801.

sued ; it had increased in size, and wasmuch inflamed, extending to half an incharound its base. The integuments werethickened, and the whole much firmer to thetouch. I ordered three leeches to be ap-plied, and afterwards a poultice, the latterto be renewed 4tis horis.On the 29th much better ; had only one

convulsion in the night, of a descriptionmilder than he had usually suffered from;the inflammation better, and the tumour

evidently smaller. Ordered hydr. c. creta,gr. viij. h. s. s., and the injection to be re-peated if convulsion returned.

30th. All the symptoms greatly relieved ;the inflammation having nearly subsided,and free from the fit.

April 3. The child was in all respectsbetter, the countenance cheerful, bowelsnatural, and the tumour reduced to less thanhalf its original size ; left off poultices, andapplied the emplastr. hydr. c. ammoniac.

upon leather, over it a compress and band-age. From this date the little boy graduallyrecovered the use of his limbs ; absorptiontook place, and at the latter end of themonth, a depression only was to be seen onthe part affected; the skin a good deal puck-ered, and somewhat tender to the touch.The child remains perfectly well. Febru-

ary 18th, 1837.

CAROTID ANEURISM.

Case of Aneurism at the Root of the CarotidArtery, successfully treated by tying the Ar-tery above the Aneurismal Tumour. ByJAMES LAMBERT, Esq. Surgeon, Wal-worth.

Case of .4M:<rMM at the Root 0/" the CarotidArtery, S!1ccesifully treated by tying the Ar-tery above the Ateeurismal Tumour. ByJAMES LA.IIBFITT, Esq. Surgeon, Wal-Yt’Olth.

N&TWiTnsTANDiKO the treatment of aneu-rism since the time of John Hunter has un-

dergone material improvement, and sur-

geons now unhesitatingly apply ligaturesto the largest arterial trunks of the body,yet there are many cases of aneurism still

regarded as incritabty fatal ; as, for example,aneurisms at the root of the carotid artery,of the arteria innominata, and of the subcla-vian and iliac arteries, when it is im-

possible to adopt the ordinary method ofapplying a ligature between the tumour and

,

heart. I possess notes of many such casestreated in the hospitals of this town ; theywere set down on high authority as 11 also

lutely incurable," and the patients wereabandoned to their fate. That such cases,however, are not absolutely incurable, it isthe object of my present communication toshow.The principle on which an artery leadiii- C)

to an aneurismal tumour is tied betweenthe heart and the disease, is well known tobe that of staying the flow of blood into thetumour, by which means the coagulation ofthe blood within the aneurismal sac is per-mitted, and this blood first becoming con-solidated, is afterwards removed by a pro-cess of absorption ; the sac is obliterated,and the cure thus ultimately effected. Aknowledge of such being the curative pro-cess, was obtained from the actual observ-ance of those cases in which a spontaneouscure was going on. It is, therefore, matterof surprise, that it never occurred to sur-geons that the same results would ensuefrom the application of a ligature beyond thetumour, and that such a mode of treatmentshould be adopted in cases where the arterycould not be secured between the tumourand the heart. For, as Mr. Wardrop* hasjustly remarked-if we suppose a case offemoral aneurism in the middle of the thigh," it is as easy to imagine that the bloodcontained in the space between a ligatureplaced below the aneurismal tumour, and thefirst arterial ramifications above the tumour,should coagulate, as that the blood containedin the space between a Ugature placed abovethe tumour and the first anastomosing pro-cess below it, should undergo the process ofcoagulation." "

It is true, indeed, that Brasdor, and sub-sequently Desault, suggested the idea oftying the artery on that side of the tumourmost remote from the hear, but this pro-posal was acted upon only in two cases;first by Deschamps, in a case of aneurismof the femoral artery; and secondly, by SirAstley Cooper, in a case of aneurism of theiliac artery. Both of these cases havingterminated unfavourably, the operation wasabandoned, and not only abandoned, butdenounced as " absurd in theory, andruinous in execution," whilst others, whohave contributed most largely in moderntimes to the pathology of aneurism, passedover this proposed operation as unworthyof notice. The merit of reviving it wasreserved for Mr. Wardrop; who has, withinthe last eighteen months, successfully ope-rated on two cases of carotid aneurism,by tying the vessels beyond the tumour.tThese cases have been so recently laidbefore the public, and the merit due to

Alr. Wardrop so universally conceded, thatit is unnecessary for me to enter into fur-

z See the thirteenth volume of the Me-

dico-Chirurgical Transactions, in which acase of carotid aneurism is detailed by thisable and scientific surgeon.

t Vide presently olume of THE LANCETpage 395.

_

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802

ther particulars. I may simply remark,that they were cases which, in pursuance ofprevailing opinions, would have been left toinevitable death. Mr. Wardrop has, there-fore, the gratification of having saved thelives of two fellow creatures, as well as of

having established a principle in the treat-ment of aneurism, the future benefits ofwhich are almost incalculable. These factswere strongly impressed on my mind, whenthe following case of aneurism at the root ofthe carotid artery, afforded me an oppor-tunity of practically ascertaining the meritsof tying the artery beyond the aneurismaltumour, a plan of treatment which, it willbe seen from the subsequent account, I

adopted with success.A lady, about 49 years of age, of spare

habit, and unhealthy appearance, consultedme early in the month of January last, onaccount of a swelling in the right side of theneck. On examining the part, I discovereda pulsatory tumour, situated immediatelyabove the sternal end of the clavicle, being Ipartly covered by the mastoid muscle ; itpossessed all the characters of an aneuris-mal swelling, and its pulsations, which weresynchronous with the heart’s beat, were soforcible, as to be visible even at some distancefrom the patient. The tumour appeared tobe of the size of a large walnut; but onexamining it with my fingers, I found thatit was considerably larger, extending someway backward, and, as it were, issuing fromout of the chest. With the exception of itslower part, the tumour was circumscribed,and its boundaries well-defined ; pressureupon it occasioned considerable pain. Theaccount which the patient gave me of theorigin and progress of her disease, wasas follows :-about two years ago, she re-ceived a sudden and violent shock to herfeelings from a most painful domestic occur-rence, and from that period she found, thaton making any bodily exertion, she hadtremblings and palpitation of the heart.These symptoms went on gradually increas-ing, and at the time of her making applica-tion to me, had become so much aggravated,that she was incapable of pursuing her or-dinary domestic employments. On walkinghastily across the room, in the attempt to goup stairs, or under slight mental agitation,her heart became affected with violent pal-pitation, and the respiration was rendereddifficult to a most distressing degree. Whenshe attempted to stoop, she said that she felta sensation of choking, as if something werepressing on the lower part of the windpipeand interrupting her breathing. The samesensation was also experienced on movingthe right arm over the head. She com-

plained of dryness in the throat, with occa-sional cough, excited by a sense of ticklingin the trachea; her sleep was interrupted

by frightful dreams ; appetite was defec-tive, and she had become much emaciat-ed. There were no marked uneasy sensa-tions in the head, but she complained ofdimness of vision in the left eye, and thiswas much increased at those times when thecirculation was hurried. On applying myhand over the pr&aelig;cordial region, I foundthe heart’s impulse to be very great, so for-cible, indeed, that it could be distinctly feltat any part of the chest ; the pulse at eachwrist was vibratory, as was also that of eachcarotid artery. The pulsations of the rightcommon carotid artery, were apparentnearly throughout its whole extent in theneck. With respect to the formation of thetumour, the patient stated, that she first

perceived, some months ago, a beating orthrobbing at the lower part of the neck;this symptom became gradually more evi-dent, until at length a small tumour made itsappearance, which by degrees attained thesize, and presented the characters, I havedescribed.There could be no doubt that the disease

was aneurismal, and apparently affectingthe lower part of the right common carotidartery ; but whether confined to that vessel,or extending into the arteria innominata,was to me a matter of conjecture, for I amfree to confess that I know of no certaindiagnostic marks, by which we can dis-criminate between aneurism at the root ofthe right carotid artery, and aneurism of thearteria innominata, presenting, as it usuallydoes, a tumour at the lower part of theneck. This, however, is not of the momentwhich at first sight it appears to be ; for, asI shall have occasion presently to remark,the operation of tying the artery above thetumour, is expedient in either case. It,oc-curred to me, therefore, that the only chancewhich could be afforded to the patient was,that of applying a ligature to the arteryabove the tumour. The aneurism had been,according to her account, of some monthsstanding; but it had increased more rapidlyof late, and the symptoms had proportionallybecome more distressing, so that a fatal issuewas to be anticipated speedily, unless some-thing was done for her relief. Previousto the adoption of any measures, I thoughtit right to obtain the opinion of Sir AstleyCooper; this I did about a week after Ihad first seen the patient. Sir AstleyCooper discountenanced the operation, andremarked that " it was an aneurism by dilata-tion, which would not increase." I must ac-knowiedge that I was not at all satisfiedwith this opinion, no sufficient reason beingshown why the operation should not be un-dertaken, and I still adhered to my opinionrespecting its expediency. Mr. Key, whosaw the case at my request, thought that. the arteria innominata was affected, and

803

that .the operation was, therefore, inadmis-sible. Similar opinions were entertainedby Mr. B. Cooper and Mr. Callaway, whoalso saw the patient.

In this state of affairs, my own views ofthe case remaining unaltered, I requestedthe opinion of my friend Mr. Wakley, whovjsited the patient, and recommended the ope-ration to be immediately performed, even ad-mitting that the innominata was affected. Ialso consulted Mr. Wardrop, who, on exam-ining the patient, unreservedly declared him-self in favour of the operation ; and, as the

patient was now becoming uneasy at thedelay, (upwards of a month having elapsedsince I first saw her,) I fixed an early dayfor the performance of the operation. Thetumour in the neck had visibly increasedwithin the last fortnight, but the patient’sgeneral health had undergone some improve-ment under the exhibition of bitter infusions,with carbonate of soda, and attention to thestate of the bowels.On the first of March I undertook the

operation, in the presence of Mr. Wardrop,Mr. B. Cooper, and Mr. Callaway. The stepswhich I pursued were nearly as follows: thepatient being placed on a table with her headelevated, and slightly turned towards the leftside, I commenced by making an incisionthrough the skin and cellular membrane, ofabout three inches in length. The incisionwas made obliquely-that is, in the directionof the fibres of the mastoid muscle, and ata short distance to the inner side of its tra-cheal edge. I continued to dissect, layer bylayer, gradually and cautiously, until I ascer-tained by my finger, that I was near uponthe trunk of the artery, when I laid asidethe scalpel, and used a silver knife. The

process of separating and detaching the

artery from its adjacent cellular membrane,by means of a blunt instrument, renderedthis part of the operation tedious, but atlength it was effectually accomplished, andthe aneurismal needle (Bremner’s) was

passed round the artery. The vessel ap-peared to be unusually large, but, in myopinion, was not unhealthy ; one ligature*was tied around it, the ends of which I cutclose to the knot ; the edges of the woundwere brought together by two sutures, andshort strips of adhesive plaster.

I experienced no particular difficulty inperforming the operation ; there was a largesuperficial vein at the upper part of the in-cision, but this I took care to avoid, andthere was very little blood lost. The edgeof the internal jugular vein was seen, but itdid not at all overlap the artery, nor was its

* The ligature (which I employed at thesuggestion of Mr. Wardrop) is known by thename of fisherman’s silk ; it is, I believe,a vegetable product.

distension upon expiration apparent, in theleast degree; the descendens noni waswithin the sheath, and in front of thecarotid artery; I took care to avoid in-

cluding this in the ligature, and with respectto the nervus vagus, it was not seen duringthe operation. The part, at which the ar-tery was secured, was immediately abovewhere it is crossed by - the omo-hyoideusmuscle.The patient underwent the operation with

great fortitude ; she became somewhatfaint, however, towards its conclusion, andI allowed her to remain on the table up-wards of an hour, before I attempted toremove her to bed. At this time she feltmuch nausea; and soon after she was

placed in bed, vomiting occurred, with vio-lent straining, tending, of course, very muchto disturb the parts concerned in the opera-tion. In the evening, as the stomach stillcontinued in an irritable state, I venturedto administer twenty drops of the wine ofopium, which had the effect of quieting thestomach.

Before proceeding further in the reportof the progress of this case, I may remarkthat a diminution in the bulk of the aneuris-mal tumour was immediately apparent onthe application of the ligature around the

artery, and its pulsation was materially less-ened.On the following day, I found that the

patient had passed a comfortable night; thepulse at each wrist was moderate in quan-tity, but that of the right side was full andstrong, as compared with the left. Theheart’s impulse was very moderate; andthe patient, of her own accord, noticed tome that which constitutes an essentialfeature in her case ; namely, that " thebeating of the heart was gone." She did

not even experience the palpitation after,or at the time she was retching violently,although such an exertion, prior to the ope-! ration, would undoubtedly have excitedviolent action in the heart. The ligature,

did not produce any apparent ill-effects onthe brain-the cerebral functions not being,: in any degree, disturbed.l On the third day after the operation, Imoved the dressings from the wound, and alsotook away the lower suture ; the upper part

Lof the wound had united by the adhesiveprocess. The aneurismal tumour had so farsubsided, that it was only evident to the

L eye, by a feeble pulsation at the part ; and,on applying the finger, the tumour wasfelt to be much consolidated, and greatly! reduced in size. The patient was, in everyrespect, doing well ; and she remarked,

that she now slept better than for two

years past, not being disturbed by frightfuldreams.

The patient went on well, and I was al-

804

most rid of apprehension; when, upon visit-ing her en the morning of the tenth dayafter the operation, I found that there hadbeen some bleeding from the wound, andthe blood was observed to be of a red colour.About two or three drachms seemingly hadescaped, and the patient remarked that itissued out suddenly, and she felt it trick-ling down her neck. The upper part of thewound, as I before noticed, had united ; thelower part was suppurating freely, the mat-ter discharged being of a healthy character.As I saw the suppurative process must

necessarily be set up in the lower partof the wound, I had during the last fewdays dressed it with short strips of adhesiveplaster, lightly applied, and over these a

poultice was put. But on the occurrenceof the haemorrhage I desisted from the useof the poultice, and applied a piece of linenrag, doubled and made wet with cold water,over the adhesive strips. I had the grati-fication of finding that the bleeding did notrecur, and from this period the wound wenton progressively healing. The relief whichhad been given to the patient now becamevery obvious, and she repeatedly expressedto me in the most grateful terms, her senseof the benefit resulting from the operation.Although I have at present for obvious rea-sons restricted her from using much exer-tion, she can now bear moderate exercisewithout producing any of those distressingsymptoms under which she laboured pre-viously to the operation. With respect to theswelling, it has entirely disappeared, and allthat can be felt on passing the finger deeplydown, is a small hard tumour having a veryfaint undulatory thrill.The successful result of this case, I trust

will be found to afford an additional con-firmation of the merits of this mode of ope-rating for aneurism. The applicability andexpediency of tying an artery beyond thetumour in cases where the ordinary methodfrom peculiarity of situation could not be Iadopted, were amply demonstrated by Mr. IWardrop’s two cases. But I am not with-out hope that this operation may be renderedstill more serviceable&mdash;that it will be foundavailable in cases hitherto regarded as utterly I

beyond the reach of surgical aid-I meananeurisms of the arteria innominata.If we suppose a case of aneurism of the arteria

innominata manifesting itself by a tumourat the lower part of the neck, let us inquirewhat would be the effect produced by ap-plying a ligature to the right carotid arteryin such a case ? The impulse of the bloodwould certainly be diminished, and more

especially at the upper part of the sac, thecourse in which the disease is extending ;the obvious eitect of an interruption to theingress of blood in an aneurismal tumour isthe formation of a coagulum, and such I ap-

prebend would be the case in the diseaseunder consideration. The diminution of the

quantity of blood entering the tumour, andthe reduced impetus of the fluid would, Ibe-lieve, allow of a deposition of coagulum inthe upper part of the sac, and thus weshould (if I may be allowed the expression)build up the sac at that part where the dis-ease was extending, and prevent its provingfatal from rupture. That the curative pro-cess in an aneurismal tumour will go on not-

withstanding that the circulation of theblood is kept up to a certain extent, is an

acknowledged fact. A case strikingly illus-trative of this important point in the patho-logy of aneurism, is mentioned by Mr. Hodgson in his excellent work on Diseases ofArteries. It was a case of aneurism inwhich the femoral artery was found dilatedinto a sac, which was lined on all sides withvery firm layers of coagulum, and in thecentre was a small irregular canal, throughwhich the circulation was carried on. Nowif such curative process as this was per-mitted in the femoral artery, while thecirculation was maintained, it surely will beadmitted that the coagulative process mightoccur in the upper part of the arteria inno-minata, and at the same time the circula-tion through the subclavian be carried on.

I am sure it would have been difficult for

any man to assert from his knowledge, thatthe patient whose case I have related wasnot affected with aneurism of the arteria-innominata. And knowing that there wasso much doubt on the case, I was led to re-flect on the propriety of operating, suppos-ing it to be proved that the arteria innomi-nata was affected, and I came to the con-clusion that the operation was admissible insuch a case, for the reasons I have mention.ed above.There is a curious fact in the history of

the patient’s symptoms subsequent to the

operation. I mean, the cessation of theheart’s inordinate action. It will be re-membered, that violent palpitation of theheart, on making the slightest exertion,formed the most prominent and distressingfeature in her complaint; this symptom en-tirely disappeared after the operation.*

Since I have performed the above opera-tion, a second case has fallen under my no-tice, in which I have also recommended theadoption of a similar course.

’ Dr. Parry in his Elements of Patlio-logy, remarks that an increased quantity ofblood in the heart will often occasion its ac-tion to be diminished, and that when. thepulsation of the carotid arteries is full andstrong, if strong pressure be made on oneor both arteries, the action of the heart willbe diminished ill force and frequency.