No. 2551.

JULY 20, 1872.

LecturesON

THE SURGICAL TREATMENT OF ANEURISMIN ITS VARIOUS FORMS.

Delivered at the Royal College of Surgeons, June 1872,

BY TIMOTHY HOLMES, M.A., F.R.C.S. END.,PROFESSOR OF SURGERY AND PATHOLOGY TO THE COLLEGE.

LECTURE II.-PART II.

WE now come to six cases in which the simultaneousdouble distal ligature has been performed according toWardrop’s method.The first of these cases belongs to Mr. Heath, to whose

enterprise and unwearied perseverance the profession owesthe realisation of Wardrop’s proposal-a step in surgerywhich I am confident will lead to much practical advance inthe treatment of thoracic aneurisms. The operation hasnot as yet been permanently successful, but in Mr. Heath’scase there was quite sufficient benefit to justify the opera-tion and encourage its repetition. The preparation is inthe museum of the College. The case is too well known tomake it necessary to read it at length. I hardly think itpossible to produce more distinct evidence of benefit fromany operation than is furnished in this case by the relief tothe dyspnoea, the diminution in the size of the tumour (sothat it receded into the chest, leaving the hole in the tho-racic parietes perceptible), and the prolongation of life solong as four years, under the most unfavourable circum-stances. Had the patient kept quiet, and submitted afterthe operation to the regimen prescribed by Mr. Tufnell, itis possible that she might have been cured; and had it notbeen for the unfortunate administration of emetics it seemscertain that the fatal growth of the tumour would not thenhave taken place. It must not be forgotten that in Mr.Heath’s case the aorta was alone implicated, the sac pro-jecting from the arch in front of the innominate artery, andhaving its mouth close to that vessel. The improvementmust be referred to the derivation of the stream of bloodinto the lower part of the arch, thus relieving the first orconvex portion of the vessel. But it is clear that in a pureinnominate aneurism, such as Mr. Fearn’s case, the effectwould be much more direct and powerful.The fourth case in the table, Mr. Maunder’s, would in

many respects be one of the most interesting if the accountgiven of it had been adequate and the preparation carefullymade and preserved. Death occurred on the sixth day afteroperation, and it would appear that it was attributed to theclotting of blood in the aneurismal sac, extending into andobstructing the aorta. The preparation, however, does notshow this, for the clot has been removed or allowed to fallout. It must be evident how strong a bearing it wouldhave had on the theory of this operation if we had reallypossessed tangible proof that so great an amount of coagu-lation could be produced in an aortic sac by the distal ope-ration.In Sands’ case there was no very marked benefit (though

it was thought there was relief to the dyspncea) and nodetriment from the operation. The paper which Dr. Sandspublished in the New York Medical Record for Feb. lst, 1869,is a most interesting one, and will well repay perusal. Inthis case also the disease, as I learn by a letter just receivedfrom Dr. Sands, was purely aortic. The aneurism arose infront of the innominate artery, and had pushed that vesselback four inches from the surface of the body, but theinnominate itself was not diseased. In fact, the state ofparts must have much resembled that which existed inMr. Heath’s patient.In Mr. James Lane’s recent case the tumour extended so

far up the neck that there could be little doubt the inno-minate artery was involved in the disease, though it wasimpossible to ascertain whether the aorta were affected ornot. However, the case proved fatal some weeks after thedischarge of the patient from hospital, in consequence ofthe continued growth of the tumour and its rupture ex-

ternally; and as no autopsy was permitted, the value of thecase for our present purpose is much diminished. But wemust not forget to note that in this case the operation, al-though, as far as can be judged by the notes, as clearly in-dièated as it usually is, proved entirely useless in checkingthe growth of the aneurism. I conjecture that in this casethe tumour, though it extended far up the neck and simu-lated an innominate aneurism, really had its origin in theaorta.

’

Mr. Durham’s case is also incomplete, for the patient diedon the sixth day after the operation, apparently from theshock. No lesion was found which accounted for death.The tumour was extremely large, and extended up the neckso far that the carotid was only accessible on a level withthe upper border of the thyroid cartilage. Still the inno-minate was the only artery actually implicated in theaneurism, although the sac had grown for so great a dis-tance along the course of the carotid; but the origin of theinnominate in the aorta was greatly dilated. In tying thearteries it was noticed that the ligature of the subclavian(the first artery tied) was followed by a very marked dimi-nution in the force and fulness of the pulsation; that ofthe carotid caused no further change. During the shorttime he survived, the aneurism was noticed to becomesmaller and more solid.The case on which I operated was in many respects a,B.

interesting and important one; but I will only briefly in-dicate its leading features, from a very good account of itdrawn up by my clinical clerk, Mr. Stir]iDg. The patientwas a man aged fifty, who was transferred to my care atSt. George’s Hospital by Dr. Wadham. The tumour wassituated chiefly behind the first bone of the sternum, whichwas much absorbed, and it also extended above the sterno-clavicular articulation for a short distance. Its aneurismalnature admitted of no doubt; but there was no bruit, andno very striking difference in the pulsation of the right andleft arteries, for though some difference in the pulse at thetwo wrists was thought to be perceived by the finger, thiswas negatived by the sphygmograph. The internal treat-ment of the aneurism, by absolute rest and moderate dietwithout stimulants, was sedulously followed from April 28th,the date of his admission, to Nov. 1st. The temporary im-provement which always ensues in the commencement ofthis treatment, as the pulse becomes regular and slow, soonceased. Efforts were made to stop the growth of the tumourby the injection of ergotine into the neighbourhood, accord-ing to Langenbeck’s suggestion, by acetate of lead longcontinued so as to produce its characteristic symptoms, andby local cold and compression ; but it became evident thatthe aneurism was slowly extending through the thoracicparietes. It was decided, therefore, that the operation ofdistal ligature was justifiable, and I noticed and pointedout to my colleagues that on compressing both the subclavianand carotid arteries firmly a remarkable diminution occurredin the force of the tumour’s pulsation and in its rate, andthat, on testing the effect of compressing either arterysingly, it was found that the effect was much greater whenthe subclavian alone was held than when the carotid wascompressed. If it had been the reverse, I should have re-commended the ligature of the carotid only ; but as I haveno confidence in the ligature of the third part of the sub-clavian alone for this disease, and yet it seemed that thestoppage of the circulation through that vessel checked thepulsation of the aneurism, I proposed the simultaneous liga-ture of both arteries. This was done on Nov. 16th, thevessels being tied tightly with a stout ligature of carbolisedcatgut, the ends cut close to the knot. I had previouslyascertained on the dead subject that this ligature tied tightlyon the subclavian artery divided the two internal coats. Ineach operation some small superficial vessels were tied, andit was found afterwards that by inadvertence silk had beenused for this purpose in the subclavian wound, and possiblyin the carotid also. The wounds were united with the con-tinuous suture (also of catgat) and dressed according to theplan recommended by Mr. Lister. The patient, however,was restless, occasionally delirious, at night, and it was foundnext day that he had disturbed all the dressings, so that theattempt to treat the case on the "antiseptic" plan wasabandoned. The carotid wound suppurated a little, but wasfinally closed on the thirteenth day. The subclavian wound

soon contracted to a short sinus, and so remained till thepatient’s death. A day or two before the fatal issue thec

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,cause of this became apparent by the projection out of the,sinus of one of the truncated silk ligatures, and after deathanother sma,ll knot of silk was found loose and lying closeunder the little opening. The tumour at first diminishedslightly in its pulsations, but soon returned to about whatit had been before the operation, and it was quite evidentthat the ligature had had no curative effect. In the lastfew days of the year it began to grow rapidly and to producegreat dyspnoea, the skin also became somewhat thin andlivid. Rupture of the sac being obviously impending, it wasresolved to try galvano-puncture. Four needles were insertedparallel to each other and about an inch apart. Dr. Althausapplied the constant current of from ten to twenty-five cellsof Smee’s battery (Foucaux’s arrangement). The positivepole was first applied to each needle, the negative being inthe first place applied to the skin; then the positive polewas applied to the next needle and the negative to the onefrom which the positive had just been shifted, the changesbeing made every five minutes, so that the whole process Ilasted twenty-five minutes. He complained much of pain,particularly when the changes were made. Arterial bloodjetted freely from the punctures as the needles were with-drawn, but the haamorrhage was at once checked by pressure..For the first two days the tumour decreased in size, butafterwards it increased both in size and pulsation; rednessand cedema extended around it in all directions, and he diedon Jan. 10th, at 9 A.M. On the previous night, seeing thatthe skin was whitish and soft, and apprehending that thetumour might be suppurating, I punctured it deeply with athin knife. A little froth of blood and a gush of air aloneissued from the puncture. At the autopsy the whole of thecellula.r tissue around the tumour was found loaded withlymph and much indurated. This diffuse inflammation ex-tended the whole way up the neck, rendering the dissection

extremely difficult. The aneurismal sac involved the wholeof the innominate artery, and opened into the aorta by avery large orifice. It was almost filled with blood-coagula,which were firmly adherent to the sac, but had not assumed.any regular concentric lamination. The aorta was greatlydilated and very atheromatous. The heart was healthy.The arteries opening out of the tumour seemed healthy;their continuity was not interrupted at the site of ligature..On the carotid, lying between it and the vein, there was alump, something like a small gland, and the artery was con-stricted. When laid open its calibre was found to be inter-rupted merely by a thin stratum of partly decolorised clot;a distinct ridge or transverse mark indicated the position ofthe ligature, and below this (between it and the heart), at

. about one-eighth of an inch distant, were two very minuteapertures in the internal coat. One did not lead throughthe walls of the vessel; the other led into the small lumpabove mentioned, which was a mass of cellular tissue anddebris of blood-clot, in which no trace of the ligature couldbe found, though carefully looked for, nor was there a traceof the ligature in any other part. In the subclavian alsothere were no remains of the catgut ligature. This arterywas not inten’UDted in its continuity at the nlace where ithad been tied, but was completely closed by a diaphragmless than a quarter of an inch thick.The case appeared to me to point to the following conclu-

sions:—That the double distal ligature will not produceconsolidation in an innominate aneurism if it is partly aortic-i. e., if it opens into the aorta by a greatly dilated orifice.That galvano-punctaare may be employed in such a tumourwith the effect, of producing great consolidation ; but that ifthis consolidation is very rapid there is risk of inflammation.That arteries may be tied as securely with the carbolisedcatgut ligature as with silk. That such ligatures melt awayin the wound without being discharged from it. That an

artery under such circumstances may preserve its continuity,whilst its tube is oblitera,ted at the part tied; and thus thatthe chief risk of secondary haemorrhage after the ligature isobviated.In the Boston Medical and 81!rgical Journal for Aug. 6t.h,

1868, a case is related by Dr. Hodges in which these arterieswere tied for supposed aneurism, of the innominate or aorta.The patient died eleven days after operation. At the post-mortem examination (which was hurried and imperfect) noaneurism of either artery was found, though both weredilated. The tumour which existed during life 11 was un-doubtedly the distended arteria innominata pushed up intothe neck by the dilated and stiffened aorta."

3 A case is related by Dr. Cheever in the same journal foriMay 6th, 1869 (vol. iii., p. 239), in which he endeavoured to! tie these arteries, without success. The patient was renderedI insensible and almost killed by ether. He took it for twenty; minutes, and finally his blood became entirely dark and; venous. The incision on the carotid artery failed to reach; it, as the venous oozing obscured everything, and the ope-irator could not see the parts. So with the subclavian :.nothing could be seen; great venous haemorrhage tookplace; the operator tried to secure the artery by touch;

in passing the needle, as he supposed, under the artery, helacerated the vein; and then tried to secure the vein byfree dissection, and at last by cutting through the clavicle,but unsuccessfully. The patient died in two hours. Theaneurism was purely innominate, contained a good deal ofclot, and the vertebral was plugged. It was therefore aa very good case for the operation.Such is our present experience of the double distal liga-

ture. It is undoubtedly a formidable proceeding, and onenot to be lightly undertaken. There are the operative diffi-culties, which, in a tumour so large as Mr. Durham’s, forinstance, will prove sometimes formidable; there are thechances of erroneous diagnosis, as in Dr. Hodges’ case,where there was no aneurism at all-in Mr. Heath’s, Mr.Maunder’s, and Dr. Sands’, where it was purely aortic, andwhere any beneficial effect that could follow the operationwould probably be secured by the ligature of the carotidonly; and, lastly, there is the danger of not being able tocomplete the operation. In Dr. Cheever’s case the failureseems to have been caused by extreme venous congestionproduced by the ether. In a second case in which Mr. Heathattempted the double ligature, he was unable to reach thesubclavian in consequence of its being overlaid by a lobe ofthe sac, filling the subclavian triangle. Yet even in thiscase the tumour was purely aortic-a notable instance ofthe impossibility, in the present state of our knowledge, ofpronouncing an absolutely confident diagnosis betweenaortic and innominate aneurism.Let us now turn to the cases comprised in our third class,

in which the carotid alone has been tied on the distal sideof an aneurism; and here, I think, the evidence of benefitderived from the operation, in some of the cases, is so con-clusive as to justify me in the inference that this operationis urgently indicated in any instance which may prove ap-propriate.

It will be convenient here to separate from each otherthose cases where the aneurism was proved to be innomi-nate, or where there were good grounds for assuming thatit was so, and those in which it was wholly or partly aortic;and I will only dwell on those cases which are known withsufficient accuracy to warrant me in founding definite con-clusions on them.Those which are reported as purely innominate are eleven

in number: Aston Key’s, Hutton’s, Dohlkoff’s, Wright’s,Hewson’s, Broadbent’s, Neumeister’s, Scott’s, Ordile’s, andthe two cases of Nussbaum. At first sight, and to one whofollowed the miscalled statistical method of reasoning,nothing can appear more disastrous than the experience ofthese eleven cases, since all the patients died within a fewweeks at furthest from the time of operation. But in someof the cases which are more accurately known to us thereis quite sufficient evidence of the curative power of theoperation to justify its repetition-nay, I think, to make itimperative.Perhaps the most striking and convincing case is that

operated on by Dr. Wright, of Montreal. I can only givethe briefest possible sketch of this important case; but Iwould urge upon those surgeons who wish to make uptheir minds fairly as to the worth of the distal operationin appropriate cases of innominate aneurism to study theable pamphlet which Dr. Wright has written upon thiscase, and to compare the preparation, as represented here,with the drawing which I have previously referred to ofthe spontaneous cure of an aneurism of this nature fromSt. George’s Hospital museum. Finding that this im-portant pamphlet is but little known, I have induced Dr.Wright to present copies to the library of this College andof the Royal Medical and Chirurgical Society.

Dr. Wright’s patient was a man seventy years of age.The tumour presented in the episternal pit, in about themedian line. It had been mistaken for an abscess, andhad been poulticed; but it had the pulsation and bruit of

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aneurism, and was on the point of bursting, the skin overthe apex of the tumour being 11 greatly attenuated andslightly excoriated." The ligature of the carotid was fol-lowed by immediate subsidence of the tumour, and rapidconsolidation of its more prominent part. And what is, asfar as I know, unique in this case is that the attenuatedskin gave way on the second day after the operation, andlarge quantities of serum continued for more than a weekto drain away through it from the subjacent blood-clot, nordid union become perfect in the resulting fistula for morethan three weeks. The tumour gradually subsided, and inabout a month had ceased to be perceptible. But aboutthree weeks after the operation he was attacked with hemi-plegia, and, after lingering in a dubious state for a longwhile, he died, eighty-seven days after the ligature, withabscesses in the brain.The immediate effects of the operation speak for them-

selves : the aneurism on the point of bursting before theoperation; the immediate collapse of the tumour, and thediminution of its pulsations; the giving way of the skin onthe second day atter the operation; the fact that the sacwas then so obstructed by coagulum that the fluid whichoozed from the rupture was not blood, but serum; the con-tinuous shrinking of the tumour as the clot became firmerand more fibrillated; and the ultimate healing of the sinusas the tumour shrank. The operation proved fatal by itseffect on the brain, the patient dying with abscess in thecerebral hemisphere, as has happened in some other casesof ligature of the carotid. But the state of parts showsclearly that, had he survived, the aneurism would in all like-lihood have given him as little trouble as Dr. Bence Jones’spatient experienced after the obliteration of the carotidby impacted clot. The resemblance is, in fact, most

striking. The carotid is seen in Dr. Wright’s, as in Dr.Bence Jones’s case, to be obstructed from its origin in thetumour to its bifurcation. The whole of the upper andfront part of the sac is filled with firm clot, and the onlyportion which remains unobliterated is the channel whichhas been left for the transmission of the blood from theaorta to the subclavian.

Dr. Hutton’s case is interesting mainly on account of thesuppuration of the sac which ensued, and which was thecause of death. In this case 11 Valsalva’s treatment" hadbeen tried previous to the operation; and if by this expres-sion is meant the enormous venesection and the injudiciousdepletion which that surgeon recommended, it is quite opento us to conjecture that both the failure of union whichaffected the portion of the artery included in the ligatureand the failure to form firm coagula in the sac may havebeen due to the impression so produced on the system. Inthis case the subclavian artery was partially obstructed bycoagula, which would have been probably a favourable cir-cumstance for the cure of the aneurism had the patientpossessed sufficient power of recovery. The failure of unionin the artery and of consolidation in the sac in this instancedoes not render the occurrence of both less probable in apatient of more vigorous constitution.

NOTESON THE

GENERAL PRINCIPLES OF CUTANEOUSTHERAPEUTICS.

BY TILBURY FOX, M.D., F.R.C.P.,PHYSICIAH TO THE SKIN DEPARTMENT OF UNIVERSITY COLLEGE HOSPITAL.

(Continued from vol. i., page 753.)

I Now turn to the general principles of local treatment.The diseases to which I am now referring are, it will be re-membered, the hypersemias, the simple inflammations in thedebilitated, eczema, ecthyma, psoriasis, acne, pemphigus,&c. I am the advocate for a much more soothing systemof treatment than that usually adopted for these diseases,of which hypersemia is so frequently a part. And this leadsto the question, What should be the object of our lpca.1measures ? P It is threefold: (1) at the outset, to moderatediseased, especially inflammatory, action; (2) to protect thediseased, and therefore weakened, parts; and at length (3)

to stimulate, with the view of rousing the dormant tisRnesinto due activity, and causing the removal of morbid de-positions and formations. My own conviction is that, inthe early stages of hyperaemic skin diseases, much of ourcurrent treatment is mischievous by reason of its activity.A soothing plan of treatment is wanted in all cases ofearly cutaneous congestions. By soothing treatment Imean one which diminishes congestion and secures an ex-clusion of air-one which, in fact, puts the skin in a stateof rest. Heroic measures, designed to cut short an earlycongestive stage of a skin disease, often render the courseof that disease chronic and persistent. In the early stages,before the deep vessels are involved, much can be done tocheck congestion by mild applications; whilst active mea-sures do harm. For instance, in acute general psoriasis Ihave often seen aggravation of the congestion follow the useof tarry applications; while great relief has been producedby alkaline and bran baths, and subsequent oiling of the sur-face. I am not by any means an advocate of an expectantplan of treatment. I advise potent remedies to be em-

ployed after the congestive stages have passed. The dan-

gers of over-stimulating are not imaginative; and they areplainly made apparent, in cases accompanied by activehyperasmia, by much irritability, or by a tendency to de-generative change in the skin, in the spread of the disease,and its undue chronicity.

I may refer to the local treatment of certain instances oflupus, quoad hypersemia, in illustration of what I mean.Sometimes we have a patch of lupus on the face, which isvery tender, very hyperaemic, and which exhibits a tendencyto spread-that is to say, there is a tendency in the appa-rently healthy tissues.to become the seat of the cell-growthwhich is the characteristic of lupus. In these cases the ex-clusion of air and the use of mild non-irritating astringentswill do good by diminishing the hyperoemia; whilst the useof caustics will be sure to cause the disease to spread, be-cause it will greatly increase the hypersemia of the partsaround, and so favour the development of the peculiar cell-growth. In fact, if one still further disturbs the alreadyweakened disease-tending tissue, one is, of course, likelyto favour disease. This is also true of simple acne, pity-riasis rubra, &e.

know for the details of local treatment.

First, as regards moderating inflammatory action. Itwill naturally occur to anyone first of all to remove specialcauses of local irritation in the case of hypersemic skinaffections. There are two sources of mischief I may spe-cially refer to; they are (a) the wearing of flannel next theirritable skin, and (b) scratching. I think flannel shouldnever come in contact with an irritable skin ; it is a greatsource of irritation. It may be worn outside a linengarment, and the patient will not, under such circum-stances, catch cold. The disuse of flannel is important innettlerash, pruritus, eczema, scabies, the erythemata, &c.Scratching does an infinity of mischief. The usual plan forpreventing it is to use some sedative lotion. I think it ofgreat importance to employ emollient and alkaline bathsfreely, to allay irritation in the early stages of local inflam-matory cutaneous diseases, and to subsequently protect theparts by appropriate coverings and applications; and byinternal remedies remove all cause of pyrexial disturbance,or alter such blood impurifications as lead to an intensifica-tion of the hyperasmia of the parts through which the bloodpasses. The baths which are best adapted to moderateinflammatory or irritative action in the skin are bicarbonateof soda, 2 to 4 ounces, size from 4 to 6 or 8 lb., poppy, andbran. The patient may remain in for ten minutes or so,and the skin should not be rubbed dry, but patted withhot towels. It is a good plan to oil the skin subsequently,or to powder it with oxide of zinc, or to apply a simplecalamine lotion. But we must take care to use such meansin due conjunction with general remedies. If bile productsor ureal compounds are in abundance in the blood, freepurgation, or diuretics employed with a liberal hand, mustnot be neglected. Pyrexia must be met with appropriatedrugs and dieting. In like manner the pain and hyperaemiaof an eczema in a gouty subject may be greatly moderatedby an alkaline bath, but a good dose of colchicum in addi-tion will bring the greatest relief. The exclusion of airfrom inflamed and bypersemio irritable parts is a matter ofgreat consequence, and the more so if the irritable part isdenuded of cuticle. The air is very stimulating to such

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