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Un dee symbolea suivants apparaitra sur la demiAre image de cheque microfiche, selon le caa: le symbols —^ signi^fie 'A SUIVRE ", le symboie V signifie "FIN", Lee cartes, planches, tableaux, etc., peuvent dtra fiimte i dee taux da rMuction diffirents. Lorsque le document est trop grand pour itre reproduit en un seul cliche, il est filmA i parttr da I'angie sup«rieur gauche, de gauche i droitc, et de haut en baa, en prenant le nombre d'images niceesaire. Las diagrammes suivants illuatrent la m^thoda. 1 2 3 32 H 1 2 3 4 5 6 LIGATURE OF THE CrLTTTEAL ARTERY Kon TRAUMATIC ANEURISM. BY GEO. W. CAMPBELL, A.M., M.D , L.R.O.S.E., *c. Pnifmor nf Svrgery. McGiU Univcr$ity, Montreal. M m^ 1 LIGATURE OF THE GLUTEAL ARTERY roR TRAUMATIC ANEURISM. BY GEO. W. CAMPBELL, A.M., M.D., L.R.C.S.E., &c. Prqfestor ({f Surgery, McGUI Unicertify, Montreal. The patient was under the care of Dr. Feuwick, from the occurrence of th« accident till the 29th January, and the description of the ca.«e till that period is from his notes. " C. A., act. 14 years, small but muscular for his age,was accidentally wounded in the right buttock on the afternoon of Friday, 17th Januan. 1862. It appears that he had taken a small sled to a blacksmith's Miop to have some part of it ironed ; the smith had heated a piece of iron of about the size of a 3-inch nail, intending to bore a hole with it in u slender piece of wood ; as he left the fire with the iron in his pincers, heated to whiteness, he accidentally came in contact with the boy, but as he sprung out of the way, and did not ex- press any sense of pain, the smith paid no attention to him but proceeded with his work. In a few moments the boy said, " I am bleeding." The smith at once turned to him, took down )iis trowsers, and in doing .so blood, in a considerable stream, spouted out of a small hole in the buttock. He immediately placed his finger over the wound, but had hardly done so before the boy fainted. Still re- taining his thumb in position, he carried him to his father's office which waa in the neighbourhood. When I saw him he was pale, exsanguine, and almost pulse- less ; complained of dizziness, singing in the ears, and said he felt sick at the stomach. No pain or uneasiness was experienced in the wound, and with some little difficulty I induced the blacksmith to relinquish his hold. As he did so a drop or two of dark coloured blood welled from a small wound, in size about that of a pea, situated about one inch and a half behind the right trochanter major. The trajet of the wound appeared to pass upwards and backwards. I made no examination of its depth, but applied a graduated compress and roller, enjoined perfect rest, and ordered cold water dressing. The following day there was slight uneasiness felt in the wound, and general tenderness ail over the but- tock. Th« bandage was removed, but the compress was left, retained in posi- tion by adhesive plaister. On the fourth day, great pain of a bursting character extending down the back of the thigh was complained of. On removing the compress, a considerable quantity of pus flowed from the wound, which was fol- lowed by a bloody ichor. This gradually altered in character, becoming puru- lent, and lessening ,n quantity. The lips of the wound presented a charred ap- pearance, and a small slough was separating. The following Sunday, ten days after the accident, he got up and was going about the house ; the limb was stiff and sore, and he could not walk without the help of a stick. There was very slight discharge, and healthy granulation had filled up from below. The next day Monday, m attempting to leave his bed, blood in considerable quantity spouted again from the wound. I saw him shortly afterwards, but the hemorrhage had thTbTl^ Tt/ X T^'''' '""^ '''- "-^ ^- «"ff«""g -""^h pain in the buttock and calf of the leg. On Wednesday, the 13th day after the acci- dent, while I was ,n the house, he called out that it was bleeding again. On 7Z^r^u% Y-' " '*[.""" "^ '*'■'•'""' ^^""^ ^P»'*«<^ f^°™ the wound with ZttJ'Z' """i^^''^*^'^ ""««^d 't ^ith my finger, and in doing so, feh the blood well up against the finger, and elevate the buttock into a sack which I judged to be about the size of a hen's eg-." iJj T "* T ^u'"* '" ^^" '''''"'y °^"^' '''"^^^ Wednesday, 29th January twelve days after the occurrence of the injury, that Dr. Fenwick, who has kindW roneTl"-ri ^'^t.'^'^^TS statement, requested me, in conjunction with D. Jones, to visit his patient. Upon examination the small punctured wound al- ready described, was observed, which led to a tun.our three inches posterior to the right trochanter, about the size of a hen's egg. The tumour was beneath the J uto..«™„«„ju«cle was very painful to the touch, and a faint i.«,V was JZ f ' T;* "PP'";"* '"" '' '^' «t^t'>°««°P«- It was evidently aneuris- md and from the course of the wound, which ran backwards and upwards for traumatic aneurism, either of the trunk, or one of the large branches of the gluteal artery, in the immediate vicinity of the notch. tion^7tL't"1r-7'l"''^"''''"^"^'"»"*'" ''"^""•^'-' -^-'^'^ «- solu- tion oftheperchloride of iron, to endeavour to produce coagulation of its con tamed blood, with the hope that further operative proceedings migit the bv be" rendered unnecessary. The stilette of the syringe'was introduced iTh/i through the wound and one drachm of the fluid injected. The tumo^ Lcam .IZlT'f'' t "^"*T' ^"' ^" '—hage ceased. The discha^ to Zl ^ afterwards, again became purulent, and the indications seemed to promise a successful result, when on the following Monday, five days afterlhe njection being in the immediate neighbourhood, I^as requited in Tea 1 1t to visit the patient. I found there had been a recurrence of free aCr a h* morrhage from the wound, a vermiform clot of about three inches in length h^nJ bleeding, by placing her finger upon the orifice of the wound. He complained ndTs!T"f, "^1-^;^^-- -*te hip, which was evidently ei ted Tour wtl 7^^"" ^''*'°''°" '^ '^' '''■ I ««^'«^'«<^ '^^ -'o»nd and tu- mour with snow, and requested his mother, should bleeding again recur to place her finger as fomerly upon the orifice of the wound, appointitg to re ur7w.U Dr. Fenwick and some other professional friends in a few hours thereafter t« take more efficient measures for the permanent arrest of the hcemorrh^e ' Upon consultation, three methods of procedure were discussed: ll. To cut 8 into the aneurisinal tumour, to turn out the coagula, look for the mouth of the wounded vessel, and secure it where it entered the sac; 2nd. To endeavour, if possible, to avoid opening the stc, cutting down upon the trunk oi" the gluteal artery, and tying it where it emerges from the aciatic notch, and 3rd. To liga- ture the internal iliac. This last, although tlit- proper operation for spontaneous aneurism of the gluteal, was rejected as unsuited to traumatic aneurism, and the 2nd was selected, as likely to be less bloody than direct incision, and unattended with any of the dangers of peritoneal inflammation, and less hazardous in its consequences than deligation of the iliac ; besides it was in close proximity to the injured part of the artery, and on that account a better operation for traumatic aneurism. I was assisted by Drs. Sutherland, Scott, Fenwick, and R. P. Howard ; the first named gentleman compressed the abdominal aorta against the spine, by means of a small book, and the others were prepared to assist in the steps of the operation, and in arresting haemorrhage, should the incisions, to -each the trunk of the artery, open up the sac. The patient was put under chloroform, turned upon his face, and the operati(jn commenced by making an incision about 6 inches long, from half an inch below the posterior spine to- wards the trochanter, through the integuments and subjacent cellular membrane, down to the gluteus muscle, the fasciculi of the muscle were then separated to the same extent, and in the same direction as the external wound, by the handle of the scalpel, the sides of the wound were separated by curved retractors, and the deeper layer of muscles was exposed. Not half an ounce of blood was lost. There was no need for hurry in the further sjeps of the operation ; the pulsation of the artery was felt for at the upper and anterior portion of the notch ; and when discovered, the aneurism needle, guided by the forefinger of the left hand, which was held on the artery deep in the notch, was placed under it ; the end of the ligature was with some difficulty, from the great depth of the vessel, seized with a pair of dissecting forceps, and the artery was felt pulsating in the hight of the ligature before it was tied. From three to four ounces of coagulated blood were then pressed out of the sac, through the wound made by th' . ^^ the trajet of which ran parallel to, and about half and inch beneath, the line -k incbion. The haemorrhage having been found to be completely arrested, the sides of the wound were brought together by metallic sutures and adhesive straps, the boy was put to bed, and water dressing applied. Free suppuration both from wound and sac, commenced about the third day, and the ligature came away on the 6th day. A considerable quantity of ofiensive pus continued to be discharged for several weeks from the sac, the wound at length healed up, and the boy has now recovered perfectly. I believe the plan of procedure selected in this case, the details of which have just been given, was more fortunate in its results, and certainly much less diffi- cult in its execution, than if the ordinary rule in traumatic aneurism had been adopted, to open the sac and secure the orifice of the artery where it entered it. The patient was so anaemic from the previous haemorrhages, and so greately re- duced in strength from sufieringand confinement, that it was essential to his very existence, that the operation should bo performed with as little loss of blood as possible. The original operation of John Bell, and the reeent one of Mr. Syme of Edinburgh, where the sao was opened, were most formidable and bloody on that arjount. Few surgeons after perusing the details of Mr. Sjme's ease, so cour- ageously and skilfully conducted to a fortunate termination, would, if any other feasible plan could be adopted, willingly undertake such an operation. I am aware that it might be objected to the method adopted in this case, that possibly the aneurism might have been formed upon a branch of the Sciatic artery ; this, from the direction of the wound, I considered as very improbable, and granting that it was so, an'^ that the ligatare of the Gluteal had failed to check the bleed- ing, by drawing downwards the lower lip of the wound already made, the infe- rior margin of the pyriform muscle might have been reached, and the sciatic •rtery secured. Montreal, 10th April, 1862. of at ir- er iin ly is, ig d- :e- ic