-if IMAGE EVALUATION TEST TARGE/ (MT-3) k A ^/ /. f/- «» <- 1.0 I.I IM I2J 2.0 lis |40 IL25 i 1.4 1.6 ^ I *fl #*<.^ v -V Hiulugi'dplik; Sciences Corporation 23 WIST MAIN STREET WEBSTER, N.Y. 14580 (716)872-4303 S',- /.. ? /I^> '#^4 v.^ ^ (meaning "CON- TINUED"), or the symbol V (meaning "END"), whichever applies. -« Maps, plates, charts, etc., may be filmed at different reduction^atios. Those too large to be entirely included in one exposure are filmed beginning in the upper left hand corner, left to right and top to bottom, as many frames as required. The following diagrams illustrate the method: Les images suivantes 6nt ^t6 reproduites avec le plus grand soin, compte tenu de la cOnditi.on et de la nettet6 de l'exemplaire filmA. et en , conformity avec les conditions du contrat de filmage. 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Les diagrammes suivants illustrent la mAthode. 1 2 ff-"^ 3 •• •v D 32 X 1 6 I. .^ ¥i '- ' THBllRTERp .-x^': Bf LIG ATUEEjb f THE MGHKIOHHB^ .CAKmD-iBrm. ,^ i* B*-™ •y-% ■.^*--- h-».,%SCM THE TREATMENT ' ^ ^ \ \ OF ANEORISM OF THE ARTERIA INNOMINATA BY LIGATURE OF THE EIGHT COMMON CAEOTID AETEKY X X J40N'EEEMrt= Printed at the Medical Chronicle Office, 42 St. Francois Xavier Street. >jiAiiu&!jii,.i,2£LvA-.»*nW*«.,, . ..ii^t;..ftvii^i-j.. v^ .^' f >l* r \ • \ - b^.-..-^' ^ ". ''^..^'/ ■■.. y^ ' ivtiiy. ^&' \, ■. f-.,.,. ,;A-'ft.Jir;;V-..i«* r.-tS&a,4j,;': . ..•:.. .-.- '. -iJ»-^ , • > t V « \ , . / « V '^ 'a i - % ' ^ , * *** r ,v J! ■ \ '■''.'tf .f. • ,7- \ « , . .« \ \ • f • « \ 3 \ ' ' '^' •'■% ■^^' iS» ! ' THE TREATMENT OF •A. ANEURISM OF THE ARTERIA INNOMINATA. , BY LIGA-FURE OF THE RIGHT COMMON CAROTID ARTERA *. ! The treatment of aneurism by the Brosg6renn operation' is pecnliar to modern surgery. Sixty years aj^o it was iinkiaown. Its eaf^iest re- cord is in the '^-^lecueil periodique de la Soci6t6 de M*dccin de Paris" for 1799. It is there stated that after a lengthened consultation upon an aged citizen, afflicted with an inguinal aneurism of great siKe, two-thirds of the members, among whom were Allan, BraSclor, Boyer, and Cor- visart, advised tieing of the femoral artery. The ligat.ire was applied, but no benefit was obtaiued, and the tumor enlarged. In this case the operator was Deschamps, and in proclaiming the fact, he informs us, that although he was the first to put it into practice, the- principle was not his own, but emanated with the gentleman by whose name the ope- ration is now conventionally distinguished. He says: "lam the first who has been bold enough to tindertake this operation, hut not\he first to propose it, for a long time ago the late dlrasdor first proposed it ohilly." Since then it has been performed not only upon the femonil, but also upon the subclavian aqd carotid arteries. With what frequenpy is, however, unasc^lpftble, for its statistics have been vationsly and in- , completely regi^pfa. In Velpeau's Operative Surgery, the operation's up to 1845 inclusive, are numbered at 19 ; and in Erichsen'is Surgery, a much later work, they are reduced to 17 ; wliilo both statements are so imperfect, that each notices examples not comprehended by the other, and neither includes instances of inguinal alieurism. The opinions en- tertained of its merits have also been confiicting. Mr. A. Burns de- nounced it as « absurd in theory" and " ruindus in execution ;" but he was too hasty and generalized from the issiio of a single Case, for iiji to 1811, when he wrote, Deschamps was without a rival." Seventeen .'V. , „ . •Re:P'lnted fr«n the Midwal thronicU for Inarch, 1856, being obBervatipus on tlfi« aub- lect, with • cMetcoamMiiiicatMi t»ll»t Joufital by WiLti aW W»idttJr,'M.'D., L.R.C,S.E,. Profeawr of Materia Medica.UmTCftityQf M'Oill CoUegi);;9oar8, as seen by Ihe light of t he origiii^twrit^ri, display a party tendency. Mr. B. Phillips, in 183 » , doubted whetherthe operation faftA ever been successfully p^rforilied,- and M. Tarr&l, in 1834, with more trnth^on his side, declared, in direct contradiction, that the operation had t^n *' completely successful," and was *' indisputably established.'* Subeequently more, modified expres- sionsiwere vea(ured,and the professian, generally, became^hary in iheir encomiums. The animus thus mimifested grew with time, W that at the present day Piirj^'s conclusion may be received as a correct irefiec- tion of popular estiipation, that " certainly this mode of treatment has not gained the favorable ppinipii of t|ie profession." The reasons for this might readily be shown, but these, with further general considem- tions, would be too obtrusive in a communication intended to consider the question of operation, soMy, as it relates to ti^eurism of the innomi- nata, treated by ligature of the right common cart tid artery. j_ This question may He profitably examined iroin pdnts of view difierent to those oustomarily adopted } iirom views that wili enable us to ascer- tain whether in cases of failure fhe result be due to inadequacy of the ; operation to accomplish the purposes/or whAsh it was performed.--or to j dangers incuned by the^ligature, independantly^f the cajise necessita- j ting its application — or to the prejudicial influence of otheir circumstances j co-exi«tent with the aneurism. And thus we tnay, secondarily, deter- 1 mine%hether the operation can be justifiably resorted to in any case, erj whether it should be wholly {voleribed from future, repetition. Hitherto there have only been recorded, in Enj^ish periodicals, lOj cases of aneurism of the innominatai, treated by ligature of Ihe right com-f mon oitrotid. In accor^fance ipriij^ the objects above, expressed these may be arranged Under 3 olasses. Istly. Cases in which the operation was suocesffiil, and tha patient survived three months or lenger. 2ndly.' Cases in which the operation was soceessfiil, but death ensued within ' three montha after. Srdly. Cases in which the opemtion was unsuocess- tat In these distinetions the word mcou^ui is used hr jeftr^noe to the alterationis produced by the ligature upon the ^^neurism— ttythe obliteraci N it thra bavin Three secon thelo their, thati Thes< Dida: moj^ plish( of sn* time, stabil Ungil ^ a Ope l.Uvi an 3. Mi 3. In T moD mor pr«8 h med tun has eve the end fied bee lat( inl ('red .i.f. N tiae on aneuristil r the inneminatal arteries. 'In /this lou the former) and" be «ulbqrobsW; f the braocKgl of iraor, likely ito be- \ manner applica- sen 'by Ihe light of J. Phillips, in 1831, issfully p^rfornieil; declared, in direct ily ■uccessful," and B^ modified expres- inmfesphary in their th time, "8<^ that at as a correct feftfc- e of treatment has ' The reasons for general, considem- uteuded to consider rism of the innomi- artery. j^^ its of view difierent enable us toascer- ioadcquaoy of the as performed— or to ;he cajise necessita- | otheArciroumstaiices j , secondarily, deter- 1 ed to in any case, or, repetition. iglish periodicals, 10| ure of the right oom-f )ve. expressed these which the opeMition Ivor longer. 2ndly.' eath ensued within ation wa* nnsuoces«- d hrjrefinn^noe to the ifuh— tythe oblitoia^ tvi citWitetioh fgqta^ -: • ■ -. . . . . ■ . Lii ' it thi^gh the carotSd^th4 ^i^ r^^ •».**«»• *^ '^LT^^ having fiilfirted the immed^le dq^t. fo» wJuch H '^M^^T^^*"* Three months lire m^lected ait period ^^^^'^^'^''^^^ ^^ second classeii because it is saflBciently k»g to dlow of ^'''^J^^ the local effects of t^e oV^r,^^on,nnih6o^vm^^J^^^^ their, account the cause of death beeomet embwia^d inttrttie J«»0'»nf that it may depend upon, or be in some way eonnecM wiOi thenh Th^a-Jdipti^* a;/:„pport.d by ^ r'^^^^^'J^V^.^t biday, the former say!> wheneTer eoagolatlo^ of -ttie Wood to ^^. mordoes take pMce, Iben the core of aneariim my be "^iZ-^^r*^": Sed." And the latterhas toed upop foot in<«thtaejheto»^pc^mt Tf success or faikrte-fot the reason given above,! h*voteduoed Ae time, and because an additional month only serves to afford a hUle more stabiUty tothe changes previoujly established. • CLilSS I. 8- Lfengihiof LiA) Oftention. Delmy in Mm- nwmoi Ligature. U>cal Aoekteiui l.UvingByean ■iter. 3. Mmonthi.^ 3. 1 months. Cot away on 7M 31 St day. SSib day. ^%>ccliisiTa inflamnwlioii of arteries (tfrighl ann. Non^ , None. • Ainttorcm«- iMlDikftein SMtoCaioUd. Mod* of ObUiMaiioik of Faiifocu Do. Do. Fibdllktiaak Do. Dm Sargaon. 9 MoRiMHtof Ayres. MottofNaw 124 Year. 189B US* ^ ' - — -^ — — ■ — ^ ■ ■ These are the only cases that faU un^er this cta8S,and their testi- mony on behalf of the opemtion is certainly favorable, but to set forth mo^MlY the effects of the ligature upon „the disease than can be ex- pr«saed.in a table, the following question may now be oxatoined :- Inffhatconditumis the aneurum flacmi 6ylA« aperaHimf The im- mediate effects have been rather dissimilar in diflfewnt^eaSei^thns the tumor has been evidently diminished, (Mott) while in the majority there has been no appreciable decrease in iU sim. In uone has enlargement evet been produced, thus disproving an, opinion enterUmed by some that the operation might induce such an over;distention of thejaoas would end in rupture> Xhe pulsations have also, at first, been varionsly tncdi- fied; generally speaking they were not lessened, but- On one occasion became unusually violent fMorriaon). Tkese primary effisets sooner or later, after thirst day, w^re succeeded by signs of iiicreasing herdness in the tumor, weakness jn iU pidimtioiii, obscurity irf it»«ii«palisions,>Bnd rreduotiOH 6f ite bulk. ■ These latter changes are highly interesting, to ^lifiy den..tft that the solidification of Oie «^Pettgg°*i^P'0<»*<^»'8' '^^ :.". -/• carotid wa.Ue4,andyettheiunomLtitroX f J 'T*"!' '''^ to be nearly .filled wiUi pletty ium cIoteTfih • ' !^ ^'' ^^fi'-wd suchasaremetwfttiaJ^J^™^'^,,^^^^^^ 'Z' similar to tern shreds called polvm Z^ru ^' different to the poftt mor. - ^^tiongoesonZu^ , X^^^^^^ pUedaiounctthe V^^lm ike^C^J, f.,^' li^ture had beenap- corroborated by the case lastcitedTh«'°°'- ^hw i- strongly adds that the clots were rtS ^'^^««^^f "' wrgeon in hisrecitaJ would befound-abTuTthrL^^peTr^^^^^ like those that has beea performed." The^lr^" .^u r '^ ^"'»'«'«° operation riable. I W not met wLT^'^ t^l^^^^^ vened. At a period still Tnr ^ ^.'^ "^^'"^ ^^""^ ^^ not super- ternal tumor isTundt ^aTe 'ZT^: ^ ""' "'"'^ *°' *'^-- signsofaneurism cease to ni^ovembll^ dj^Ppeared, and the visible . in the casesabove tabnlate^-lrSs r«««^''.'^"*^«'^°*'^^^^^ a walnut, and, in Mott's the sL« Ar l^^ *""^' ^"^ «" large as appearan;e wis pTrJe t-'n C's^ o^^ '""^^ 't«dis- Evan's, rather mo^e sLyTul^'i^^.tlt^^^^^ - complete, or, rather, was lol so pZ^ed t S wT "^ "°* ^ aneurism of the right camtui i^L """"cea, as there was a concurrent may readily be cone Lre't^a^^^^^^ ^'T'' '"^ *^« *""- ^^ thearieurismin the chest areJ? "'/^**'"'*^°°''^°°"«°t^ with to describe i^en^Xr^XTZ^JlT^JZ' '"" ^"^^ ^' -'« --X bywhichtheycanbedemortmted SI ''"°"°*'"^°^^^ -increasing hardness, aTdec^^L^^ir"^r "^^ -l^^fi«<* ble that the changes blgun pro^Z a^nd taTaV^^^^^ 'l *''«'"^ P"**" zation occur in the fibrrnou, aS ^^^ "**'^*^P*'««esof organi- cured byeither comp' Z^^^ -Uced in aneurisms thod. In Morrison's ca^ th« in„ ,T f*" ope«tion, or other mo- held, the arteria i^oS.a ^'fo!"ir ? ^"^f «* *^*"^°'*«- -«« proper hulk, instead o7r«TarrtuZTK""*^ *° ^''^^ *^^«« i*- .ni»,SS* "" *""" "'"«"' •"«? '«"«»■ .he vcJume of ™™.™,., ciltaUon. ., ° "'° «'>n"»'K>n of Mood Mw«ed io in oil. eroiag theincep- y the London Mf- i7 days aftar the says, «waa found * * similar to ' to the poftt mor- row is, that coa- ^re had been ap- Th^ is strongly >on in his recital re like those that iterian operation changes is inva- had not super- 3rred to, theex- >and the visible rikingly obvious was as large as in both itsdis- >eration, and in ice was not so iS a concurrent the tumor. It 'onneot^d with iy it were easy lal observations ibove specified ' highly }noba- lasesof organi- t in aneurivnis ) or other me- lt mortem was thin twice its 9 it extended nina, and the I the preced- finnominatal the sac. td in its oif. 4. This process ensues as favorably as when induced by auy other operation, either artificial or natural. CLASS II. Aye. 61 66 48 47 Time of Deaih •fler Opentioa. 4 Uoora. Tlh Day. 19th Day. 66t^DBy. Cause ot Dealh. Organic Syncope. Pneumonia. Pneumonia. Uleemi into Tr^^ Broncl ncllM. State of Aneurism After Death. More than half fiiled with consolidated fibrin. Sac diminished in size, and ailed with oloia of fibrin. Sac sPghtly diminished, and nUed with a mass of straU- fied fibrin, weisUnff ^ os. Ttnnor diminished. Coagu- lation had occurred, bat saUMqB«aUy had broka down irom pus of inflamed Sac Sergeon, Key of "*■■ London. Feiigusson of Lontlon. CampbeU of Homreal. Hnttoii. Year. isaoi,"!"- 1S41. 1846. ^hese cas«^it will be seen, substantiate the «1educUops that have just been made. But they are chiefiy interesting from the information they afl!brd, m reply to the qupsUoB :— ^ "" mey Ik>e$the operation entail any spedai danger,? These case^, taken in connexion With pthers in which the carotid artery was tied for innomi! wi r''"''°'rr*^*^"-*'"*^''°' *^« operations have been m9 owed by an early death. In the three that aYe fin.t detailed, the & terminauon IS to be referred to interruption in the circulation, produced by the obliteration of the vessel. In Mr. Key's c«,e this ^^. tekab^y evident. In ,t there was an abnormal conformation of the X ctdel t« • r*"*'''J5,^^i* *^° »"-i'^«'y k--»' -ould have ^rt c uded the opemuon. The b«Mn was freely supplied by only a single artery, and as it afterwards appeared, this was the one ligaturedL /he compem«tion which under the normal disposition wouW l^v£ been afforded for its oUtruction was withheld, for'^e vessels that rlma^eS natur! Th' 7"°°P« *^' "taenia supervened of an irremediable nft ^;« ^T'"T T °°* "-^^ "^"^ °^ ^^'^^ fo' had this lesion not been present, and had the same opemtion been executed, a similar nTbT. r'°"'"^'- ^'^ 'J-th. then, was due to the ip^m" ^ ral^r /J ^"^ "'^ "P""*"**'* ^°' aneurism, but because it was an ope' ration upon the con^on carotid artery-not on account ofanyspecbl t^t would have been as surely met, had the vessel been tied for ^^ rtr,ri^°*^t'"""-. I»--«^-llyal«urdtosuppo«,tt: -^^^^t ^g the an ,„ i„^ w««4n.tr««e«t.l » p«J4.g the- coarctation of the lefl.««tid and vertebral axteriet that existed. U the same manner the two deaths that next follow are to be ascribed to pnen monia induced by ligature of the common carotid— essentially to the ligature, and not to any influence caused by the coincidence of aneurism. Without this explanation, it must be assumed that death was, jn some way, caused by the aqeurism, as for instance, by the changes updepw^ent, since the tumor, from being "Soft, mobile, and yielding, was^converted into a hard, incompressible and ponderous mass ; and in this latter state would exert, as might be supposed, by its presence in the chest, an amount of pressure on the contiguous organs of which it was incajiable in the fluid condition. The details, however, of the cases do not agree with such a view. In Mr. Fergusson's case the pneumonia wasconfin-' ed to the middle lobe of the left lung, while the rest of the pulmonary - structure was perfectly healthy, and the tumor had not pressed upon either the lungs or their nerves, nor had it displaced the bronchi. In Dr. Campbell's, again, the tunior had produced compression, but it was upon the superior part of the right lung which was simply condensed in subtance, while the inflammation was seated, not there, but, in the left lung, « posteriorly and inferiorly," where there was nb^ressnire at alh The truth these facts teach, is what was to be expected; for iit thelib- stract, the pernicious influence of the tumor was alike both before and after the operation, since aside from its density, its positive bolk and occupation of space wore similar at both times. The history, too, of intra-thoracic tumors, generally', evinces no tendency to the pniduction of pneumonia. When, also, thoracic aneurisms are lefl to take their course, pneumonia is neither a complication nor a termination. Upon- these grounds it may be concluded that the aneurisms were not the cause of death. Returning, then, tc the original proposition ; it may be asked, as the alternutive,— is there any reason for considering the liga- ture to have been the sole cause of death ? All precedent is in ikvor of the aflirmative. Pneumonia after operations, of every sort, is a common event. From an analysis of 62 autopsies, given in the Medico-Chirilr- gical transactions, Vol XXVI, of persons on Whom capital operations had been performed, 39 presented signs of pneumonia more or less ad- vanced. But this fact is especially applicable to the common carotid ; since after it has been tied, for whatever cause, pneumonia is of fre- quent occurrence, probably ranking, in point of accidence after the cere- bral sequelsB ; so much is this disease, then, to be expected that Mr. Miller, in his Practice of Surgery, specially warns the opterator against it, he says, " after the operation congestion of the lungs with its baneftil con- sequences must be guarded against." Mr. Erichsen likewise Tefiers to t)te prevalence, of pneositive bnlkand le history, too, of to the pniKluction left to take their mination. Upon- jms were ttot the tsition ; it may t)e sidering the iiga- ient is in ikvor of sort, is a common e Medico-chiriir- lapital operations more or less ad- common carotid ; imonia is of fre- ice after the cere- d that Mr. Mifler, tor against it, he h its l)anef\tl con- likewise refers to I eommon carotid, i this oireumstance, considers it most likely owing to a derangement in the functions of the brain, and medulla oblongata induced by n disturb- ed state of the encephalic circulation. His opinion seems probable and perhaps the peculiarity of the left lung being affected after ligature of the right artery, as in the above cases.' may be attributed to the same agency as that whereby palsy is made to occur on a side of tho body opposite to the one in which the cerebral lesion exists. With these argu- ments before us the two cases of pneumonia must be placed in the same categ]iterated. shehaviqgalUlong is of aneurism, and ilure of the carotid it little douht that a }t operation, had she (y to prev^t such a Im saved by; it."— ^. it, at first sight, iQi For while Mr. loie prudence be«n itaplace amon^Ahe kOQ^rotid isnot mn- aom^natal aneurism, that! in reality, dfli- o aneurism in exist- licQ-Gninifi^l tmn- m oourly half of the ofithr- rnally^^ver Uiis dla- vicle. There was also extreme dilatation, and ossific degeneration of the thoracic aorta. On the 25th September, 1839, the right carotid was tied On the nth day, the Hgature came away ; the tumor was evidently lessened although pulsations continued. He left the Hospital against the wishes of the Surgeon ; the tumor then rapidly increased, attained double Its former size, and he suffered so much from dyspnoea that 69 days after the first operation, the subclaviaa was tied. The report says by the latter his life was prolonged 76 days, and that before it was un- dertaken « he api>eared to be almost at his last gasp from suffocation, and great fears were entertained lest he should expire under the operation." The further details, as in the former case, are here omitted from being irrelevant to the question under inquiry. The failure of the carotid de- ligation is not accounted for ; it may have been that after having left the Hospital too early, he resumed his usual avocations and old habits, be- fore the fibrinous changes in the sac were strong enough to resist' the excitement of circulation, induced by his premature indulgences. Thus assimilating the case to the forn;fer one. The third case in this class i&usually disregarded, because its principal, details are unknown, and no ojfiinion can be formed either of the extent of the disease, or of the effect pf the treatment upon it. In the Lan- cet, for 1834-35, it is simply slam that a man had a prominent and fright- ful tumor of the neck,which wis supposed to be an aneurism of the iunomi- nata, and was menacing rupture ; the right carotid was tied by Mr. Snott The upper part of the swelling, sometime after the operation, appeared to have diminished, and afterwards the sac opened, probably from havine inflamed, and a quickly fatal hemorrhage ensued. No post mortem was allowed. These cases, then, are not calculated to originate any unfa vorable impression against the real merit of the operation. But leaving this:-the question of failure may now be examined in a more general way. If we are to judge firom 6 of the 10 cases of innominatal aneurism of which we have the fullest particulars, we shall not entertain much hope for the ultimate preservation of an individual siihilarly circum- stanced ; for their character is of a hopeless nature, it appearing that Although the oijeration be perfectly successful, yet life cannot be enjoyed any great length of time afterwards, in consequence of the destructive influence of kindred morbid causes with which the aneurism is asso- siated. A patient may, therefore, survive the dangers of the ligature ind surmount every circumstAce connected with it, the occlusion of the' «c inay also be most satisfactory; yet other agencies are at work, from ^hich he cannot escape, as they are not remediable. Nearly all cases )f this a_neuri^„gperaled upon, have Wa complicated with disease of= ne aorta of the class of disorganizing inflammations; frequenUy, too. lications interfere with a salutary termination L ev'dencS^^y contrasting the results that have followed B-^ d^^-I- ration in inaominatal aneurism with those that have succeeded i in cases of aneurism of the root of the carotid uncomplicated by any other vas- mina arteri und'e *Itha atton jiarati andtl thati From of tht lation branc :rars.au; of\^^^ one supposed case ; of the former 3 were complete recoveries, 1 was suc- cesshu's^ as th; aneurism was concerned, and in only 1 was there no improvemwt. The comparison just drawn also suggests that were on aneurism^of Jhe innominata placed under as favorable conditions as one of the carotid; the chances of hfe would be materially lengthened, and be oi> a rar with thpee afforded by the latter. For this purpose, the sac shoitld U confined to^e upper part of the vessel or near its bifurcation, spring frjn the left segment of the artery, and be unimplicated with disease of tht aorta or he>rt, or with aneurism of the aorta. A combination so fortuitoii. will, h9weyexA)e of great rarity ,and altogether exceptional to the rule. I _ZL^^eJ^ is to form a guide.we must conclude that alU^gll IhUo^^l^y swcewfuUy obliterale-tBeaSera^ ^^«wl ily, in addition, with ity of an aneurismal lase A morbid state er than it otherwise ervation and its ini- ation o( the carofra lombination is shown ted. 2. os- ■ctation of Ee of bolh imprefwion eiil laryn- !. Dilitaiion Ossilic de- ; aoria. 4. jiilricle. rith 3. Cftl- Surgeon. Morriaon. Key. Fergusson. Campbell. Feain. Wickham. heir complications, as Mott's no mention is ng two the facts are of complication^ with seding tho statement a salutary terminatioti ullowed Brasdor's ojie- e succeeded it in cases ed by any other vas- five lonajide case6,and 2 recoveries, 1 was swc- in only 1 was there no suggests that were on ble conditions as one ol r lengthened, and be on rpose, the sac shcrtld be bifurcation, spring frt ni ted with disease of tht jrobinstion so fortuitoiii ;eptional to the rwle. If conclude thai altbougl iunsm, yet it is jwoWe matical. whether this circumstance will delay death, and that the es ence of morbid accoiapanin^ents with the aneurism should preck the ligature of the caxo^i^. -tTnless some very urgent Reason arise, a« the peril fi^om instant rupture of the external tumor, when even\ though the forbidding complication^ co-exist, t|ie operation may be per- formed, as the probability is it will then lengthen life. Such an advan- tage was eyidently obtained in Wickham's case,.where death which was momentarily anticipated before the artery was tied, did not occih- till two months after the operation. Ami agnin the mean duration of life after the vessel was tied, in the Ciises exaniiuecl, has-been four and a half mouths. The inferences deducible from the foregoing are :^ 1. Failures pf carotid deligatiun to ohliteruteiinnominatal aneurisms are attributable to individual irregularities. 2. Failures of cart)tid deligati^.to lengthen lifejn innominatal aneu- rism, exclusive of the accidents of the ligature, arfe prinCi[«lly referrible to co-existent disease of the heart, ur aorta, or aortic aneurism. * 3. The operation should not .l>e attemjited in cases where there is a complication with these morbid states. 4". Unless there be imminent danger of death from rupture of Mve sac, &c. . _ 5. The most promising cj^e for the operation is when the innomina- tal is most like a simple carotid aneurism. And lastly, this operat|on may be compared with others for the cure of the same afiection. These are:— -1. Deligation ol .the arteria inno- minata on the cardiac side ; 2. Ligature of both the carotid and subcla- vian arteries; 3. Tieing the subclavian artery; and 4<. Securing the arteria innominata on the distat side. The first is either impracticable unc^ef the circumstances of the case, or if practicable, inevitably fatal- ^t has been proscribed by Velpeau and others. In . the second the* oper- ation varies as to whether both vessels be tied simultaneously or on se- l^rate occasions. The simultaneous ligature has been executed but once , and then under very unlucky auspices ;'it having been ibund postmortem* that the only pervious iartery supplpng the brain was the left vertebral. From the deligation not being feasible in any other than the third pert of the subclavian's course, it follows as there will still be active circu- lation of Uood through t^e ttfmor, and frpm it through the principal branches of the subclavian artery, which are all giveiiod'flrom'thia vessel before it extendi beyond Jhe icaljipjTSBWBlei, iHiraTpSs^ :k.; A.-,. vj s^^iM^^si... !i ; 12 will be but a fractional addition to the stasis of blood caueed by occlu- sion of the carotid ; and when, for this trifling gain, so many additiona dangers are risked, the danger, of a double instead of a smgle l^g;^'«'^ does not.eem warrantable to incur therh for the trxv.al, Pe'»»*P^.^""f " advantage acquired. The ligature of these vessels on separate ojcas^pns Ls been practised twice, but in addition to what baa been just stated which is now equally applicable, it may be objected that the procedure re- lucesthe case down to a single operation, since before the --nd « p^^^- lormed the collateral eitculatiou will have become developed, and thus countemct all othfer advantages exc.pt those unrnedmtelysecur^^^^^^^^ tirst Thirdly. Tieing tVe subclavian artery alone, this is, of course, en to the objections jL raised against this ve»el -henl.gaU.red simultaneously with the Wrotid. By, obliterating the carotid halAh6 CvoTim^e of blood that entered the aneurism is obstructed, whereas, bv (deluding the subclavian a check is only given to one-siXth,.. j., one-Thi d th! amount destined for passage through the vessel this Tpc^^tLnt difference depending ur«n the carotid being a long tran^ dving off no branches between the sac and ligature, while the suSvian cives off all its largest branches between these two po.nts. Last^y^'^thearteriainriouiinataonthedistalside-thisise^^^^^^^^^ LSr e y^o the first variety.^ According ^s> writers, it would be he true . BmsdTrean .nethod, for they have divided the distal operation into, 1 he Brlore4n,and2 the Wardropian ; but the distinction is unfounded, for in casTrequi ing it the first cannot be performed, as the encroachments of the tumor in l^th innominatal and ingviinal aneurisms leave no space for he Cture of the end of the innominata or of the common femoral, so hltfSa divisional branch, either carotid or superficial femoiB, mu t bf Ued. Moreover, there is no authority for thus hmitmg M. Brtdo?s propo^l. for so far as is known, he intended it o be executed ^rn the principle expounded by Mr. Wardrop in his self-styled new opemtion." And in conclusion it may be inferred :— 1 The ligature of the right carotid possesses advantages over alter- native operations which entitle it to preference in practice. 2 Opinions aato the probable benefit of carotid deligation in innomi- natal aneurism, fpunded upon the results of tieing the subclavian artery or both subplaviih and carotid arteiies cannot hold good. X. « fi,« inferences of the antecedent disoiission, it may be conclud -^ w,:^»r^n agam treating innominatal aneur^m by liga^ur. " ."'J^ghrc^ ci^tid artery ; hay, more, that m certain cases h. v:>\. 1 caused ty occlii- 30 many additional B. single ligature, it 1, perhaps, doubtful I separate oiJcasions as been just stated at the procedure re- e the second is per- leveloped, and thus Italy secured by the this is, of course, jel when ligatured le carotid haltth^ " bstructed, whereas, fi to one-sixth, i. e., rh the vessel, this being a long trank, gature, while the in these two points, -this is equivalent in it would be the true operation into, 1 the 1 is unfounded, for in le encroachments of as leave no space for common femoral, so superficial femoral,^ or thus limiting M. ed it to be executed lis self-styled " new ivantages over aller- )ractice. leligation in innomi- he subclavian artery good. I, it may be conclud idant justific&tion t< ineurism by lijratun it in certain cases hf , 13 would be deserving of censure if he permitted his patient to die without having been afibrded the benefits of the operation. The correctness of many of the foregoing statements is strikingly at* tested by the following case which occurred to me last autumn. It was ^- that of a septuagenarian, having an innominatal aneurism which pointed externally, and so superficially that its spontaneous rupture was hourly ex|)ected— the carotid artery was tied— life was prolonged three. months — the aneurism underwent reduction in size — fibrillation occurred the sac was occluded, and circulation from it to the artery ceased—^p local accident interfered obnoxiously — death Was caused .by tfferebml disease'"'/ '' / the result of the ligature — no event Jtappeilieid that would not have *^ . o*'^ equaHy fbllewod^ hud. the iigtttiire been cardiac instead of distal aneu- ^ rism of the arch, and other evidences of arterial disease, were ascertained post mortem — and the relations of the aneurism proved that no other operation would have been as useful as the one executed^ — and, in addi- tion, the case presented some unusual features, giving it a singular cha- racter. The details, as noted at the time, are these : — Pierre Bridor Was brought to the Montreal General Hospital on Satur- day ,'29th September, 1855, by Mr. Picault, a medical student, for my advice concerning a supposed aneurism at the root of the neck. The tumor Wad situated in the episternal cervical pit ; having for pil- lars the cleido^mastoid muscles, and being interposed between the lower border of the thyroid gland, and a line drawn across the sternal ends of the clavicles. Although fixed, it could be slightly displaced, as, latdrally. l-iv ■I ; ,1 i by manipition, and. anteriorly, by effurls of deglutUlon. Its pojitiofl was relatively affected by changes in the ^tate of the neck ;dun0g flexion, i/s lower segment' touched .he snjKTior border of the st.rnum but whi the head was thrown back, these parts were separat. 4 by a fingerXeadth of intervening space. It had the appearance of luo s>.eUiL united in one. of which the largest was hem.spher.cal the ,, ze Ufa sjlit pteach-and the smallest ovoidul.hke an almond kernel ; m re- fereL to the mesian line, tue form, r was nearly symmetrical, while the /atter U on the right side, a.d. by its snperadd.tic.n, destroyed he cir/ularity, which, otherwise, theoulliue would have bad. 1 he enlire tuLr measured, vertically. IJ inches, and transversely 2i niches, its cintral a^is projected about IJ inches from the superficies of the neck. Its surfac^ was uniformly smooth, and rounded ; the investing skin had a lurid red color, and the centiie spot presented an aspect of pointing. t)eing greatly attenuated, slightly excoriated, and seemingly on the eve ofbursting: inshort.Jt looked like a ripe abscess, and misled by this facirsfatua,\he patient had b^en treating it with poultices. Moreover, it felt sofl.and fluctuated most 4istinctly. But again.it pulsated forcibly ; the pulsations were, everywhere, equable-as marked around the peri- phery as over the summit, and no variations could be discovered m their force, by producing the displa<;eraents above mentioned^ It cxi-anded with each contraction of thel hedrt, and subsided during the diusiol^-. A bruit desoufflet was heard proceeding from it ; although the murmur was ' limited to the sides.and only heard when the stethescope waspre^sed rather firmly against them, and it was not accompanied by any fremissement, or thrill. ; The swelling, by direct compression, curefuliy applied, was, in great part, emptied of its contents, and pressure upon the right carotid artery rendered it pale, dimmutive. and flaccid, in consequence of syn- cope, which was alaa.i^diiced by this operation. It was first noticed on the 23rdi Septerii^r, and was then as big as the top of his finger, it sub- sequently ^ola^ed day by day until it had reached the dimensions above detailed ; it had begun with the samg softness and compressibility it now possessed, and it had never been hot, nor tender, nor painful, al- though for a few days before its developeroent, the skin, in sttM,seemed • unusually red. " . * " Having ftext examined the chest I found the top piece of the sternum dull on percussion, and I heard throughout this s[>aM a strong pulsation which was lou^st along the superior border, cleaf^ distinct from the cardiac sounds, and most faint towards the region of the heart. No de- ^ cided bruit de souflJet could be distinguished, but ^here was nfear -the right^stcrnb clavicular articulation, tbe modification Wsound that oftenj Ulon. Its position the neck; during er of the stt rnuro, re 8epBrat(4 by * appearance of iwo lispherical, the size noiid kernel ; in re- symmetrical, while ition, destroyed the e haA. The entire rsely 2^' inches, its rficies of the neck. ! investing skin had as|»ect of pointings, e^iingly on the eve and misled hy this (ultices. Moreov(r, ,it pulsated forcibly ; led around the pori- le disciovered* 111 their onedi* It expanded during the diil^1ol^'. )iigh the murmur was pe was pressed rather y any fremissement, reftilly applied, was, ipon the right carotid consequence of syn- t Was first noticed on p of his finger, it sub- the dimensions nhove lid compressiliility it nder, nor painful, al- ! skin, m sitM, seemed ) piece of the siiernnm acfi a strowg pnisatjon L^ distinct from the of the heart. No de- ; there was n'ear -the }ii Wwiind mat often, 15 , by augmentation, passes into a bruit. The right infra clavicular region was rather dii41er«*iign_the correspoi}lling one of the opixieite side ; here, als», respiration was^nerally w!;eaker, and over the costal cartilages more blowing than natural. The pulse of the right Wrist was somewhat weaker than that of ihe left one, but no difference was noUli in the beats of the two carotids. He was 70 years of age, by trade a hatter, a stout strong-buiIt> man, with large h< ad, short neck and capacious chest. During his longlife he had been seldom seriously ill. His chief ^Iments began a year ago, Whfn he experienced a difficulty of breathing, which he believed was asthma, since then he had been liable to puruxysins that supervened mc]jithly, and afler cuntiuuing for. a few days left hir^flj^well ais before their accesision. The first seizure was aci^nipinied with dropsical en- largement of the abdomeip^nd limbs, that ltste;d for six months and then completely disappeared. Ever after the first asthmatic attack he had * Weil troubled with cough, which was neVer very annoying, and gene- rally of slight character. It was attended with the expectoration of a scanty frothy mucus s{Hitum, but at no time with hoemoptysis. Ifis nt-ck had a tendency to " tippet shape," the base was pjiffy, pitted and had a doiighy feel, with an obscure crepitus on being pressed. A month jirt'vioilsly a swelling commenced in the submuxillury region and rapidly extended oVer the neck ; after persisting for a few days it went down, but rt-turned in two or tlir-e week's time ; and at the date of examina- t on hud So far declined as to present a mere trace over the clavicles, as already stated. When these tumefactions ensued they were accompanied by pams, which he took Ko be rheumatic ; the latter were mostly felt in the ^right shoulder and sjireud thence upwards along the neck. When at their greatest height, be, also, suffered from a sensation of cephalic tension, or as he said his head felt as if it had been jammed into a tin case. The cutaneous venules were slightly varicose in the external part of the right infra-elavicuiar'and mammary regions and axillary side of that arm.. No such appearance visible on lefl side. \ In the course of the afternoon I returned to the IIo$})ital in company wihi. Dr. Campbell, our Professor of Surgery. This gent!feman, after a thorough investigation of the tumor, felt convinced thatat was an aneurism of the innominata,and at his stiggestion a consultation of the medical stifiYf the Hospital was called for next morning. There was a full attendance of t!ie members, and all 'present were unanimous in diagnosing the external tumor to be aneurismal ; and' prognosticating the certainty of the man's death in, perhaps, a few hours, or at furthest,. in a few days if he was leA alone to his fate. After a maturerdeliberation it was resolved that S the right coihmoiwparofiil aflcry should be tied on tlie morrow.' l! 16 y% f- October 1. Noon.^THE OP«iiATioN.~The patietit WM plaoeB^on the operating taW*, in the recumbent posture, with hu neck extended pnd face inclined to the left side. An incision was commenced behmd the angle of the jaw on the right Side of the neck, in front of the st^rno- mastoid, and continued downwards, nearly paralell to the anterior b^rd^- of that muscle, lor the extent of three mches, so that its ^«'™"jOT5«| approached the circumference of the tumor. The skuj and ^MAt cellulo-adipose membrane having lieen divided; ^h" P'^^^f '»27^ came into view afad was cut thr*.ugh upon a director by aJ^i|it4flJ^ J^pt- ed bistoury; a sman'iisrvous twig (superficialis ^^'^'-^JMIl""^"'''^ the centre of the wdund was purposely incised. A^^pTfetratum, of fascia was then divided in the snipe way as the 'muscle had been, ^nd exposed several large veins below, which were cardully displaced and retmcted ; more fatty membrane next presented itself and was can- tiously cut through. Afler which the sheath of the v s-sefs was seen and opened in the usual manner. The wound, having bten gradually decreased in length ai each successive division, had now a triangular shape, the apex being upon the vessels. The needle was dipped,and astt was entetinga large vein rolled forwards,but this having been held aside, tha instrum^iWas passed from without inwards ; the 8tr»cture,howev%r, it surrouncMproved tg be the pneuraogastric nerve which h»y anterior to the artery instead of in its usual position. '1 he needle was^disen- gaged and. reintroduced, but in the direction of from within outwards, when the primitive carotid artery was at once secured. Having assured myself the vessel was isolated from its neighbouring associates, I now firmly tied it by a reef knot : one end of the ligature was cut oft and the • other allowed to depend from, the wound; The wound was closed by a stitch and a couple of straps of adhesive plaster, ai well as by a band- age turned round the top of the chest. /Scarcely any blood was lost, the drops that did flow proceeded Ixm the integumental incisions as no h(Etoorrh3gg occurred during 4&i||^'"t manipulations. ^Upon opposing t^her the sides of ^j^Hlfe'^ °^ ^PJW^"^ "^^^ T' ind\iced, but it was only of mo|HiP|Pion. AliTtightening the ligature there was a total absence of pulsation in fhe temporal and othei branches of the external carotid ; there was also an appreaciable altera lion in the tumor, as it became less tense and pulsated more feebly Chlorbform was not ad^ninisteredi and the suffering was endured witl rej^arkable fortitude and suppression of feeling. 4P M.— Tumor pulsating strongly, rather larger, particularly to th( M«€butmen,t, owing to participation in generaf vascular excitemcn fST bis pulse IS 92 and fuller, and he is feverish. While returmng fron The theatre to the ward he vomited a Uttle, but toncp then fie has beei tiompo a vein and CO Liq. pi :itulis, i,e had lillit; ilid. ' 2nd satiu^i little ii free ; added solid ; finger if it dept. lanced produc ingly I not m( hJA JiA 3rd, auU th to be a ripplin water) now,n with St feeLs I! out dis upper rehiov jelly a serum swelli not gn ation, at«d « tissues fused, I ^niiKti / 17 511 was plaoecl>on the leck extended pnd nenced behind the 'ont of the Bt^rno- 1 the anterior b^rde lat its termi skin and ^ ^^ |)latys^u>iiiV»><^ rbyai^iltt^,!^- \j 4Mil,'i"|^ ^^''^'^^ Ai»'i^fflpP^triitutn. of iscle hud* been, «and liilly displaced and itself and w.us cau- le v< ssf Is was seen ring bien gradually lad now a triangular was dipped, and as'tl /ing been held aside, e 8tructure,howev%r, i which Uiy anterior 3 needle was disen- m within outwards, red. Having assured ng associates, I now' re was cut ofl, and the jund was closed by a is well as by a band- ny blood was lost, the ental incisions as no napipul^tions. ^ Upon epj^gL^id 8«4zWe wai iifllTtightening the he temporal and othei in appreaciable altera pulsated more feebly ug was endured will ;er, particularly in th( r vascular excitemcn While returning fron t>ompo8ed and has had an hour's sleep, jxii. of blood w«re drawn from a vein of the bend of the elbow. Lint soaked in the following lotion and covered with oiled silk, was constantly applied to the tumur. ft Liq. plqfibi diacetj ss ; ucid tannic .3 sS ; aquce Oss. And B tinot di- ;itulis, vini antinibnial ana M x ; qiiaque secunda horar-which mixture ^e had been taking during the |>a8t 24 hours. Absolut© rest and tran- llllity enjoined. 9 P. M — Tumor seems lew prominent and more ilid. No other change. 2nd October, 12 A. M.— Tumor appears rather more dilTused. Pul- satioiis becoming weaker. PiiLe not so strong and only 82. Dozed ii little Just night, head is slightly giddy ; skin still rather warm ; towels free ; no pnui anywhere. Two drojw of tr. aconite (U. S. Ph. j to be added toeuch dose of mix)fure.' 7 P. M.— -Tumor certainly feels more solid ; skin over centre very thin, candid, dry, and partly fissured, the finger ain invert it by gentle pressure without feeling any pulsation, but if it cause more than a slight dejiression pulsation becomes evi- dent. Pulse fulTer, firmer, and 86. A vein near the inner ankle was lanced and about 3 x of blood allowed to escape,; faintne»s was not produced either by this or the former venesection. To use fluids as spar- ingly us |)Ossible— ordinary drink to be water flavored with wine, and not more than 3 i ss of latter in the day ; he has been, for lust years dV his Jife, accustomed daily to take whiskey and wine freely. 3rd, noon.— About 7 a. m. the centre of ihe apex of the tumor cracked, and there escaped, from beneath a scale of cuticle, a quantity Csiipposed. to be a few dracbHw; of a fluid-which the Uoiise Surgeon, v.'ho watched it rippling away, describes as very thin, clear, transparent, yellowiah and watery, it has since continued to ooze out, though mote tinyly, and iha' now,noon,8een by myself, has the characters above stated.and is identical with serum. The aneurism is, in consequence, less tense and promkien.t, feeLs much haider and throbs more feebly. Wound was dressed with out disturbing him from the dorsal decubitus : it looked very well, the upper part appeared to be united by primary adhesion ; the stitch was retaov^. Posture not to be^changed. IHet to consist o( calf's loot ' jelly and strong beef tea, with corn starch. 7 P. M— The leakage of serum continued during the greater part of the afternoon, leaving the swelling pt reduced that the latter now consists, of a central rising not greater in circumference than a shilling piece, with a lateral elong- ation, the residual site of the lormer tumor is firm and marked by india- at«d welt like borders feeling like solid lymph in the sub-integumeiAnl tissues ; W»We pulsation still easily seen in all aspects and generally dif- fused , tangible pulsation also very evident,bypal|)ation, and lastly, o»rf«W(j^ incetlienfielaulbeei ^nliSlion is win«iiRsni~6il^ the aac opened j the cutaneous discc v> t^, '/ * 18 loration has been gradually lading with the disappearance of the intnm- jescence. Patient feels well and has no Cause of complaint • bowels open ; pulse rather weaker, but of frequency last s|)ecified. 4th, Noon.— The flow of serum has been gradually detreasing ; pretty 'firm pressure can be made over the aneurismal debris, with no other effect than the extrusion of drops of serum ; the central flake of cuticle has separated, exposing a minute slough ; the fluid that escapes, is a little darker, and more viscid, than previously, but its other charac- ters are unchanged. 6, P.M.-^Progressing satisfactorily. 5th Noon.— The scrum that now escapes is slightly opalescent, as it mixes, during its transit, with a httle pus secreted by the ulceration around the slough; wound looks well; pulse. 78. Stethescopic signs, over sternum, unchanged ; they are myre superficial and sonorous than the cardiac, and easily distinguishable from them. 6, p.m.— He broke through restraint, and 1 found him sitting up, eating his supper, and sup- ported in bed. An egg a day added to former diet. 6th— Slough detaching. Complains of pains along the right side of neck and head. Piilse 78. Cubstitute for former lotion, B alumin 3iss., spt. lavend. CO. 3ij., Aqua;. OSs. 9, P:M.-Appears to be progressing favourably. 7th, 9, A.M., (Sunday).— Cervical pulsations have been weakening and becoming less extensive. No change in those over the sternum. Slough cume away, exposing an ulcer the si/.e of a sliirt-button, through ■whjch, by pressure on surrounding parts, drops of strum may still be ex- Jruded. Wound dressed'; its appearance is favorable. Fains not so lictite, but has an uneasy feeling in the right ear. 5i, P.iM.— Had chicken to-day. 8th, Noon.— The external aneurism has been gradually disappearing, the former indurated elevations have been subsiding, in loco the parts feel soft, and are somewhat depressed. Ulcer healthy. Pains continue, they are remitting in severity, becoming worse at 9 or 10 at |iight, and continuing severe till the morning; they prevent his sleeping soundly, and are confined entirely to the right side. He sleeps well in the day- time. 9lh.— Visible pulsation, only perceptible when he is sat up in bed— it ifi then quite obvious in the old situation, although the vestiges of the ori- ginal tumor have been removed. A little serum still escapes; it has a reddish tint to-day. Appetite good, and relishes food. Pulse 72, regu- lar and normal. yNot wishing to incur. the " explosive eflects" of digi- talis, the naixture was replaced by one containing ipeoacuanha and -c i trat y o t asa. istoji, with d throug extent reetly theotl and ki I felt J was, o follOWi lower ness in tioii hi 12tli ISth ed thr tion of pirati\ abated the rij men, i 64. J Dose 1 ch. iij. 14tli 15tl] pecton iiitegu and al gular, wine, in dn'i felt si hyd. c 16ih ess in where ng sci 17tt vostrs 10th— The episternal cervical pit has now an excavated appearance, espira ranee of the Intum- ilaint ; bowels open ; adiially decreasing ; .mal debris, with no he central flake of le fluid that escapes, but its other charac- orily. itly opalescent, as it i by the ulceration Stethescopic signs, il and sonorous tlian 6, p.m.— He broke 5 his supper, and sup- iiig the right side of lotion, Baluniin 3iss., rs to be progressing JVC been weakening le over the sternum, sliirt-button, through itrum may still be ex- jrable. Fains not so ear. 5 J, P.M.— llud adually disappearing, ling, in loco the parts Ithy. Pains contuiue, . 9 or 10 at night, and his sleeping soundly, leeps well in the day- lie is sat up in bed — it the vestiges of the ori- stili escapes; it has a food. Pulse 72, regu- usive eflects" of digi- ling ipecacuanha and excavated appearance; 19 is Soft, and, apparently, of normal structure, yet it still pulsates, ihongh with diminished energy. The ulcer has contracted to a minute openings through which a probe may be passed along a fistula of nearly two inches extent, in a direction of first backwards to the mesian line, and th^n di- rectly downwards ; this fistula was discovered by Dr. Holmes, who, with the other physicians of the Hospital,manifested a lively interest in thecase, and kindly visited the patient from time to time. On probing this Irajet, I felt strong impulses communicated to my fingers, and the instrum'ent was, on each occasion, sensibly elevated. No escape of blood or fluid followed ihese explorations. Wound- in upper part completely healed, lower part suppurating. 5, P.M* — Pains rather worse ; has some uneasi- ness in chest, but no cough, nor dyspnoea. His old cough and Expectora- tion have been gradually leaving him since the day of operation. l"2th. — Passed a good night. 13th. — Seized last evening wiih dyspncea ard cough, which continu- ed throughout the night, but relieved this morning, after the expectora- tion of a large quantity of pituitous phlegm. He is now, noon, compa-. [Miratively easy, hut does not feel as Well as usual, and the cough, though abated, Qontinues. Right side of chest feels tight, and respiration around the right nipple is harsh, and abrupt ; has some uneasiness in the abdo- men, and last ulvine evacuation was unusually co(>ious and loose. Pulse 64. Adde niisturae Jviij. ut supra; tinct. lobeliaj 3iss. ; tinct. cocii 3j. Dose as before. Sinapism over right side, and pulv. ipecac, co. gr. v. ch. iij. i quaque quarta bora. Hth. — Rather better : pulse 60. 15th, 12 a.m. — No return of dyspnoea; cough still troublesome; ex- poctoralion s.'ro.ilbiituiiioiis, fruthy, and more scanty; slight oedema of iutegiimeiits at hase of neck ; complains grently of the pain in the ear and altout the face and nock on the right side ; pulse* only 57, firm, re- gular, and ci impressible. Appetite failing; sleeps well; ordered Jiv. wine. 5 p.m. Complained of some dysphagia, also of a void sensation in ehi'St, which he says, although he djjd not mention it before, have been felt since operation, and been gradually increasing. R doveri gr. iij , hyd. c. creta gr. ij. ; quaque 2 da hora. Pergat. in usu mist. 16th. — Better ; pectoral symptoms improved ; slept well, and pains ess intense ; wound healed throughout, except at inferior commissure, where ligature emerges ; ^stulous opening still p-itulous, and discharg- ng scantily ; pulsation in episternal pit has been growing fainter. 17th.— Much worsfe. The change set in last night. Noon : Greatly wostrated ; face sunken and suflused ; pulse 52, small and weak ; hoa lot swallowed asythiiig for some ho{irs,its besBys the passage iroloseUf= espiratioD noisy; sonorous rales, in various modifications, heard over the xS, ,.Mm^^. i . •- t^ 20 front of both lungs, but loudest over the right side ; voice, though w^k, It otherwise id. and has at no time deviated frorn ord.nary cha- meter- cough occasional and short; expectoration scanty; mtelhgence "naff t d ; had no sleep la.t night ; bowels open ; urine natural. In heu of former kixture-R tr. cinchon. co. 5ij.. spt. ammon. arom., sp • cm- nam co aa 3vi., aqu» 5ivss., m. ft. mist. Sig. coch. maj., secund qua- nrC Siv brandy in addition to wine. To. be given hquors as rnchTndn:;:. sLpism to ..est. ^ V-ra. Y^^^^^^^^^^;^ Campbell, He had not swallowed anything smce I last saw h.m. Chere was now a disposition to sopor, slowness and imped.me.^in articula .on, HS^tinv'olunta":^ twitches in fingers of right hand. Ojher . mp om unchanged. At Dr. C.'s advice, a blister was put on the « «' ^^e neck, and mustard applied to the feet ; the ^^^er measur^J^_ co^. nued Wound looked well, and no signs seen of suppumfg^j .|its vici- nity. 54 p.m. More somnolent ; did not know h.s friends th^safternoon ; r^hthalfofmou.h is inc J dependant thaU the left; "xoans consider ably coughs but seldom; no heat of scalp; pulse 55. Has taken the medicine "and some of the brandy, but refuses nourishn*nt. Enema terebinth statira. Omit pulv. 18th, Noon.-Better ; conscious and no tendency to stupor complains of makise, and of old pains in particular, feels very unwell, pulse 48 stronger, no muscular twitches, otherwise no alteration. Kept sinap Z, blistered surface to be dressed with cerat sabin. 5i P-^-'f^^^ ed Nourishment for the first time this afternoon ^nce ^h- la»t atteck Its ingestion required a double effort; respiration tranquil, and physical signs less loud. Make brandy into egg flip. , j u 19th Noon.-Dysphagia lessened ; appears much as formerly describ- ed ; pulse weaker and 46. Had an enema terebinth this '"ormng. 6 p.r;.i-Has since had two stools. Cough troublesome expectoration dif- St -respiration over both lungs harsh and rough, but much loudest pain continues severe, Add spts. sulph. OBther. co. 3v.i to ™'^ ' 20th Noon.-Symptoms generally ameliorated, no pyrexiul tendency ^.lera^fewjiours last nigh '^ 6 j.m. Has been u nl a fa^share of nutnment for last two days, strength augmenting, r now r gets out of bed. with assistance, to sit on the night chau. Pulse 48 marcins of wound red and swollen. ^^ad l?!;«l,.ic symptom, mentioned on the .8.h have been he»m inl eenecally developed, and now hemiplegia is decidedly ma°if skiui no it old 1 senii 31 but SUltU rHqiii reui-1 the I betbi iiave troiil ible. on c nues has a chan Nc iwhei iudia 7tl las I nd I 'isit( 9tl limt loasdtelancem corresponding ^f^'^ ' :''" "^"'"r^^^^ ^ lengthened; left half of hps pendulous and apposed, wh Jo xigM con- m^ t«cted and open ; during a strong expiration the left cheek « puffedout n, voice, though weak, from ordinary cha- scanty; intelligence ine natural. In lieu naon. arom., spt. cln- jh. maj., secund qua- . be given liquors as isited him with Dr. last saw him. There limetit in articulation, id. Other s>mptoms on the na^ of the ieasure» ^i^ conti- uppniptpin fft its vici- [riend* tmsalternoon ; eft; moans consider- 55. Has taken the lourishraent. Enema y to stupor, complains very unwell, pulse 48 eration. Kept sinap I. 5i p.m.— Swallow since this last attach, tranquil, and physical ih as formerly describ- linth this morning. 6 ome, expectoration dif- igh,but much loudest thirst and heat of skin ; | o. Svj to raixt. , no pyrexiul tendency. Her. 6 p.m. Has been | , strength augmenting, sit on the night chaii. I8th have been becom' 13 decidedly manifest : half of nlse 64 ; surface hot ; cough troublesome j "Ualysiftas^ teat-re po rt .- — ■ ^ - -- -— nth— Recovered from the mental annoyance, and the consequent pxcitemetit ha.«! passed ofT. I3th.-Ligature removed : in attempting to draw it away it broke, and rather sLgely, on examining the.wound attentively, a small wh.^ liectonwa" Lni in the aperture left by the healmg o. the ab- projection ^ op.^aring to be al8o thread was pulled when r Cainde T the ligat .re was extracted ; the latter coniained a diynoTnle whi^ ^-enting part.-clearly showing -he l.ga- t.^ had sTprlted internally from the ar.ery sometime prevu.us.y. He ture had sepr -^ j ; he can bend his elbow, and raise the aZ oftVeEedtd "a level wUh the top ui his shoulder ; and can . n !l!noh his hand, bnt he cannot make the fins^rs touch the "tf: whlesU^^^^ move the leg and bend the knee, but in ^a^.thleTa^gs; facial distortion not more pronounced than when L tnotic^ ; appetite Moderate and general health good. P.dse 60^ 26th -Hen^plegic symptoms have grown worse ; tenable to walk unsupportedTmental faculties decaying, is very troublesome, peevish arpa^onae; sometimes tklks a little silly. Compluius ol ,>a.ns in nit ear and over corresponding side of neck and head having retiirn- e^J nd wl d7s essing TcutenL. Of late has sulTered from urgent ti^X Exhibits no feb?ile symptoms. When vis.ted is generally sitt- ''];^t^^X^orse,cou^e^ to bed in dorsal decubitus, un- able to help himself, seemingly much exhausted, loss of power over le arm Ind leg is complete ; urine escapes, involuntarily ; Ix^wels sluggi^i . pube small! weak and slow ; tongue when protruded comes agamst left c.tertf mouth.. Cont quin. wine, brandy, and nourishment ; together AS ith an occasional dose of ol ricini when required. . m!!^ much improved in feeling that be sat up and used food. Paralvsis as before, articulation more difficult. , , , , •„ it J!llnother Lad turn similar to that of the 5th instant, but he is now, in addition, soporose and there is a tendency to stertor in resp.ra- ♦ •«„ . K.wels costive : pulse feeble. Habt ol ricini 3ij. mXr" a ■»»« wakeful and aUe>„pU .. reply .0 ,ue.,on. J!d kim 1 b„., i,.m the lo» of .rtic„la.ioa.h,s meanrng cannot be an. deratood Has latterly been taking very liltle nounshment nT-arbad involuntary .tartingsof paralysed ex,remmesi bowel ■^ k.in onened for the last 3 or * days. Habt ol ricmi 3ij. " mh-Crn of drovrsine.,, paralysed parU st.ll reta.n sensatron Bowels now only moved when he is given the od. ,wels now only moved when ne is g.v«» ^"^^ tbioty^takes »ot 1« 23rd.-Sleep8 most oftfie time; when «^ ^"^r^^^ '^^^^^ jiut , hardly any nourishment ; piUse barely appreciable,. there is an oasinca,.^ it away it broke, ively, a small white healiug of the ab- [ was piiUed v'hen latter contained a ly showiiig'he ligu- me previously. He >lbow,and raise the J shoulder ; and can i fiiigtrs touch the nd the knee, but in (Mouiicfd than when rood. Pulse 60. ie ; unable to walk ronblesome, peevish impluins o( {lains in head having return- mflered from urgent ted is generally sitt- dorsal decubitus, un- »ss of power over left i!y j Ixjwrls sluggish; ed comes agaiust left ourishment ; together sat up and used food. 5th instant, but he is T to stertor in respira- i 3ij. } to reply to questions neaning cannot be un« Lirishment. id extremities; bowel ricini 3ij. still retain sensation occasionally observed ; 3 left cheek swells out 1. reisverythisty, takes jle,. there is an oasifica 25 tion of the vesselVhich pirevents the beats from being distinctly felt now that the blood current is so weak. 26th. — Has been gradually failing. Lies on his back in a torpid state, but he may be easily aroqsed and sometimes wakes up moaning^, respira- tion is tranquil, and the pupils are not dilated and obey the stimulus of light. 27th. — He_ died this morning at an early hour. Nboropsy, 2i P. M.— Present: Drs. Holmes, Cam|)bell, Fraser, Sii- therland Scott, iMcCallum, and Graik; Messrs. Kirkpatrick and Picanlt. With the assistance of Drs. Scott and McCallum the neck was carefully dissected and the cavity of the chest fully exposed. Between the stewo-maistoids, the'subclitarieous cellular tissue was condensed and un- usually adherent. The episternal cervical pit preseiitfed no tumor, ridr other morhid condition. Behind the first bone of the sternum was a large globular aneurism which "had caused the heart to be clisplaced inferiofly. After observing the relations of pirts ; the heart with Hsl great vessels, as well as the wind-pipe, together with the aneurism, were all removed en wiossc and taken home for closer study. The lungtf were rather voluramoits but not emphysematous, they had a dark color and contained a large quantity of black blood which was chietfy sdtiled about their posterior parts. Laterally the pleurae had contracted adhe- sion to the sid«8 of the great vessels connected with the heart/ BmAiit.^The right hemiS[)here appeared larger than the left, and wa^ altered iii' shape ; the ailtertbr extremity, especially, being fuller an^ rounder. Upon sectu)n four abscesses were discovered in it — the largest was in the centrun ovale minus, occupying the anterior and middle lobes, it ountained about 3 ij. ss. of pUs. Its outer wall was very thin, sepa- rated from the pia mater by only a few^ lines of cerebral substahce ; by jt3 pressure it caused a displacement and atrophy of contiguous parts thw was especially obvious with regard to the corpus striatum, which Was flattened and narrowed ; the optic thalamus was also changed. The pus was tbick, of a green color, fetid, and, in part, clotty ; upon itg removal, the inner surface of the cavity appeared very smooth and glis- tening, as if lined by a serous membrane — the cavity was irregularly spheroidal, and had no communication with the lateral ventricle. The abscess next in size was in the posterior lobe, to the outer side of the eoruu, but distinct from it, it held about Jss. of pus of same character ; iiu .uediately below it, but completely isolated by a stratum of cerebral jjubstance, was the third abscess, it was of still smaller capacity, and was not larger than a small marble< The last was in form like a bean, and just about as bulky ; it was aj(uated externally to, and behind the, oor- \ ii ' p6rti quadragemina. The fluid in each had the same cliatacter, artd was like that described as foimijl in the first ; and the wall of each had a similarly worn appelirance, r^« lering; it as smooth, as if lined by a mem- brane. The medullary matter cjroimd these abscesses was firm,und rather indurated, particularly the portions which seemed to have been most en- croached upon, as the outer wall of the largest abscess, this was, in its thinnest part, almost coriaceous ; otherwise the brain substance was re- markably healthy; no fluid found in the ventricles ; no unusual conges- tion of the veins ; the membrane was health yj there seemed to bpsome slight serous effusion beneath the arachnoid over the lefl hemisphere, but it was vgry slight, and not decided. The right crus cerebri appeared to be more diffluent than ordinary, but the change was only in its medul- lary exterior, and had not destroyed the original white color. No alteration in pons, medulla oblongata, cerebellum, nor elsewhere. The parts removed having been dissected by my friend. Dr. MacCal- lum, and myself, the following additional facts were noticed :— Aneurism.— The aneurism began in a dilitation of the arteria inno- minataat its- origin ; and this enlargement, as it ascended, became so great that the vessel had given way, and a sac had been formed, partly by the arterial coa»s, and partly by surrounding textures. Its sac was formed anteriorly and sttperiorly ;.by, firstly, the righ^. sterno-hyoid and ster no- thyroid muscles, which were attenuated and flattened, and were bound to theanalagoHS muscles of the opposite side by the deep layer of - the cervical fascia, which was, here, strongly condensed, and much thickened; secondly, by a submuscular stratum of fat in considerable abundance ; and, thirdly, by subjacent cellular tissue in a condensed state. Posteriorly, and elsewhere, the sac was formed of the expanded coats of the innominatal artery, which were thinned, and covered by a consistent layer of adipose tissue. The right carotid and subclavian •^ 25 arteries arose from about the middle of the outer circumference of the swelling ; they were, here, somewhat dilated, particularly the first vessel, each, forming an infundibulum which, by diffusion, was lost in the general envelope, aud also contributed towards its formation. The aneurism formed a tumor of a spheroidal shape ; its, longest or vertical axis measured 2i inches, its transverse Hunches in the widest part ; its greatest curcumference was a litlle more than 6 inches ; above thi« It became gradually rounded, and was lost in a superior segment, having ipo outlet ; below this it grew more slender, and most inferidrly was only ^ inches in girth. It was placed obliquely across the lower part of^6 trachea, the inferior extremity pointing to the left, and the superior! to the right side ; the main body of the tumor was on the right half of the trachea. The tumor and trachea were separated by a firm and den^e layer.of iat ; in the back part of the former yffaa a groove where the latter had rested. The aneurism, posteriorly, had also the following relation^ from without inwards :— superior intercostal artery, phrenic nerve apd mternal mammary artery, while more posterior to these was the pn^uraogastric nerve, ar>d curving round the swelling the recurrent laryngeal branch ; its external border was conniicted to the inner sur- face of the superior lobe of the right lung, by transverse bands of cellu- lar membrane. The aneurism was solid ; and upon division its cavity was found filled with a hard mass of indurated fibrin, disposed in con- centric lamina, and of a bufly light red color. The only communication through the aneurism was a channel, admitting a bougie, through which the blood flowed from the aorta into the subclavian ; and a small fissure existed x)n the exterior of the tumour at the junction of the sterno-hyoid with the sterno-lhyroid, and nearly in the mesian line. It led into « canal directed downwards and backwards, situated within the fibrinous maaa, nearer to the anterior than the posterior wall of the sac, and ex- tending nearly across from the one to the other. Right Common CARorro ARXERT.-This vessel was intercepted 2* mches from its origin, it gradually tapered to this limit, as a firm dis- tended, shghtly flattened cord j but here its place was occupied by a strip of condensed areolar membrane, which connected the former part with the rest^of the artery ; beyond this band, the artery began pointed, and graduaHy swelled out into its usual form and calibre. The interior of the portion below the band, was filled with a clot of lymph, which was farm, truncated, reddish, fibrillated, and adherent to the inner waU ; the Biiperior portion was occupied, for nearly an inch, by a similar plug, but above this pomt, the artery terminated in the external and internal caro- Id, both of which branches were pervious, although ti.e former con- toi ned, at I t s origin, a deljcat^elot, measuring three fines in teirgtfr,anr- '' II 26 extending from the rest. The sheath of the vessels was confused, and not distingitishable at the place where the artery ''««/«^«'^^'^« ' ^ ^^°;' ^l*^^ tance above and below this, it was thickened and adherent to the outer coat of the vessel ; and still further upwards and downwards, it was re- maVkaWy well defined, but scarcely abnormal. The V^^^^ogantnc nerve proceeded between the internal jugular vein and ar ery, from bfe- hind forwards, and continuing to be directed anteriorly, it lay m front of tl^e latter infe;iorly, ana was separated from it for the distance of two lines; it next approached the sac, became flattfened runmng. m h s condition, over the right segment of the aneurism,:and leaving the lat- ter opposite the commencement of the subclavian,, where it gave off the recu rent, and then proceeded onwards in its usual course The inter- nal jugular vein was external to the artery and nerve, and on a higher leveUhan either; its lower part was directed more -t^^'j J^^ usual, it impinged on the top of the tumor, ran over its external circum- ference, un ted with the subclavian, and the continuation (vena mn<^ m[nata) passed across the tumor, and joined its fellow of the opposite ''/ORTA.-The ascending portion was considerably dilated, being 5i inches in circumference acfoss its inner surface. The limng membrane was scabrous from atheromatous deposits, some^of which were disj^ed in an annular form resembling ring worms. Ihe Arch was aneurisinal and extensively degene^ted. The dilitation^as pnncipa ly obvions be- tween the left carotid and left subclavian arteries, where it me up like a bladder ; it also, conspicuoualy. involved the anterior and posterior waUs of the arch just above its commencement ; drcularly the arch, here, m^- suredei incies when flaccid. In the upward p-otrusion there wa^b^m clot, locking like placental structure, of a buff colour. ^'S^t^^ ^J^J^^' reaching as low down as the innominatal opening, and connected tathe "tiguous surface by delicate trabecule ; a second clot of similar ap- r^^arance, but much smaller, was, also, found attached to the upper i«rt, Thttle further forward.- The lining membrane was variously dis^^^^^^^^^^ ,„ part eaten away by minute erosions; m one place lo;^!"? ^'^^ J^" dc^r. there beingan irregularly ragged solution °/ J^^^^^""^ ^''^J^^;^^";^^^ membrane which was walled round by a raised fungoid border, hav ng " Us fio- the middle coat, stained of a dark red color ; aud measunng . 14 inch by 1 inch ; elsewhere the inner membrane was irregula ly thick- et rnd'atheromatous, here rosily stained and there morbidly whU^^^ The descending aorta was. also, in a state of atheromatous degenemUon. HEART.-Aortic valves normal.but the ostium ossific and studded with Jy^lIlesT mitral valve fibroid, base ^ncirded -ith -ka'.ous^^^^^^ ^ posils of coralline shape: BothTH^seWryescl«^Frf«'t«y,andP'«^l«^ 5V regurgitation of fluid. Tricuspid and pulmonic valves healthy. Left ventricle hyphertrophied.its wall being seven lines thick j no over capa- ciousness of its cavity ; left auricle slightly thickened. No further leison. ascertained. The characters that chiefly distinguish the preceding case from its fellows are as follows :-the situation of the external turaor-the resem- blance of the latter to an abscess-the modification of its direct symp-' toms^-the initiatory redness-the inadequacy of the acoustic signs de- rived from the chest-the slightness of the remote symptoms-the ana- tomical difficulties of the operation-the external opening of the aneurism -he fistula to which it led-the symptoms of deranged cerebral cir- culationaS witnessed in hemiplegia, ushered in by pfleudoHioma, and varied before death by intercurrent stupor and vigiUium-and, lastly, the subsequent discovery of abscesses in the brain, and of a peculiarly constructed aneurism. Each of these calls for a few remarks. ♦», : ^\® "^"**"*^ o^the t»™or appears peculiar when contrasted with ^t of othera,beforequoted, in which this circumstance is precisely stated. Of 8 cases of mnominatal aneurism treated by carotid deligation : in five it was directly above the right sterno-clavicular articulation, or inner ex- tremity of the clavicle, and behind the lower end of the sterno-mastoid mi^cle ; when large it projected so as to be visible on both the tracheal and oiUer borders of the muscle. In one it proceeded outward about one-third along the right clavicle. In another it was still more ex^ ternal, and was seated oyer the middle of this bone. And in the last it IS described as "immediately above the sternum, bounded laterally by AH tl!. ^K /T*"'^^ «»argiaof thesterno-cleido-mastoid muscle." ever tr "ft ' '"'"'' P^"'""' '° '^« '^'' ^ "^^^ ^-^^^ibed, how- Z ' > f "^"^ ""'''"" '" "^^ *P>«'«"»^1 °«'^i«^l pit. Bu while this situation was exceptional to that seen incases similarly trelted It accords with what has been observed in other cases of 'nnomlnaui irZLtt 'rrw '" "'T^'' ^P^"^*^'^ "?«"'- have beT C! Ik«„^\ '"'" •'" ^"''''°°- ^^^ '^^^''^l "tuation is occasionally Sr^erv ;d ^ n'^J^T"''''" upon aneurisms, (Velpeau's Operat^e itE^v?; ' ^' t'^ ^^yj^-^l^en an aneurismal tumor shews .r*^7 the upper bone of the sfernum, it happens as often that i! ^hTcltTt'n ,35^? "f " *'^ °-minata.'>%akist:r(V«el^^ to^\heTX^Jt^^ describes a case of sacculated aneurism that sprang r/okt^ ^'^T'""*^ caus^ a suprasternal tumor; on refer- ring to It, the reader will remark thai the latter bea» maay point. 4-- resemblance to the one in the case al^ve detailed. Tt "rirporl^T 2« matter to be able to distinguish whether aneurism pointing in this part arise from the innominata or aorta ; as if it be the former, operative in- terference may be justifiable, while if it be the latter, such procedure is inadmissable. In some cases this diagnosis cannot be made during life, but in others, ora les^obsciire kind, a correct Conclusion may be formed— and perhaps in future cases the folldwing differential arrange- ment may be found useful. It refers merely to the distincition of the Uimor in the epistetnal cervical pit, and not to the diagnosis of the oneunsms generally. #. INNOMIHATA.L. Most Trequent. l)evelopeni«nt more rapid. I'liilaleral. lacUiieU to the right. Vroceedn from the right to the mesian line. Atntcbmeai expaiideil. Basis &c., as well as by an absence of the posi- tive characters of innominatal^neurism. • II. The likeness of the superficial swelling to an abscess was striking, and it is, therefore, not strange the patient should have mistaken it for one. In other cases this resemblance has been so strong, as even to have deceived surgeons themselves. Mr. Norris (op. cit.) has published two such instances in which the sac was incised, one of which hhppened to the late Mr. Listen. This error, for the most part, only hapi>ens where the more prominent symptoms of aneurism are absent : such as equable expansion and declination of the sac, synchronously with the systole Attd diastole of the heart; collapse of the sac, upon pressure of the nrmi <>" its cardiac side ; emptying the sac by direct manipulation ; inability to remove pulsation by displacement, &c. ; should cardinal signs like tHeise be absent then, indeed, a wrong diagnosis may be veiiial. WMle, however, it is true that an aneurism may be cons idered t o be an afe^^^s, the converse does not necessarily follow, as is unconditionally inting in this part mer, operative in- er, such, procedure t be made during DHclnsion may be Berential arrafige- distinction of the ) diagnosis of the BTIC. lal. < «r stife; ited. dli between the innoml- im iiivarisblc «iid evideht. ' centie o( manubrium, I of aneurwm occur at lea^^j he leA siile. to one or more of other diagnoses. \o vessels ('innomina- rarity, an aneurism lateral diversion of roid, middle or in- bscess. Such cases [ "features, as the. :)scnce of the posi- bscess was striking, ive mistaken it for )ng, as even to have ( has published two which hhppened to jnly happens where it : such as equfeljle with the systole attd are of the arUlir on Illation ; inability to inal signs like tHelse be venial. Wfctle, red to be an at>ate^i«, " is uncbnditiouaHy • stated m some hand-books, Ce-g., Erichsen,) and I believe it may he aWettfed^JJat an absoeis cannot be mistaken for a^ aneuriam.-— For that could only occur when an absfeess possesi^ed the most distinctive of the> sign* of aneurism as those just specified ; while experience shows that such attributes are never present. An abscess may pulsate and thus simulate an, aneurism, but this is merely a suggestive sign of aneurism, and unless accompanied by the cardinal signs is never consi- dered to be conclusive in its indication. An abscess is more likely to be mistaken for an aneurism in its earlier stage than when fully maturated. Lanoisi (De aneurysipatibus, 1728,) bears witness to the correctness of this proposition in the following decisive words:— ''Fdi- whatever pulflitile power an abscess tnay be supposed to possess, yet its pul- ^tion only laats until pus is generated when it ceases." Owing proba- cy to th^ hard fibrinous exudation of the first period being capable of exercising a degree and kind of pressure upon contiguous vessels, which the purulent secretion of the latter is unable to accompliish. Occasion- ally, bowever^'few exceptions are observed where an abscess in the fluid condition does pulsate, but these are so uncomplicated as not to embarras the diagnosis. And from ihapi th? practical conclusion follows j that swellings in the neck, "though soft, liquid, fluctuating and pulsating, if deficient in every other mark of aneurisntir may be safely treated as abscesses. III. Some of the direct signs of aneurism, or those proceeding imme- diately from the sac, were deficient ; as the absence of thrill and indis- tinctness of bruit. This peculiarity is to be ascribed to the nature of yie aneurism ; it was of the species known as sacculated or false, and still more appropriately called by Petit, aneurism by efiusion, the latter appellation implying that, the blood escapes or is effused from^he artery to which it returns after having circulated through an intermediate sac. • In every such aneurism, according to this eminent surgeon, who wrote in 1736, thrill is rarely perceptible and bruit is seldom, or else but indis- tinctly pin-ceived. He uJso mentions another distinguishing feature, that further identifies the Above case, >vith this class — it ia that in aneurism by efiiisicn, the enveloping " integument assumes a brbwnish Or leaden tint, as if there was a bruise." These observations, also, go to show that Petit, more than 100 years ago, was*posilively in advance of the know- ledge entertained on his subject at the present day. Contiast,for example, yriik his clear observations the remarks on diagnosis between true and false aneurismp, as stiated by Chelius, and which are so inapplicable as to n have^rewtt-forthThe^^Offimenti trf even his editor, Mr.^oatfir TS«" '30 discoloration last noticed generally supervenes when the swelling bo* comes superificial, and the surfaoe takes on a species of infammatory action. " - IV. The redness oT the skin that preceded the swelling may bd bx- plained by assuming that^when the arterial dilatation first gave way^t left a very minute % ening and that through this chink d little blood escaped, ♦and was impelled upwards into tho sub-integumental tissue, where, upoa becoming" extravasated.it stained the superimposed skin ; being produced in short, after the manner of an .ordinary bruise. Swelling succeeded gradually, because the tense, unyielding nature of the thoracic fascia had to be overcome ; and this obstacle only yielded to frequent repeti- tions of the systollb impulses, that had caused rupture. When at length it yielded, ^ diverticulum of blood was forced with sufficient momentum to protrude forward the epistewal cervical pit. This is the way in which some cases of false aneurism are developed at the bend of the elbow after venesection. And it is also the origin of some cases of dis- secting aneurisms, as is thus described in Jones and Sieveking's Patho- logical Anatomy -.—» We sometimes meet with small ecchymoses under the lining membrane of the aoita in the dead body, which indicate the commencement of this form of aneurism. A minute, and, sometimes, imperceptible fissure in the inner coat allows of thd permeation of a' small quantity of blood, and the first step having occurred a succession of simHar deposits may soon cause a greater accumulation, and necfii- sarily a coincident separation of the coats." V. The acoustic signsdid not indicate, correctly, the existent state of the heart and largo vessels. The principal abnormality heard was a strong pulsation, which was double or formed of twastrokea, and denot- ed by two sounds. These, in special character, resembled the cardiac sounds, but differed from them in being more superficial and more sonorous ; they appeaired to be loudest about the right superior angle of the sternum, and grfew progressively fainter as they were examined at remoter spots. So thaf, including the heart's region, there were pre- sent in the chest iwo distinct centra of puimion, which Dr. Stokes has iJQformed us, is the simplest expression of physical diagnosis in aneurism. The distmction between these aneurismal souhds was not very obvious* till afler the operation, ^hen they exactly simulated ihn bruit dt choc of some French ausf ultators,-the greaters clearnes at this period may be referred to the improved conducting power of the sac afler fibrillation of .ts blood had occurred. With the„ pulsation there was no distinct _j^ q««>"fflet. : And t h us ihe geoeral rule in th^cic aneurism ww & swelling W inflammatory g may be ex- Eive way^t left blood escaped, 3, where, upon sing produced ng sacceeded horacio fascia squent repeti- Hien at length at momentum I the way in e bend of the ) cases of dis- lung's Ffttho- ymoses under ti indicate the d, sometimes, rmeation of a a succession I, and necfia- [stent state of heard was a !s, and denot- i the cardiac al and more srior angle of examined at re were pre- r. Stokes has i in aneurism, very obvious » bruit de choc )eriod may be er fibrillation IS no distinct neunsranwar ai ved ; but an exception \o it might have been expected, for the tumor was dompressed posteriorly, bj the trachea which had left its mart upon It, and, anteriorly, ,n a less degree by the olavicle arid sternum. C.r- " ™T?ir'^' '^' '° '^^ °P*°*°° °^^™« Pathologist^, would be caiwes to^the passage of blood, from the .sac through the left .ubclavian, ther! was, however, an approximation to a bruit. The above signs, at most only denoted a thoracic aneurism. And did not imply its^rilTc^l h ty as. for aught they shewed, this may have been'the ascend7n7aoTa, or the arch, or the .nnominata. Sec. ; they did not indicate whether there was only one. or more than one, a;ieurism ;-and they were inexnres- sjve of the actual size of the aneurism. Thus substantiating tbe c^n: ^Z?/rT °^"^'"' •" ^'- ^°"' ^h°°o«tend that stethescopy cannot declare the true seat of aneurisms kbont the root of the' neck and Dr. Stokes who has said that an « extremely weak, almost imnerl ceptible impulse, may attend even a large aneurism of the aorta." But to some, the signs present may appear still more vague, since they close- ly siraulat«}d those heard in gouty aortitis, permanent patency of the aoruc va ves, &c. There was a still greater lack of intelligence cln! cerning the state of the heart. The impulse of this or^n d!d^ot seem abnormal, and yet there was a considerable hypertrophy of the lefl yentricle ;-the sounds were not accompanied with^or replaced by any bruit and yet the aortic ostium was inlaid with bony plates and the mitral valve was fibroid in its flaps, as well as calcareous round its base. The latter negation is easily understood, as the report shows ha^ any tnurmuia existed, they must have been of the « obstructive'' or direct kmd for no regurgitation had taken place. Now of these a disastolic mitml murmur is the rarest of rare sounds ; Laennec knew of no instance but hypothetically inferred the presence of a bruit, and up to 1848 o„Ty on^ case has been recorded, and that is by Andry. Systolic aortic mur- mur is on the confrary of common prevalence ; its absence was probably due to the ostium being smooth as the deposits were laminated and plane. And lastly, the roughened aorta did not cause a murmur, -thus agreeing with the observations of Harae^jnk of Prague, who doubts whether a bruit will arise from a roughened aorta, although the contra- ry IS usually believed among English and American auscultators. yi. In comparing the above case with others, the slightness of the re- mote symptoms ,s at once evident. In it pressure upon the branches of the cervical plexus produced pains l^o rheumatism in the right shoulder and a^ong the neck ;-instoad of, as in others, dull aching p^n in th^ t^- tA<«. -u , • . , ' ""icia, uuii acning pain in the tu- Jifl^ahaqx neuralgia la the arm,^de of face and head, sho ulder ahdt^^ / tJllJliAiii**ir^^-^ 32 St. Pressure on the air passages provoked paroxysmal attacks of asth- ma, — instead of continued dyspnoBa: the laryngeal irritation, from pres- sure on the recurrent laryngeal nerve, was signified by a short persistent cough, scanty mucus sputum, and no change of voice, — instead of diy cough, paroxysmal cough, (tussis clangosa), sero*mucus expectoration, laryngeal stridor, and hoarse, husky, or whispering voice. Pressure on the vena innominata caused a tendency to tippet-shaped neck — instead of oedema in the right side of the face and neck, the front of the chest and arm ; a varicose state of the cutaneous vems in the external half of the infra-clavicular and mammary regions, and axillary side of the right arm,— instep of an enlargement of the superficial veins of the neck, right half of the chest and arm forming a continuous mesh of knotty swollen big veins ; no change of features— instead of staring, protuberant eyes, with lips, nose, and countenance of a livid hue. Pressure on the oesophagus had, at first, caused no dysphagia,— instead of great Jand ex- treme difficulty of swallowing. And pressure on the subclavian artery had made a variation in the two pulses, but itwasslight— instead of strongly marked. The moderation of these eflfects may have been owing to the feebleness of the compression exerted by the aneurism, and this, in turn, may have depended upon the peculiar direction of the latter. ' VII. An unusual relation of the pneumogastric nerve to the carotid artery and jugular vein, was observed at the point of deligation. The nerve was on a plane more anterior than that occupied by the vessels, and although, thus, the most superficial of the contents of the sheath, it still preserved its median situation as usual. It is more than probable that instead of being an original conformation, this relation was acci- denUy'produced by the aneurism. As from the protrusion of the tumor forwards, and the position of the nerve on its anterior face, the nerve was drawn away from the direction that it would have otherwise occu- pied. Hence it appeared, on dissection, to be passing downwards in a diagonal line from behind to the front, and the vessels not undergoing a corresponding displacement, the alteration in relation necessarily oc- curred. The possibility of an aneurism thus causing an anatomical de- viation i$ an important fact, inasmuch as its knowledge prepares the surgeon for modifications it may necessitate in the usual perforpiance of his operation. In the above case the difficulty was obviated by intro- ducing th^ needle in a reverse manner to that commonly directed. VIII. Tl^e most unique circumstance, in the above case, was the ex- ternal open ng of the aneurism. As had been predicted, before the lapse ^ many hojjrs the episternal tumor op ened-exaetly 43 hnnra titet]^ stttitcksofasth- ion, from pres- short peraistent instead of diy expeotoration^ . Pressure on neck — instead it of the chest xteroal half of de of the right I of the neck, esh of knotty ig, protuberant ressure on the great [and ex- ^ian artery had ead of strongly 1 owing to the d this, in turn, ;ter. to the carotid igation. The y the vessels, 'the sheath, it than probable tion was acci- 1 of the tumor ice, the nerve therwise occu- wnwards in a ; undergoing a lecessarily oc- inatoraical de- I prepares the )erforpiance of ited by intro- directed. e, was (he ex- efore the l^pse iounMaftejp4t^ 33 operaUon— but instead of an issue of blood w^ its fatal consequences serum alone escaped, and safety foUowed. This event established the utility of the Ugature, by indicating the perfect way in which the blood of the sac had ooaguUted, after the operaUon; a soUd clot remained within and unmixed serum drained away. I can find no record of aneurism terminating similarly, so that the above case may be regarded, as exhibiting ft fact in pathological knowledge not previously demons- trated. It has frequently been observed, that after operations tot aneur- ism, the clot was xemarkably firm, and it has been received as a neoes^ sary belief, that the forcible action causing this result must have induced, as a cotemporaneous result, a thorough separation of serum • but until the above incident, this opinion had probably not been substan- tiated by any ocukr proof, or by an experimentnm cmcis of a positive kind. Contrary to what might have been ezpedted,the episternal swelling completely disappeared, and left no trace behind, after the eva- cuation of the serum, neither corrugated sao, nor partially filled tumor. This peculiarity appears to have been dependant upon the musonhir co^ vering of the aneurism. Before deUgation the sac, being then in fullest size, caiuied the greatest distention of the surrounding muscles (sterno hyoid and sterno thyroid) j as 'ong as its volume remained un- reduced, the latter parts were incapable of exerting their tonicity, since this power was overborne by the force of the constantly recurring circu- lation. When, however, this last was weakened, by ooagulaUon and ita attendant serous discharge, then tonicity came into ptay,the muscles abbreviated themselves, and the sac was by so much diminished. As the amount of drain augmented, the contraction of the sac increased and, pari passu, its capacity was unavoidably decreased. It is, therefore! easy to understand that in the closer approximaUop of sarcous element?, which these changes imply that the peculiarity mentioned was produced, so that there was a complete adaptation preserved between the capacity of the sao and the bulkiness of its contents, for as the latter lessened so was the former decreased. Had, however, the wall been simply mem- branous, then the evacuation of the serum must have left the sac par- tially fiUed, or, in other words, too huge for the contained clot j and its pa- rietes not being resilient must have partially oollap«;d, and,consequenUy, there could not have been the complete disappeaianoe which did occur. IX. At the qiot where these muscles first touch each other upon ap- proxinalion, a smaU fissure, as has been stated, was found during dis- section j it oorresponded with an opening, observed during life, in the in- tegumentjtowhich the exterior of the sao was intimately connected by wterveninf eellttlar lisMi»,«fta iiied iato^ a mimit* ainlsoated in tfie^~~ interior of the aueurismal dot. This was the ovne which the probe '■ '•■?j ^^-mmaumm^^^i^u-i^--^. + &■' ^ 34 followed, H^hen first introduced, on the tSth October. The canal only extended •throdgh a part of the coagulum, and its flobr was formed by very dense resisting fiferin. Its formation may be referred either to force used in the iutroductibri of the probe while the fibrin was not yet thoroughly consolidated ; or to the insertion of the instrument be- tween ivro (joricentric laminoB of fibrin, which were, at' the time sohiewhai Separated by interposed serum. The latter of these reasons is the more likely, from the circumstance of the fibrin, underneath, not havmg^been pettfetrfeted so as to draw blood from the artery immediately below, for had the clot bieeft actually pierced, the probability is the same force Would hav^ rendered the perforation Complete throughout. It is, also, for the'abo^e reasoti, more t)robable that it was a natural channel accid^feiitally aiscfe^e^e'd, than one fortoibly piadna^d, and it toay have so happened that th6 jfrtviBe was inierted into the conduit along which the cxlrudeid^^efiim J^feparatedfrbhi/the consolidating fibrin. The features, we hive been cdnsfdering, ^exhibit proof of the perfectness of fibrilla- tion rofcoureeth is'^fit^ct ^k-dsdiife 'to the ligature,— hut how far the topical applications resorteatb,niay have beeu adjuvant in establishing or streng- thening it, Ibnof easy to dttermine. It does not seem proper to deny them an]^ merit, nor to suppose they were who'ly nugatory, for it is well known that under favorable circumstances chemical agents become powerful inspissants. Guerin, in 1779,raentioncd cases of encysted or mixed aneur- ism, which were cured by applying to the tumor compresses soaked in cold lead lotions ; by administering to the patient acid drinks of 3j of the eau da rabel to the pint of diluent ; by keeping the patient perfectly quiet; and by favoring the action of the refrigerants, by a suitable re- grmen j ahd finally by avoiding all compression. X. The opinions entertained, at the present day, of the danger to the brain from cutting orits supply of Nood through evefi one carotid are diametrically opposed to those ttaintained by diatinguishpd stirgeons of a later period, and even by some not many years back, ad Sir A, Cooper Mr. S. Cooper, Mr. Miller and Mr. Wardrop. The first observes, "the carotid may be tied without injuring the functions of the brain,'»and the latter in Costello'9 Cyclopedia of PracticalSurgery remark^, « no ode now (184i; entertains tlie slightest fear for the intellect and other func- tio^is of the brain," afYer obliterating the carotid. Of the extreme lia- bility to occur of the result here dialed, there can be now no doubt raised ; and aware of this fact, the qnealion arises,— how far shotrid the danger it entails, form an objection to the hgatuie of the carotid artery in m^ominatal aneurism. To this I think these words of Dr. Cheeveri J«;'e"«d ^? toJ>g Jed'a* not renderlngnt nil doublfrtl the The canal only was formed by 3 either to force 1 was not yet nstrument be- , at the time, r these reasons nderneath, not y immediately Ity is the same ugboirt. It is, itural channel t taay have so DOg Which the The featnfes, ess of fibrilJa- farthe topical bingorstreng- r to deny them is well known jme jx^rfiil mixed ancnr- ises soaked in ksof Sjofthe ient perfectly a suitable re- danger to the ) carotid, are I stirgeons of 3if A. Cooper, •serves, " the rain," and the lb, " bo obe d other func- extreme lia- ow 00 doubt r shoufd the nrotid arfery 'r. Cheever's Tilfete rip pl y doubtfrtl (he 85 - proi)riety of the operation in tho majority of the cases iu which it is at pre- sent had recourse to, but as strongly discountenancing it in nearly aH instances where the disease for which it is employed does not positively threaten the paiienCs existence." (London Med. Gazette.; Statistics prove that cerebral symptomghappen to one of about every eight cases in Which carotid deJigation is praclised^a^d that they are the most common cause ot death in fatal cases, instituting two and one-third of the whole r/^l". ; .u ' notwithstanding this frequency, as well as the circum- stance of theix repented accidence afler the Huhterian onpration, the in- stonce above described contains the first Record of fatalcerebral symp- toms having followed the Brusdorean operation for innominatal aneurisit.. I .^^r^^\**« v»e«^ to determine the character of the cerebral disorder, hiiherto witnessed, after ligatiue of the car<^tid for the XJure'of aneurism Ttt iTrr 7^"^. ^' ^'^''' ^y Norris(ey. ««) have been examined, and think the following species may be identified j in which the prominent and freqneut occurrence of paralysis is remarliable. _ 1. Symptoms of phrenitis. Happening a few hpurs ^fter the opera- tion, and disappearing in health. . J, Immediate apoplexy: (within twenty-four hour^ after deli^tion ) partiaUecovery, but deatii before many day^ 3. Clight convulsions, ending in recovery. \ i 4. Simple cerebral disorder-variously exempli^ed ; as in loss dr per- version of one or more special senses, er,or of common sensation, llita- tiou of one pupil, dysphagia, feeling of bewilderment : unaccompanied with general^aralysis, and not producing death. \ 5. Vague symptoms of cerebral disturbance, preceeding naralysia which latter seen on fourth day. ^vccu.ng paraiysw, 6. Paralysis confined to one extremity. Of temporary duration j oc- curring on the eight day, and disappearing four day'a ^fterwa^s ^T^aralysis more general, and ushered in by drowwness. Also tem- 8. Paralysis preceejed by convulsions, and by stupor! Convulsions appearing 1 j hours after o|.eration ; stupor lasting twc^days ™iv. T f l^e"iiplegia, symptoms persistent, death eurly. (Pa- ralysis first seen ao hour alter the operation, and fiital on the fifti; day J 10. Temporary hem.plegia-slow in accession. slight in deVeioiement short in duration, and ending HI recovery. ej^e"*! ement, In addition, twitchings, tremblings. &«., have been noUc«d with aid ^^ii^nin'-'i "^"^'^^ ^" i«raiy.is,or:^n:r tri "'.^"l^^yl^raJlQg.J.asged. offjv.i Jj nt .O ^ecnrredntwasexhiS-t »vh.h the artery had been tied, but when o^J ^:!:X^:!',;^;'Z. -'^i^^'^*^^,SMmi,^ -. '^1 36 displnyed irregularly. In the case I have reported, the .lemeiological toturea were different to the foregoing both in kind and in arVaitgement. The first marks of cerebral distorbance were obM)rved on the 6th day •fter the operation, as pains akmg the rightside of the head ; afterwards Ml uneasy feeling in the right ear; on the 13th day, evidences of pul- monary congesUon or dyspnoea, cough, pituitous sputum, copious, ex-, pectoration ; next day, slowness of the pulse, only counting 60 beats a tT : "'/ f *1 T'^' '*•* P"'" ^"" *° *«' "^ '^'^'•8 the rest of the time^ It fluctuated between , this number and 64. On the 'Tth '^U^aI'^ ^' ^' ■• '* '^*'^' ^""" encephalic oppression, and sig- mfied by adynamic phenomena/as gravescent stupor, difficulty of articu- hjtion. involuntory twitches in the fingers, &c.; out of this fit, hemi- llfr^ fi^rst VMibie in the lips; afler a few hours the patient gradually regained intelligence, and recovered from all the pre- vious symptoms, except the paralytic, and he endured the latter till 70 days longer, when he expired. Xn. The symptoms that immediately ushered in the hemipleria of the carrotid, has been long known. The Arabians called this vessel .the apoplectic vein," thus connecting it directly with this peculiar state of the sensorium. Avicenna remarked thai, when these^^essels were tied, sense and motion were instantly lost. And nearly every an- cient writer, Grecian or Roman, from that time forwards, referred to the same circtirastance, either in yicqniescence or denial. The history of the above .case reminds one of paralysis from extravasated blood, by showing that apoplexy was followed by hemiplegia. Out .of 14 publ«,hed case. I«„l only find two that bore any resemblance to it. In one, reported by Magendie, on the «xth day thb patient was at- tacked with low of comwiousneasj ..very slow" pulsej irregular resnim- t^n, occasionally, nojy J with evtey mark of approaching dissohition. Some ime alter, fwhen not stated,) hemiplegic symptoms supervened. The other particulan^ are entirely dissimilar. The second is by Macau- ay and w somewhat analogous to the last. In the remaining 12 cases the c imcal histories are so imperfect, that no correct information can be obtained a, to the proportionate frequency of the symptoms under ccusideratiou. In some it is distinctly stated, that the aniecedents of hemq>leg,a were of • different chi^racter to the proceeding, and in others no allusion ofany kind occurs. *nmaer8 XIII. As the case advanced, there were superadded to the ordinary symptom, ol hemiplegia, indications of decay of the mental fiuinltie.. i^'rS^i^.dS^^eS^^ •-<» of im^irr^eM^T^^ ■go, w •^ ^ qemeiological aiVtutgement. D the 6th day d; afterwards [ences of pul- 1, copions.ex-i ig 60 beats a he rest of the On the :7th sion, and sig- ultyofarticu- his fit, hemi- I the patient ill the pre- latter till 70 3 hemiplegia after closure ;d this vessel this peculiar :hese vessels ■ly every an- I, referred to The history isated blood, Out>of 14 blance to it. ient was iat- [ular respira- dissohition. supervened. I by Macau- ing 12 cases mation can ttonis under ecedents of ud in others 16 ordinary k1 feenltiei, tj>f ej ^ vile distur 37 - bance: but a more singular event than these, was an intercurrent 8tu|»or and vigillium. This remarkable alternation was noticed during the last three we.eks of existence. The stiipor was associated with signs of weakened volition, sensation, an-l apiiareutly great exhaustion. It generally lasted for 36 or 48 hours, was always connected wath eostive- ness, and usually passed away after a free evacuation of the intestinal canal. A sort of reaction then occurred, the patient became wjikeful, pfjwer and feeling returned, this continued so for about 3 days during which the appetite would be good, he would sit up in bed. talk and enter anxiously ujion personal matters. It was observed thai with each relaj«e into drowsiness, the symptoms of jairaplegia became more niurked, as if the drowsiness were attended with periodical exacerbation^ of the centml lesion. And again as the recoveries became rej.eated, the Ia6t, in ordt r, exhibited greater signs of sympathetic disturbance than its predecessor, thirst became more urgent, the desire for food lessened, the pulse lowered in strength, &c. XIV. The (?ferebml lesions to be expected ufier ligature of the carotid are of a two-fold kind, those from 1st. iuanition, and 2ud. overstimulation. The hemisphere eorrespouding to the occluded artery is antemic, whilst the opposite onC; is over-vigorous ; upon the first there is a deficient, while upon the^ecoud there is an increased pressure, from the altered degree of fulness of the blood vessels. The effects proceedmg from both these conditions are sometimes only temporary, because they are soon remedied by a new oi comj^nsatorj^ arrangement of the circula- tion. At other times, however, serious changes of structure are grudu- ally established, and a sure foundation is laid for permanent disord. r. The morbid states hitherto recorded have been congestion, simple in- flammation, atrophy, and softening. The case descrilied stands alone, in presenting a new cerebral lesion— abscesses— after carotid deligation. I am not aware of any reported case in which a similar result is des- cribed. Indeed, it is so far different, from what is usual, that some might believe the abrcesses were not consequent uion the ligature, and that their occurrence in the right hemisphere was a mere coincidence. They were not bordered by softening and had all the characters of chronioity. For anything that appeared to the contrary, their origin n^y have been before the day of the operation. Like many other cases of encephalic suppuration, there was a remarkable immunity from the ordinary symji- toms of phrenitis; a truth which is sometimes so forcibly. declared, that not a single symptom of head derangement exists although pus in large quantity is prtaeut all the whfle. The alteration in form and size oi the ago, when the connexion between these parU and the extremitio waa m •Miffa.'«»i'«Hlttl^- w 38 , r - v«ssfi, ,if, ln.wever, the aneurism weredexoHt*.r.,l tKon .1 » It has, then, borne its testimonv to thf> fen«.l,,i.t., ^t «u Holouged if not saved when There 'sT 'h .^ ''' "^^ "^'^^ ^^ vatiuns it has oriirinated U.i. . ^!J^^J ^ ' ^'"^^y' ^^ *•*« o^eer- -jJt 1'^.'?'* """'°''' '•'y""°lti -i°»oinl- i.i .nfn,ani win, liiu... ■*«• *n,S.r1ftB, „«,4, ,„„„„^ __j,^^^ ^^^^__^^^««^w«M«™r-^ 3. segn X 4. near 5. aortii 1 iMMiiiri immT i-iTnri«iinirii , as ufiurdiug' a henjijiJegitt. rnished several lateral disjfesi- as a practical conclusion to arotid deliga- ■yirom which erred to, there the introdiic- :ined for this 16 same bene- B subclavian, it named ves- i again, were symmetrical blood woiiid iring may be an of oppra- time. peration ; to >rrectness of he weight of gatiireo/the iunomihatal :atnr0 of the life may be whiqh re- itions/popu- Miller, that B(ftinciple« hi the facts nnominatal the ^obser- positions,H8 39 3. Cases most favorable :— when the aneurism proceeds frutn (ho lell segment or anterior circumference of the artery* ^ 4. Cases less advantageous :— those in which the external turner is nearest. the middle of the clavicle. 5. Cases contra-indicating;— complications with aortic aneurism, aortic disease, Sec, unless Excepted by extreme urgency. .--f^J'fC - .f I aneurism. »ith iftimt> JvC'c^'Jl • 1 ■■ ' ' ■• i / ^ - • 1 1 •■ . • - ,/ / * 1 r :... ,.._;.._„Vv -^ — J — ^-- "■--• v 1 . . i- .... 1 ...