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Medical Societies.ROYAL SOCIETY OF MEDICINE.

SECTION OF SURGERY.

A MEETING of this section of the Royal Society ofMedicine was held on Dec. 7th, Mr. RAYMONDJoHNSON, the President, being in the chair.

Sir CHARLES BALLANCE read a paper on

Ligation of the Innominate Artery for InnominateAneurysm.

Four of his own cases were described. ICASE I.-Female, aged 60 years, who had had syphilis.

She had deformed tibia and an old iritis. There was a

pulsating expansile tumour rising from the superiormediastinum above the inner extremity of the right clavicleand the suprasternal notch. Radiographic examinationshowed that the aneurysm was limited to the upper portionof the innominate artery. The pulses in the right arm andright carotid were markedly weakened. As there appearedto be a portion of the innominate artery not implicated inthe aneurysm, it was decided to explore the mediastinum,and tie the proximal portion of the artery. This was doneon Dec. 31st, 1918. The aneurysm was reached through amedian vertical incision, in the lower part of the neck, witha transverse incision across the upper part of the sternum.The muscles were detached from the inner part of the leftclavicle and the left portion of the manubrium, and theinner extremity of the left clavicle, together with the leftupper portion of the manubrium, were removed. The pleurawas pressed away and the upper part of the arch of the aortafound by dissection in the fibro-fatty tissues of the medias-tinum. The proximal unexpanded portion of the innominateartery was then easily traced and ligatured with two strandsof kangaroo tendon tied in a stay-knot, without rupturingthe inner coat. Pulsation in the aneurysm ceased at once.The wound healed by first intention, and in six weeks’ timethe aneurysm had shrunk much in size and become solid.The right arm was troublesome at first, being cold andpainful, but improved slightly, although pulsation couldnot be detected in any vessel. In January, 1921, the rightarm had completely recovered, the two radial pulses beingequal. A large vessel felt crossing the right posteriortriangle of the neck was thought to be possibly an enlargedtransversalis colli artery. In May, 1921, the patient wasreadmitted to St. Thomas’s Hospital with severe albumin-uria, ascites, and oedema with cardiac complications. Shedied on June 6th, 1921. The autopsy revealed a largeinfarct in the long which was the immediate cause of death.The large vessels at the root of the neck were dissected outand distended under pressure. Sir Charles Ballance showedthe specimen ; the artery was obstructed at the site ofligature, the aneurysm had disappeared, its remains beinga mere fibrous mass. The greater part of the right subclavianartery was patent, and circulation had apparently beenre-established through the branches of the first part of thatvessel. The transversalis colli was not enlarged as hadbeen supposed.CASE 2 was reported fully in THE LANCET, 1902, II.,

p. 1180. Sir Charles Ballance recalled its salient features.The patient was a man, aged 35 years. The aneurysminvolved the bifurcation of the innominate artery andextended some distance into the right side of the neck.The patient had previously undergone a course of Valsalviantreatment. The proximal portion of the innominate arterywas exposed on this occasion by dividing the manubriumvertically in the middle line, and transversely at the level ofthe upper border of the second costal cartilage. This portionwas tied with four ligatures of goldbeater’s skin tied in twostay-knots. The patient died 30 hours later, after exhibitingsigns of a left hemiplegia. At the autopsy the great vesselswere removed and preserved. The right common carotid,internal carotid, and middle cerebral arteries were found fullof clot.

CASE 3 (a case previously reported in 1912 to the ClinicalSection of the Royal Society of Medicine).-In a clerk, aged43 years, the aneurysm involved all three parts of the rightsubclavian artery. Sédillot’s operation was attempted, butabandoned on discovering the nature and extent of theaneurysm. The upper portion of the manubrium was thenremoved and the innominate artery exposed and tied in astay-knot with kangaroo tendon. Pulsation in the aneurysmceased at once. The right arm was very little affected andthe tumour slowly decreased in size. The patient could,unfortunately, not be traced subsequently.

CASE 4.-A man, aged 35 years, who had had syphilisseven years before, seen in 1909 on account of a large andincreasing pulsating swelling in the right side of the neck,diagnosed as aneurysm of the bifurcation of the innominate.As the condition was progressing in spite of rest in bed, itwas decided to operate. A portion of the manubrium wasremoved, together with portions of the left first and secondcostal cartilages, and the proximal portion of the innominateartery exposed. As the ligature was about to be passedthe aneurysm, which was being pushed aside by the fingers,ruptured. Sir Charles Ballance controlled the haemorrhageby passing his fingers into the aneurysm and plugging theinnominate, and the vessel was tied with kangaroo tendonand a stay-knot. The patient died 30 hours later, and thespecimen was not obtained.

Surgical Aneurysm of the Innominate.Sir CHARLES BALLANCE showed a specimen (K 0.1507)

from St Bartholomew’s Museum as typical of surgicalaneurysm of the innominate-i.e., one involving thebifurcation of the artery whilst the proximal portionremained unexpanded and available for ligature.Anatomically speaking, ligation of the innominateartery should be a cervical operation, but from apractical point of view it was advisable to removebone so as to obtain a clear and free exposure of theparts. The amount of bone to be removed variedwith different cases. He had found the operationnot very difficult, although he would not go so faras the late Sir W. Mitchell Banks in describing it asa " mere surgical amusement." In 1915 Thomson(" Annals of Surgery," vol. lxi.) had collected 52 casesof ligation of the innominate for subclavian aneurysmwith 16 recoveries (30-7 per cent.), and five furthercases had since been reported, with two deaths,whilst in one of the non-fatal cases pulsation reap-peared in the aneurysm in three weeks. Sir CharlesBallance wished particularly to emphasise the follow-ing points :-

1. That cases about to be submitted to operationshould not be previously treated by the method ofValsalva.

2. That there was a group of cases of aneurysm ofthe innominate artery (aneurysm of the bifurcation)which were suitable for proximal ligature. Distalligature caused the aneurysm to become a diverti-culum of the aorta and so increased the pressurewithin it, and should not be done when proximalligature was possible.

3. That the presence of the aneurysm necessitatedremoval of a part of the manubrium in order to gaina free and clear exposure of the vessel below theaneurysm.

4. That the ligation of the innominate might besafely and surely accomplished if the ligatures weretied in a stay-knot without rupturing the coats.

Sir Charles Ballance added that the tension in thewall of a vessel varied with the size, thus explainingthe prevalence of aneurysm in the aorta and otherlarge vessels. The tension in the large vessels wasmuch greater than could be explained merely on thegrounds of the higher blood pressure in them. Whena fusiform dilatation occurred the tension in thewall of the vessel was still further increased, thusexplaining the tendency of aneurysmal swellings toprogress. The same factor occurred in steam pipes,and lack of recognition of the influence of the sizeof the vessel on the tension within it frequently ledto bursting of the larger boilers in the early days ofsteam power.

Discussion.

Sir CHARTERS SYMONDS said he also had ligaturedthe innominate artery. The case had not beenpublished, although a brief account of it could befound in Jacobson’s " Operations of Surgery." Thecase was one of aneurysm of the second and thirdparts of the subclavian. The first part of the vesselwas exposed by a cervical incision and two attemptsmade to ligature it, both of which caused severe

haemorrhage. He then decided to ligature theinnominate artery, which he was able to do from theneck without removal of bone by making gentletraction on the common carotid artery. Mild suppura-

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tion occurred, and several pieces of catgut and oneof silk were discharged from the wound, but thepatient made an excellent recovery. The aneurysmbecame quite hard. He had also ligatured the rightsubclavian and common carotid arteries for aortaaneurysm causing pressure on the trachea. The

patient was relieved.The PRESIDENT inquired why Sir Charles Ballance

used kangaroo tendon.-Sir CHARLES BALLANCE

replied that he had found that kangaroo tendonremained unabsorbed for 80-90 days, a period whichcould not be obtained by any method of preparingcatgut.

Sir G. LENTHAL CHEATLE described

A New Operation for Inguinal HerWa.Several cases in quick succession presenting diffi-

culties in the efficient excision of the sac had led himto devise a new method by which these and othertroubles could be easily and successfully dealt withwhen they arose. He approached and reached theback of the inguinal canal from a middle-line incisionin the lowest part of the abdominal wall. Unlesscompelled by some complication he did not open thegeneral peritoneal cavity, all the work being done ina space made in the subperitoneal tissue. He hadoperated in this way upon 41 patients. In the firstnine all the incisions were longitudinal ; in the

remainder he had traversed the abdominal walls byPfannenstiel’s method.

,

The patient was placed in the Trendelenberg position andthe operator stood on the side opposite the hernia. Atransverse skin incision 4 or 5 inches long was made 1 inchesabove the symphysis pubis, with its centre in the middleline. A similar incision was made in the aponeurosis ofthe rectus abdominis of both sides, care being taken notto injure either linea semilunaris. The linea alba wasundercut upwards and downwards to within one or twoinches of the umbilicus and to the symphysis ; in doing sothe sheath of each pyramidalis muscle would be opened.The opening thus made in the aponeurosis was retracted upand down, and the subperitoneal tissue exposed by separatingthe abdominal muscles in the middle line. The peritoneumand its contents were then pushed up on both sides, and, ifnecessary, kept up by packing. Two retractors were

inserted on the side of operation. The retractors shouldhave long, separate and blunt prongs. The lower retractor,by far the most important instrument in the operation,should pull the abdominal wall downwards, outwards, andforwards to lift up the abdominal wall. Its prongs shouldreach the deep epigastric artery and vein. Nobody shouldproceed with the operation until he was satisfied that thisretractor was in its proper position. The upper retractorpulled the structures outwards. After more completelypushing upwards the outer part of the peritoneum andthoroughly exposing the iliac fascia it would be possible tosee the neck of the sac entering the inguinal canal. Thedeep epigastric artery and vein were then delimited andseparated from the inner part of the neck of the sac. Cheyne’sdissector was a very useful instrument to use for this pur-pose. The spermatic veins and vas deferens with its vesselswere found and separated from the whole length of theexposed sac. These structures were usually on the outerand under surface of the sac. The sac having been clearedit was pulled out of the canal by gentle continuous tractionin the direction in which it lay. If there were no indica-tions of the possibility of its easy extraction the sac wascut and the canal portion replaced. (Congenital herniaewould belong to this type.) The neck of the sac, includingpart of the parietal peritoneum, was then transfixed andremoved. Finally the inguinal canal of the opposite sidewas examined, and if abnormalities existed they weretreated on the same lines. He had only once had to ligaturea vessel in the subperitoneal space, and that was a smallbranch of the deep epigastric vein.

Sir G. Lenthal Cheatle then described the com-plications and structures with which he had met, theherniae he would avoid, and the herniee he wouldselect for this operation. He had found and removedunsuspected and potential hernial sacs from theopposite side in three patients. In others he hadcleared from the internal opening of the canal firmlyattached dimples of the parietal peritoneum. Inothers he had removed fibrous cords that passed fromthe parietal peritoneum into the canals. In one

patient the urinary bladder occupied the canal and Iwas practically a part of the neck of the sac. The (

peritoneum was peeled from the bladder and thesac was radically excised. When he met this com-plication again he would distend the bladder withfluid. This would render the separation of the

peritoneum safer and easier. In seven cases hefound the urachus which bore the same relation tothe sac as the bladder. The urachus was traced toits union with the bladder ; it contained a good dealof unstriated muscle, very tortuous patent arteries,and some fat. In a few patients he had tracedadhesions between bowel and sac, and omentum andsac into the general peritoneal cavity which he hadbeen compelled to open to clear them satisfactorilyaway. The herniae in these instances appeared to bereducible before operation. The obliterated hypo-gastric artery was recognised in the sac in three cases.In one of these the lumen of the vessel was notobliterated at the point of section. Sir G. LenthalCheatle said that from one patient he removed asmall sac entering the canal, and missed a muchlarger one that was plastered against the iliac fasciaand outer part of the inguinal opening. It was thismistake that made it so essential to expose the iliacfascia. In another patient he had the followingunfortunate experience. He had removed the sac onthe left side and found an unsuspected sac enteringthe internal ring on right side. He congratulated him-self on removing these two sacs from the same opening.In six weeks the patient returned with a directhernia on the right side. Rightly or wrongly, heassociated his operation with this new hernia, anddetermined to take Mr. Victor Bonney’s advice andadopt Pfannenstiel’s method of traversing theabdominal wall. As an unusual complication SirG. Lenthal Cheatle mentioned that through the sameopening he had removed an appendix from a patientwho suffered from appendicitis and inguinal hernia.The herniae he would not select for this operation

were direct hernia, irreducible enteroceles, hernia inmale children under 7 or 8 years, and old herniae inwhich the opening has been dragged down oppositethe external ring. The herniae he would select werethose in females of any age, and all uncomplicatedinguinal herniae in males over 7 or 8. He would notexclude irreducible epiploceles. He had approachedfemoral herniae by the same method, but the caseswere too recent to be quoted as successes as yet.

Mr. McADAM EccLES inquired whether the patientshould be regarded as cured by mere excision of thesac.-Mr. PHILIP TURNER said that he consideredexcision of the sac cured almost all herniae, with onlya few rare exceptions. In his practice he nowrestricted the operation to excision of the sac, exceptin cases of obvious weakness of the abdominal wall.This he had been led to do by the success of thatoperation in children, and he now considered itequally successful in adults. Sir G. Lenthal Cheatle’soperation had the great advantage of rendering bothinguinal regions accessible, and he intended to givethe procedure a trial at the earliest opportunity.

MEDICO-PSYCHOLOGICAL ASSOCIATION OFGREAT BRITAIN AND IRELAND.

THE ordinary quarterly meeting of this Associationwas held at the rooms of the Medical Society, London,on Nov. 22nd under the presidency of Dr. C. HUBERTBOND.

Dr. BEDFORD PIERCE, the chairman of the com-mittee who have been revising the Handbook onMental Nursing, presented to the meeting the revisedhandbook, setting out the improvements which hadbeen effected. The cordial thanks of the meetingwere accorded to the committee for their labours.

Dr. M. HAMBLIN SMITH, medical officer, H.M. Prison,Birmingham, read a paper on

The Medical Examination of Delinquents.He said that John Howard’s book on prisons in theeighteenth century showed that the medical sideof prison administration was, at that date, practically