantity of 
dark-colored pus, mixed up with more or less broken-down and disintegrated 
eoi^uluni, and, perhaps, sooner or later followed by a stream of arterial 
blood. 

Occasionally, but more rarely, the sac, extending inwards, perforates the 
eaviiy of the chest and becomes adherent to the pleura, and may give way 
into its cavity ; or, by pressing upon the lungs, may become incorporated 
with tbem. Of this remarkable tcrmiuation two instances are recorded, in 
one of which recovery took place. 

The first case of the kind is one in which Bullen ligatured the subclavian 
utenr for axillary aneurism. Eighteen days after the operation the tumor 
bc^D to increase, and to take on the symptoms that are indicative of suppu- 
latioa. On the twenty-sixth day six or eight ounces of bloody pus were 
expectorated during a paroxysm of coughing, and the tumor suddenly dim- 
ioiflhed to one-half its size; it was now punctured, and 6ve ouocea of the 
same kind of matter were let out with great relief When the patient 
ooQghed, air passed into and distended tlie sac through an aperture between 
the first and second ribs, near their sternal extremities, through which the 
oootenls of the tumor had escaped into the lung. The discharge from the 
external aperture greatly decreased ; the cough lessened ; and, finally, three 
months after the operation, the patient was quite well, 

GriWB tied the subclavian artery for a.\illary aneurism on the I8th of 
February. After the performance of the operation the coutenti? of the tumor 
Buliditied, and its volume progrcdsivoly diminit!hed. On the loth of March, 
the patient autfered fmm fever, and slight ten()ernc»4 on the apc\ of the 
tumor was perceptible. On the lltth he was sudiicnly »ei/.cd with intense 
pain in the choit, which was {>articulurly severe at the base of the right lung, 
aad extended up towards the axilla. Respiration throughout the right lung 
was brunchiat, and there was dulness on percussion over the lower ribs ; the 
aneurismal tumor had suddenly disappeared at the time of the attack. On 
the I>Sth, the patient experienced a sen.-iation as if n fluid were passing from 
the pl«ural cavity into that of the anourisinal tumor ; and, upon auscultating, 
a splashing sound was heard at every inspiration, tlie noise resemhllnL' that 
pr.'Juced by shaking water In a closed vessel. On the 'iOtli. he died. Upon 
dissection, the aneurism was found to comniunicttle by un aperture, one iuch 
sad tbree-<)uarter8 in length and an inch and a lialf in width, with the pleural 
aTity; this opening was situated between the first and .second ribs, and was 
obvioufllr the result of ulceration and ab.-iorption. eiiused by the pressure of 
the tumor. Both ribs were denu'ied of their periosteum. The ri;;ht sitie of 
the chest containetl nearly three quarts of bloody serum, intermixed with 
laminated clots and flakes of lymph ; the former i>f wliieli had evidently lieeu 
lodged originally in the aneurismal sac. 

Besides tbe^e cases, a somewhat similar one has been recorded by Xerct, of 



2»S 



SPKOIAL ANBURiaUS. 



Najicj. A pnticiit wn« ndmitiod into t)i« hospital, suflbring from luBnoBtjM. 
nnd on cxamiumlon wm t'outiil !•> have an ani<urisni nf Uie Irft •abeuvin 
art<^rT ov liirgt> as n chi-Alniir. He ilkvt (tluirtly aftt^r admUdoii; Mkd, «a 
exnmiuation, the anetirintn wun futitid lu ciinimuDirfliP with a lai^ caviljr in 
the upper part of thf lung. 

The cause of dcAth in Grnm's aiM- was prohahly the fact nf ihn ixr iipea- 
ing anil diKcharning iui (^int^nta intn tlie pleural c&Ttlj. ThU dcic* im^L 
app(*-ar to have )>cciirre<l in Hutleu's, in which a cfimniunication wn* niab- 
tislied directJy with the lung, the conteota of the ahsc^si BndJDj; exit ibruuKk 
the uir-tubed. The process here was analogona t<i what iK-cMslouatlv otrcurB 
in hepatic iib«cew wneu tlii^ o|>eu8 through the luog)>. miht^iuM hnvmg prv- 
viouxlv tnktfii pUce betweeu the uppuveil ourfaow ot the plfuni. 

lu f'unier s c»&e uf asUlnry nueurisiu, ImUi urleriev l>ecmtn« afivct«(] Uj tbr 
diaeaM, aud both euhcl&vinua were tied in th« third part of their ixiurve at 
en iutcrvul of abuut liilvi-u uii>uth8. Id this niont ronmrkable aud ial«f«it- 
iDg caae,the reoult of which reifleots much credit uu chv skill and dcdaoo of 
tbe operoti)r. tiie pallenUa stODemBSou by trade, made au (ixtvlleul recover; 
from the titfit o)ieratiou. After the i!e<Nind <)|reratiou he progrcaeed tMA 
favorably for twelve weeks, by which lime the tuuior had diminianed lo nodi 
a« to be mit more than e thin) of its original sise. Without ubriDui reesoo 
febrile disturbance wt in. the tumor enlarged again, and showed agaa of 
BUppurating. Funier now loade a free incision into it Lhn>ugh the pectoral 
muscle, and let out 18 or 20 ounces of very ofTt>n8tve pua una brokm-^town 
congiilum. The iintient spee^^lily recovered, the tumor dJHippeariog entirely. 

The principnl danger, nnd the mofit frequent cause of death atUr tbe wip- 
pnradoa of the sac, is the supervention nf profuae Arterial hemorrhage. IVh 
may occur cither from the distnl extremity of the artery opening into the 
■AC, or from one of the large branches which serve m support the cidlateral 
circulation nvund the shoulder, such as the sul>»upu1nr or poaterior circam- 
flftx, coming off either immediati^ly above or behm the «bc, or from the wc 
itaolf When hemorrlingc docs not take place oiler stippunilion of the ac, 
it must be from the fortunate circumxtanoe of tbe occlusion of the main 
trunk, where it opens into the tumor. It can scarcely be from the occlwioa 
of the principal collateral branchca; as there would, in this event, b« a dif 
fioulty in the preservation of tbe vilalily of the limb. It ia ea«j U} under 
fltand that, if tbe aac sprang from the axillary, at a tittle diatance above the 
orifices of the subscapulnr and circumflex nrt«riea, nil that portion of iht 
main trunk which intervenes between tbe tumor nod tfaeee vevcU might bf 
occluded, nnd thus hemorrhage be prevented on suppuration taking place; 
wbikt the collatenit circulation would take place uninterrupfe^ltv thmngfa 
these vQBBela. If this portion of the artery have not been occluded by inflaai* 
matioQ, the safety of the patient must depend upon the not-ident of a 
lum or piece of laminated fibrin being liied or eotauglL<d iu the mouth of i 
[,aao. 'I hill inn^ prevent for a time the escape of arterial blood, which, on 
endi a plug being lo<:jeeQeil. may break forth with impetuositr, and either oC 
onoe, or by iw recurrence al interval*, carry off thfi fMitient. 

Another danger may be superadded iu thcfie oucs on the nip|>uratU« of 
the aac and the aupi'irventiou of hemorrhage — namely, the occ4irreBefr of la- 
flainmallon of the pleura, lung, and |>ericardium, from extenaion towmrdaof 
the morbid prooeaa g«)lng on in the sac-. 

Siifoadary hanftrrhao* d^iea not frrqucntlT occur in aUiRa of ligatare of ihe 
Aubclaviati artery in the third part of it* course, except na a ciiUMcqueDo* of 
siippuraliim of the aac I mvself have teen but two case* In which il«Ath 
occurred from hemorrhage taking place from this artery at the part liga- 
turoil. One of these happened to Liston, and the preparation b pmerrod 



AXILLAKT — INFLAMED SAC — TREATMENT. 233 

» 

in tbe Museum of the College of Surgeons CNo. IGSo*). In this case it may 
be seen that the artery was diseased at the point ligatured, and that the 
bleeding occurred, ai usual, from the distal side of the ligature. Barwell, 
taking Koch's table of 79 cases, and adding to it 11 collected by himself, 
&a*ii that of 32 deaths occurring in the 90 cases, 10 were from hemorrhage 
frora the site of ligature. 

Gangrene of the Hand and Arm is but seldom met with as a sequela of the 
operation we are considering. This is doubtless owing to the fre^om of tbe 
anastomasiDg circulatioD between the branches of the transversalis colli and 
ffuprascapular, and those of the subscapular, circumflex, and acromio-thoracic 
arteries, as well as between the superior and long thoracic and the branches 
of tbe interooetals and internal mammary, by which the vitality of the limb 
ie readily maintained. The principal risk from gangrene would doubtless 
arise from the subscapular artery being in any way occluded or implicated 
in the disease, as it is on the anastomoses of this vessel that the limb is mainly 
dependent for its supply of blood. But, at all events, this danger is small, 
the only case in which it appears to have given rise to a fatal termination 
being one in which Cotlis tied the artery; gangrene of the limb came' on 
after much constitutional disturbance, with rapid, weak pulse, thirsts, sweats, 
nstleBsnefls, and delirium. In Blizard's case, there were sloughing of the 
me, and pericarditis, the gangrene being confined to two fingers; and in 
Brodie's case, it occurred in both the lower as well as in the upper extremi- 
tiee.and must, therefore, have proceeded from some constitutional cause alto- 
gether independent of the mere arrest of circulation through the subclavian. 

Failure of the operation to cure the disease if the above accidents are 
STuided is a very rare occurrence. A case of this kind occurred to Berkeley 
Hill in University College Hospital. The subclavian was successfully tied 
for a large axillary aneurism; there was some tnflamniatiun about the sac after 
the operation, which gradually subsided. Some months afterwards the tumor 
b^an steadily to increase in size without pulsation, and finally tbe sac was 
laid open and the vessel tied from within, and the patient made a good re- 
oorerr. 

On reviewing the causes of death, it may be reasonably hoped that the 
avtrage of success will be materiuliy increased by the use of ligatures which 
di^ not di%'ide the ct>Hls, and by the prevention of septic and spreading in- 
flammation in tbe wound by the employment of antiseptic dressings. 

Treatment of Inflamed Axillary Anenrism threatening Suppuration. — 
The ca*e of an axillary aneurism bocoiniiig intlnmed, iin<i threatt'iiing to 
Hippurate before the Surgeon has had an opportunity of ligaturing the sub- 
clavian artery, is one that is full of important practical consideratinns, and 
that admits of little delay ; for if the sac rupture, or be opened, fatal liemor- 
rhase if the inevitable result. It would obviously be impossible, in a case 
of ^jKintaneous aneurism, with any fair chance of success to lav open the 
tumi-r. turn out the congula. and ligature the vessel above auii IkOow the 
m-'Uih -ff the sac ; the coats of the artery, being mtt only diseased, but still 
farther g'iftene<l by iuHummHtioii and supervening suppuration, would not 
t»e in a cunditinn tu hold a ligature. There jire two other courses open — 
viz.. liirature of the subclavian, or amputation »t tlif shouldcr-joini ; and in 
tbe wicciion of uue or other of these, tlie Surgeon must be guided by the 
pr>>irre?9 the disease has made, t lie coiHlitinn of the lind) ns in cirL-nlatiou 
and t»-mperature. and the solidity or fiiiidiiy of the coiilenis of the tuinor. 

If the tumor be of moderate size and t'in'uniscrJbed, and tin- arm of a 
g*""*! temfierature and not very o-deniatous, fii/olurt' nj the arienj may hold 
out a n'««'inable chant.* of success. It is true tlnit this is but a ehaiice: for 
the blourl will, immediately after the noose is tied, be carried by the supra- 



284 



UPBClAL ANSUaiSUS. 



scapular an<l posterior scapular arteries into tbe tubecapaliir and cinnimllKK, 
and by lli«iu into tbe axillury at uo ^ri*at dislnow from tbu iiioutb of ibc 
eac ; or it may cuter directly iutu tlio ujoulIi of ibo latUT, if tbe tubacua- 
lar or circuiuUux sbuutd c-lianu^ bi tako their nrigin fnini ibo ditated puruOB 
of tbe vcsiM^t. llcuoe, tbo uuly sul't-'guard agaiii^l iIh> »u|<i-rvri)t.i<ia uf MOior' 
rbagi- aa Btmti an llic eac has bum tir Ik-cii ii[h!di>iI, or biit dim-liurged Its ena- 
teuls, will be tbe iioctuaioo bj* thrumbneu) of ihac jKirtinu vi' tbe artfry whidi 
interveiHS betweeu Ihwsa two collateral brHiicla-a hihI its luuulti, ur Lue acvi- 
dvntal tttitaugleiuuiit iu the latlvr uf n ruu^ uf laminated Hbrio. Yetr in 
che rirctimstaiiou) as to tbe eiiudittoD nf tuiour aod Uiub ibal liave joat bini 
meiiiioDpd, it would be bul right for the Burgeon to give the ]iatient a chuioe 
of preserving hi» arm. 

Shonld, however, hemorrhage ocfur nn or af\«r tbe discharge of tbe cob- 
teata of the auc, the Bubclavian having previously beeo ligatured, «bai 
sliould be done f If the bleeding be modemie, an attempt eliould ht; made 
to arrest it by plugging the wound, nod by tbe applinttion of a oMspnw 
and bandage. W it recur, or Im? »• profu»« aa to threaten tha life of tlt« 
patient, what courM should tb<^ ^sir^t-im llieu pursue? Twu lino of prw- 
oedure are op«u to him ; t.-ither lo cut lliroiiKh tbv pect^Tal muscles ao at w 
lay the sac open fully, aud nttcinpt to include the uleediug oriHoe bvlwwD 
two lignturea: or t^i nit)putnt« at tbt^i sbuulder-joluU 

If a Burgeon were tu uixiertuke the tirst of them) altcrnatlTes id ■ oan of 
spoataDeous aneurism, of which nione we are now epeaking, h« woold, ib all 
probability, find the part iu sucb a condition lus would prevent tbe pOM' 
Dility of bis completing tbe opemtion he hud commenced. AfUir Uyiag 
open a large sloughing cavity, extending under tbe pectoral muaolca pv- 
haps as high aa the clavicle, and clearing out the broken-down oongula oob- 
tjuoed in it, in what atate would he find tbe artery? Certainly, ibfl probft* 
bility would be aironglv against Its beiag in aucJi a condiiioo' aa to near a 
ligature, even if it c'.)uld be included in one. Its ooata, in tha imfni^tatr 
vicioily of the eac, oiuld not, in accordance with what wft know to be ai- 
noet universally the ca8e in spi^iiuaueoua anenrisms of large aiie oroldstAod- 
iog, be cKpoctc<l to bo in anything like a flound tirui Biate. and would aloMial 
certainly give way uuder prcesurc of the qoom ; or tbo veasel might haw 
undergone fusifurm dilatation, »a U common in this situation. befur« gi 
riso to the circumscribed false aneurism, in which caao it would be im_ 
ble lo aurround it by a ligature; or. again, tbe subacaputar or eircumflci 
orterioa mi^^bt arise directly fmrn, and pour tbeir recurrent blood iuui, tbe 
sac or the dilated artery, and, as they would lie in the mid»t <>f inflaiDcd 
And itougbiog tiuuea, uo attempt at including them in > Hjfature could he 
succcMfullj o^e. In Buch cireumi»liinc«d as th<«e, the daup^r of thn patieul 
would be considerably iucroasud by the irritatinu and iuQtimmfltiiia tbat 
would be occasioned by luying ttjpbU and warrhhig fur the bU'ttlitig vrwal 
is tbe SBC of an iuHumeil, »u|i{mrutiug, and slougliiiig MueurtHiu, und much 
valuable time would be Um iu wliuL must be n frultleit! o|MTtiti'>ii ; nl ihi; 
clow of uliit-'h il noiild, in nil prulmbility, become ueceatarr to liave rvcuono 
tu dinnruculntiorr at tbt; ibouMer-juitit, aud thus U) remove the wb"!i* dtfoat 
at once. 1 itlunild. therefure. be disposed to have roooune to </■ 'ow 

at the fhouUrr-Joinl M once, i a ull caeva of profuw recurrent In ..:ij«. 

foltuwin^ Bluugbiog of the sac of uu axillary aueuriHm. which could outlm 
nrrvsicd by dirwl prcaaure ou the bleeding utiticv, ul'tcr tbe subclavian baa 
bci'ii tied. 

There in nnotbor form of axlllaiT aneurlam that requim immediate am- 
putation at the fthuuldiff-juint, whether iho subcluviau artery have previoualjr 



LIOATURB OF THE AXILLARY ARTKRY. 



235 



bceo HgBtDred or not; it is the caee of diffuse aQeurism of the armpit, with 
tbresleoed ur actual gangrene of the limb. 

Ligature of the Axillary Artery. — Should ligature of the axillary artery 
ml MDj time be required, the vessel may be secured in one of two situations, 
in the fpece that intervenes between the lower margin of the clavicle above 
the pectoralts mioor, or in the axilla as it lies on the tendno of the latit-si- 
muf dnrei. 

To expnee the arterr above the pectoralis minor, the shoulder must be 
puehed upwards and aflowed to fall backwards as far as possible. An incis- 
100 b then made, slightly curved with its concavity upwards, commencing 
immediately above and internal to the tip of the curacoid process, and ter- 
minaiiog immediately below the clavicle, and about one inch from thesterno- 
davicular articulation. The skin and fat are divided in the first incision, 
and the pectoralis major exposed. The fibres of the muscle are separated in 
the ioDer end of the wound, and the finger introduced into the space be- 
neath ^iding a probe-pointed bistoury, with which the remainder of the 
motde is rapidly divided throughout the whole length of the wound. In 
doing this, several lai^ branches of the acromio- thoracic artery are divided 
and must be tied at once. The next rallying point is the upper border of 
the pectoralis minor. This must be found by tearing through some loose 
arwlar tissue with the forceps and a steel director, so as not to wound the 
branches of the acromio-thoracic artery and vein. The cephalic vein lies at 
tbe oater aogie of the wound, and is usually not seen. \Vhen the pectoralis 
minor ia found, it must be drawn downwards with a copper spatula. In so 
dcnng, tbe coslo-coracoid membrane beneath which the artery lies is brought 
fnlly into view. This membrane is seldom sufficiently distinct to be recog- 
nized aa a definite structure, and it can readily be torn through with a pair 
of furcepa and the steel director. It is perforated by the acromio-thoracic 




Tig. i-\. — bikgram of Ligaturacif the Fimt I'art 
«! tbr Right AtilUrj Arrerv. ji.m.a. Pcrtrirm- 
-.» aajur. the fibrri )r]ianite(l in the mner half 
v! ifac «''UDi adJ (liridcil in Ibe outer: p.m.i. 
Part.ralit ainnr: o.r. .ieruniio-thurncic urtery 
•ad T*in; o.r. AiilJarf reio ; a. Axillae}' 
wtM-j ; II. ItracbisI |ileiui. 




FiK. 4S2. — Itiugrnm nf T.igiiture of 
the Axillary Artery in iti lower 
third. r,'>. Coruco-bmchialid : in.ii. 
Median Derve; ii.ii. I'lnar nerve: 
I. CM. Internal cutuneoii? nerve : 
r. Vein : 'i. Artery. 



artery and vein, and the external anterior thoracic nrrve. These will be 
Ktn mi thf areolar tissue is torn through, and vrnMri be drawn inwar(I.< with 
abluDi hiK»k. In the living body the vein next cnnui' into view, and must 
be drawn inwards, when the artery will be seen Ii> its nutcr siiU', The in-odle 
miut t«e pHsseat from the vi-in ami us nvar tlie ctuvii'li' i\^ po.ssil)le, well iibuvc 
the r.riirin of the acromio-tlioracii'. If it is |>(i,sjiil)lc In lie oiilv in cluife 
pp.xiniiiy to thiit branch, it would be safer tn apply u li^iiturc to it aUo. In 
ptaciL-iug the o|»eration on (he dead body, the vein oftiii is not seen, iind it 



238 



SPXCIAL A>*GVBI9M9. 



b customary to 6n(! the nrterr hy followin;;; r.hc flfniiiiio-thorsric lo ita origia. 
There is liuU rUk of including; a conl of tlie brachiftl pli^xits, lu the Dcrm 
lie well lo the coracnid v'ulv, iwpHrnted by a Blij;hl interval (n>ni tba mritrj. 
It U frequently found io the dead body that the ligature hu bvea appIiM 
above the lower border of the first rib, the end of the aubolariui Mng 
aotuallr the reevel tied. This operatioa ia a very ditficult oDe, OD aoeovat 
of the (lepth of the wound as well n« from the embarruameot occanooBd I7 
the Dumeroua venous and arterial bniiiche§ which raniifyaeroai th« fpaea b 
which the veascl lies, and li^ture of the third part of the sabctavimu m ta 
be preferred to it whenever it ia practicable. 

If it is neccBsary to tie the axdiary, aa in the case of a puucuired woand, 
the oporatioD rcaimoieDded by Quthrio ig probably safer and simplpr tkaa 
that just described. It cotuiata in making au ini-iaiuo from the centre uflbt 
claviclti directly dowDwurd^, in the course of the veasda, to the luidille of tba 
anii^rior fold of the axilla. lu this way the akin, euporticiul fascia, and 
grenter pectoral muscle, must be aueceseivoly divided. The leawr perioral 
will then be expoa«l ; and the artery may lie lifi^ntiired above ur bemw thit. 
without further division of miiacular BubstaDce, or if it be thought dc*irabl« 
todeligate it under this, the niuacle must be cAUlioualy cut thrt)Uj7h. \^*Iicd 
this is done, a very di<itin^t and firm fascia will came into view ; this miut be 
picked ap and cnrefnily opened, when the artery and vein will be teen tyiof 
parallel to one another, thi; artery being t^o the outer Aide. The vein bavtae 
neen drawn inwards, the aneurism- needle niiiat be- carried belwern it and 
the artery- The second part of the artery has the thre« coril* of the brachial 
plexus in close contact with it, tlie inner lying between it and the veto. Ai 
the lotrer border of the pectoralis minor the inner bend of the median croMti 
tb« artery. Care must oe taken not to ioclude thea« nerve« in the Mgattm. 
The gnai advantage of this operation is, that tlie wound is o|>ea and fr«e, 
and tliat, conaequeutly, the artery cau be more readily reached in any part 
of its course. The disadvantage is the great divtsiou of muscular Bulntaace 
that it entails. This, however, need not leave tiuy permuneot weakoeMof 
the limb, aa by proper positiuu ready and direct' union may be effMied 
between the imrts- 

Tbe axillary artery may also be lifraturod at any point below the lover 
border of tbe pectoralis minor, by maKing an inctaion pnratli-t to its coune 
in the axilla. The )^iding tine for the v«w;l in tUia situation u obtained 
by dividing the 8|>ace between the anltirior ami [losterior folib of Uic axilla 
into three eoual part?, when the artery will be found lo lie at the juoriidO 
uf the nntenor with the middle tliinl. The arm being held at an obtuse 
angle with the tnink.so as to utako tbe akia tetue, an incision b 
ooramenciug at the thoracic liorder of the axilla and extending for a 
nf abont three inchf^ parallel ti» the e(iurM> of tbcnrtery. The iocuioD 
be made so oa to divide the tikin only. The fascia, being expoaedf nid: 
earel'ully o[>ened, when (lie Hxilliiry rein will come into view, and 

drawn to one side with a blunt hook. The artery will now Iwseen su 

by the nerves of tbe bmchini plexua. In front of it or to ita inner side ff 
the internal cutaneous. To its inner side Ih twei-n it and tbe vi-in is ll»e 
ulnar; the ntrve of Wrtidwri^ ij- still further internal, Hsinillr bfvnnd the 
vein. To tbe outer side is the median, »nd for a abort dietanw nln'Te llw 
external cutaneous lien nn the same aide of the vesael before entering tbe 
oomco-brachialis. Ijehind ia the muaculo-tipiral, and aa far at the upper 
border of tbe teres major, tbe circumflex. The nerve* are easily held aside, 
and the li^iurc is paaK<l round the artery from therein. If tbe ligature 
be applied near tbe termination nf the axillary' artery, as it lies over the 
ttiudomi of the Intiasimua dorsi and teres major, it will not be in iBBinadiata 



AWXffBIftX OP THE ARM, rOBBABlC, AND BAXD. 237 



llT lo aor \aryt' lirancli. Ahitvi; this point, it mostt he npplled cloM 
ik« »ulnu'ii|>iilur or the circumtlex arLeries, *hw\i would perbap* 
■NBdwhal uM to thv tlnoger of seoondary hemorrhage. Iti a fat axilla 
ibKfv ts Mthie rUk of miwitne the artery hy <lri(liiig too much towards the 
pMter: r of the axilla. To nvoid thia, aud also to get rid of the in* 

9^-—- i'-l l»y ihe sitimtiort ot' the veiu coveriog the artery, Mal- 

(i. • itiat the iiicixiou sbuuld be lunde a little oear>>r the 

amiit..-. .n.^,,. , ... Utc Bxillu, and the edge of the coracobravliialia nought 
m lb* first rslt yioi; [i<-<int. Wbeu thin la TouDd. it ia drawn slijibtly forwards, 
•fcaa Uw uwdiao ucrvv will be seen ia contact wilh it. If liiis be dmwii on 
warn aide. Xhm arterr at onoe oomee into view. By thio method ihe artery cao 
bs lied without the vein Uriug oeeu, aud it ifi iupusAible to mti« the 
hy gcttiD^ t^K> far to the iuner side. Ligature of the axillary i» very 
njdjr r«i|nirvd for aueurism. It haa be«u duue aa a distal op^ratiou fur Bub> 
dttTtaa aoeuriam, but wiibuut aucccM. 

AXBrmau or the abu, forearm, ako band. 



SpaaUaeoBR atieurisni rarely occurs bclrtv the axilla, yet it may occa- 
ifaHMlly be neC with at any port of the appcr extremity. Thue Palletta, 
Flaiam, Pdletao, and othora, relate cues ol spoutaneoua aneurtara at the 
hMd of Um arm ; and L^iaton itates that he once tied the brachial artery in 
■a old sbip-earpeaier, who, whilst at woric, felt a» if something bad snapped 
im hb arm. Pilcher hat recorded a rase of aneurism under tlie ball of the 
ligbi Utovb, vbicfa vai produced by repeated though slight blowM with the 
kandle of a bamner mea by the patient (a working goldsmith ) in ha tradti ; 
tbe mdial and ulnar aricric* were tied immediately above the wrist, and the 
Ammt vae tbua cured. Aneuriani has alxi been met with in this aituatioa 
after aCtempled rcductioo of a dialocation of the thumb. In the Museum of 
tbe Cvllcge of iSurgeoiis there it a preparation of a radial artery with a small 
■MeriHB. about tb« tliird of au inch in diameter, formed by the dilatation 
«f all cbe ooale of a narrow purtioo of one-half the circuDilereocc of the 
vi^bI. a liUk above the origin of the BUperficialie volie. .Spouiancuua aneu- 
rMo ia the Sanum u of extremely rare ooourrenoe. Todd and Arnolt (at 
Catwniljr ColLefC Hoeuital) have both Ncceasfully tied the brachial for 
Doua aaenriau ot the liirearm — in il£ upper third. DeMorgau reconla 
of Sfwataneoua aotiurisui uf (ho uluar, and Spautoo one of the rulial 
In OMM of the cases iu which tbe brachial artery and ita primary 
hmrw been the seat of sp«)ntaoeoue aneurism, diaeaeo of ine heart 
■hI mi ibe arterkl lyBteni in nther part£ hue coexisted. 

While ■pontaiieMa aneurisms are ran.- in these ttituatione, the traumatic 
feoH of tbe dbeaee an, aa has already iH^-n stated (vol. i. pp. 458, 4R.J), of 
■an fti i —>t neoarrenoe, and may rei]uire ligature of the hnirhial. or of 
oiWr nf the BrtHiM of the forearm. 

TiU-aTMEMT. — Id ca«C9 of aneurism Ik-Iow the axilla, direct pressure may 
W cri«:d with atlvanlag^, provide^i the tumor be of small sitx and unattended 
b» ioflaminatioo of the euperjat-eot inleguments. Compreasiou of the trunk 
ti the arltry above the tumor i* rarely applicable, on account of the pain 
tiMi ii ioduced by the pre*Hum upon the neigblxiring nerrea, which cannot 
hi ■slated frt'io ihe artery. Bi^idea thi». the brachial artery is fo mobile, 
(^ tbe fcunenw so small and n^und a bone, that the verael cannot be 
g^Mij aamunmBA afaiusi it lur any length of time, but will roll away 

Eaader uw Drewur*;, even if the patit-nt could War the |iain of it. The 
eadoB ef .LaBarch's bandag« under ehtorofoim iiiigbt Iw tried iu suit* 



2Sd 



8P8CIA.L ANHDBISVS. 



Ligature of the Brachial Artery.— The bracliinl arter7 may b« lifnrtured 
in thv mS'Mlr cj ihf arm. which is considered the soiit ufelecttou of thifluperv 
tion, by making an incision, almul three inchos long, parallel Lo ami upon 
the iooer cdgf of ihc bic^pe (^Pig. 483), which i;^ the " directing Hue," »ai 
the first rallying point; the fa^oia, which ia expose*!, must be upenrd ea»- 
Aitlj to u corrcdpundiog exteot, aad the edge uf the bicepe drawn autwania 



Fig. Its.— Um of Indrim for LiKstuni of Iha Br««fcUl in tb* aiMdta at ik* wm, 

when the me-dian nerre will rommonlr he ecen crnaring the arlrrr; IMk 
must be drawn downward* with a blunt hook, when the artery, arconiMiilad 
by its two vein*, will he exposed; these vcttscU must then be «>pnriiLeil UftM 
■>ne another, and the li|<atur« panaed and tied in the umial war In P^''^^4|H 
ing thiA operation, the principal point to nttend to it to cut down ii]>i>n cla 
inner edf^e of the hicepo, whlrh will t>e the sure t^ide Co the artery i Fi^ 
4M). If the Surgeon keep too low, he may fnll upon th» ulnar otrn aad 
the basilic vein, whioli niiuht i*OMitily be miHiakeii for ihfr brachial arterv: 
by takinj; care to expose the fiom of the bicepe in hie early inctaioo, Ite wlU 
avoid iliM error. 

The fascin over the raeiJiau nerve must be opened tboroiiffhly, oihennta 
the artery may be drawn un ouc side with it The needle moat be pamtd 
from the ucrve. 

lu the ttppiT jtarf of the arm the operation for ligature of the brachial b 
practically ideutical with that for ilic terminal part of tha axillary, the 

inner edge of the curaco-brachialn bring 

„ ^ taken as tbe dtroctiug line anij ifae fint 

i- - _ rallying poinL 

^- -^^ A I the hrnd of the Mow the brachial 

^^^fc xrlcry may lie reached by ninkine an 

^^t incirtion about twoinrhee in lrni:thdnwn- 

^^^^'^ Munl;' and outwards, pnmlU-l to and 

inmieiliiitely above the metlisn basilic 

vein, when that vessel can be Mcn: whm 

it cannot, the inriaioD mast b«> al an 

anple of 45" with tbe line of tbe limb. 

cnnifflencin); alxiut one inch exiemiil to 

and half an inch al>o«e the tip of the 

inner condyle of the humerus, and ler> 

roinnting al tbe outer side of the leodoa 

of the bieepa. It muH not be earrietl further outwards or )be median 

oephatie vein will 1h> div'i<lr-i(. If \\\f median lutpilic vein is seen, it must be 

drawn downward* to avoid wiiiindiiig cIm< iilnnr veins which entrr it below. 

As t("in a» the integurnenliil structures are divided, with tbe braiichea of tbe 

inlemal cuUneous ncrro, the strong proceBs from tbe tendon of the bleepa to 



J I, ■■■ " 

Pt(. 4S4.— DI»cruB «r lb* p*rtt ci>Been>«<l 
la Llptar* of Ifat Bn*h)«l II ibt mid 
■II* of lb* aria, ■■ a, MediaS ntits 
drawn lawftrUfi A. Ukav^ii «.*.¥•&« 
dabIui ( «. hnokUl *n«t]r. 




LIOATUBE OF RADIAL AND ULNAR ARTERIES. !289 

cbe fiucia of the forearm, the bicipital fascia, comes into view. Tiiis must 
be carefully divitled ; the artery will be found beneath, having the biceps 
leoduD to iu outer side, the median nerve to its inuer eide, and a vena comites 
on each side. The needle must be passed from the nerve. It sometimes 
bappena that the operator misses the artery and cornea down upon the bruch- 
taltt amicus which lies beneath it This muscle ia readily recognized by its 
nr&ce being composed at this part of alternate strips of tendon and muscular 
fibre?. If circumstances require the operation to be performed a little 
bii^ber up. the edge of the biceps must be taken as the guide, as in the 
middlo I't' the arm. 

Ligature of the Radial and Ulnar Arteries. — These arteries may be liga- 
turv^l at any part of their course, but the operation i:^ never performed above 
thr middle thinl of, the arm except in cases of direct wound. 

The Ulnar Artery above the wrist may be readily ligatured by making 
an incision (Fig. 486) about two inches iu length along the outer side of the 
tendon of the nezor carpi uluaris, which is the directing line to the vessel. 
Tbe incision should terminate about half an inch above the pisiform bone. 
If the eilgt: of the tendon cannot be clearly felt, the incision must be made 
in tbe line of the artery. This is liiund by draw- 
ing a straight line from the tip of the inner con- 
dyle of the humerus to the radial edge of the pisi- 
iltrm bune. The 6r»t rallying- point is the edge of 
tbe tendon of the Aexor ulnaris. As soon as this 
is dearlv exposed it must be drawn inwards with 
a bluot liook, tbe wrist being slightly flexed to re- 
kx tbe mD«cie. A distinct tascia, usually marked ""- ^ fCcM.1. 

by trmosverse fibres tben comes into view; this y.^ <8S. — Diagrnm of ibe 
must be carefully opened and the artery will be xrimr ArtBrj at the Wri»t. 
feand beneath, accompanied by a vein on each side jir.t»h. Flexor Rnbiimta di- 
and tbe ulnar nerve to the ulnar side (Fig. 485). gitorum: fi.c.Hi. Fieior 
Tbe needle must be passed from the inner side. orpi uimris: rx. Vdnc 
Tbe artery lies between the tendons of the flexor <■. Arury. 
carpi ulnaris and of the flexor digitorum subliniis 

and up<>D those of tbe flexor profundus. The mistake most likely to be made 
is carrying the incision too far inwanls so as to miss the tendon ; the error is 
Roignized by finding fleshy fibres directed downwards and inwards; the 
tendon is to the radial side of these. 

Li^tnre of the Ulnar Artery in the Middle of the Arm is a more trouble- 
fome operation, as tbe artery lief> deeply on the flexor pnifniidus covered by 
tbe BUiterficial muscles of the Ibrearrii. Ii can, however, be reat-hed without 
difficultv by separating the flexor carpi ulnaris from the contiguous border 
of the nexor digitonim i>ublimi3. 

To find the iutervul between these two muscles, n line iiiuet be drawn from 
the tip of the inner condyle of the bumcriit< to the radial edge of the pisiform 
booe. This line corres|>onds to the outer edge of the flexor carpi uUiaria and 
also, in its lower two-thinls. to tbe course uf the artery. Tlic upiKT part of 
tbe artery fiajises beneath the superficial muscles of the foruarui from the 
middle "f tbe hcilli>w in front of the fureariii to the junclion of the upper and 
middle thirds of the Hue jur*t mentioned. The operation ie thus performed : 
ibe guiding line having been found, an incision two inches in length is iiiudc 
ia it f Fig. 4bfi) through tbe skin and fat. A white line comes into view 
fiinueil bv a tew tendinous fibres in the edge of the flexor ulntiris. If more 
than ■'•ne white line is seen, a piece of ligature thread may be placed with one 
cifi on tbe inner condyle, and the other on the radial edge of the ]>i:^ilnrm 
brjoe: the line corrcapouding to this U the one sought for. Tbe point of the 




SPECIAL ANKDBISMB. 

luhlly along the niilial side of the line, Mftet whtclite 

I flexor iilnarli can Uc eosilr Mjiarmud villi the liuiiUtrf 

Tb* ^ecli'in of the tnlcrspuoc is tawarda tlu- ulna. On aiflr 

the artery may a|ij)«Hr at onoe with a rem dd each nil 

:«a Ute fl<xnr [ir»ruiuluri. More commonly t)>e ulnar utrvi it Ant 

thii comes iiitu view, the d>>xor eublimii mukt be nu««il aid 

aiU.war<t», whco the &rt«ry will bt: founil comiDf; out fmni b«iomtliii 

•»>»■ the iit>rve lower down. The needle must be |»aMed fmni thv i&wr 




/Urd. 



Flf. iM.^I,tiiw of Ia»|*t<ia for Uplur* vf tb* Br*«bi«l Artw? bI ibe Vrnd of tb« vlWv, m4 

tb« lUdlal ktid Vlami ArtniM Id iba fi-teanu »iid ■! tba wrUU 

V. "^''^ comrann error Id this operation coDBtstB in mtking tiw inc^Hon too 
uucb to the radial side and openiug the ioterral between the flexor iiihlimu 
auil the palmaris longus by mtBtake. The error is at oao» recognised by 
Tir*"' ''^**^ "" '"'''"P"* !*•*** tou-orda the radiiia instead of the oloa. 
The Kadial Artery than the WriBt may be ligatored by makio^ an 
mciBioD about one and a half to two inches in Icngtn, a quarter of an inch 
out8id« the i«ndon of the flexor carpi nidiali*— the "directing line;" wben 
after the division of the ^uperScial and deep flMcis, th* 
artery accompanied by iUt two veins will be expoeed 
(Fig. 487), and may be tied in the uaual vay. Tbe 
artery liea bcttweeu toe tandooa of the flexor carpi radi< 
alis and supinator loogus, and in separated. by •ootc' 6U 
from the pronator quadrntiifi. 

The £adial Artery in the middle of the Forearm cao 
cwily be ligatured by an incision (Ftg. 486) made in a 
lino drawn fruni the middle of the hallow in fruot of t' 
elbow tu the root uf the styloid prooem. At this [tart 
is overlapped by the belly of the supinator longua. 
Ilee on the insertion of the prooator leree. The iuci 
should be about two inches in length; after the fiwcta 
divided the supinator cumea into view, its internal edM 
must be found auil the muscle tumetl outwards, A dw- 
tind bscia is found beneath it, on npeuing which the art^^rj mill be s«a 
with a vein on each aide. The radini nerve ta about half an inch to ilie 
outer side, ami iu iiHuatly not seen. 

Lif^tnre of the Uadiid Artery at the Wrist hiu »<)mt'tlm« l>eea done ttr 
aneurbni uf the palm, but in ninn- cuininunly rci^uirod for wound. Tba 
artery at this luirt of itj course lies deftly on the extemal laEeral ligunent 
of the wrivL-Juiiit. It winds round the lower end of the radius, pasaiitc 
beneath the extensor om'm metacarpi and extensor prim! interno<lii pnllkas, 
and tfa«n under the extctisor sccundi intemodiu The operaUon is |torfitrmed 
by making an incision from (he base of the metacarpal bone of the thumb 




lk« Rwlial krimj. 
n4l»U*: T.r. V«la*i 




OP THE ABDOHINAL AORTA — SYKPTOKS. 241 

btlke pofterior part of the root of the styloid procesB of the radiua in such 
■ nj u to be midwaj between the teodoiis of the extensors of the firet and 
NCBDd phalmnm of the thumb. In the superficial fat will be found the 
niial vein (which must not be mistaken for the artery) and some branches 
tftlie radial nerve. A fascia extending between the twu tendons is then 
tonai and carefully opened, when the artery will be seen crossing the wound 
oUiquety rather towards its lower end. This operation should never be per- 
kmei in preference to that in front of the wrist, as it is more difficult, and 
ii apt to leave some Btiffness in the tendons of the extensors of the thumb. ' 



CHAPTER XLV. 

AXEUBISMS OF THE ABDOMEN AND LOWER EXTREMITIES. 
AITEUBIBM OF THE ABDOHINAL AORTA AND ITS BRANCHES. 

As, until recently, any surgical treatment of these aneurisms was consid- 
ered impoenble, they were left entirely in the bands of the physician; but 
■Dcc the introduction of compression of the aorta under prolonged anGosthe- 
■ia, br Murray, of Newcastle, they have become fairly entitled to a place in 
a woA on Surgery. 

Aanriam may affect the abdominal aorta at any part of ite course, but 
dw moat common situation is near the origin of the cceliac axis ; and here 
tlM diBease is often not confined to the main trunk, but one or more of the 
bcmncfaea are aleo affected. The situation next in order of frequency is at or 
■tar tlie bifiircation. Aneurisms may form in connection also with any of 
the main branches of the abdominal aorta, most frequently on the superior 
■eMnteric, splenic, and inferior mesenteric. The aneurism may be saccu- 
lated or tubular. When growing from the main trunk, it is usually of the 
fonDcr variety. 

Stxptoms. — The chief sign of the disease is the existence of a pulsating 
tQmor, situated in or near the middle line, somewhere between the costal 
nargin and the region of the umbilicus. The pulsation of the tumor is of 
the expansile kind characteristic of aneurism, and there is frequently a dis- 
tiDCC bruit. Walshe mentions a single systolic murmur, a dull muftied sys- 
tolie sound convertible into a murmur by a little pressure, a sharp, abrupt, 
ibort systolic murmur on the letl side of the lumbar spine, a systolic mur- 
■or audible below the sac, but not over it, and occasionally a dull 8ecr)nd 
nand. as having been heard in various cases uf abdominal aneurism. The 
exact shape and size of the tumor and the nature of its pulsation can in 
■any cases be ascertained only by fully relaxing the abdominal muscles by 
the use of chloroform. The sensation of pulsation in the epigastrium may 
be Terr perceptible to the patient, or may be entirely aWut. Gmstant 
■duog' lumbar pain is a very frequent symptom. The pressure-signs are nut 
nwisllr very marked till late in the disease. Pressure on the vena cava to 
iDch an extent as to cause cpdema of the lower extremities is almost uu- 
ksown. The sac may press on the lumbar plexus, and give rise to signs of 
irritation in the course of its branches. The most marked of these are pains 
m the groin and testicles from irritation of the genito-crurul, and occasion- 

TOL. II.— 16 



S4S 



9PE0IAL ANRUmSMS. 



ally shooting pains down the thigh, in the course of the nntfrior oruTsl or 
''^xteinftl cuttineous n^rve. When the bodies of (he verii?i>nf an •ttnifd, 
coiistHut liimhHr piii) will hv tVecpiontly prc^iil, of the Minie biirnii)]^, boring 
character ut that li'lt in thoracic iiupurtsm UDtltrr Minitar t*ircuiUF>lai)r<». In 
■ome CM»i» Ihc [ir<.iuinv iimy nilvcl the gruat intestine, cauainj2 cunMil^rmbl* 
difficulty in dereciilioii. (>ci.-ii»ionn.lly the tumor niav atUiu Ut nn eii«rmiHi0 
$\k before (teach, half filiing ihe cavit^r nf the abilumen. The fatal icrroiaa' 
tion may be due t^ uniilual exhauBtien from pain ami interference with tlia 
fuuciiona pf tlie abiioniinaJ vivcera, to sudilen rupture of the sac into tlw 
peritoneum or Hibperitoueal tinue, orintosnuic partof the alimeotarj oaoal, 
or, nii>re rarvly, into the pleural cavity through the diaphnigro. 

The DiAUNUctiK rests coiefly on the situation of the tumor, its dtstinci a- 
ipunile pulaation, the existence of an ancuristnal bruit, and the prcHUie- 
ugns. Verv marked epiffostric puhalion is not nn unfreqneni symptan ia 
amernic piitients eutfcriu); from ntonic dyspepsia, and in tbcee caata ytfj 
slight prc»»ure on the artery from a stethoECopo will give rise to a iftttirt^ 
bruit. L'nder these circiimstanci^. it is aometimea not easy lo ipoak paB> 
tively n? to the coiidiliim of the artery, hut iu the majority of ouw a ou*- 
fut examination under the influence of chloroform will readily dotal 
the nature of the diM-nsc. A dieptaeed or enlarged heart also givn 
distinct epigastric pulsation, but this can hardly be mistaken for anec 
A atUid maat offetxs accumulau'd in the transverse colon may roceive * vflny' 
distinct iropulae from the aorta, but the duuehy feel of the maaa, ils mfm^ 
ficial nature, and the history of the caac, will usually readily detarauM 
its nature. A prtyminent lumbar mnritbra also puabing the aorta forwaid 
may simulate a dilatation of the artery. Cantctout tumbar gtcmdM aorround- 
ing the artery may give rtfrc to cooftiderahic difficulty iu diagnoaia; and bat* 
again a carel^il exaroiualiun under cbUin>form is the most likely uuana of 
arriving at a correct conclusion. Caneeroti* tuinm-t growing from the ftpwai 
niav give rise to almost insuperable ditGculliei* iu the diagnosis. Front fiuaasa 
of the. var'ni\i» abdotuittal viarern, tlie disgnusis must be made on general prino- 

Sles. The amount of fal in the abdominal walls uecesBarily baa n great Ift- 
oeooe on the diificultv or ease uf coming to a definite conctusion. 
TRfiATMKyr. — In all cases of aneurism of the abdominal aorta, oonstiiu- 
tioual Irentmeut should be given a fair trial before aoj' more wvcfe meMiana 
are adopted. Tufnell has recorded two casea in which a cure waa eflh o to j 
by diet and rest — in one case in 21 dayii, and in the utber 37. If this treat- 
ment fail, the only resource left ia oompreuion of the abdominal aorte. 
The. piiiu of this application is usually very iK-vere, so tlial, in ortli-^r Ut r^ 
lieve it, patients should l>e kept under the iutluvncv uf chlorufunn for many 
hours. The cnrdii of iutroduciug this mode of treatment ia nndiiubinllj 
due to Murmy, of Nt-wcostto-on-Tyue. The o|K>raii(iu has now been par 
formed for aortic onpuriem in nine cases. In fix, undur Murray, OurbaM 
and Mdxou, Durham, firee.nhow and Mulke. Pollock, and 8ir .lamrv Pagci, 
tile [inKsure \vu» apfilied on the proximal side uf the sac: Of ihcer, tlima 
— Murray's, Durham and MoxonV. and Oreenhow and Hulkc's— wen* sue- 
ccasfut; one, Pollock's, faikd; and two, Durham's seeondcftae, and Sir JaoMB 
Paget'fl, were fatal. In throe the pressure was applied OD the distal aid* of 
the sac; one, under Hrvani, lerniiiiated fatally, and the other two, aodar 
Maraluill and Uarwell, tJiiled. In every case the pressure had bc<en appli«d 
by the iuHtrument known in this country as Lister's aortic tourniquet. That 
this iu«trum<--ut may in some cases be fafely apjiUed to the alxlominal aorta 
frotn the highest point at which the artery can he reached to ils bifnrcaiiun, 
is clearly proved )>y results of the caaw above mentioned. In Durham and 
iiuxon's case, it is stated that " by poeitioniug the hotly of the |iati«nt, jusC 



or THK ABDOJUINAt, AO BTA'— TBB ATM BSfT. 





itafMca TM aflbnieil for tbv iulrudurliun of Ihe ^1 of the t4)urni- 
i^^H brtwe ea Uie eanil&gtw or tii<; rilis ami ilie aneurism." In (_in>euh<>w 
uhI BqILc'v cue. il «a0 ii|>plie<l luiilway l>«(ween (Ih* xiphuid cartilage and 
nmbilirus. iDinivdialely above the tuniur. That three uut of the eight 
bavr teraitnaled faullyebowa. however, that the o|*eratioD is by no 
deroiil uf danger. Id Polloek's uasuwus^ful vu^u the patient suffered 
fhuB hjemaltiria, and in (treenhow's caae albumen appeared in the urine 
■ftar Um last t>peraii<>n, thii^ sliowiog terious interferenoe with the circulation 
Ib tba kidnejr. In Marsliall's caae the imtient sulTireil from ret4.'tition of 
mtittm ftr m>mc days nfl«-'r one oftoration, probablr from some iujury to the 
lljrpo|t«*tHr pl«xu«. Tn Brraot's caae tiie paa'tnartem examination showod 
biniai- ' '<>- meMntvry and iutctilinc aiid pentonlttg, and "the tiaauea 
II ^ipreawd aorta were loaded with effusetl blood." In Paget'! 

ai had formed in the raefentcry, peritouitis had been gvt up, and 

itaric artery was fimiid lo be comprwed and floltcned. and embolic 

data wtr* found in itii hraiichc*. Id Durham's fatal cam there wero sigtu 
«f braaiing about the paocrest, ami the aneurism wua found lo affect tlie 
■HMrtMH artery. Tb* time duriag which the presaure ha^ been maintained 
im tmntd cotuiderably. Murray's case waa cured by one application la^tin^ 
iva bcmra; Durham and Moxoa'a in 10} bouni; Gre«nhow aod Hulke's, 
b«l2tfvaappliealioni lasting 05 minute?, 4 hours, aod 3 hours. In ManhaH'fl 
MM iliatti PTMaure was applied without serious cnuseqiiencee, ou oue occa- 
■ao ior lij hours, and on another for 19 hoars. Vomiting has been found 
to ba a trtmlileaome cumplieaiion in several vasea. Of the sueceasful auBS, 
IfntrnTN is the ooly one io which ihe pulsation of the tumor ceased per- 
■^ntuir imtnediiUelr after the operation. In (ireenhow and Uulke'e case 
ItimA ool tin&lly disappear till ^me days after the last npnlieation of the 
111 liii|iii il ; and in Durham and Moxou'm, akhou-;h it ceaftod at the time, it 
Mnmed io a few hours, and paraisteil for a mouth before it tiually dis' 
■wiMn«1 Frun iJie above caaM, it will be geeD ihat there ia abundant 
fndaaee of the aafuty of the proxitnai operation, aud sufficient probability 
-' •nnceaa to ju.*ti|y di in adopting it m every favorable caaa. Further 
oce i« r«>-{uiroa before abanduning dUtat preaiare aa absolutely u»c)cu. 
tu iSryaat's filial caae the uc was found to he filled with firm clot, which 
VMS cooaldered to have been sutBcient, had the patient lived, to have cured 
tfea anauriia. In Mar*h&ira oaae the tumor was thought to be slightly more 
wRd sAar the aperatioos, but no permanent cfToct was prodaoed. The dislal 
ofMfatioa. bowerer, does not aeem a very hopeful one. The nuniher and 
mm of tba brmodica coming ofl from the aorta at it* upper part, and the 
fiafMMwy with which the «iKalic axis and ila large branchcjiare implicJiteti, 
B* WT aafhTorable circumstancee lor distal preMure. The anutomoeis of 
Ibc eolnilanil veaseis is, moreover, so small coniparwl !■> the immense ititer- 
witb the direct circulation, that the only elfn:-t of fliutal pre«8i)re 
be fitr maoy hour* greatly to increase the teneiou in the vesseld above. 
la pcribmiiaK the opemtiou of oompression of the aorta uuder proloiigod 
few points re4}uirF npet-iitl attention. The patient should be fed 
tbe day before the operation. Ou the day of the operatiuu he should 
fluid Dourtshmeat only, and (he bowels should be well emptied by 
of a oo|i)oaa enema. The touruiijuct must be upplicd with the 
inunediatelv above the tumor, and Mith no more force than a 
itdy iiiiwillji H much force be rci|uirad before the pulsation in the 
arterial is arreited. it is probable that the pad of the tourni'juet ta 
M* in tbe right ptaoe, and various attempts inUAt be made till the b\kH is 
fca^ wbare the aaalkai amount of preasure will ctmtrol the circulalion. 
b will bv Ibuftd cunvenicot to insert a S'lfV hollow sponge under the pad of 





«4 



BPBOIAt. ANIVSISBIB. 



1^ hMiRiKiart. M it then accotniu<xlatee iteclf tuore mdil^ (o tlie faiti 
but II II it *"^ '^^ spinu. I>urtng ibc ufwraliou the patienl mutt be watebe4 
vtffT Mrvfullv. «nil llie iiiuriii(|Uet elackriu-d at uDce if anv aTmploiMflif 
ftilifw >ni«'nr<'n<^ Obelinaie vmiiiiiDg may render thu cuntiouaocv of tW 
t -' n inipouible. It is difHciilt to say whetbur ibU in iliielo prea>ofe«a 
l§fff»i»»tiMnic or to ibe influvoce uf tJie chlurofurui. During ine applic*- 
llm ^ cbf loarniqiiet, it h aJvUable to bave the lower liiulw niiaed ra tW 
kl aad vamhIv vnii)p«4l in oiUoa-woul, ait marked coldocn and atiiom 
have usually been noticed arivr the conipreiebin hsi lasted a abort 
if DfcMMry, nutritive eaetnata and brandy may be admlniitTrd 
m^ lb« aiMMthMia. 

INUL'INAL ANCCRISM. 

Am QiM <'<* Ing^uial Aneurism mar arise from the external iliac, or fron 
|Wc(Mttnii)» fcmurul artvry ; lumt truqueutly it spriae« from the bitter, and, 
' laktM K dirvrlion upwards, )>UGbt.-8 ihc ywrhimvuia Lefon; it, and thus en- 
imnwCw aonwwhnt upou tho cuvily of the alidonit^n. The an^urieni a cum- 
ImmW of the circumscribed tatse variuly, though oonietiniM tubular. It 
ntrwtv, if ever, l>ecome8 dltTiuwd, for the reason lonr ago pointed out by 
. - ' , that the Ipmoral artery, above the edge of tne mrturius murde. m 
hy m dense a shuath. anil Is so cloaely bound down tu the wleb- 
CurMi^ lusoiii, that, when dilated into an aneurism, it does not reatUly gtre 

SWiTt'tuii. — When first noticed. the aneuriiim isnfimAll.siifl, comprmibla 
Univ>r, wilb jiuluitinn and bruit, and i» generally nltcnded by little naia or 
tuwasinnw- It rapidly fnlnrg<>», however, and mnr attain a conaiaerable 
< MMt^itudf ; beiup often nimipuhat lubiilaled upon the surfare, owtnz to the 
tuie<iual i-iinstriction exercised on it by the fntteiie under which it ItcH. At 
llic 'luuc lime, it usually becontea more solid ■ and the puls&liun in H 
>>« considerably, iir even coaeeti entirely. A« it increases in aiae, it 
....!., !.:;<;•« the iapbena and iVmoral veins, thus giving ri«j lo oedema of the 
limb: and, by stretching the genito-cninl and some of the bniochn of th* 
aalvrior crural nerve, il occasions con^dernble pain in the tht^ and leg. 

UlAOi(O0id.— The diagnoeis of in^tuinal aneurism is not always so easy at 
Might at first ap|)eftr. It has movt frequently been confounded with abseni 
In ibe groin, with carcinomatous tumora in this rituation, and with mtao- 
uwurism. Tbv diagno«bi from abgcesa must be made on general priuriplta: 
bat in tome instancets it aiipeare to be replete with difGeiilty, as there are ool 
lb tew caaca on record in wliich uneurismp in this situation have been mislaliCB 
lUld punctured t'T Hb»cv»eB, no error that has three times fallen under mj 
jMmofaaervatioTi, and ono which has in everv instance proved fatal. The 
[ dinRnub of an inguinal auviiriem, wdiditied fiy the deposition of lamioBled 
flhiin. and pulnatiag but imli-itinuliy. from a putsatitiy tartomn in the grain, 
k lurrounded by the grratetit dJIhcuWv, and cannot, I believe, frith thenicanf 
we at present ptwesB, be accomplisbeil with absolute eeruinty. The fkct of 
the two diftcnsce having in two inslancee been confounded by two of the mosl 
dbtluguii»heil Hurgeons of the dav, Hlanley and Byrne, is sufficient eTidcnee 
of the difficulty attending tlwir (liAgnoeiii. 

Tbeathknt. — It occasionally happens that inguinal anenrtanu, even of a 

very large size, undergo epontoneoiis cure, or become conaolidaud by direol 

prtature citnjnined with coni<titutiunal treatment; but these iuitaooes are of 

I neh rare occnrrcnoo, that such n result cannot Iw relied ou in any iwe ease. 

tCnmnrefsion of the aorta nnder prolooged annsthesia has of late years baafl 

[fbund so successful, that in do case uould a trial of it be omitted wbai 



ILIAC — LIOATDRE OK THB EXTERNAL ILIAC. 



245 



povible (see p. 242). Sbould it fail, it becomes necessary to tie the vesBel 
ieading to the sac. lo the majority of instances the tumor, though it may 
kave encroached OD the abdomen, will not have reached too high for the 
external iliac to be ligatured ; should it have done so, however, the Surgeon 
mar bare to tie the common iliac artery ; but in some instances even this 
Bay not be practicable, and his choice must lie between the slender chance 
oOned by constitutional treatment, and the fearful alternative of ligaturing 
the aorta. 

Ligmtnn of the External lUao Artery. — There arc two modes of tying 
the external iliac artery — the one originally practised by Abemethy, con- 
■iderably modified by Liaton; and the other introduced by Sir A. Cooper. 

Ahemeihya modified method (Fig. 48S) on the light side consists in com- 
meDciag an incision at a point about one inch above and the same distance 




Fi(- 4Sd. — Ligktnre or the Eilernal IliiiC b; Abern«tbj'd OperatioD, modiBed. 

internal to the anterior superior spinous process of the ilium, carrying it in a 
corved direction, with the convexity outwards, to a point about three-quarters 
of an inch abt>ve and half an inch external to the middle of Poupart's liga- 
tneoL When the operation is on the left siile the incision should bo com- 
menced below and carried upwards between the two points mentioned. The 
wmint] thus made is altogether external to the inguinal cnnat and to the line 
of tbe epigastric, and above and internal to the main trunk of the circumflex 
iliac artery. It is about four inches in Ien;,'th, and, if necessary, in fat sub- 
jects may be extended at the upper end. After cutting through the skin and 
taperficial fascia, the tendon of the exteriiHl oblique i? carefully tlivided, as 
tsuch %M possible in the line of its fibres. The internal oblique and trana- 



246 



SPECIAL AKEDRISHS. 



vermtis are Dfxt diviiletl with great caution, when the traiUTcnalM iMida it 
nacl>e<l. uud n;nigiii»!ii Ity itui <liill whit<^ iippeurance. Benrath tbb wbb* 
brauc there is nflf ri a littlu fat, <¥]i<!<-tal ly at the Jnn-er part of the irooml. A 
Itroail piirlinii of the fttfria, at thu lower end of the wiiiiiif). is now canifalljr 
I'nueti with the force|ii!i, and rut through with the hUde of thewmlpel ludon 
the Bat. A bnmd hernia-director k tbeo introduced, and paned uttdemmh 
it, when it ehuuhl l>e laid open to the full extent of the wound. In doioglUi 
care tnust be inkeQ not to wound the peritoneum. This n most likelr !■ 
happen in consequence of a fold of that membmno overlapping the end of 
the director, so innt the knite woundit it when run along (he grvtove. T> 
avoid this it is safer not to push the knife auito to the end of ifae dirrctor 
The risk of wounding the peritoneum may oe also avoided br uarinff tbi 
tnuMT«tsa)is fa^toia with the tingere jostcad of usine ih« koiRk Bout ikt 
.ftKiatmnsvor^aJiaand fit8ciailiao& arc firmly attached to Poupart'alif^ameat. 
Lh> that there 'a no ri«k of stripping up the latlL-r foAcia in «ucb a way m lit 
dijptocc the vesaeJs. If a hole be made io the faacia trauBremali* larga 
enough to admit the tipa uf the two forefingers, it will be found alwayt U 
tear with the greatwt ease lo the full extent of the vtimuil. When lliit is 
•ceonipliflhed the whole inner side of the wound is drawn inwards and 
■lightly downwards, the peritoneum being gently teperated fruiii its Ioum 
areolar eoDnections in the iliac fo»a by the Surgeon's lingen; tl must be kept 
out of the way by an aseistant. who holds it up with a brood bent copper 
spatula. The arterv will Dow be felt pulsating at the brim of the pvl vis, and 
is readily brought into view at the bottom of the nound. It is escloeed tD K 
very loose areolar f<healli, and has the vein lying to ite toDer aide uid tin 
genital hmnch of the ;;euit'>-crtiral n|>ipn it. It h crossed near Poupart's 
, flgament by the circunitlex iliiic vein. The investing areolar tissue must bv 
'scratched through, mid the ncedti; pfuscd from the inner side iM-twera 
tba vcsscU. When the vessel is much dimaaed, it is utUiu very loriuouv, and 
may dip down iul^) the pelvis so aa to make it difficult to uxpuee it except 
close to its lower end. Orcasionully cnlurgctl glnnde round itie artery ^19 
•ome trouble by obscuring it and rendering it (fifficult to clean. 

In Sir AtUty O>oper'$ opcraiion the outer two-thinlti of the ingninnl canal 
are opened. An incision is made about three inches in Irngtli. Itrginning 
oloae to Poupart's llgtiment, aboiil half an inch outside the external aWlomiiuu 
ring, and terminating about one inch intf^rnal to the anterior sup^'rior opiooiM 
'nrooeaB of the ilium. The line of incision is not quite parallel to Poupart'a 
lijjament, but rather to the tibres nf the tendon of the external oblique. Is 
dividing the Auperlicial fascia, the luperticial epigastric artery is cut and most 
be lig»lure«l. The external oblii|u« having lieen exposed, asaiall liole is 
through the tetidon at the lower end of the wound, and a direi^tor inserted 
which it is divided to the full extent of the wound, taking «aretu cut exscll? 
parallel to the lihree to ue to injure the tendon as little as potsible. The knife 
niav now lie laid aside, themibsequeut eteiis of thv oix-nition being cnrrird out 
with a steel rlircclor and the force{>8. 'Iho divided tendon of ihr vxtrmal 
obliiiue being held open with blunt hooks, the cunl, Burrotmdn) by tbt 
Oreniasler, and tlio lower edge of the internal oblique come into view. Soma 
looee areolar tisme aud a few fihref^ of the rrcmanter muul now bi' Fcratcbed 
through, elupe to Pnupurl'ti lignnient, and the Rngrr pnsBctl bcni'ath thea>rd, 
which muKt be pushed upwanh*. The iran^venutliii farcin in thro carrrullr 
torn through with the director anil forcepe, nnd the artery can then be fait 
ivovered by a little &l and areolar liseue. Two copper spaiulu' are then 
{aaerled through the opening in the tranaverealis fascia ; the internal of 
'Ib drawn upwnrdit and inwards, rabing the oord and drawing the epi^ 
artery out of the way; the external pulls the lower border of the iniem: 



must 




HBTBOtiS or TVt.VO KXTBftSAL ILIAC. 247 

ohliqac intl of the trflosireiiKlifl apwartlfl and nutwMnli). Both npatolip ratM 
liw p«ritooeDm. Bv i'l«sriji£a«ny a litllc loofte areolar tiMue, the artery can 
h« mxpam i for «De itteb ana a half or two inrhes withniil diffictilty. It ha« 
iW genital braodi of the j^nil'vcrunil lyiii^ on it, am] U in crossed by tlie 
dnmBflcx Uia« v±iu a liltle above Poupart's lif^tnfnl ; the external iliac vein 
■ Id it! inner aide; thtae nuMt be careftillr avoided. The needle roust be 
pand from the iani*r aide not lew than one inch ahore Poupnrt'fl ti}|rument, 
•»H In mrtM the epij^tric and circumflex iliac arteries. After the opera- 
das ft (Iraina^fivtube may be inserted nt the lower auijle of the wound, and a 
Miciit auture iiiftertt^l in the divided tendon of the external oblique. 

Cn eiMupuriDi; the two o(>eratioQ», it wuuld appear that the principal di»- 
adranUf^ of AbemethyV i*, that it \» apt to leave a temleucy to nernial 
pnitniuon, in n"n*^(ueocw of tlic abdominal n'ull being much «v««kea«d by 
tW fr- - '>int nrv ii«!c«Bary tbruui'li tbti muwular planes; the great 

>dvmi> Nt.' it i», that the external iliiu.Muuy be liKiitured at any part 

«f ito iwurw. and that, if r«t)uieite. the iocisiua may be extended upwards, 
•ad iW ooramoD truuk secured. In 8ir A. Coopers operation, the lint- uf 
iadiiaa lies directiv acrom the oiurse of the epiffai^trio artery, which, aa welt 
mtkm eirmtnflex ilii, if it ariite hi^h. an<) the circumSex vein, which erosaea 
ibe iliac arlery at this ttotnl. and ii^ otWn anniewhat funoel-shapeil, tuny be iu 
dufcf of being Kounue«). The ttpermatio oonl is Itkewtae anmewbat in the 
waj IB this operation. Dupuytren artunlly woanded the epiga.stric artery iu 
mm case; aad Houston had much difficulty from the circumflex vein in 
Mother iostanoe. This operation has also the disadvantage, that the incision 
■|Manb ouinol be convenienll y prolonpet^I so as to deligate any portinn of the 
1 except that which lies immediately above the eriiral nroh ; hut the peri- 
ia MM diatitrlted than in the other case, and there is less tendency to 
pratniiion afterwards. .-Va a t:;eneral rule, I think we may eonofude 
Am; Id caaa of spontaneous aneurkm, in which it might, fVom the size of the 
naar or tka diwased state nf the vcaseU, he found neeenary to applf 
Ae Ugawre to a higher point than wiu intended before the opL-ratiiin com- 
nsacM, il will Iw safer td have recourse (o Abernelhy's plan, niO'liBed 
a* abnre dewribrd, for in this way we aball be able to liffslure the veswel at 
aay part fjf it* c^iarK; whilst in ca»e« of bemorrba^ after nmputatioo, or 
of tnHinuiticfoitKinil aneurism.in which the artery is ngt likely tt} be diseased, 
raeeane sboald be had to CVwper's operation, more particularly if the 
|mImC be thin, and the abdotncn flat. 

la ooiuMctioa with the ligature of the external iliac artery, there are some 
pHMlieal poiatB that deserve mention. Before the operntioQ. the colon 
AaaU be anptied by mean^ of an tnemn. and the pubes shaved. The 
tadMOB is thtt abdominal wall must be Budiriently exLcnaivc. 

la Abemethy's method, modillcd ns above described, there ts no fear of 
waBdiairtbe digastric unless the inciaion be carried too far at its lower end. 
Tbe aitary may be ruuf^hlysaid to run in n line dran'n fmmn point at which 
ibe AsBoial anerv oruasca the brim of the pelvis to the untbilieus. In 
aaithsr oMCbod of^otwratiug should the inri^iion implieatJi the external ring, 
U« It jcivv rise to a tendency Lo hernial proiriiatou. ('are should ho taken 
act to woaad the peritoneum; for, alth-»ugh two patients in whom this was 
4aae by P<hC and Tait both recovertNl, yet il is uf course a daiij^erous 
■wiJin'l. and ah-iuld, if poMible, be avoid^. The peritoneum must not be 
tiiffa ttp tnofff than (> anMilutrlv neceKtary, lest hemorrhaife or subsequent 
pariliMkitti ucvur. In rntsio); llie (leriloiieum, care mu!>c be taken not to di*- 
ajMaa fh«- < '•' li lin; 1(hm'Iy in the Mibjieritoneal tiMUe. and can 

■SMmIt ■ -|>nluln. or pti»h«<) over the brim of the pelvis. The 

■yaietfiin <>i Utc pvriuitivum i» much facilitatvd by the Surgeon holding the 






;:z=-^ i^'ic; 



. .rr-. an. nm 






t. ' . .rsi: a .r 



:-.-.— ::.r ria- 

"_ --■ UiSf » 
:. : --.;:■ II. .1^ 

,.*: ..-■ .pfn.-.i a 

: - ..' |i: is*- 

i ■ :;.;;.!- ti j. 
:.:.:.: .| .i.i. .5:^ 
■■:.";i. Ii-i.l'::l. :iAT 



.■l;.-- 



SgSULTS or TYlSa TBI COUHON ILIAO. 



249 



B** •utwtirs wtib Banrell's sunplpmentarf cfl»s give •omenhat dif- 

mulu. ileninrrhai^e occurred in '24 of tbe 141 cases; of tbesc, 9 

and IS di«xL Gangrent^ trna tntnl in 0, peritonitis in 2, retro- 

•upfiuration in 2, and various ol.tier caiues In tbe remaiaiog 6, 

tiafC a Uital of 31 dmthn in llie 141 cases. 

liicalurv nf the pxiertml iliac for aueurumal varix in the oroin afifurds 
'^-ifC oiotrasi with that for »pontAneoua aoearism; the fuur casea 
ill (imvin^ filial, two 'tyinjj of (rnnKTene and two of hemorrhage. 
cmM«Gurbrie h«!! rvcoinuii-tMlcd tbat tb« tumor aboulil be laid upon, 
Uiv art«t7 li);aLur»l above and below the 
turv ID iL Duriu];; the operatioa tb« artery 
W mdilr comm&ndvd above the seat of 
by the np|ilicKtt(>D of the abdomipal tounii- 
, «UMr to the aorta or to the ooiumou iliac at 
tbria of the ftp! vie. 
iMuriacD ODcaiMuiiKlly lakes place m tM groin 
of the amne ride; here the ligature uf the 
■Ucfval iliac will cure both diseaaee. Of four 
«Hi in which thia oomplicntioa occurred, the 
vfumiion waa f ucceasful in three, one patient dying 
«f yaagrese: and in him the popliteal aneuriam 
«ai m tlie point of bursting at the time of tbe 
ifUBliiiii. In two of the three cuBm that re- 
— WW J . pulMlion rftumed in the inguinal aneu- 
liiM^ Imi dtnpMared aAf r a time. 

LifBtu* of ae Common Iliae. — This artery was 
icM lied br Gihaon, in a case of gunshot injury, 
iIm patiest dying of iieritoniiis and secondary 
tWMinliaiia oa t^e thmeeuth dav. The groat 
Aaerinao Sorgvon, M»tl, wns the lint ifbo tied it 
ftr aaeariaai, tlie palleol TDskin;; a goMi recovery. 
If Um aAeurlsm in the gmin extenJ so high that 
thcra i« not Bufhcient enace for the exposure and 
fi^tsrt of th« external iliac artery, it becomes 
avscflMnr Ut tte the ovninioo truuk. Tbia may b« 
4aa» by «xtmding the iocisioo ibat serves for the 
%atar* of tbv cxteroal ilinc upwards and slightly 
immmrdo Ivwards tbe ambilicas, to an extent cor> 
iBpnarfiog to tbe degrw ofofaeeity of the patient. 
in tkal it asnnwa a somewhat semilunar form. If 
th* op«fatioa is oommeaced with the intentioo of 
■pfljriafaligaturv to the main trunk, it is of great 
■■pvtaoee in dctemiiniug the Icnjjth of the inci- 
iiBa.aad calculating tha puint at which thv nrtt-ry 

«kU bs mat with, to remtiuber the di^rrent betmnijt of the parti in thr neigh- 
kmrhamd ^ du retitjg, and tbo retalive fretfucnni with irAi'cA fA« origin and 
^mimMmtt ofthe arterj/ terrttpond uftlh certain JixM poitdi tJiat may readily 
bcddaeud. 

TW poiati of importonoe are tbe rolalinns of the TcmeU to the lumbar 
micbvK. to iIm ere«t uf the ilium, and to tbe umbilicus. The ordinary place 
•f dinboo of tbe abdominul aorta is ou the body of tbe fourth lunilmr ver< 
lebcm, or on tbe invrrti-hral duik below it ; according lo Quain, tbi» was the 
SBK ia Chf ■• of \.\\v biultcA be exniiiiii^, or in 1>S6 out of Idt}. lu 

lafa'd lu II li ttetween lli« eiiuntloti of the bifurcaliun of thv aorta 

•wl %ho cnat ol ti*e ilium, wo find it, accvrding to lb« »ame aualomut, to 



Flf. 4».— Oblllvniiaa of 
Pvinonil V«1h bj InfMlaal 

AMdlilM. 



250 



SPEOIAI. AXRURISHS. 



have nu)g«d to about four-fifth* of the cases between hnlf nn iorh BbnTB ml 
below the level of the higheet point of this part of the tvme. With nfanan 
to the umbilicus, no definite rule tnn be laid down ; but it mmv ba brawlir 
8lflle<l tliat the hifuraition of the aortA la a liltio to ita led. A* a graenl 
mle, tliat i^iven by Itnrgrave is perhape sufficicotljr good for ordiMirT po* 
poaea. If a poini be taken about half or thrve-quartcn of aa tnch btlnv 
and a tittle to the l«A of the umbilieus. nnd a line be drawn nn each mtt 
froui liiU point to the centre of Poupan'R lignmcnt, we obuin aboni ibc 
direetioD of tht common aad external iliac arteriM, On dividing tbcH 
tines into ihrco equal parts, the uppor ihifil will correspond to the oMsmM 
trunk, AQiJ the tower tw<>-tbirdft Ui the external Iliac, and the juoctioB af 
the upper with the middle third to the bifurcation of the eomnidB Ulae 
artery. 

The point of division of the itommrin iliac artery i», in the tnajurity of 
caaes, opptwito the lumbo-sacral articulAtiinn ; and if it be not in thii aitoa* 
tlon the iliviaioti will pmhnbly be Inwer <lon-n. The leii|^ of the vomI 
varies greallr: aecuriiing to (^uain, in (ive-seventlit of the onea it rangfJ 
betweeti oae aud a lialf and three inches. 

Tlie artery lies at the brim of the pelvis. The vtaat oo tbe two aiilsa iflfllr 
in their relation to tbe arteries. The left vein lies to the tuner sidv of Ibf 
left artery, and then passes beneath the ri^ht commnu iliac artery to join tW 
right vein in formtnu the vena cava inferior. Ou tbe right eide tb« Tcia i* 
St first beueuth antf tbcu tu the outer side. Tbu comiuun iliac titmn '» 
eroned by the ureter nenr its lower end. 

The Incision to expose the commnn iliac extends from a point alwHiloot 
inch BXteroAl to and uiio inch alxive tbe middle of Fou)>Brt'«> lipiment ia S 
curved dinNPitton to another point about two inchos above and the 

distance internal to the antcriur Fn[K>rior iliac spine. Tbe cunre m 

such thnt if pmloDged the inrifion woulii reach a pointabout midway bclwesa 
the xiphoid cartilage and tbe umltilirus. Care must be taken that the b- 
cisinn 1m> not carried ton low down or too tar forwarths; nnthinj; oa ha 
gained by doing »o, and therA tu br^AideA the addiiirinal risk of the rirramHa 
iliao or epif^lric being wounded, ait hapitened to Mott ; and »m these are th« 
priDcipal agents in the ADSDtomiwing rirvulalion, their injuiT is a aerioos ac- 
cidenL The muscles are cnrefully divided, ts in th«> operation for the exter- 
nal iliac, and the transversalis fascia opened in the same way. Tbe perho- 
neuro now comes bulging into tbe wuiind, pressed forward by its cotiimta. 
It must be gently stripped from the iliac f(««a by the Rurge^m carefully ia- 
sinufltiog his hand blenenlb it, care being taken to r«isv it directly inwanls 
towards the brim of the pekia, Ht which puiot the external iliac will be 
fimad, which serves as n guide to the pureat trunk, Thv ureter always 
oomes up with the {KTitouvum, and is ubuuHv nui seen. Tht< peritoneum 
must be well drawn inwards by hniad copper spatuln. The ligaturv mm! 
be pMsed niuud tbe artery on the left aide from within outwanlft, a alight 
•Oratch having been made through the fsficia, euverinc the venri by ni 
of the linger-uHil. by which it may also be separated Ironi tbe noc^tmp 
ing vein. Oa the right side great onulion roust be used, on accimnt of 
poBitiiin of the luft vein l>eneath the artery and tbe right to its outer I 
Id the later stages of the operation, the patient should be turned cm 
sound f>ide in order to prevent the Intestines ftrom falling over and 
tbe peritimeum intu the wound. 

Atnlta.— Writing in 1d^2, 1 stated that when we look at the depth at 
which thLt artery is situated, its ^rcat size, and proximity to the eentrv of 
the circulation, and conudcr the foroe with which tbe blood rushes through 
it, we cannot but bo struck with the raooeis wbiofa baa attended its tigatar«b 



RESULTS OP TYIKG THE COMMON ILIAC. '251 

Of 17 CUM io which it had tlien been lied, 8 were cored. au<l 9 died ; in 11 
at thm c Mw ihd ItgAUire wu appii«d fur M>eurii^iii, nii'i of ihew.- 7 n-cu^ured. 
Tht 4 thai (ikd pembdd rather from the amguituile nod cxtvut uf ibe dia- 
flSM thdux from thr ■•ITrcts of the ujwmlion ; nml it is n>rimrkable, as »bow- 
iB|E tile power of th« auutomoses id uiainuiniDi; the vitality of parts, that 
IB DO iiMUDcs did nngreae eosue. Sinco tiiis )K-riud th« ujieraiii)U has been 
perfDfiiMd laanr iTnics, but witJi much less salinfactunr reaullB. Stt!|tUen 
sMtlb. of Kcw V'>rk, published the ^tatistira uf ihis oiwratiuu iu \HWK fi'n- 
log ch« detail* of '.i'l cases; of tiuxe, ho says, 'iO died aud uuty 7 recovered. 
I thiok tbc Dumlwn should be 24 and S; and in one case (Bui)be'e\ tlie 
(wt infant i died two maQths after the o[>eratii>ti, tho lij^aluru bavin}^ 
1 aud the Brtory In-ing occluiled and ihtin ihti di'lj^alion having euo 
Ciirlt, nf Berlin, in rF|>r<>duciii>r Smith's tables, adds 2 cases, both 
To lime most be added a\m a faiitl case by Dugna, of Charleston, 
\§vt in vbidi the operation h&n. within th^^ Inst f^w yt-nr^. Keen [itrformed 
il dua cooBtrr ; noee by Bic-ken>t4-th, of Liverp'Mil, stiooewfully ; once by 
lUlprnve, of t>ublin. whose patient died on the ^erenty-third day aAer the 
tftnikn, of fan(rrent« of tlie foot and profuse discharge fmni the wound; 
IM ooeo hj Alauuder, the patient, a man forty years ot age, dyin^ on the 
lixtb day mmi jcanilTene of tb« luw^r extremity; by Morraot Baker in a 
natk Ql 17, for hcm-irrbage froro a branch of the internal iliac, coiie«|Oent 
«a vloermtiuo product-^l by sacru-iliac disease— fatal on the day lulloninK the 
apentioa. During the Anterican War the operation was p«rfuriiied in 5 
caao^ all mistircvwfiil. These casai increase th« total number tu 4-1, uf 
wUcb 9 rvcuvrrc<l and ^o died ; initof thecnsen the peritoneum was wmiiided, 
sad of ibose H proTol fatal. Of 19 cnse» in which this vessel was lte<l for 
b— orrl M mP. 14 proved fatal ; the majorily of the recoveries took place alter 
flpHStii-n for annirism — which c^mstituteti about half of the cases. 

Tlw Old OpentioD has been performed in more than one cose of iliac aneu- 
amm, wbcn from tpccinl circumstances it was not poBsible to tie the artery 
thm Mc. In Hrroe's well-known case the sac woe laid open and three 
-[iplied. which norc believed lo include the exteniat. internal, end 
10 arteries. The patient practically recovered, but died of 
aotte mooths after, before leaving the hospital. The poet-mortcm 
showed that the ligatures had been placed on the external iliao 
«fy. Sir Astler Cooper attempted the same operation in the coae in which 
ha salvKiomtlr lied the aorta. Heath laid open the sac of an iliac aneu- 
nm vhich ha^ been opened hy mistake for an absceai before beiDg admitted 
jl&a UnivereilT CoDefe Iltepital. Tbe external iliac was lied from within 
Aa time but the patient dit-d {mm aecourlary hemorrhage. The ulil opera- 
«■■ tmn tmiw be perdrttied when il is possible to compress tbe aorta above 
iW mc ; and coiuec|uefilly, ua IIoImM [>olntji out. tin attempt should he made 
to etfr^t a cur* by eomjir'^-iMri licloreso dnn(:cnitu' an operaliuu la attempted. 
ftftWHt hy CompresHion hm been >urct'.<<«tiilly applleil to uneurism of 
llw iliac aMi--rie«. Tbe comprevwioii inu^t W iipj>)t(d to the aorta by means 
itf I^sMrr's ti LtfiiiiKii t. IU ill llie tnrHliiieiiL of aiieitfinm uf the alHlnminal 
■acta (p. '2 rnhle number of cases have now been cur^jd by these 

■aaris 1- - — i _.. jidy been n'fernwl to when treatini; Kenemlly -tf the 
wkject of fiupfcaMon of the arteries for tbe cure of aueurieiu. Murray itt- 
■Maoai the importaoor of cttuiplete arrest of the circulation in these cases, so 
Dot Uic sli^-btnr; iMirrrol of blood should pas tliruu^h the sue. One of 
9Mfa waa cured in ihrre-ciuartcrs of an hour. Uuo of Heath's (of New- 
U) eosHoUdatrd in tntnty niiuutee. I^awsou in one case applied two 
to tl)« ubiluminal aorta, the other to the femoral uelow the 
■bdoainai tourniquet liad Iu be removed at tbe end of tvieuty 




252 



SPECIAL ANBORISlia. 



minute*, owioe to collapse and vomiting; tbe rerooral one wiu TnaioteiMd 
in iKJsilion. When the nlxlomiDal ojnipreaBor wan removed th« pulaation 
hiin already dimiiiisbed, nod at the end of four houre they ombhI ; tb» 
patient innktng a good recovery. Hulmea has oullect^d 10 caan of iliac or 
ilio-lcinomi aneuriua, treated (iy this method ; of thcw, 7 were niml. and 
in 8 the treatment bilcd. Tbew 3 afkcrwards underwent ligature of tht 
artery leading to the sac — in una cue the abdominal ooru — and all died. 
Theee statisiica clenrly show that oo operotiTC troatmeDt is juBtifiabIo,cxotft 
after the fuilurc of corapreaaion. 

Ligature of the Aorta.— It is impoaible not lo eontetnplate with admi»> 
tion the man wbi«»e miud n-aii the bnt to c^ACciv^, and whoH band «*■ tba 
first to carry out, the detenniiiaiion U> apply a ligaiuDi to the abdomiail 
aorta ; and who, gnided by patholoKicul ohtiervaliua and physiological «xpcii> 
meot, vcnture^l to Arre«t at once the circiilalioit tbrougn the maio ebaiuMl 
of supply to the lower half nf tlie bixly, trusting to the collateral cireala* 
tioD fur the mnintenauce of th« vitality of the paru thus duddooly deprived 
of IiIimkI. Sir A. Cooper vu the fir&t to place a ligature on the ourta, ii 
1617. Since that period the operation has been fix limeajperforiHd fbr 
aneurism; viz.. by Jaoics, of Exeter; by Murray, at tbe Cnpe uf Qood 
Hope; by Monteiro, at Ilio Janeiro; by South, of Louduo; by McGiJtra,af 
Kicnmoad, U. S. ; by Htokex. of Dublin ; and once, in ciniuiualaouei wbkk 
will be preecolly dcsLTilNHl. by t-VTuy. of Vicuna. 

TABLK OF CAKES OF LlOATUltK OF AKDOMINAL AORTA 
FOK A.NKURWMS. 



«(nta(o>. 


flax. 


ASB. 


l>ATB. 


RArCM 
IIP AKBCatllM. 


ni^a«rroUL 


uavuk 


1. Sm A. CooFXK. 


n. 1 US 


1817 


DIITumkI tuguinal. 


XnciMoD 

UircKii'li 

MritaaButn. 


IhtBth fa M 
boun. 


'i JaUC8. 


■a. 44 


18» 


£xt«rua] iliac 


I><Mtb In • 










iur>! dni: 


(few b«on. 












pertlitiMuiu. 














Of>»D*d 




8. Mi-asAT. 


IB. 


• H 


18S4 


iDgolaaL 


AorU Ued 


OcMb ia 11 










Iwhind 


hoMf*- 












peritonvum. 




4, MoMTStao. 


B. 


■ *• 


IMS 


Diffuwd ingutnal. 


Ai»rU Had 
twhibd 

pert ion oum. 


Deatb an Ittk 
day 


fi. tioum. 


■b 


28 


leu 


OoDtmoB iliaa 


Aurta U«d 

bebiud 
perlufucum, 


I>Mtb til W 


fl, McOttlBB. 


■1. 


80 


1066 


Lower i^arl of 
aurik. Biitbcam- 
Bi'tn lllav*, and 
l«ft«KteriiK]lltac, 


Auru tied 

bebind 
(wrttoneuiD. 


llnlh la U 

b»un- 


T. W. StuRn. 


IL 


60 


IMB 


lltw. 


AorU tied 
brbitul 

|Mritt)R«tm. 


[>«Ub in » 
buurt. 



Id Sir A. Cooper's coae. the inguinal aueurism had bunt, and tbe aurta 
was tied about turee-^uortera iif an inch above iu bifureuliun, by making aa 
incision three iucbca m length Ibruugb the abdumeu, a liulc to the led uT 
the umbilicus, the fingere taking paased betwcua tbe convuIuiiooB of the in- 
toaUoea, and tbe jieriinneum covering the artery being ■ or a t ebed thr)Upb- 
The paiient aurrived forty houn. Jamea ligatured the aorta maeh in tha 



LIOATVJIC OF ^BDOMiyAL AOBTA. 



SfiS 



V V :^r A. Oxipf-r did, in a case in which he had previously em> 
tnr ill«ial o|w-rnti<*ii fur an ii>t;iiiua] aii4furi»m; but wtlhout succras, 
psUrnt >{>ct'<iilr •lyiiif;. Murray ligutuni-d tlj« vesae) by inakiog aa io- 
iio tli« Itrft ii'lo, til front of the projccliug <^tid of the tenth rib, ouil 
ryiDie it downwards for six inchm tu the anterior superior epine of the 
Ttie |«rta were then carelully divided to the peritoneum, which was 
tdl fn>ni the iliac fijwa and the pums muscle, when, with great diffi- 
ItT. and by Bcratching with ibe end of an elevator aod the fiaKer-uails, 
nMMi wad made for the p«Bsag« of the ligature round the artery, xliich was 
tioi three or Jiiur lints above ita bifurcation. The ))&tieDt dieil in twcuty- 
thnm haur& The must iutereatiag cuae on record u^ that by Montelro, wlio 
tied Um uirtA Ibr a large fatae aneurism on the lower and right side of the 
■MiMen; bere the iocisioa wau uiade much us iu Murray's case, aD<l iho 
axtarj DgKtnred with great ditficully. The patient lived lit) the tenth day, 
b* died of secondary beniitrrbage. In !:*4>uLh'e case, the aorta was tied 
~ tlw peritoDCum by an incision on the left side of the abdomen. Tbo 
died in forty-three bouTB. Mc<-iuire'a patient had in ancuriemal 
of the «ie of a gooac's ege iu the lefl iliac region. Dintal preaure 
tlu umbilicus was aiieniptcd, but could not be done. Tito operator's 
fiMMtiaa wan at firvt tu tie tne lefi common ilinc artery ; but, finding the 
dilMw more KKtentuve than he expected, he enlarged the incision and tied 
Am aorta. The mc buret during the ninnipulalion ncceseurj to reach the 
a«n&, and about a pint nt' blood was lust. The patient died in eleven hours. 
8tolu* cwnprwicd the aorta with a silTcr wire passed round it in the way of 
frlioUMl*. He made a crescentic iociition five and a half inches b length 
h UM Uft Md** of tbr abdomen, extending from an inch beluw the t^^nlh rib 
■o iba ' '' Pnupart's ligament. The abtlouinal mu»cles and ttiacia 

InMv- - ' f^ then incised, and the |)eritoQcutD expiKic-d and drawn out 

of lb* iltav liiwa. It was accidentally, but only slightly wounded. The 
ffttisttt being turned on his right sitle, the arferiea aod aneurism were ex- 
paavd, and tb« wire pawed by means of an aneuruim-needle round the aorta 
MBBadiataty above its bifurcation. The patient died in twelve houre. 
FMm^ Um meat interesting point in this remarkable case is the fact of the 
flMtluB rctaraing iu the left (sound) femoral artery nine hours after the 
nmmtiao ; sbowiug how rapidly tbo collateral circulation cod he reestablished. 
Cmmj*» auc soarcely belong* to the present category, but mav be mentioned 
b*i«. Tbe patient was a French soldier, ibe Dp|>er part of wliose thigh had 
bam ihalf CI r I by a ball during the Franco-German war. Secondary la-nior- 
rita^oocBrring, Oserny tied the common femora), and also the superficial 
faBorml below the origin of the profunda. This arr£«ted the htuKirrhiigc 
Ibr » ttme ; but iu #ix days it recurred. Cxcrny then Lied the cummuii iliac ; 
bo. as lbs bttmonbage coutinac<i. he ihou^-lit thnt he had tied the external 
iImt. and prooacded to apply anuUier iigat tire — which he placml by mistake 
^ |b» aurla. Tit*! pataut survived tWL-niy-Ki\ hour*. In this ca»e tixi, 
f i» tT-two houni after the ii|H>rutii)n, the injured limb wa£ C4)ld and as if 
di»i, while tbo oppm^te liuih was warm, and retained aeusatiun and mutton. 
Jr, '^,'i.. ..i^m't,,n there are not only alt the dangers attendant upon the 
t' the drat magnitude, but also the risk of producing 
'■,>.'ihi;r the abdomen he cut through, or the vestwl ^nght 
. up th*i fieritoneum from tbe iliac fiiasa ; and it appears to 
lit tfullrnng from ao large an inguinal aneurism a» to jtiotify 
siirta, would have a Iketter chance of recovery, or mlhcr of 
' life, by the adiiption of proper cnnatitutionul treaimcntt 
-'■ssurc upon the tumor and tbe distal ligature or c^toiprixiiua 
LiMcr'a aortic cumpr[-«»or might be applied in such cases, ao 



jai 
tare «f the 



tPKClAL ANSURISUS. 



■^•^ i^Jtjtm* i^ fl<*<* ^ blond. ShoiiM the opcrntion be tgain atiMafttd, 
JLpf. fi ^tl» J>Hibt tluu tb« itici»i<ti] nilupuii hy 8ir A. Cuop«r would betk 
|MM, M tW ouear Af peritouitis ii much leas uDd«r the [tKMUt modacf 

X^tV^U!^ "F W lyiERN'AI. Il.I.VC AND IIS BttAycBlK— Ajl«OriMB D^ 
„jft iymmk ^'liW Intrmtl IHat Artery U extremely rare. The only eiue okb 
«|ilrb t ui ftnjountvd is uue r«l«led by 8(iii(lifort. Th« three tinD<-j|Ml 
hiMwbO fl^ t^ artery — the GtuUat, lh« Sciatic, and th« ftu/ic— bH«-« ftH 
iMMiii««tiT tlM«gb rarely, be«u Ibuud adwted by this dUteue. Of iboe 
hlflMb* tW ghlKAl bw bvi'u iiKwt fre<[ui;ully found uaeurixDial, the pcatie 
gau, sad the pndK- lenat frt^tiueiitly : iudt*fd, I um sff^uRinted with ooly «m 
f^mmof «f attfuri*!!! uf ll)ia veewt. It in the prepamlinu 1701 In the 
jIjjj^bi fif thr Onllf^ (ifSur^oDg; and it exhibits on RUcurigm uf ibe 
Ma«k f^* iW fwdic iiriirly uti iikjIi iit iliiim<-'tcr, full \ti lamiiialod ctul. 

«r the Qlut«Rl and Sciatic Arteriea may be either tmuoMiie 

li* Hanovfr. ha»^ publinlipil with commenla. in the AreMiw fBr 

fit, the i-Kc-onb of thirly-liTe caws of gluteal Korl acUtie 

.:ioh must be addtvl a (Ttsc nf gluteaJ Biieurism dMcribed bv 

__i«rf Naplw, iind one by Bickeratelh, oT IjiverptMl. In tvr«ntT>«#TN 

^^^jtaiwwT* the aiiciiriem wne distinctly gluteal ; and in six distinctly KtAtie. 
f|llMm« t^f ihf filutenl nneiirisms, and tiTo of tbu Bciattc, were of irumatic 
^Mk; (Uirtrfn gluteal and four eciattc aDcurisnu were ApontAoeoua. Th* 
29^1 iMfvrbm bni been generally found 8itu.-tted ui the iipp«r part of tb* 
MM n'Mllc nololi; but may eil^itd over a \aTgf: portion of tb« butlvdu. 
J^4litiriittruriiiin lies more deeply; and a portion u( the «ac may b» witbia 
^ ^lYi», Tbp Hiice of these itiieuri«ms varitM fmm a xlight ■welling lo t 
ittm^ ^ latTP? »* A child's hcfld. In almoat all (he record«d oaMt there hat 
^MM tin'O); puliuitioo, i«ocbroi)ous wilh the heart's bent; and whirring aod 
^111 g niiiriiMirn are beard uu audcullalinn. Thei\- i# atmnat always pain 
tlk ifcv tumor il«elf and in the citurse uf the nciatic nerve, which may be fbl> 
^uil Itr pamlvBis of the pHrtg supplied by it. 

I'fcv altWtiout wilb whicn thene ADeurisras are moat likely lo be eunfouodad 
UV AbwHwea, aoll sarcomRta, cyvta, nod sciatic hernia. The diagnoai* '» 
«MiM(linM didScult; tbui Guthrie ligalured the common iliac artery for a 
hfttfv puluting tumor in the gluteal re^oo. which prescaled all the obar 
MM* of aueuriam. but which prored, on the death of the patient ei|^ 
Httuiiha aniT the operation, to be a sarcoma. 

lUulenl uneurtsma have on aevenil oceasiona been opened by mistake for 
atwtNMara. Aecurdin^ to IIdIiih-^, this nceident bait inwt frt^quently happeoni 
tflivu ibf BiienriBm hae been more or leas diffVi»ed, and in nucb cacea b* 
•lW)tt«tH [hill the aj>piraEor ^lioiild be u^ to render the diagnoaia certain. 

Ill ilir Trratmerit, viiriiiua lueibodH have been uniployed. TheaaehoMlttm 
ktid 9pin and the |;luteal artery lit-d in Ave itimns, nit of which recorcrrd. la 
aottlhar iiutaniv. aller luyiug open the sar, the anenrintn {}*tntenl) waa foond 
to KXtrml intn the jietvis; and the internul iliur artery waa litsl, with a fatal 
rMiilt. Ligatare of fht internal iliac artery haa been perfurinrd iu elercD 
(«aM, *ix of nhich recovered. Tke ooutmon iliac arirry \\ttA \yt»n tied in tbiw 
tiaara. (ill "f which proved fatal. Irjr^ction of the prrehfitride of irun baa been 
tM'd in n'ix cmv* ; four recovereil, (»ie died, and in one the mult is unt knowa. 
i.iffttt\tre of thti neiatie urfirry without npeoint; the aac baa been pcrfonaed ta 
Iwti riun», iiiH- of wliirli recoreri'd. 8p<pnlAiicouA rreovery is rvporled to ham 
tHii'iirn*>l it) oiii- rjiM'. 

Itf atnra of the Internal Ilite. — This veaaet was ligatured for tbe Bnl 
lltuv W 1^1'- Tim u|wnition n-an performed by Stevens, of tit- Cmlx. on a 






tMOBAL AND POPLITKAL AKBCKISMS. 



255 




wlw oaflernl fnim an aneariam of the n%UA, 8Upi>oaed to be <>t' the 
wtcrTi but found after de^tb ttir«« yeura subMi)tjenlly to luke iu 
uw •ctaiic. Stephens iu thiri c»»v lumlv an iuristcm five inchM 
lb«)«ft«cleof tbeaodom«o,cAn.Tully<ji«e««t<;<l Ibruugh the fwrietes, 
' iIm penloueum fruin tbe iliac fossa, turued it on one side, tugetht-r 
urMvr, aad paiw«d a ligature round the artery without much diifi- 
SiiUM thai tinK' the upi-niliuD baa be«n done twenty limes; iu six 
auccew, by Antdt, White. Mult (who accidentally wounded the 
i), .Syme, M<>rtou. and Galloui; in fuurteeo casai unsucceMfully, 
..of York (whose patient died, on the niueteentb day, of eec- 
beuiorriiage), by Uiiceluw, Turracchi, CiautiDue, I'urtB. Laudi, Kini- 
ftnOlIer, Tbofnas. J. K. liudgers, and Uigginsuo ; and three times by 
ia tfa« AioericaD Civil War. 

tbal has hitlierlo attended tbif upemlinu b certainly remark- 
w« take intti conslderatiuu i ht <ie|>th ul which the artery is situated 
Mte; it matt, 1 think, be accuuntvd for by the fact that, allhuugh 
Uie patieat fudb the ordinary ri^ik^ alteudant on the ligature 
larger |>elvlG arleiriea from the (?X[>osure and hnndling of the peri- 
I, Tct ha is sared the danger reaulling from the gupcrreiition of gan- 
Lue anH^t«>mt]8i8 t>etween ila braucbe^ and that of the neighboring 
k^og tu free, and the course traversed by the blood so shorit that no 

arise in the mainlenaoce of the ouUatcral circulation. 
ite|a of the o{»eration Dcccwary for the exposure of the inLcmal iliac 
j« prceiselr analogoui to tboae n>qutMte ior the ligature of the com- 
Kuk. Wboi the veasel ia reacbcil, it must be n^memherod that both 
Hrtkal and internal iliac veins are in close relation to it ; the one being 
awr side, the other behind iL As these veaaels are l>Tve, and their 
lin, it is neoeMary that they should be separated by the finger-nail, or 
i end of the aneurism-needle, befure the ligature is pamed round the 
oare must be taken sImi unl lo put the veMsel too murb on the stretch 
rin|[ ibe ligature, le»l ihe ilio-lumbar artery be ruptured. There is 
ik M tncluding the ureter which crone* the artery ioternalty, as it 
■dhw firmly w the pcrituueum and b pushed on one side with iU 
laaglk of the artery varies luuch. usually ranging between one and 
Mi, and ai when it is ahort it has a tendency to be placed deeply in 
it wald. 1 think. b« more prudent, and ocoasiou leas chance of 
ry iMUorrbage, for the Surgeon to ligature the common trunk. 

rEMORAl. AXP POPLITEAL AXEUE1BX8. 

BT«, in the preceding section, considered aneurbma affecting the 
kicfa are hy no moans unfre<)upnt. Aneurisms of the thigb are 
but thoep in the bam arc very commonly encountered. Thus, 
1 HHB of aneurism recorded in the British medical journals of the 
Htaiy, Crisp has found that 137 atlected the popliteal, and only ti6 
Mai artery. Of thc»e 6tj, 40 were situated either in the groin or 
ait fif the tfaii;b, and H only were truly femoral or f«moro-|K) pi ileal. 
of this diJTvrence in the t'rwitiency uf the oceurronoe of aneurism 
-• -T-t. uf the veaeel. may be acoiuntcd for by atteutiuo to it«ana* 
t4. In lijuking at the main artery of the tower extremity, in 
!r< m i'ouparl's ligament to where it lermimiles in the anterior and 
ttbuls, we sM thai it may be divide*! iu relalion U> the mu>M:iilar 
aiUTuuud it. into ihrve prii)t:i|>al |>ortiun9 : I. That which is 
rtao Poupart's ligament and the luuer margin of the earturtu«, 
■Hsy be eunndered inffttituU: % That which intervenes beiwem 




SM 



SPKCIAI. ANB0K1»M8. 



thin point and the aperture iu tbc n<J<lucl<ir tendon, ood which mty bt . 

ttt'lcrrtl femoral; ana, li. That fliviHiun of Lhc vctvel which corrapoBdi h> 

bam, aiid which mny Ire Cinisiilcri'il popliUai. Of ihpw three dlTulfiBi,Ch« 

firet itud lut are eompnnuivttly su|>erliriHl, ntiil, t>i<)ng unsupported by mtud*, 

rviulilT expand : while the central portion i)f tho anerf ia uliM^lr tar- 

n>und«d <iD ull sideft by muscular maaan, and it vory unlikely Lo b« Jil 

iotu ail ani'urUmal tumor. We Rnd, a.\m, that tho ingoinal portlim uf 

T««t>i it dfwoly and firmly iavested hy a detiire aud nvMUot (Sbro-a 

[•heaUt. and is wpU supported by the faecia lata ; whlLit iu th» puplt 

{ffiace the artery is surr-Miuded merely bjr the orilioary aronlar shealn, i 

^ receivTS oo aiHincurotic support. This diflerenrc in the cunuectioos t>f tbeN 

[two parte of tlie Tcsel maT, to a <Trtatn«xicnt,c][plaiQ the erfiat«r fr*qa«(iy 

■of atieurwn in the bam tKan in the upper part of the ibigk. 

AxKVKt^M OP THE Dscr Kesiokal Aktcht i« of extr«>Rit*ly rare ooev' 
rcoee; iudvvd, I am actjnainted with fire caMi only. Oni^ of ihem ocotned 

ia • vcaD| man under mv rare iu Uuireriiiy Out- 
lege Uoipttal. iu 1870. There was a larn uxmr 
at U« «pMr |NUt of Ibe thigh, over which lay tbt 
Mperficial Monl artery. pulMting frvely. The 
MMM vae cuivd by L'oiupreseiun of ihf omBioa 
fcnonl artery, hydrate of chloral bcin;; irirea 
relieT* jiaifl. AiHrtbcr eaae u recorded by llry 
aa karrag a e wiii ed io the practim of 'o>cIi 
Gay's HoqiitaL Tbe aneurum was situated 
the erigMi m ike deep ibaoral artery : the ex 
tSae aaa tied, bat thepatient di'e^l nine 
dhr ika «pintiw. Ff^. 490 is ukra fmm 
fatieBwlN dMaf potamonia shortly aAer id- 
■AiiM iMi Vabanity Collie Ifospital. 
csiaiBaiiM aAar daub, a large tumur of 
ihMi. aWcfc hai aol beea vary oloaely exant 
dafW Bi^ ptavid lo be a dreattMcribed t 

appanatly arinag fmm rupture of a 
if' artery, moet probably the r-^n*. 
■ »f amtiliaai (TJoiv. Coll. MiiM'Utn. i 

are moitled by P. Manhall mri ^ 
WiM^ la tke oaw which aaa under itir oare 



:•* 



na«MH 





IB Ifae Uewtat. tbc diecaae waa rvcu^iied 
Ut&mm^ <V^ vbicb an duuactcnetio 
astaadad from three 

to tbe middia of 

y sepantisg the addnetor 

aoeoriuQal tigaa were 

a pecaiiarir load and harsh 

' fcmgral artery could be 

of tbe tnmor, but dear «( 

ia Ibepefdiltat aad iu divimnw 

■■al mgm bwhuI ob omipremug 

am l e ai of iag tk» pr—u re. 

of tbe deep Moral artery eao 

of the MMU. Tbe diaga<aie 

suglaal lad uf tbe practhioaar. 



kw iAUaw iki* 



<w OwalUd w ai> M-ortm U IW proAiaiU, bM 
MBrtba tbuwj It (u b« fiat of ■ partiaatiac aiury. 



In tha DrmtmaU of these ■ueurUme. the Surgeon han the choice of lhre« 
OMtliada, TIB., conprMMuii in tiic t'l^iiu, auti lignturc of ihe externa) iliac, or 
of ill* omniuD frtnoral. ll ihe cuiumuu remoral ever should he lignlured 
farmsMirinn, ikit hnpcun tu me to be the ctue bmt suited for iL But the 
abwioa b cl w wn the ligature of this artery or of the external iliac must in a 
pvmx meavnrv depend u{M>ti the Surgeon 'd judgment as to the r«lativ» expe- 
aivocT of titber n[>erRti<>n. and on the height to which the aneurii>iu extendi 
vp thm grrrin. But nritlier artery ihniild be ligatured until roniprfiuiiiin hao 
MHl fairly inerl md biu faile^l. This may be done digitally or by Curle'd 
iaitnii' ' r« the artery paMea over the brim of the pelvis. It is 

MpaciM. . ■ lo lucceed in aDeurisni of the prutunda, owing to the short- 

BMBof tW trunk and Ihe way in. which it breaks up into many auualomnejug 
bcMKliM. Hence there in not a free current of bliKKJ passing from one large 
TCM»I of etttri' U> antilhrr of exit, but.nH it in broken up and ba^ to filter out 
tfcfwyb a nunib«f of uiiuur vee^eb, ita coagulnliim may readily be hruuffht 
•tnaU In the case treated by tiio, cunipre««i'>u effected a cure in twenty- 
fcar boon, though the aueuriKia was very large aud active. 

AjmnuBUfi of toe ^i'perficial Fk.moual a>'D I'ovliteal A irrKitiBO. — 
Tb^« occur oommonly ub»ut the midille {ktiihI of life, and are alniodt inva- 
liabljr met with in maleti. being at letust twenty limes njore fre(]ueot in them 
iktta iu wiHoes. Both aidcB are affected with equal frequency, and ocea- 
■naallr at ibo mno time. According Ui Cri^p, milont would npixear to be 
morm liable U* this variety of the dii^a^e than any mber cbu^. Tlie&e ancu- 
tmam art moat frequeotiy tuicrulatpd ; in the ham they are always so, but in 
lfe*lfa%fa tbey are somotimes luluil.ir. 

t^mflom*. — The symptoms of Femoral Aneurism prewot nothing neeuHar ; 
ibvtOBior osoally enlarging with considerable rapidity, with all the char- 
■EtarittM nsna of the diaeaw, and OMuroing a pretty regular ovoid fahape. 
fbplitMd ABeQriim usually commences with stiffnesa and a good deal of 

r' 1 about the bam and knee, which I have more than once eeco mistaken 
riMUHMtifm ; in fad, ••> commonly docs this happen, that the Surgeon . 
dbooid Dcver fail to p«ua his band behind and examioe the ham in every 
erne of peraitteot " rheumatic " pain iu the kue«. There is also a difficulty 
iigfat«xiiDg the limb, which is generally kept veiuiflexed. The tumor 
iwually with great rapidity, aud Iihs a great tendency Lo beenme 
Aftwed ; lbe»e conditions will, however, materially dcpetid on the side of 
Ifte aitery from which it eprings. When it ariees from the snlerior aspect, 
DcxC tbe buuc, it iucrraari slowly, beiuji compressed by the firm atructurcs 
bdbre it. In thii' ease, bovever. there is the great danger that, by ii« prea- 
Mff« spun the bones and knee, it may give rise to caries aud destruclimi uf 
Ifc* jnini. When it aprlogi from the poatenor part of the artery, where il 
J, it increaara rapidly, aud may speedily become ditfiiee. The 
uf an aoeuriam in thu^ situation jiiuy take place in two dirt-ctioDS. 
fMBuru-ptipliteal, it mav give way into the general aret>lar li«jue of 
.?. .1,., i,|(nm1 dtfllntng Utv\{ a* hi^h, perha[», as Scarpa's triangle. 
lined lo ihe nam, it may give way either under the inlegn- 
the superficial wructures uf the limb, or else under the deep 
facJa uftitc Irg. wbi-rcit will compreffl the posterior tibial nerve and artery. 
l» all Mam, the diflusion of popliteal aneurism ia likely to be followed by 

'~' 'iHgncMis of popliteal aneurism has to be made from 

. Ii'ir*al fnlargements, aoij fn.m dolid tumors. In dis- 

" nb»ee4*, no srrtriuH ditfieulty can Well be experi- 

■ .1 tlinl, when an aiit'uritim ha» suppurated, coii«i<ler- 

tlilficuliy ansrs lu determiuing its true nature— whether it be merely aa 
u.— 17 



■ 




METHODS OF T'' 



tBNAL IMAO. 



247 



oliliqtie an'l of ihe traoBvcnialis iipwnn^ii ami ouUxAnU. iluth spatulie ruBO 
ihc peruoncum. fty cI<>ftHiiK awav « lillle ioo(<* ureolm- tissue, the nrterv cua 
be expowd tor une inoh and a half or two iiichcw without difficiiltj-. Tt liu 
thff genital branch of the genito-crunil lying on it, Km! it is crossed by tlie 
orcnmfl«x iliac vein* little above Poupart's ligament; theexteroat iliac vein 
b to it» innerside; th««e nitist be curet'nily avoided. The needle niuet be 
puie4l firom the inner side not lens thiiu one incb above Poupart'a ligament. 
•0 u to avoid the epi^uatric and circuiutlex iliac arteries. After the opera- 
tion A draiDA^tube luuy he inserted ut the lower angle r^i'the wnund, nud u 
etteatautur« iueerted in the divided tendon of the external oblique. 

On compariae the two oiwrattone, it would appear thut the principal dis< 
aiivnntage of Abernelhy'a ie, that it ih apt to leave u tendency to nernial 
pnitruniun, in cuusequeuce of the alidoRiintil wall being much weakened by 
Cl»e free iocleiuuB that are uece««Hry through the muscular planes; the great 
advaDt«g« alteudiuc it is, that the external iliac may he ligatured at uuy part 
of it« course, and that, if requisite, the incision may be extended upwards, 
and the ronimon trunk secured. In Sir A. Cooper's operation, the line of 
iDcbinn lies directly acrora the course of the epigastric artery, which, as well 
■■ the cinrumdex ifil, if it nri^e high, nnd the circumflex vein, which crosses 
the iliac artery at this iKiint, and in ofU>n somewhat funnel -shaped, may be iu 
ifauiger of being wounaed. The spermatic oord \s likewise somewhat io the 
WSJ in this opemtioD. Diipuytreo actually wounded the epigastric artery in 
m» owe; and Houston had much difficulty from the circumflex vein in 
•aother instAOoe. This operation has also the disadvantage, that the iucieion 
apwarde cannot be convenic-ntiv prolongofl so as to dctigate any portion of the 
veanl except that which lies imnicdtntely nhovc the crural arch ; but the pert- 
toneom is fcas disturbe*! than in the other case, and thoro ia leas tendency to 
hernial protruiion atlerward^. Ah a general ride, I think we may conclude 
that, in casod of spontaneouA anenrism, in which it might, from the ^ire of the 
tumor or the dt-teasetl fttate of the vefwels, be found neca»nry to apply 
the ligature to a higher point llian wiwi intendetl before the operaliim com- 
menced, it will be Mifer to have recourse to Abernethy's plan, niotiified 
ae above described, for in this way we shall be able lo ligature the vessel at 
any part of it» course; whilst in c«8e« "f hemorrhage after amputation, or 
of traumatic femoral aneurism, in which the artery b not likely to be diiieawd, 
recnut>e eliould be luid to Coii|>er's operation, more particularly if the 
patient be thin, and the abdomen tlat. 

Ill connection with the ligature uf the external iliac artery, there arewjrae 
practical points that de«erve mention. Uelbre the operation, the colon 
ibould be emptied by nicaun of nn enemu. nud the pubea shaved. The 
incision in the abdominal wall munt hts t>ut!icieutly extensive. 

In Aberucthy's method, mndilimi ii» ubovu described, there is no feur of 
tronnding the epigaalric unlefv tht? inrit^ion bt> carried too far at its lower uud. 
Thv arttry may lie ninghly said tn run in a line drawn from a point at which 
the femoral artery cro^^es the brim of the jielvia to the umbilicu». In 
neither method of n[>erating shouUI the iniMsiou iin|)lii'aie the external ring, 
Ittt it give rise lo a tendency to hernial prntrufiion. Care should be taken 
not tu wound the [leritoneum; for, although two palienis in whom thie was 
done by l'<«>t and Tait iKith reaoveret), yet it is of course a dangerous 
accident, and should, if pik^ihle, he avoidefl. ThF« [teritnneum inur^t not be 
lorn up more than Is ahwohitely necessary, lest hemorrhasre or Hulisequent 
perilonilifl owiur. In raising the peritoneum, care must he taken not u* dis- 
place the artery which lies !fiiK«ely in the suhiwritoneal tissue, and can 
M eaiily ratseii in the spntnla. or pushed over the brim of the pelvis. The 
.Kpvadon of the peritoneum 'a much fncilitabcd by the Surgeon holding the 



LiaATUBE or THE SUPERFICIAL FEMORAL. 



2d9 



remored or taraed on one Bide. The fascia lata is then divided, and the 
cnirml abeath exposed. This muBt be carefully opened over the artery, and 
tbe needle passed from the inner side. The femoral vein lies to the inner 
nde, And the anterior crural nerve a short distance away on the outer side. 
The origiD of the branches is very uncertain ; tbe Surgeon must select that 
fmn of the vessel for ligature which is most distant from any branch. 

The stfttistics of this operation are so unfavorable, especially when per- 
formed for aneurisms, and secondary hemorrhage has been so frequent and 
fUal an occurrence, in several cases requiring ligature of the external iliac 
tar its arrest, that I do not think it is advisable to have recourse to this ope- 
ration in preference to ligature of the external iliac ; and it may be laid down 
aa a mle in aurgery, that in all those cases of aneurism that are situated above 
the middle of the thigh, in which compression has failed aud sufficient space 
doea not intervene between the origin of the deep femoral and the upper part 
of the aac for the application of a ligature to the superficial femoral, the 
extemml iliac should be tied. 

Lifatare <rf the Superficial FemoraL— The auperfictal femoral artery, in 
tia ooune from tbe origin of the deep femoral to the aperture in the tendon 




Pif. 401.— Ligature or the ?ii|ierficiiil Femoral Artery. 

ot the adductor, is divided by the cros,sing of the sartorius muscle into two 
portions of unequal length, which have different relations to neighboriug 
■tnicturee. The upper division of the artery, which liea above the anterior 
■argiD of the muscle, is of most interest to the Surgeou, as it is in this part 
of its course that it is iuvariably ligatured in cases of aneurism. It is true 
that John Hunter, in the operation which he iiitnidured for popliteal aneu- 
riam, exposed aud tied the vessel in the middle third of the thigh; but his 
example has not been follower! by modern Surgeons, on account of the far 
greater difficulty in reaching the vessel here than in the first part of its 
The superficial femoral, where it lies in Scarpa's triangle, being 




SPKClAI. AKEUR1SM6. 

eownd ■writ I7 lb* oDBimoQ int«gumcDt, the nuperficUl fiueU uh) tbc 
hecia laUu ■*▼ ^ reaeb«d by as sitopie au operation tw aor that the i^urgvoo 
bae to pfrfcwm" fcr ibc ligature of ibe larger ve«el». Tlie Him; Ui tbe arifrr 
ii ukf« M ^)it«»: The leg is flexed and ihe thif;!) rolaled outwanU. Tbc 
OuiBiuw warfci ■ point exactly Diidway betweeo llie aoterior aapcrtnr tpifl* 
of w iK«M *Bd Uw Byn)]»liyi»is pubis. From tliis lie draws a liaa Ut tbe ■(■( 
■fOniMMI P*** *>f ^)c iuuer coudyte of Ibc feiiiur. Tbe poiot aclcdcd for 
nim tW aiMfT BBSl bu alKJut tive inches below Poupan's JinuDcat. la Um 
jjLiurt «iU IMO be at A »alc distance iroin tbc profanda, tb« loval 
tOJ.jj'ilJ |«^t ^'^ orifciti r>f that veeecl bi-ing: four iarhra belov th« li|pBBtnL 
n* iMeUna ^y*S' "l^l ) i^ °iade in tbc Hue abnve iDdicnted, and i^iaold bi 
|hw« tkn* b* >ix iuchpH in leoglli, acconliu^' in tbc ani<iunt of nv 
Al, li ttttst be so arranged that iho point Keltt^livl fur the .. ..i< 

•fib* liKaturotfhall tie iu ttie middle of its li-ngth. Theekio anil Miuerti 
Ihfwin baviDjc bfWQ divided, the faM:ia laiu ta ex[Hieed and opened to uie aBOH 
«xu»l «* ihpinmion in the iniegumeDte; ihc rausculnr tihrt-snCiheaartoniM 
^v CfHBV uitv %-tew. W the incision have been Diade loo far inwards, it b 
Msib)* ibal tho ft(h)uctor InnffUi) tuay be exiNvod innteAd of the aartoiiiii: 
t^ MT\tr is n*ndily r^-cojiniized by ohM-rving the direction of the fibr«*. tbtas 
«^ kb* adductor bein^; downwards and oulwardp, and tbfise of tbe sartdfius 
«UtwD«iar<is and inwards. The edges of the wound in the fa»cia being beU 
aiian with blunt hooks, the sartorius is seited in the fon-ops and drawn nal» 
wards, the fihrf-s of tbc areolar tissue »iirn>undiu{; it 
being touched with tbe edg« of the ecal|«el, if nee**- 
Miry, until its inner edge comva into view. If lb* 
ofieralion b« performed a little higher than usual, or 
if tb« sartorius b« feebly developed, its inner edge 
may cniD« into ticw as soon as the fodcta lau is 
divided. The edge having been, found, tbe muscle 
must be turned outwards, uud held on one »ide with 
a copiMir spatula. A litUe looee areolar ttasue most 
then be clc&red away from beneath it with the handle 
of thesoUpel. and the shenth of the vcesela cmmi 
riearly into view. The sheath must be caatloosly 
u|>cne<l, a email hole being made in it aa in tbe 
dia^nim (Fip. 41)'J). It niun be remembered tbat 
atler the fascial ttheath common to the artery and 
vein hnn been opened, there is »till the proper abeatb 
of (he artery to be divided before the ligature caa be 
safely passed. The vein lies beneath the anerr, and 
consequently the needle may bepniaed fnjui ihtTinntf 
or outer side indifferently; it should be 
ttOATiaed, and then he threaded and withdrawn. Uiiually, do D«rve 
during Llieo|>(:rAlion, but the internal sanhcnousocca.'aiuually comes tuli^ vie*, 
and niujit be ovoided. After the operation a drainage- tuliu hLouM In-* inserted 
iu such u way ihnt iu end shall lie beneath the sartorius, and tbe woutd 
b elueed with aiilureft. The wound is (hen semiflexed, somewhat ratnNl. and 
laid on ils outer side and wrapped in soft flannel ur cotton-wool. Thrsrven 
pall] which is ubuhIIv coinplaiued uf about the luiee aAcr tigbtcaiug tb« tiga* 
turo may Ih' relieved by it Aill d<>»e of opium. 

Iu this ojwratiun tlitre are several points of considerable importaoct tbat 

renuim special attention. 1. The incision should be made airecUr iu tbe 

liue of the artery, care U-Jug taken not to incline it inwanu in tbt 

t ,, .> ^)f Ibcfiartoriuf. 2. In cuLUiig down upon the uru'rr, the sapbcooua 

ould be avoided, by taking care nut to make tbc ludikm loo Ibr 



Ltin FMSsnl ArUrj *t 
ApM at &Mrp«'i Tri- 
•lifl*. ». »»rWrlu»; /. 
hCBora I (bf ktk ; n. mttrnty. 



K It h%a, however, Jiappened that the ligamre hns been plat 
mm-qn&rten of as inch at' tbv ori^ii of Iho deeji femoral, without 
Briaus aHuequencM rvwiUin^. fi. The greatest <»re inii<it be taken 
MKinil tliu femoml vpin, which lio« iH-hiiiil iho Hrtnry in the sitiintinn 
lb a liirature t!« iiMially np[)ii(Nl. If the vubwl is tied n little higher 
naJ. tbc! vein wilt Im> towanU the inner filile, and then the needle 
! paflBcd fn)ni within oiitwunlH. Wounding the vein is best avoided 
oag^hlf cleaning the artery ; the while external coat must he thor* 
cxpaaed, and while the needle ig being nitMed the sheath ihould b« 
riHighIr on the si retch, the Surgeon holding the edge of the opening 
Mi fn*m wbit-h he b parsing the needle, while the lusistAnl cjilcht^ 
■fctf side- in a pair of furcegu and draws gently upon it. In pawing 
mU, its end i^hould be kept very clo^e to the artery, and made to 
Hind it. The veiu is generally t>erfjruted by dipping the ui^odle too 
nod Iwiog th« contact Iwtween it iind ihw artery. When the needle 
^t up oa the outer side of the nrlvry, it anmll purtioo of the sbeatb 
iisMi pusb^ up br it ; this must hv torn by piucbiug it with th4 
, Vben the needle may be carried round the vcsbuI. 
Mi. — Ugatur? of the femoral artery for popliteal aneurism b an 
9a that ha« b«en au frequently perfurmed, that .Surgeons seldom think 
rding caaea of tbis descriptiou, uuleaa tbey present com plications or 
t i^f unusual iuterwt ur wverity ; hence, but little importance can be 
d to any ^laliAticwl deductions from r«!p«rte«i caees m to the riitality 

oprmtinn, although they may perve a;? n rough estimate of the pro- 

BiBinlaioed between the <litlenrnt Hccidoniii, such as hemorrhage, 
IM, etc. that follow it. That ligature ol' the femoral artery 19 nt- 

wbfa more succeed than that of any of the other large trunks can 
>f ao doabL This 10 not only in accordance with the gcucral expi> 
afSnmtms, bat is conBrmed by the stali^lii'^ of published caseid, even 
i ■■Ictfig alloTT&nee for the pnibnbility nf more of the uunueccMful 
leeWiAil having been rcoirded. Tliuii of 1 10 instanMis, collected by 
«bicb tbe femoral artery bad been ligatured for popliteal aneurism, 
ralve are reported to have died; amongst tbe«e, four deaths were 

hj MCondxry hemorrhage, three by gangrene, and the others by 
ifai, Utaniu, cbe*t-diM'«ac, etc. Higher rate* nf mortality are, however, 
^ wUhtr anibor* ; thun, Norrta stat^ that nearly one in four die after 
Htmiioa; Ilutrhinson findii that of thirty-three caaea operated on 



2d4 



IP£C[AL ANEUBISMS. 



ai to mixlfTate the flow of blotwl. .Should the oponitioD be agftln Ulcoplcri, 
tli«rtf i>t lillle diiubl iIihI tli« inciHJuu adopteil by Bir A. Coop«r would be tbt 
MftKl, as tbe oaug«r of iwritoojlin u much leaa iiader the preMwt ntodeiaf 
trentiiient. 

AM^VRt-M Of THK IvrERKAL Il,!AC AND ITd BkANCIII-:9. — All<*Uriaill nf 
the Trunk of the Jntermd Sdac Ariery it extremely rare. The onlif cue '"ith 
which 1 ati) apnuaiut«ti is one reUlud by 8aiii)ifurt. The three iiriodptJ 
branches of this artery — the Qiuteal. the Sciatip, and the /Wic— barr all 
occasiooatly, though rarely, been fiiund afTected by this disease. Of thos 
branch&t tlic gluteal has beea tnost frequeutly found BDeurtamal, thr srjBlJe 
next, iind the ]>utlii! leaeL frt^quently; iodeed, 1 am arqiiainicd wiiJi only eot 
inetuDoe of aiiciimri) uf this vessel. It is the [ire[)aratinu ITOI in tb* 
MLii>outn of the (.Ville^ uf Surgetms ; and it exhibits an amMiriffOi of tbt 
trunk of ihv [xidit^ luitrly an iuch in dinmoler, full uf laniiuauid clol. 

Aneitrismi of the Gluteal and Sciatic Arteriei may be rith«r umui 
or »[i<iiitani»>u»t. 

Fi^L-hcr, of Hanover, has published with comtneots. In the Ar^kit 
ktinUeiu Chintrgie, the records of thirly-Hrc cnMA of gluteal and aciaiie 
aneurism, to which must be added a cnsc of gluteal aneurUm deacribod by 
GalloEzi, of Naples, and one by BickerMeth, of riverp«H>l. Id tweaty-Mm 
of tbe caaeo the aneurism was di.ilinctlT gluteal ; and in six dlstincclr adatlr. 
Thirteen of' the glutrnl aneurisms, and two of the sciatic, were of tnituatir 
origin; fourteen gluteal and futir sciatic aneurisms were !tpoataiie>t>tM. Tbt 
gluteal aneurism has been generally found ailualed at the t)pp*r pari of lb* 
great M-ialic notch; but may extend over a large portion of the bullockj. 
'Nriatic aneurism lie« more deeply; and a p"rti'>u of tbe •■*»: may l>e within 
the pelvis. Tbe slxe uf thege itneiiri)>n)s varies from a flight swelling to ■ 
tutuiiras large as a child's head. In almost all tbe recorder] casea then hai 
been i<lnnig pulsation, im>vhronous with the heart's l>eRt: and whirring and 
buzzing murmurs are bean! on auscultation. Tlienj is alittiwt always pna 
in the luni»r ilM-lf and in the course of thtt sciatic n«rve, which may be f<A- 
loweil by paralysis of the parts supplied by IL 

The nflectious with which these auc-urisma are moet likely to be iimroundtd 
are abacessea. sotl aurctimatu, cysts, and sciatic heruia. The diagnnts b 
soiuetimee ditKcult; thus Outhria ligatured tbe cumniuu iliac artery for ■ 
Urge pulsating tumor in the gluteal region, which presented all the char- 
ncton of aoeurism, but which proved, on the death uf the |>atient eight 
m«mt.h» after the operation, to be a sarcoma. 

(jlutcfll nneuriani!4 have on aevenil occasiona lieen opened by mistake for 
abooeaBca. According to Holmes, this uccideot haH mnet frequently happanai 
when the aneurism has t>een more or leas dilFuxed, and in such caaea ba 
auirgCMts that the nspiretor should be used to render the diagnoms oertaii 

In the IWatment, various methods have been employed. The$Mluui 
(aid opof and the (gluteal ari<?rr tie<l in live fitscn. nil of which roeovuned. 
another instance, after laying upcn the sac, the aneurism (gluteal) wi 
to extend into the pclns; and the internal iliac artery was tied, with a fatal 
reeull. LigaUtrt oj the iutcrtxnl iline artery has been [wrlwrmcd in elerea 
cases, six of u liich recovered. Th< rommon Uinr: arUn hits been tied in thcte 
caaes, all of which pn>ved fatal. Jr^e^liou of the ftrrAloridr of iron has 
used in six caaes ; four recovenyl, one died, and io one the result is not I(d< 
lAyaturt of the $eiatic artery williout opening the sac has been p^Tformed 
two cases, one of which rec<uvered. Hpoutaneous revorery is rvfMtrteiJ to- bare 
occurrixl in 'ine mm-. 

Liguture of tbe latemal Iliac. — This veasel was ligatured for the fim 
time in 1812. ThK operatioo was [wrfomied by Stevens, of Bi. Cfolx, ua a 



I 



fORAL anB pAplitkal axBukIsms. 266 

negrcH who dutff^rod from an uneurism nf the daios, 8Ufi|ti)«o(l lo be »!' tli« 
gluteal artcrv, but found after death three yeani )iiihi4ei|ii«t)i.ly tu Uke in 
origin from the iciatic Stcphena in thiii oai«e ttinde an incision tiv« iiicb«s 
long 4in the led wdoof the abdomen, carefully dij«»ect«d through the paricte*, 
Bepantled the peritoneum from the iliac fu6»a, turned it on one side, lugethtT 
with the ureter, and paMed a ligature round Llie nrtery without much diili- 
culty. Since that time the uperation has been done twenty timw; iu eix 
cacea with eucceu, by AriicU. M'hite, Mutt (who aci:id«ntally wbuiided the 

feritoueum), Hyme, Morton, and Galiozzi ; in tburteeu oiujcm uueueuccHifully, 
y Atkinson, of York (wbo(<>e patient died, ou the nitieteeulh day, of eec- 
ondary hemorrhage), by JJiKelo«,l\irr8ct;hi, CiuuUoue, Porta, Laudi, Kim- 
faaJl, Allmiiller, Thomiui, J. K. Itudgen, and HiggiuBuu ; and thrue timce by 
f?urKeon>* in tJie American Civil War. 

The aucc-ivna llinl haa liilherlo atti-tided ihia uporaliou IB certaiuly rejuark- 
able, when we Uike iiilLi coueideraliou the depth nl wbich the artery is siluutud 
«ad itagrCMaiM; it must, I thiEik.be uccouuted fur by the tiict lliut, aitliuu);h 
in tbeae cugb the patient ruat> the ordinary riske altendanL un the liguture 
of the larger (lelvic artoriM from the expieure and handling of tho |ieri- 
l4Uieuin, yet he u a^tved tho danger resiilling fnim the BU|H]rventi<>n of gau- 
grmae; tbti anatitomoeia between it(> branohisi and that of the neighboring 
T nac ia being eu free, and the course triiver&ed by the blood bo short, that ou 
difficulty can ariiie in ttie maintenance of the tiuliateml circulation. 

The atepa of the oiwration nect'eeary for the exposure of the internal iliac 
artery are precisely imalogoua to thoeie requiBite for the ligature of tJie c-oni- 
iDDii trunk. When ibe vessel is reached, it ninat he rememberer] ihnc both 
the external and interoul iliac veins ure id cluee relallou to it; the one being 
to its outer oide, the other behind it. As these vessels are Large, and their 
CMls thin, it is nece^ary that they should be separated by the finger-nail, or 
the blunt end of the aneiirismneedle, before the ligature is po^ed round the 
artery ; oare must he taken aUo not lo put the ve«»el too muL-b <ni the stretch 
in applying the ligature, Ictft the ilio-lumbar artery be ruptured. There is 
tittle risk of jncludiag tho ureter which croaaea the artery internally, aa it 
slwmva adheres firmly to the peritoneum and i» pushed on one aide with it. 
Ai the length of the artery viiries much, u^ualty ranging between one and 
two incbea, and oa when it id nhort it U&tt a tendency to he placed deeply in 
the pelvis, it would, I think, be more prudent, and occasion lesa chance of 
■ecoodary hejuorrhage, for the 'Surgeon to ligature the common trunk. 

FEUOttAL ANB POPLITEAL ANRUBISMS. 

We have. In the preceding fteetiuu, oonsidered ancurisnia aHeeliug the 
groiD. which arc by nu nieau^ uufrcijuent. Aneurismu of the thigh uro 
Bmcb rarer; but those iu the hum arc very commonly eucountcreil. Thus, 
oat of 551 caote of aneurism recorded in the Hritish medical journals uf the 
praeot century, Oitip has found that I'H aHt;cled the popliteal, and ouly 06 
the femoral artery. Of these iiii, 4'> were situated either in the groin or 
opper jiart of the ihigh, and 2) only were truly femoral or femuro-pupl ileal. 
Ine reaaun of ihw dilference in the freciuency of the occurrence i>f aneurititn 
difierent parts uf the vessel, may be uccoiitiled for liy utteiitton to its ana- 
itcftl relationa. In looking at the main arti^ry of the lower extremity, in 
. course from Poupart's ligament to where it terminates tn llie anterior uiid 
paateriur libiala. we Bee that it may be divided in relation to ihe muscular 
mames that tiurround it, into three itrincipal portion.'i : 1. That whirb h 
dtuated between Poupart's ligament and the inner margin of the sartorlus, 
and which may be euDaidered inguinal; 2. Thnt whieh intervenea between 



2S5 



SPECIAL AKBURI3U8. 



this point and iha aperture !□ tbc adductor tendoo, nod which miiy be coo- 
$\dsnd femoral ; aua, 3. Thnt divi»ii>ii of Lhe ves»«1 wlitcli c<trrre|w>ad« tollK 
bam, aod which may be KoaaUivreii jwjfliteai. Of IhvM lhr<w <livUii<at, tbe 
first and liut are comparatively suiKTliuiul, and. twiug unsupfxirted tiy muscle, 
raulily expand ; while the central purtiuu of tht> artery is eluvcly Mr- 
ruundod oo all tides by muscular mafisHi, aad ig vury unlikt'ly U> b« dilaM 
into UQ aoeuri^nuil tumor. We Had. alm>, that the inguinal portion of tli« 
veBMl 18 cloecly and Brnily iaveated by a dense aud resistant fibroareular 
ahcAtb, and is wpll supported by the faitcia laUi; nrhiUt in lh» popliteal 
space iha artery is surroniided merely bv the ordinary areolar sbeatlt, aad 
receives no aponeurotic dupporu 1\m ditferenee in the coDoectiuoa of Omt 
two purls of Uie vi!>ael niav, toa certain exleni, explain lhe greater frequeae^ 
of ane'iimm in thci ham titan in the upper part of Xha thigh. 

Anrl'kihm of the DEi:f Fi:moual Artehv ia of »;xiremcly rar« oeesr 
reooe ; iuilt^l, I am acquainted v, ith five eaaee only. Ouo of thesfl oceumd 

in K v.tuiiu; man under my care in Univcrsiiy Cbl- 
tcgc Hit»pitul, in 1870. There was a lar^ tunw 
at the upper part of the thl]fh,overwhicD layjlM 
superficial femoml artery, putsatiog freeljr. 
diseaae was cured by cnmprcMlan of ib<> ca: 
ferooral arterr, hydrate nf chloral heine pn 
relieve pain. Another case in recorded hy Brrant 
aa having occurred in the practice of Coca at 
Guy's Hospital. The aneurism was situalfd at 
the origin of the dt^ep femoral artery : ll)« extMVtl 
iliac was tied, but the patient dit^] nine weclt* 
afler the operation. Fij;. AW i« (ak«-a Cmm a 
patient who died of ptieumonia ithorlly alter ad- 
minion into Uiiiv<Titity College Hu«pil«l. On 
I >^H '/*11^^H exnmtnation after dealii. a large tumor of the 
y \-^V bJ i^^V thigh, which had nt^ heeo very cloet^ly rxamilMd 
\ -^ .^uJ^^r during life, proved to be a cireuuiscribed Um 
aucuriam apparently aribiiig from rupcurt of a 
perliirating' artery, nxiet pmbably the oooae- 
uuencv of cuibulieni (Univ. Coll. Museum, VUAl 
Two cuMX are recorded by F. M&raball and J. 
Wal»t)ii. lu the eaiw which was under mv art 
in the liospitul, the dii»ea»e was refxigntxe«l dv the 
fullnwiiig uigna, which are charaetertatic of it: 
I, A large tumor extended from three tarfafa 
])elow Foupart'n ligament to the middle of iha 
thigh, raiiiing and slightly Hepnrnting the add 
BiiHclca and the rectus femnritg. 2. All the ordinary ant-urismal aigna 
pment in this tumor — the most marked being a peculiarly lond and ' 
bruit, and a dry, forcible thrill. 3. The superficial femoral artery eon 
felt running over the anterior and inner aspect of the tumor, bat rlntr of, 
and distinct Imm, it. 4. The pulnalion in the popliteal and ita diviainM 
WM Strung aud perfect 5. All tlt*r aneurismal signs ceawxt on o^mfrrflMlaf 
the common femoral artery, and returned on removing the prasure. 

The only disease with which an aneuhun of the deep fenKffal artery cU 
readily be confounded is pul»atiDg sarcoma of the femur. The dia^ous 
from ibis muet be left to the surgical tact of the practitioner. 

I la former aditlona tkii c-mo was dascrllxd ss an aofforlim of lb* nmAind*, b«l 
oarefbl mteamtoNtioa at th« pivjiMmUtm sliowi It lo tw tmn at • pvifunliQi' vterj. 



^ 



f\f. tva.~Vmlf AacuriMB of 

■ I'srlorktltig MtMJ- 
U CottMsn Vmsral. 

4, AsMiliui. a«t opaQ. 



or ffUPXBrioiAL pkmoral and poplitkal ahtbries. 261 



la Um TVmtment of tbeae aneiiriaiiu, Ute Surgeon huit the choire r>f ilirre 
B*tbcid«r via^ eonipr¥»i(iii id the gntiu, «ii(l ligHturc of the external iliac, or 
of l^earamii femoral. Il the comniua femoral ever should be lignturvd 
fcr aacnrtMB, this fti>pmra to mv to be the case best sujled for it. But tlie 
Ankett btlircen the li|niture of thiti artiTv or of the external iliac mutit iu a 
znmt meatart depoDi) upon the ^urgooii s judgment ns to ihc relative exjw- 
dtrtH-y of rithcr npt^rutititi, nud uu ihe hfit;iit to which the nneiirif>ni extends 
vp lk« emin. But neither artery should be Itgulurcd until ci'tmpre«!-ion hiiB 
mmt birljr irird and has failed. Thin uuy be done digitally or by Carte's 
TMriiiiii m. «li«T« the artery [uusea over the brim of the pelvi«. It is 
a|vci»llv likely to luccred in aneurism of the pmlunda, owiDg to the ^horl- 
••■I nf liie tniuk aad th« way in which it breakx up into rnnny auasloiiiiising 
bfmodkM. Heoce there is not a free current of bliMxl paiuin];; iroiu uiie lurge 
wmmi of rstry to another of exit, but, ns it is brolcen up and has lo litter out 
t linw fh a D(imb«r uf tninor veaaels, il9 conKulntioii may readily be brought 
AbottL lo Itie c*M treale<l by me. compresiion eHei:ted a cure ia Lweoty- 
finr kMin. iboggb the aoeuristD was very large aod active. 

Ajivjmaaa or the Sutcrficiai. Fkmokai. ahd Poplitkal AnTx^iUBs.— 
Tkes* iKTur cDutnunlT about the middle period of life, and are alniusi iava- 
mbly DKt with io aialee, being at least twenty titucii more frcqueut in them 
tkaii in »DD»t]. Both sides are aflvctcd with equal frequency, aud occa- 
■■■bIIt at ifaa saioa tiine. Aecurdiu{; tu Crisp, sailore uinuld iippvur to be 
mo€m uaUc li> thb variety of Lbe diseuM.- tlian any i>ther ela»i. I bene aneu- 
riMM arc mmt fivquenlly sacculnteil ; in the hum Ihi-y an; alwajis en. but in 
tba tkif fa tlkej arc eomeiimes tubtitar. 

Jyipiaaw. — Tbe sTraptiitns III' Femoral Anearisin |)rrsrnt nothing peculiar; 
tiM tasMtr Bsoally enlarging with cnnsiderublu nipidily, with all the char- 
■eUriiUc aq^ns of the disen.^e, and uisumiiig il pretty regular ovoid shape. 
Va^litaal Aneariani u.<!uallr nmimencefl with atttfnesn and a got^d deal of 
pain ab««ut the ham and kuee. which I have more ihau once seen mistakcQ 
M rbramatiam ; io fact, so commonly does this happen, that the Surgeon . 
' r-til to pn.<9 his haD<l Ix^hind and examine the ham in every 
I " rht iiMiatic '' pain in the koee. There is also a difficulty 
the limb, whic^i i« geut-ralty kept semiflexed. The tumor 
with great rapidity, and has a great tendency lo become 
cnditioos will, however, materially depend on the 8i<le of 
Uw artsry frnn) which it springs- When it arii^es from th« aoterior aspect, 
Otsit ike b- ' rvasee elowiy, being c<.>Dipr(-«-ed hy the firm ntructurea 

before it. I .>ye, however, there ia the great duugur that, by its pres- 

mum opoo th« buui-9 and koee, it may give riMi l» curies and destruction of 
tW jouM. When it springs from the poeteriur |iart of the artery, where it 
ipP M S t d, it iucreiiwa rapidly, and may speedily become diHii^e. The 
of an aacuritmi in tbu< siiuation may take place in two directiona. 
fecnorvpoplittral. it niav give wuy into the general arailar tiraue of 

^1^ the lilouil dillbeing Keelt w* high, perhaps, as Scartia's triangla. 

WWa It ia con&ned to (he ham, it niiiy give way either under the integu- 

ita, and Into the superBriul slrttcturrs of the limb, or else under the deep 

•<f the Ifg, wherr il will compress the posterior tibial nerve and artenr. 

I tamtK th« diflUsioD of popliteal oocurism ia likely u> be followed hy 

~' liagoneis itf popliteal aneurism has U> be made from 

< Knntil niliirgeiiicntji. ami from solid tumors. In dis- 

r- a/mtrMt. no serious ililfifully can well be expen- 

. I llmt, wIh-ii Rh aneurism liQA stippuraled, consider- 

I ^iAcmlty arur» m ilclermining its true nature — whether it bo merely an 

»i.i II — IT 



258 



>EOIAL AKEI 



•bsoeM or ool. Oo such tajh^ no ilies4>, the otAte of the drculBtka !■ 
the lower part of tfa« limb will throw much littht. Bnrtot htman, oftca of 
lorgv elite ami miiltilocular, nre out uafre^ucDtly lucl with id the huii ; hut 
I hiivv uevcr fnuod auy grc-al difficullv in dotci'niiniu}^ their true nntiirv, thrir 
'alaslicity uud nmnducsi, together wiili their mobilily aod waui nl' imlMlJon, 
bein^ Ku6ii>k>i)U}' iudicativo of thvtr character. The mewl aeriiiue diaguuctic 
(liHiciilty way urise from eoufoupding eulidJOed ntieurisma uf the ham with 
aolid ttimort. uf a aarcomatiius cbaractt-r, Apriu|;iDjf from the lihia and fcniur; 
and I have known one race of aneiiriHin in Uiib mmliljrtn, in uhirh amjiuia- 
lion was p^-rfiirnied on the ;4nppiwili(in of iiK hiiin^ a mtVul itimor i Fig. 447). 

Tro^mrnt. — The trealmrtnt of femnrnl and ]>>)|tlil(«l aiK'uriBtn may be ooa- 
daeted either by conipre«flion or by li^ntiirr! of the reaarl leading U> the ne. 
Aa a gent^ral nilf, for the rea»mA alrpjidy msi^mI, cumpreeeion should ba 
eninloye>d in prntf-renc^.' to Mature; but caaes do arise in which, from the 
failure of (v>nipri-ftsion. or for other reasons, it beoucDM necraaary lo ligatate 
the Ifeinoral iirlery. 

The Trentmmt by Campremon in pectiliarlv applicable lo theae anruritnt, 
and, indeed, it ia to \\\t!m that it hae chiefly been emploved. I i\vrA, there- 
fore, eay nuthinjj; iti>eciat about it liere, but would refer ifie reader to Chajiur 
XLIII., page 1<V>, for a dtwi-riptioo of the subject, 

Flexitm of the knee, which may be consideml a modidcalion of compr«»- 
sioD, is applicable to thetw cases altio, either alone or in cotnhinatinn with 
comprewion of the main trunk. It is peculiarly applicuble in tboae cam in 
which the aneuriiiiii is uituatc entirely in the ham (fee p")^ 1^6), 

Li^tnie of the Common FemoraJ. — In li>nking at the femoral artery, it 
might at first be nupp^iecd tliiit the common trunk, situated euperhcially 
betwe«n Tuupart's ligament and the on^'n of the profunda, would be tM 
most convenient situation for the application of the li^ture ; but experi«DC^ 
ha« shown that dellgation of the vessel here is bv no means a ^acccsaAjl 
ration, cspecialtr when undertaken for aneunsm. This arifiea from 
shortneas of the trunk rendc-rine it necesBary to tie the nrterv in close prox- 
imity to the collateral bmnch that will oonstitnte the moat direct and imme- 
diate agent in the anastumtiaing supply — riz., the deep fcmomi, so that tbt 
InternnT eoagulum would not r»idily form. In addition to this, a number of 
email inguinal brancbos, the superficial epigastric and circumflex iliL, tha 
superior and inferior external pudic, and verr commonly one of the eircom- 
flex nnerica of the thigh, more especially the internal, ansa ftom the common 
trunk in itd short course; and iheaevcMcls, though small in siao, cooalituiea 
source of great enibarniMinient to the Surgeon during the operation; fiir, if 
wounded near their origin, tliey bleet^l rnoKt furiouiily, and are a eau»« of con- 
siderable danger aAernards, by inlt^rfering with the proper plugging of the 
vessel. The ligature of the coiunmn femoral has, howerer, deveral advocates, 
more particularly in Ireland, where tliR oiieratioa has of late yean l>cvn ilooe 
nine timeH, for wound and aneuri^fo, witu six recoveries and \.\\tw dcoths. 
The succewful cases were m follows: I'orler, sen., three; G. U. iVrtrr, one; 
8myty, one ; Macnamaru, one. In the American war, however, the o[ieratiDO 
is reported to have boeu pcrfurmcil in eighteen cases with only four reoor- 
cries; and fiarwell states that out of thirty-one msee in which the artery was 
tied for aneurism, hemorrhage occurred in eighteen, and of tbcoe tiralvt 
died. 

The venwl may he reached by a vertical or a transverse incision : of th«» 
the former is preferable. The incision coniniencen at Foupnrl's li^^iraent, at 
a point midway between the BymphyBtaiinbis and anterior sufwrinr iliac sptoe, 
and is carried downwanln in the line oi the artery for about two iuchea ; the 
aUn, fat, and aupcrficinl fascia are divided, and the lymphatic glaa^ 



LIOATDKX or TUX SrfKRFICI AL FEMORAL. 



■■■Ofva or luraea oo one 
wual ifaaub expuicd. Tbi 
tW DMdta {MMBed thim the 
mIb, and tbr anterior crural 



or turned oo one side. The fiuv'tn lata » thi'o divided, aad the 
This tuiut be uarerully ofieniKl over the nrtery, aod 
iaaer side. The femoral vein life to the inner 
iml nerve n ahori diiilanoe away on the outer side. 
Tbftcrtgia of thf brari<-hi>M is very uncertain; the Sui^eon niuM i«lcct that 
pan of ifae v«vel for ligsliire which is moBt distant from nny branch. 

Thft •taltRtloi of thiit nperation are m unfavorable, egpocially wh&n pet' 
fa n a ft fur incoriBOU, and secoodary hemorrhage Una been m frequent and 
Au»l BD nccurrence, in several eases requiring ligature of the externnl iliac 
fcr ia amat, that I do not think it ia ndrisable to have rreriurKC lo this upc- 
ralioa id pniierence Uf li;d;aiure if the external iline : and it tnay be laid down 
■as inloiDHrKetT, that in all thoae eiucsof nncuri.^n) ihnt aresituntcd above 
tfaa auddl* of the thigh, in which compr^Hion hn« failed and sufficient apace 
doaa aot ioierrcne between the origin u( the deep femoral and the upper part 
of tb» aae for the application of a ligature to the superficial femoral, the 
bf lie*]. 



lal iliac thould 

Ucmtor* of the Bttperflcial Femoral — The superficial femoral artery, in 
tta eoune fn>iu the origin of Ihe deep femoral to the aperture in the tendou 




Fit- tti'—UgUun af ttta S^ptrtcUl fauoral Artary. 

■etor, to divided by the croasing nf the aartorius muscle into twu 
of nn«<]uai len^li. which havp difTprenl rehiliunii to oci^liboriug 
Thv upper divifiim of the nriery, which lies above the anterior 
mmrjpa of the muscle, ia of moeit int^rent tn the Hurgeon, an it ia in this jmrt 
«f Itt niurae tluit it ia invariably lifnttured in cases of aiifuriani. It in true 
Am Jrvho Ht)Qt4-r. in the operation which he inlroducrd for (KiplitcAl aneu- 
rim. «xpnM<d and tied the veesel in the middle thiril of the thigh; but hifl 
•xanple has Dnt t>eeTi followed by modem Burgeona. on account, of the fnr 
pmMir diA^-altj in reaching the vcaael here than in the fint part nf ita 
QMUML The MfK^rficifl] ft^monil, where it lies in Scarpa's triangle, being 



260 



:CRISHS. 



covered m«r»ly by the ooiunutn iDt^utnent, tbe euperficiA] fanciii aad 
faacitt laUk. amy be reached by eu siiuple bd operatioD u suy timt the Sui _ 
bus U» p«rloriii fur tbe ligature of the larger vrwels. The lut« to tbp aii^ry 
is tiikfu Bn lollowe: The leg is flexed aud the ihifih rotated iiutwaitls. Thi 
8urei-uu marks a iwiot exacdy midway bctwecD tbe aDterior Nporlor spiot 
of tne ilium and tlie synipbytie pubis. Frutu tbie bedravrea line to tbe mail 
promiuc-ui part o( the iuuer coudyle of the femur. Tbv jHiiot elected for 
tying the arterv must b« about tivo inches b«Iuw foupart's It^auieut, aa the 
ligature will thru b« at a iMife distance from the pruitiinla, the luvm 
rptonlrd ptiint uf ori>;in uf ihatvewel beinif four inrlifs hehiw tlii^ ligament 
The InriMnn kPig. 4^1) is made in the line above iinlit-iilrd, and ahixiM be 
from (bree to eix iocbes in length, accoriling lo the amnunt uf ful its 

faU It mtiBt be en arranged tliut Lb» ixtint eele<-(frl (or the ;< <uo 

of the ligature Ehnll Ik> in ibe niiddle of iia If^ngtb. The dkiu nml Miprrlirtal 
fa»(.-ia Imviiig liefii dividpil, the fuitria lata iB e!(|Hie«d and ii|H-iieit to thoniBe 
extent as tlie inciHion iti tbe integuments; ihf niUKciilar (ibresof ibe sutriorius 
Dow come into view. If ilie iDei»i<>n have been made loo far itiwarda, it b 
iMMJble that tbe adductor tongiK may be exnoaed itwtcfld of lb«nru>HM; 
tbe error ig readily recogntEe<)1iy olworving tne direction of tl>e fibres, ibm^ 
of the adiliiclor being downwards and outwards, and those uf tbe parloriui 
dowuwanl<< and inwnrds. The edges of the wound in the fascia being held 
a[Mirt with blunt hooks, tbe snrturtus is seized in tbe forceps and dra«D out* 
vmrtU, the librea of tbe urmdar liasue Burroan<ling it 
being touched with tbe edge of tbe scalpel, if neces- 
sary, until its inner edge comes into view. If the 
operation be performed a little higher than usual, ur 
if the sartorius be feebly deveIoi>ed, its inner edge 
may come into view ne soon as tbe fascia lau ' 
diviiled. The edge having been, found, tfae m 
must be turned outwards, and held on one aid* 
a copiwr spatula. A little looae areolar tUBUO mtnt 
then be cleared away from benenlb it with the handle 
of the scnlpel, and the shenth of iho veaela cones 
clearly into view. The sheath must be eaatiooaly 
opened, a small hole being made in it as in IM 
diagram (Fig. 402i. It must be remembered tint 
al\er the fascial shenth common (o the arterr and 
vein has been ofieoed. there is still the pruper ahealli 
of the artery to be divided before the ligature can be 
lafely passed. The vein lies lienealh the artery, sod 
OMUequently tbe needle may be passed fmm the inucr 
or outer sidt indifTercntly ; it should be pasted 
unnrmcd, and then be threaded and withdrawn. Usuallv, no nerve it seea 
during the operation, hut the iniirnal inphenous occattioually coitie* into view, 
ud must be avoided. AAer the o))eratl(>n a druinage-tulw should W iuscrted 
in such a way Lliai its end shall lie beueatb the sartorius, and tlic vroood 
it c)'jee<l «iith sutures. The wound is then semiflexed, somewhat raised, and 
laid on its outer side and wrapped in soil flauuel or cottonwool. The 6v\vn 
pain which is ii^unllT vomplauicd of about the knccailer tigblening the liga- 
ture niBV i>e relieved by a full doee of opium. 

In this ojK-Rition there are icvcraJ )K>iiits of considerable importanre that 
retjuire spn-iul ntlention. 1. The im-i^ion Rhoutd Iw made dirccllv in the 
guiding line ol the artery, euro bring ttikcn nut to incline it inwarifs in tbe 
direction of the «sirti>rius. 2. In (-niiing itown iijMtn tbe artery, the aaphenoui 
Tein ahould be avoided, by taking care not to make tbe incisiou loo far 



7t(. -m.— IHftrua or tb* 
t>«ft Faneral Arltrr at 
Ap9x of lJ«Br|M'* Tri- 
Mtgtt. ). tMlvriafi /, 
fMaotkl tliMibj •- ulary. 



Abt parallHl wnou^ brunch Lhnt may he itiel witli niui't Ik- drawn 
ctdc 3. AfU'r ihe slieaih liii.-^ b€«ii opened, il will somelimrd W I'oimd 
tliat a mtlicr lar^f muscular branch is given ufT fn»m the artrrv at about the 
part «h«rrv il wa« intended to ligature it; it' so, thi» inii^t b^ carefully nvoidcKl. 
•* vrll aa anr amall veins that croiw the main trunk in thi« situation. 4. 
TW H^ture «bniild not he nppliffi \t»s than four inches belovr Puiipari'K 
UgUDVDt, au that siifficirnt fitacv amy intcn:cnt> biMweeu the origin ot th« 
data ftHBaral, nhi<!h is uauallv t'rom one to two inchn hclov the orurnt arch, 
aaa tiw poini dfhgatcd, to n^mit of the forinalion of a proper coa^ulum in 
•L It haa, however, happened that the ligature ha* been placed 
thrw-qonrteni <tf an ineh of the origin ot' the deep femoral, without 
IT tnjuriou* < utit rr-Miitiinf;. ii. The };reategt care muxt he taken 

at to wiMMid I' il v^in, which lie» behind the artery io the situation 

rbirh a tiKature in ukumIIv Hppli>>d. It' the ve«wl ig timl a little hit;her 
uaual, lilt vein will t>e towanls the inner »ide, and then th« net;dle 
BiuMt hti p«Med from within outwarda. Wnunding the vein is l>e8t avoided 
bv tburoagfaly cleantuic the arterv : the white eKtern&I coat must be thor- 
ax 




jmi 




ily axpoara, and while the needle ia heioe imased the ehoath should be 
ilioraugfaty on the atrvtob, the Sureeou hofdiDg the edge of the upeoing 
OB iba fide from which hu is paaiog the needle, wliilu the oMtstani iiitehes 
tl» opposite aide in a pnir of forceps and draws gently upon tl. In pa«aing 
A» aaadta. ita end should be kept very cl<«e to ihc artery, and uimlo tu 
fliiflle round iu The vt'ia im generally pcrfuruled by dipping the iio»lle ton 
daaply and l.jaing the cnnlart hetween it and the artery. When the neeflle 
ii DTOaght op oo the outer side of the artery, a Kninll portion of the i^healh 
■MBatinfli poshed an by it; thin muft be t^irn by pinching il with the 
when the needle may lie carried round the resHcl. 
tM. — Lwature of the fenmral arlery for popliteal aneiirutn is an 
aMtatifltt that aw been so frequently performed, thatKurgeon.'t fieldom think 
«r rceonling oaam of this description, unleiK they present cnmplicatinn.<^ or 
WMeba of anuaaal intereK or severity ; hence, hut little impnrlAnce can he 
" ' ;) to any sUlisttea] deducliont from reported cn»os as to the fnlality 
'iperation. although they nt&y serve as a rough estimate of (he pro* 
BMiintaiued between the diderrnt accidents, ftuch aa hemorrhage, 
etc., that follow it. That ligature of the femoral arl«ry >» at* 
with more euccws than that of any of the other large trunks can 
gidniC of B4 dmibt. This \i wA only in accordauce with ths general expe- 
if confirmed by the stati»tica of published casea. even 
M-p for the prubahilily of more of the unsaccessful 
: rco-mied. Thus of HO instanoes. Collected by 
. -irtery had bevu ligatured for poplileal aneurism, 
maif twelve are rep^rttxl lo hare died : amongst theae. four deaths were 
rawnl bjr aecoodary hemorrhage, three hy gangrene, and the others by 
pblabttist tetanus, ehoit -disease, etc. Higher ratev of mortality are. however, 
^Mher authunt ; thus, Morris states thut nearly one tu four the afler 
ttuo: Hulrhin)!»ii finds that of thirty-three casea operated on in 
Iftrn were fatal, five deaths resulting from gangrene. Holmes'a atal- 
, which an* nxlrt-mely valuable as being collected directly from hospitala 
'Irnm publt^Ktt rannn. nhnTr very favorable re^ult^. Of eighty-seven 
in which the operatioa was peribrmed for f>!monil or popliteal aueu- 
^IhlrtMfl died, and in three the operation fitilcd to cure thcdiaease. 
nmtrred twice, nnd suppuration of the »ac not once. Of the 
Il fntm smallpox, two from wound of the vein and phlebitis, 
. :«aiim, twe from gangrene and amjtutation, one from nisease nf 
dw tudovya. and iIm rest from various other causes. Berwell hn? collected 



than voccoBrul 
Crisp, tn which tht 



£62 



SPEOIAL ANKDRISMS. 



aloi) frvm hospital re[Htrt8 67 caseii («ciirring in Uie tea years 1870 tn 1K7^ 
in<-lii!tivp. Of ihe*e 10 dieH. Most of ihe tlfAllji occurred, boiievrr. in ih» 
fint hnlf of thU p^rifwl. in which ^2 cftws were openled on, uith 7 i)<-nlla 
aod 2 flmputfttions; while in tht; m^oiikI half, out of 35 c*ww tlirnr wrrv ll 
deaths and no ainputnlion^. Bnruell has hI»u contnu-t*^! thr nwull* with 
refereore to tlie various nmt«riaU tweol aa ligatun-^. He litnU that lu 14 
cu««s silk vii« used ; of ihi'ee 3 died, 1 of mitirv of sa uneiicitm «( tb« titi* 
of liKiiture, 1 of «ccondnry hemorrhage aud I of p;:i.'mia, and in 1 oim- i1u> 
antrumiu relapsed. Id 27 caees catgut was used, of thwe G died and 3 ir- 
lapaed. or the deaths. 1 aruw; fnini crukv unconnected with the upvniioiD. 
2 of eecoadur^v bemorrhuge, and 2 after relying l<>r rt-'lapee or aaeurUni at 

, Uie site of ligature. In 4 casoi the ox-aorta Itgaturt; was umhI succeMfulljr. 

>Tb« cutgut used some years ago was- eoroewbat uncertain iu tt« i|ualil)', aud 
in one of the cawa iu vihich sei.'oDdary hemorrhage nccurred, it waa B|ipli«d 
without antiiteplic precautions, and cotisequeiilly diflereil but little fnitu the 
old iiilk ligature in its pn>pertie». It remains to be determiaed >*hat forni 
of ligature gives the beat rceulls — whether catgut prepared according in tlte 
later melhod^ {vide vol. i. n. -1*24), carbolized silk, or the ox-wtrta, appiitil 
in such a war as not to divide ibe inner and middle ciiata. There is lictk 
doubt that the low deaib-rate of the later ]ieriod in due to improvement to 

I (be ligature and in the aAcr-troatnient of the wound, and there li evenr 

[Teiiann to hope that it will at least be maintained, and probably be Airtber 
rcdHce<i. 

Accidenta. — Wound of the Femoral Vein ia without doubt the miMK wrirrtu 
accident that can happen in the (ipertttioo for ligature of the superficial 

' femoral arLer)', and \a one of wbi<-b there i^ cit|>ecial risk when reconrve it 
had to this oiicration tor aneuriam ; as in this diaeaM; thi- fine iireoUr tiarae 
wbirh naturally connect* the two vemeU often becomen thickeuMl anii indu- 

, rale<l, iu couftc(|uence of chr<«ic inflanimntion exteuiling upward* from the 
•ac to tlie sheath of the vcmcIs. It in l>esl avoide<l by pajving the newlle in 
the way that bag be«n iilreatly recommended, unnrmed and without tb« em* 
ploymeot of force. This accident ia aluioet invariably fatal, there beinK bnt 
very few inBtauccs un recuiti in which patients have survived it; death 
uiually resulting from septic phlebitis, or the supcrveution of gaufme. 
The true cauiw of the fatal result in these cases waa tirst pointed out by 
Hadwen, who showed that, when the vein is wounded by iha MMurisHh 

'needle, it is tranelixed at two points, tietneen which the thread is drawa 
acruee; and when tliis is tied, a segment of the vein i^ necessarily includtsd 
with the artery in the jitxiee. It is thiH incUieiou of the l^!ature within a 
portion of the vein, where it acu like a H.-tiin. and kee|iH up constant Irriia- 
tiim. that orniHionn thnimlHuHis and (lulHieiiueni iliHiutegraiirm of ibr cImI ia 
Ihe inLt'rior fil' the vnuel ; ami it ia ci>ni4e<piently ihiit circumHinnei', ami m«l 
the murt^ wound of the vein, that detenninee the greut fululiiy of this arvi- 
deuu Guided by ihi.'* view, the treatment beoumes obvious. It cowsins ia 
renuiTing the ligature at onre, and thus, by taking away llie source of irri- 
tation, converting the wound into a Bimple puncture of the vesMd, wbidi 
readily heats. The Surgeon should, therefore, an so*in as the accident is per- 
ceived, withdraw the ligature, and, o|M?ning the »heath about half nn ini^ 
up, reapply it to the artery there. The itemorrbage from the punctured 
vein readily ceaM« on the application of ii comprcM. 

The occurr^-nce of Seconaary Hemorrliage after the licntnrc of the super- 
ficial femoral ifl a troul*l««uiue accidetit, and one in which tbr Surgeon, to 
uite Fcrifumiin*') expreftviuo, " will movl oMuredly find himself in an eventful 
dilemma ;" and in which it in neceeeary that bis line uf action sbduld have 
HO well considered Iteforehand. as he may not have much lime to span 



rHkction wbcs rack an vveut takw place. In cbmb of tliia kiml four linee 
wf inmtBWfil pn*eat ihtrtii^tflvt^. viz. : the tm|>li>yiiicDl ut' jiresBure: ligaturo 
of the ttmti M m higlivr pi>iiii : (ItfligHlion of the Liltvdiiig artery iu the 
wvtiad: ur ntnpubilioa u( the limb. 

iSvmmii may U* upjilit^l by pliK-ii)^ n griKluHtHl cumprera of lint or coot' 
unmtA fffMiifrr nvcr the blei!<Iiug uriliei*, ami fixing it there firmly by u 
BOfiBiior tuuniiijtii^ Thi^ nioilt; nf irfHtmeni. nlihouf^h cxlrtiuely unccr- 
IMB. Dcnuioaally AUiKfudit: xhoulil it not do ao. however, niul bleeding rvoiir 
mmamd tuoe. it ix um-Ic-ih to continue it, ■» expcricnct' has ihowu tbat tbv 
h«DocTiiafte «i]l ri'nttnuc until (ht? )Mi(ic-nt i« worn ouL 

hifHmrt of the tftiixrHcial tV-monil ot a hij;hcr point, or, if the artery have 
Wan tirfl Kio liijih l>ir thi!>, doli>;uli<iii uf the common iVmoral or of the t-x* 
knsl ifinr. pn-».-tit» it#elf a» A probiiblc means r>f arrv4>tinK the hemorrbnge. 
ftwb lioMcver, id fraught with dunjjtT, and Tias, I belif^ve, in- 

tl iMil hy gangrene. It might »l first 1m* iiU|>|HHed that the 



limb Mwutd not l>f> tilac*^! in a worn situation aOer the ligature nf the exter- 
aal Uuc, wfaetbcr toe euperticinl femoral bud been previously tied or not; 



Iha aMMtaaNaing t^auoela remaiuiDg the eniiie in either caw. Btil in reality 
it it nnt fv; for. although the blood might find its way through the epigas- 
tric, Lb« circumflex ilii. the gluteal, aud sciatic arlcrie^, into the deep femo- 
rmt sad its braucbe». yi-c fmm this poiut the didiculty of it^ tranenii^ioQ 
■bftnifll Uw limh ntiuld be muierially iucrea«ed. If tho superficial femoral 
baafKti. it Mrr^'ra aj a dirt-ct and ea^y clmunel for the cunveyaoce. to ibo 
9tmth of i1m? lf|c and tiMil, of the blow! bniught by Uii- aiuutli'>iu<jae». But 
vfaea the Bupi-rfiinal femaiat ie tied, thi« hiiKxJ must find lU way ibroueh 
k Mcood cliain nf tinHatomneiof; t«<«i'I«, — ihuv^e ititerveuiri;: U'i\ui'u ine 
bcmaelHM of tfar d^t-p rt-nionil nnti the arlicular aru-ricit of ihi< kuee ; and 
ban tlw rvul difficulty would arise, its iiii[Hil»f- not lifiii|r sufficient tii over- 
COHM tbe olelnirljon to itfl (Ui»>agc through LbeM< enmlt chuntiels, which 
■MptU not improbably he still further obstructed hy the pressure of the 
aacuriuB. Khnuld the aruutomofiing circiihition be t^ufficiently fn?e tn main- 
tain tbr vitality of tltv limb, it is not impmbnble that thr- recurrent blood 
w.^h! <*capr fntrii tbr dini.il side of the liniilure, nnd thus keep op the 
h— iifrhatfe rxnctly n* in t'ascof wound. It iip(M>fir» inde^'d that the femoral 
M IW J . in a <-«M7 of H't-i>iiii>iry hemorrhage ntiei the application of the li^a- 
tMt%, i* in Very much the -ntiu' ouiditioii as nn artery which bu been 
woawM. and in Mhich the b!ix-<)in^, hnvin;; l>een suppressed fur some days, 
kaa Ktaroed » ' ••••v : nnd certninly liie iK-st aiurne for the Surgeon to 

the t iteu that he would follow iu the event of secondury 

rfaaf^e oocumujt iruni a woundeil veeeel. vis.. Utcut down u/wn ^/te bltea' 
m^ pmrt *»d affpiy a iijfulurt to it. Thai »ui-h an ojienitiun is surrounded 
«idi <lifficaUie« raonut be doubt^-<l : yet none would preseut tiivnisvlves that 
flW bchI akiU might not overcome. The burgeon would certainly have to 
est iDlu a (lort iDtiltmieil with blood, in which the difiereut ti»ues c<iuld not 
majil|r )— ■!'-tiiigui>bed, and the vevwel when reached would be found to be 
iaimi'- llMied : yet. by frve direction above and below the wound, 

■ [nrtx>4i >>' It iriig;bt at last lie exposed, where ltd conls Would hold a li;<a(ure; 
ar ahtMiM thia not be found, the wound might be firmly plugged from the 
Uoom with ciimproKd swioge; or the bleeding n[kertiire might be louche<] 
«ttli KbcB£tualrauta*7'. nhoald thcK means fail, it would be safer to ampU' 
liA tkt tmii. than to rndf^vor to arrest the hemorrhage iu any other nay. 
of the Limb in perhaps the most frequent source of danger aUer 
' I iral arti-rv ti>r poptiteitl anenrisni. It setdiun iHxitiri 
«j of con«id«rublv maguiludc, have become diffused, or 



SPECIAL ANKlTHiaUS. 



Otherwise intt^rfere serinusly wiih the cinnilaLiim ihroiijjli tlie limb. I have, 
however, seen it follow llm n[jeralioii when the |»»|ilileal nneurism was uot 
larj^or than an orange; but, in this euge. there was nmch (eilt^ma ami i^unffea- 
tion 1)1' lilt' limb beture the operalion ; and, on examination anemanls,!! 
wm found that the prtpLiteal vein had been nbtitcrnted by the premureof the 
tumor. The gangrene, may, in some casea, be prevenleil by the treatment 
that has been pointed out nt p. 445, vol. i. Wlion it has fairly ilectared 
itaelf, there is necessarily no resource left but amputation, and this nperatioD 
is sufficieotlj successful ; for I find that of fourteen oasi-s in which it was 
done, there were ten recoveries, and but four deaths. 

The Eetorn of Pulsation in the Sao nftcr ihtt operation for popliteal 
aneorifini ia by no means of frequent occurrence: yet it has been met with 
in some instances, and Secondary Aneurism also has been fciuod in this sit- 
uation. In these costs the palii-nt slicHild be pm upon a careful dielecic 
plan, the lirah be kept clevnlt-d and itt rwt, and direct pressure applied by 
means of a roniprrfw and bandage. In tiiiit way cHrcH have been cfftclcd by 
Wisharl, Turner, Uriggw, and Listnn. Iu conjunction with such treatment, 
or in the event of its iii/t sufficing, the compree<iion of the common femoral 
arterv as Ic poseea over the pubic bone would iu all probability effect a cure. 
Should it not do ho. and the tumor continue to increaae, threatening to: 
suppurate, or to occasion gangrene, amputation would bo the sole resource. 

If calgut be used, return of pulsation may be due to premature softening 
of the lifjature. This is recognized by the presence of pulsation at the point 
at which the vessel was lied as well as iu the sac This is hardly likely to 
take place if welL-preparod irut be used, and the wound 
be kept perfectly aseptic. Should it happen before the 
wound is healed, it may bo opened up again and a 
seennd llpituro applied above the Hitiiation nf tho {IrsL 
If llie cualit appear to have been damaged by llie lirsC 
ligmur«, the vPA>4el may he tied nn each Bide of the 
injured Kpoi. In mme ('a-iea iti which nbsiiirbable hga- 
Ciireti havf been used, the recurrent pnl^Htion has ap- 
peared at a much later period in mnsefgiience nf a 
rcHloration of the lumen of the artery. Should rhts 
happen, the artery may be safely tie*! in Hunter's 
canal, ait was successfully dnne by C. Hmth under 
these rircumBtnnces in University College Hospital. 

Ligature of the Femoral Artery In the Middle of tha 
Thigh (Honter's Canal). — TIte point nt which Hunter 
tied t.he artery In bis earlier eases, was &ituttle<i midway 
between the groin and the knee. At this point the artery 



1 




\g. 4V».— t)i>Kr<iiii ..r 
LlgalUT« or llin Laft. 
FaoiOTftl Arler^ in 
HunUr'* Citttitl. «. 
nrto(ia« dfann io- 
wanti;/. rMcikelof- 

f bf llMeiOal. npVMi] 

fraalj I m, Ihe ftrlcrj, 
villi k •miiU a|i«(iiiJt; 
km Iu (Watt) for the 
fMMC*ofUi« needle; 
uk k«f •■pbanuui 



ticj in the an^le formed by the vastus inlernus on the ^ 
outer aide, aiul the tendons of the adductor longut> and ^ 
ad<luctor mugnutt behiiuJ. It is cuver^l by a dis