No. 2552.

JULY 27, 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. ENG.,PROFESSOR OF SURGERY AND PATHOLOGY TO THE COLLEGE.

LECTURE II.-PART III.

CONTINUING our summary of the table of distal ligaturesof the carotid artery, we come to the cases reported asmixed innominate and carotid or subclavian, which areseven in number-viz., Evans’s, Morrison’s, Rompani’s orVilardebo’s, Pirogoff’s first case, in which the carotid wasjudged to be also affected ; Mott’s, Fergusson’s, and Porta’s,in which the subclavian was implicated.Of the first four, allowing the accuracy of the diagnosis,

it seems that the first two were cured. The third died fromthe effects of the operation, but the aneurismal sac wasfound almost filled with fibrine three weeks after the liga-ture ; and Pirogoff’s patient derived so much benefit fromthe operation that he insisted on leaving the hospital tenweeks after the operation.

Evans’s case is so well known and has been so fully com-mented on by Mr. Guthrie that I need not spend much timeon it. The attempt Mr. Guthrie makes to show that thecure which undeniably followed on the operation was due to" inflammation" seems to me quite unsuccessful, and I ammuch surprised to find this explanation adopted by eminentsurgical pathologists. It is true that the explanation isthat of Mr. Evans himself, deduced from the acute sym-ptoms which are described as preceding the disappearanceof the pulse from the right arm. But the phenomena whichattend the impaction of clot in a great vessel were then un-known. Judging from the analogy of cases like those alreadyreferred to, in which symptoms of precisely the same naturefollowed on the impaction of clot, with no possible cause orsuggestion of inflammation, and of such preparations as thatdescribed by Mr. Lawrence (St. Barth. museum, ser. xiii. 69),which shows clearly how easy it would be for a small pieceof clot to be washed into the mouth of the subclavian arteryas it leaves the tumour, and how far such an obliterationmight ultimately extend, I have no hesitation in ascribingthe symptoms to the latter cause. If I understand Mr.Guthrie’s (or Mr. Evans’s) explanation aright, they conceivethat, the ligature having been placed on the artery nearthe tumour, either the foreign body might have propagatedinflammation down the coats of the vessel to the sac, or thedisturbance of the cellular tissue near the tumour mighthave caused it to inflame, and hence the subsequent ruptureof the sac. The latter is, indeed, a probable cause of inflam-mation of the tumour, whatever we may think of the former.But how would either explain the rupture of the aneurismafter a year’s interval of health ? It seems to me clear enoughthat the ligature produced coagulation of blood in the sac,and that afterwards (the patient living an irregular life andbeing frequently thrown from his horse in the interval whileintoxicated) some accidental violence caused the tumour tosuppurate-an event by no means unusual after the cure ofaneurism in other ways. At any rate, there is no doubt ofthe reality of cure, for Dr. Evans of Belper, the nephew ofthe operator, tells me that the patient lived till the year1865, thirty-seven years after the operation, dying then ofbronchitis at the age of sixty-seven ; and he enjoyed goodhealth, and lived a life of great activity and, for some timeat any rate, of great irregularity. There was no autopsy,consequently the exact position of the aneurism was notascertained.

Dr. Sands, of New York, in an interesting paper in theNew York Record before referred to, speaks of this case asprobably aneurism of the carotid only. It is impossible nowto decide the question, but it seems to me more likely thatEvans was right, since, if we look carefully at the notes, we

shall see that the cure of the aneurism did not commencetill the symptoms announcing obliteration of the subclavianhad set in. I have little doubt therefore that the inno-minate was really implicated ; and the facts I have stated,I think, go far to show that in aneurism of the innominate,after ligature of the carotid, should the mouth of the sub-clavian be anyhow obliterated, the cure of the aneurismwould be the natural result if the patient survives.

’

In Morrison’s case, again, there seems no doubt that a.

perfect and permanent cure was effected. The man diedtwenty months after the operation, of disease of the heart,if I understand the account aright. One interesting featurein this case is, that it is almost the only one of the kind inwhich a very great increase of pulsation is noted as follow-ing immediately on the operation. The exact condition ofthe tumour at the conclusion of treatment is not described,but the man recovered sufficiently to 11 labour hard at themaking of charcoal," and dropped down dead quite suddenlyafter a walk, twenty months after the operation, being thenin good general health. The account of the post mortemexamination is as follows :—" The right subclavian arterywas traced to its source, at which point it was partiallydilated. The arteria innominata was double its ordinarysize and studded with spiculæ of ossific matter. The rightcarotid, from its origin to the point to which the ligaturehad been applied, was dilated into a sac, which was pluggedup with a dense fibrous deposit. The portion of the tumourwhich was within the chest was much more voluminous thanthat which rose into the neck. The anterior surface of thethoracic portion of the tumour was firmly adherent to thesternum. There never was a more splendid specimen thanthis, showing the manner in which nature cures this for-midable disease, when assisted by art." The diseased ap-pearances in the heart walls and valves are then described,and to this cardiac mischief the patient’s sudden deathseems to have been due.

Vilardebo’s case, so far as can be judged from the slightnotice of it in the Arch. Gén. de Méd. (ser. 4, t. xv., 1847,p. 547), seems to go, along with Mr. Lane’s case, with thepreparation from St. George’s Hospital (vi. 133), and withmany other of the published cases, to show that coagulationmay be produced in the carotid portion of an aneurism in-volving the innominate and aorta, by ligature or oblitera-tion of the carotid. The notice in the Bulletin of the Acad.de Medeoine runs thus :-

" M. Vilardebo communicated a case of aneurism of theright carotid and innominate, operated on after Brasdor’smethod. In this case, the patient was a negro aged seventy,who had, on the right side of the neck, between the sternalextremity of the clavicle and the lower border of the jaw,an enormous rounded, pulsating tumour. Valsalva’s treat-ment having failed, the common carotid was tied below itsbifurcation. The patient died on the twenty-first day.*On post-mortem examination, the carotid was found oblite-rated at the seat of ligature: the aneurismal sac in theneck had been formed at the expense of this vessel. Strati-fied layers of fibrine, firm and very adherent, covered allthe internal surface of the sac, except at the highest pointof the tumour, where the skin was very thin. A smallquantity of black viscid blood filled the rest of the cavity ofthe aneurismal sac. The latter, which was of considerablevolume, extended downwards and outwards, resting by itslowest part on the right lung, which it compressed, and’inits course it also compressed the subclavian artery. Theinnominate trunk formed a second tumour, much smallerthan the former, springing from the posterior portion ofthe vessel and extending backwards; it was almost entirelyfilled with fibrinous concretions, which left in their centreonly a very narrow channel to give passage to the blood.The aorta was much dilated."Of the three cases in which the subclavian artery was im-

plicated in the aneurism, as well as the innominate, by farthe most interesting to us is that under Sir W. Fergusson’scare, of which the authorities of King’s College have beenso kind as to lend me the preparation; and this case is madestill more valuable by the fact that its history has been re-lated in full, and with a commentary worthy of the import-ance of the subject, by Sir W. Fergusson. In that excellent

* The case spoken of as Rompani’s in Schmidt’s Jahrbueh, vol. [xxvi]p. 236, was also a man aged seventy, who died on the twenty.first day, andalso had a double aneurismal sac. I have no doubt that the two are iden-ticaJ.

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:paper Sir W. Fergusson calls attention to the diminutionin the size of the tumour which followed on the operation,and to the formation of clot, which, he says, was nearlysimilar to what is found in aneurismal sacs at about thesame period after the Hunterian operation. The carotidalone was tied, partly on account of the much more markedeffect produced on the size and circulation in the tumour bydistal pressure on that vessel than on the subclavian,* andpartly in deference to Mr. Wardrop’s opinion, who saw thecase, and believed it quite possible that the ligature of thecarotid might be perfectly successful, and no further opera-tion be required. It seems, however, that the fact, shownby the preparation, that the aneurismal enlargement affectedthe subclavian also, renders this very doubtful; and thecase also illustrates the additional danger which mightbeset the attempt in such a case to secure the first part ofthe subclavian artery.In Porta’s case, as in that above referred to at Boston,

U.S., the mistake was made of confounding a dilated con-dition of arteries, resembling that shown in the drawingfrom a preparation at St. George’s Hospital, for a sacculatedaneurism. Otherwise the case is of little interest, for thepatient died on the second day after operation.In Mott’s case the improvement was so great that it may

be said that the patient was temporarily cured. When thefirst notes of the case terminate, all tumour and all pulsa-tion above the clavicle had disappeared, and the man hadgone home as cured. But the tumour continued to growinternally. The man soon began to suffer from dyspnoea,the consequence of pressure on the trachea, a lobe of thesac having passed between the bifurcation of the tracheaand the arch of the aorta, and he died of dyspncea sevenmonths after the operation. The amount of coagulation inthe sac is not described, nor is the account of the tumoursufficiently exact to enable us to judge what had been the

real effect of the operation. Mott, in his remarks on thecase, regrets that he did not tie the subclavian as well asthe carotid. The disappearance of the upper part of thetumour after the ligature of the carotid appears to supportthe idea that the obliteration of the efferent artery wasaccompanied by obliteration of the carotid portion of thesac, but that this was insufficient for cure in consequence ofthe preponderance of the subclavian portion.We have next four cases in which the aneurism was either

purely aortic, or aortic and innominate, and for which theright carotid was tied-namely, O’Shaughnessy’s, Camp-bell’s, Knowles’s, and Hutchinson’s, of Brooklyn. In thefirst case no time was given to test the effect of the ligature,galvano-puncture being resorted to only a few days after-wards with fatal results. In Campbell’s case there was aconsiderable amount of coagulum in the sac, but the aortawas extensively diseased, and the case was probably in-curable. Hutchinson’s case is both curious and interesting.The operation was undertaken as one of ligature of botharteries. But no pulsating vessel could be found in thesituation of the subclavian, and after death it was provedthat the substance around which the ligature was placedwas not that artery. The subclavian was obliterated; theoperation on the carotid did not check the growth of theaneurism (as I believe it would have done had the aneurismbeen purely innominate), and the patient died in six weeksof dyspnoea,.The table is completed by seven cases in which the left

carotid has been tied for aorti aneurism. These cases

belong to Rigen, Tillanus, Montgomery, S. Lane, Pirogoff(two), and Heath.In all these cases I think there is clear evidence that the

operation was beneficial, except in Pirogoff’s last case,where the patient died from the direct effects of the liga-ture upon the brain.The cases of Tillanus and Rigen are those which are best

known and most universally quoted in proof of the proposi-tion that aneurisms affecting the arch of the aorta may besometimes, at any rate, checked in their progress by liga-ture of the left carotid.The following is what Velpeaut says about these cases :-" It would appear a priori that ligature in the hyoid* It may be remarked that in this case, as in that of my patient, in whom

the double distal filature was perfotmed, the distal pressure produced notmerely a diminution m the size of the tumour and the strength of its pulsa-tion, but also a remarkable retardation in its rate of pulsation.

t Nouveaux EJéments de Méd. Op., 2nd ed., 1839, vol. ii., pp. 243-4.

region might suffice in all the cases in whioh the aneurismoccupies the carotid only ; but that it would be necessaryto join to this the ligature of the subclavian when the in-nominate trunk is itself affected. Now M. Kerst, of Utrecht,has communicated to me two facts, which, with those ofEvans and Montgomery, prove incontestably that the liga-ture of the carotid only may arrest the development notonly of aneurisms of the innominate, but also of those ofthe arch of the aorta." A man was admitted into the civil hospital at Amster-

dam with an aneurism projecting above the sternum.M. Tillanus, believing it to be an aneurism of the leftcarotid, tied that artery a little higher up. The patientrecovered. Five months afterwards he died suddenly. Theaneurism, which occupied the arch of the aorta itself, wascompletely filled with a white coagulum. The preparationis preserved in the Pathological Museum at Amsterdam.

11 In the other case the aneurism appeared in the samesituation, and was on the point of bursting. Believingalso in this case that the aneurism was of the left carotidartery, M. Rigen, of Amsterdam, tied this artery a fewinches higher up, on Feb. 21st, 1829. The grave symptomsdisappeared and the tumour diminished considerably. OnMay 9th of the following year it became necessary to ope-rate on this man for strangulated hernia ; but he died onJune 13th with symptoms of spasm or asthma. The autopsyshowed that the aneurism affected the arch of the aortabetween the left carotid and the innominate. As inM. Tillanus’ case, it was filled with white coagulum andconsiderably diminished in size."

After relating the cases of Tillanus and Rigen, Velpeaugoes on to say :-°° We see then from this that ligature ofthe carotid on the method of Brasdor deserves trial even incases where the aneurism appears to be prolonged down tothe aorta. I must, however, still doubt whether thechances of success would not be notably increased by theligature, simultaneous or consecutive, of the subclavian ;only there remains the doubt whether the internal mam-mary, vertebral, thyroid axis, &c., would not keep up thecirculation in the root of this vessel, and thus destroy allthe effect of the ligature upon the aneurismal sac."Montgomery’s case has been very fully detailed and com-

mented upon by Mr. Guthrie, and he uses it as anotherargument, in addition to Evans’s, to prove that the distalligature, if it cures, cures by producing inflammation in thesac. It happens singularly that Evans’s and Montgomery’scases, which were alone known to Mr. Guthrie, are the onlycases, except that of Hutton, out of the whole twenty-nineoperations in this class in which this event followed. So

dangerous is it to generalise upon the result of one or twocases. Whatever else may be thought of Montgomery’scase, there can be no doubt that the operation was followedby a great subsidence of the tumour.In Pirogoff’s case which survived, the operation was

followed by striking relief to the dyspncea from which thepatient had suffered, and some diminution in the tensionand pulsation of the tumour. The patient quitted the hos-pital relieved in about ten weeks. We can hardly doubtthat in this case, as in Mr. S. Lane’s, the carotid portion ofthe sac was consolidated, and the tumour thus diminishedand its growth stopped for the time.

Mr. Lane’s case is usually quoted as one of aneurism ofthe left carotid, since the aortic portion of the sac was im-perceptible before the operation, and it was, therefore,diagnosed as a carotid aneurism, but the account in the lastedition of Cooper’s Surgical Dictionary (vol. i., p. 215) re-moves all ambiguity. The preparation has unfortunatelybeen lost; but Mr. Lane’s description of the post-mortemexamination states distinctly that the patient died on thesixty-eighth day after the operation from the increasedgrowth of the lower or aortic portion of the sac and itsrupture into the left lung, while the upper or carotid por-tion was entirely consolidated. The aorta in this case wasnot itself dilated, but the opening of the carotid arteryfrom the aorta was; and it is quite evident that it was theentrance of this great stream of aortic blood into the sac

; which hindered the consolidation of its lower portion, andprevented the complete success of the operation.Mr. Heath’s case is the latest in which the operation has

been practised. It is not at present completed, but as faras it has gone it furnishes an ample justification for thecourse pursued. The relief obtained by the operation was

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great and immediate, and there were no unpleasant sym-ptoms whatever from the operation. As the patient happensto be in town, I have asked him, with the kind consent ofDr. Cockle, to at,tend here in order that any gentlemanwho wishes to exa.rnine him may satisfy himself from theman’s own stat,ement of the reality of the relief which theoperation produced. He can now wa,lk fourteen miles inone day, and feels perfectly well. The left side of the chestis quite fl-tt. The tumour is felt pulsating in the episternalnotch, and the right thoracic parietes bulge somewhat for-wards, but the disease is plaillly receding. The patient wasa man aged forty-eight, a fa.rur labourer from Cambridgeshire, who came under Dr. Cockle’s care in January, 1872.He had experienced pain, for four or five years, in the

right side of the head, neck, shoulder, and chest, attributedto rheumatism. In April, 1871, he noticed a pulsatingswelling- in the hollow of his neck, and was in Adden.brooke’s Hospital for two months without relief. AfterChristmas, 1871, he was compelled to give up work, fromthe increasing pain in the shoulder and neck. He presentedmarked symptoms of aneurism of the ascending and trans-verse portions of the arch of the aorta. There was displace-ment of the right sterno-clavicular articulation, with pro-jection of the right and upper portion of the sternum ; andthe episternal notch was filled by a pulsating swelling.There was a strongly heaving and expansile impulse overthe whole of the swelling, and marked dulness on percus-sion existed over the whole area of the tumour. No bruitcould be heard, but a double concussion-shock was felt.The respiratory murmur was feeble or absent over the upperportion of the right lung. The heart-sounds were dull andmuffied, but without appreciahle murmur. There was no

cough or difficulty of deglutition. The left radial pulsewas decidedly feebler than the right; and the left pupilwas much dilated, and the left eye congested. On exertionhe complained of shortness of breath, palpitation, and pain.Mr. Heath tied the left carotid artery above the omo-hyoidon February 26th, 1872. Carbulised catgut was used forthe ligature, and the wound was covered with cotton-wool.No constitutional disturbance followed. Within forty-eighthours the patient could lie and sleep on his right side,which he had been unable to do before. The left pnpilbecame natural. and the congestion of the eye disappeared.On the eighth day, when the dressings were removed forthe first time, the wound was found completely healed bythe first intention. Since the operation, the condition ofthe patient has in every way improved, the chest havingbecome flatter, and the heaving impulse greatly diminished.He was free from all pain or inconvenience.Onr table concludes with two cases in which the sub-

clavian artery has been tied in its third part for innominateaneurism. The first is the well-known case of Mrs. Denmark,operated on by Wardrop. The patient had very clear sym-ptoms of innominate aneurism, and was suffering from mostdistressing feelings of impending suffocation. The pulse inthe branches of the right carotid was imperceptible, and itwas thought that there was no pulsation ia the trunk ofthat artery, though on this the report is less positive. Thecarotid being, therefore, taken to be obstructed, Mr.Wardropthought it well to tie the right subclavian in its third parton July 6th, 1827. "There was an immediate relief in herbreathing, which now became free and tranquil, aud thischange was more striking as during the preceding twenty-four hours she had suffered an’unusual degree of suffocatingdyspnœa.......The peculiar sensations which she complainedof in her head were also removed." The pulsation of thetumour was also thought to be diminished, though its sizewas not. On the ninth day a pulsation became perceptiblein the carotid and temporal arteries, which Wardrop re-ferred with great probability to a diminution of the size ofthe tumour, and consequent liberation of that vessel frompressure. The ligature came away on the twenty-secondday, by which time the tumour was "greatly reduced insize." In the sequel she remained for some time withhardly a trace of the former disease, insomuch that a sur-geon who saw her at the end of August declared that unlesshe had previously been acquainted with the nature of thecase he should not have known that any aneurism existed.At the end of the year she suffered severely from bronchitis,and was treated on the strongly antiphlogistic plan. In

August, 1828, Mr. Wardrop makes the following note onthis head : ° It is important to observe that from the com-

mencernent of my attendance on this patient she has nowbeen bled above fifty timps. to an extent at, each operationseldom less than a pint of blood, and freqnentty to nearlydouble that quantity. Since the ligature of the artery shehas been restricted to about an ounce of soiirl meat daily’and twelve ounces of fluid. Besides these, however, she hasfrequently taken a very small quantity of hrc-ad-arid-butter,and occasionally a little fruit. No tumour was now per-ceptible in the situation of the anenrism, but a hardnesswas perceived there from its condensariorz. She had hadtransient œdema of the feet, but this had subsided, and shetakes exercise in the open air daily." This note was madeon Sept. 9th, 182S. The patient survived till Sept. 13th,1829, when she died of dropsy, and previous to her deaththe aneurism had enlarged above the sternum and np theroot of the right carotid artpry. Wardrop proposed to tiethe right carotid, but was dissuaded, apparently, by someconsultants, who thought the diagnosis wrong. However,on post-mortem examination, the tumour turned out to bean innominate aneurism. "The clavicular and tracheal por-tions of the sac were filled with firm coagulum, the cavity ofthe aneurism being cbiefly limited to the division betweenthe sternal and tracheal portions, and was about the size ofa walnut. The layers of the coargulum were remarkablyfirm, and of a pale colour, being of a softer consistence anddarker colour as they approached the boundaries of theaneurismal cavity." The aorta was healthy.As far as this case goes there seems no possibility of

denying that the patient derived benefit from the opera-tion, though the possible effect of the rigid depletionbefore and after the operation must not be left out ofsight. It is greatly to be regretted that the carotid wasnot tied, for the post-mortem examination seems to haveproved that the subclavian portion of the sac was obliterated,and if she had survived the ligature of the carotid, therewould have been a good prospect of the permanent cure ofthe aneurism as in Mr. Fearn’s case. It is also much to beregretted that Mr. Wardrop did not fulfil the intentionwhich he expressed in his report of this case, of presentingthis very valuable preparation to the museum o’ this College.The only other case in which the subclavian has been

tied on the distal side of an innominate aneurism is thatby Broca, of which full details are given in the " System ofSurgery," and of which it will be suffcient to say that thebenefit from the operation was well marked, and that thepatient’s death was produced by a disease which seems tohave been quite unconnected with the anenristn.There is a case on record (by Laugier*), in which he tied

the axillary for the cure of innominate aneurism ; but thisis not an example which anyone, I think, would now follow.The case is one of great intetest in this respect that thecarotid artery was obliterated, and the subclavian healthy.The patient died from cough and dyspnœa, and after deathextensive disease of the vertebioe was found. As far as theaccount of the tumour enables us to judge, it is verypossible that a ligature placed on the subclavian at anearlier period, before the vertebræ were implicated, mighthave been successful.

OBSERVATIONS ON THE

FOUR CHIEF ORIFICES OF THE HEART.

BY HERBERT DAVIES, M D. CANTAB., F.R.C.P.,SENIOR PHYSICIAN TO THE LONDON HOSPITAL,

FORMERLY FELLOW OF QUEEN’S COLLEGE, CAMBRIDGE.

IN a paper which I had the honour of reading before theRoyal Society in the early part of 1870, I attempted toestablish the existence of a law which determines the rela-tive magnitude of the areas of the four chief openings ofthe heart, and I also sought to show the reasons why theorifices differed from each other in size. I took as thebasis of my calculations the facts given by Drs. PeacockReid, and others, and I assumed-1st, that the four open-ings during the time the blood traverses them are circularin form; and 2nd, that the area of each orifice is un-

changed-constant-during systole and diastole. I propose

li * THE LANCET, 183 F, vo. i., t,, 891.D2