410 Dr Wall's Case of circumscribed false Aneuriam

anee, after typhus fever; ttle affection was generally removed by a few doses of purgative medicine.

In submitting these remarks to the public, [ am making no claim to originality of either views or treatment; I indulge in neither fine drawn speculations nor theories ; I merely wish to detail a line of practice, which in my hands has been marked with decided success in the treatmel:t of typhous fever, as it existed in this district during the late spring season ; and to conclude, [ may not perhaps inaptly add,

" Scripsl fide medica probaque pietate

si quid novisti reetius istis

Candidus impe~ti : si non his utere meeum."

KLZXN. Interp. clinic.

ART. X X V I . - - A Case of circumscribed false Aneurism of the Brachial Artery, caused by Puncture in Blood- letting, and cured by Operation. Communicated by THOMAS WALL, Member of the Royal College of Sur- geons~ London; and Resident Surgeon to the Cork General Dispensary and Humane Society.

P~ta'RICK Connell, aged 27 years, of a sanguine tempera- ment, and plethoric habit, by occupation a labourer, and living on the road to Ballincollig, about two miles and a half fi'om this eity, was admitted a patient at the Cork General Dispensary on the l l t h of August, 1886, suffer- ing from severe head-aeh. He gave the following report of his ease to his medical attendant Dr. O'Flyn. About five weeks previously he had an attack of fever, and since his convalescence, was troubled with uneasiness in the head. His habits were temperate and regular, and he always enjoyed uninterupted good health up to the period of his late illness. He was treated with purgatives and

of the Brachial Artery. 411

tonics, until the 19th, when he directed the doctor's atten- tion to a " lump" at the bend of his right arm, and which he said was gradually increasing, but gave him little or no pain. On inspection, the doctor perceived that it had an ambiguous appearance, and called my attention to the case. At first sight it appeared a circumscribed tumonr, about the size of a pigeon's egg, at the bend of the arm, having no discoloration of integument, or inflammatory appearance. After close examination, we discovered a pulsation, which was rendered very evident by the stethoscope, and a cica- trix in the median basilic vein. The nature of the disease was no longer doubtful; pressure on the brachial artery stopped the flow of blood into the aneurismal sac, which could be easily emptied, and refilled with a sudden gush on removing the pressure. The patient then stated that he had been bled in that arm five weeks before, and that the young gentleman who performed the operation found it extremely difficult to stop the bleeding, and likewise, that the venesection had given him very great pain. The doctor having transferred the case to me, I explained to the patient the nature of the accident, the necessity there was of implicitly following my directions respecting rest and regimen, with the almost certainty of an operation ; and though a poor uneducated peasant, he unhesitatingly agreed to it, or any other mode of treatment that I thought neces- sary to adopt. I was anxious to try what local and consti- tutional remedies could do, and accordingly ordered some purgative medicine, followed up by nauseating doses of tartar emetic, tincture of digitalis, and the recumbent posture. I placed a compress and bandage over the blxtehial artery and aneurismal sac; having first emptied the latter of its contents. Unavoidable circumstances pre- vented my seeing him for a few days, when I thought there seemed some decrease in the turnout. I continued

412 Dr. Wall's Case of circumscribed false Aneurism

this treatment for eight days, until I perceived considerable vaseularity, glossiness, and thinning of the skin covering the tumour. Besides these appearances, the limb was swol]en ; and the patient declared he eould no longer bear the necessary pressure.

On consultation with Doctors Hobart, Townsend, O'Flyn, and Mr. M'Evers, I determined on tying the artery the ensuing day ; and having prepared the patient by suitable purgatives, I proceeded with the operation on Saturday, the 27th of August, assisted by the above named, and in the presence of many other medical gentlemen.

Having laid the arm supine, and extended on a table of convenient height, I made an incision about two inches and a quarter long, in the line of the brachial artery, at the lower'third of the arm, about one inch and a half above the bend, avoiding the median basilic vein, which lay in my way ; cutting through the skin and common integuments down to the brachial aponeurosis, which I next divided on a director, to the extent of the cutaneous wound. I then laid bare the inner edge of the biceps muscle, and with the handle of the knife, worked a little through the cellular tis- sue, so as to bring the sheath of the vessels fully into view. Having done so, I pinched up a portion of it between the blades of the forceps, and with cautious touches of the scal- pel, held horizontally, cut it close to the point of the blades ; this made a small aperture, through which I attempted to pass the aneurism needle, armed with a ligature, round the artery; but without success. Meeting with considerable resistance at the radial side of the vessel, I hesitated to make a large opening into the sheath, or disturb the sur- rounding parts ; however, at the suggestion of my medical friends, I enlarged the opening, upwards and downwards, to the extent of about three-fourths of an inch, and when I got a full view of the vessels, the artery, which looked like

of the Brachial drlery. 413

a nerve, but redder, seemed not larger than a common di- rector, immediately ceased to pulsate, as l~ewise did the tumour and radial artery; the inner vena comes appeared very large and distended with blood. The cessation of pul- sation in, together with the diminished size of, the braehial artery, tended to embarrass me for the moment; but after waiting a little, the pulsation returned, though feeble, and I was then able to identify the artery, and pass a single silk ligature, waxed, round it, without disturbing it to any ex- tent, or at all interfering with the inner vena comes, or mediau nerve. The artery having been tied, all pulsation ceased in the turnout, and radial arter.y ; nor did the patient complain of any pain during the operation, or on tighten- ing the ligature, one end of which was cut close, and the edges of the wound brought together by adhesive strips. A point of suture was made in the centre, and the ligature left hanging out in a line with the noose on the artery. The diminution ill size of the aneurismal enlargement was now evident, with a bluish col(mr of the forearm and hand, and the natural heat somewhat dimilJished. A compress was laid over the tumour; and a flannel roller put on loosely fi'om the tops of the fingers to the axilla, so as not to impede the enlargement of the anastomosing branches, but to impart sufficient heat to the limb; and the patient was conveyed to bed.

Seven o'clock in the evening, (four hours after the ope- ration.) The forearm and hand are feeling warmer; com- plains of slight pain in the tumour, and also in the arm ; he describes it as i f " in the bone ;" is inclined to rest ; and in all other respects going on very well.

Temperature of the affected limb in axilla 98; bend of arm 92; palm 90. Temperature of the sound limb, in axilla 96; bend of arm 97 ; palm 98. Pulse at wrist of left arm 84.

voL. x. NO. 30. 3 f~

414 Dr. Wall's Case of circumscribed false Aneurism

1~ Acetatis Morphim gr. �88 Aceti Distil. ~j. Solve, et adde. Aquae Cinnam. 3v. Vini Antimon. gts. xl. Syr. Simplicis 5ij.

Fiat Haustus Anodynus, hera somni sumendus.

28th. Spent a good night; slept well after taking the draught ; pulse 80 ; no stool ; tongne clean. Temperature at axilla 99; bend 96 ; palm 92. Temperature of left arm at axiUa 99; bend 96 ; palm 96.

Repr. Haustus Anodynus hera sorani.

29th. Had a good night, slept well; pulse 80; tongue white; bowels still confined. Temperature at axilla 94 bend 89; palm 92.

I~ Submur. Hydrarg'. gr. vi. Pulv. Jalapm ~)i. P. Zingiber. gr. iv.

Fiat bolus, statim sumendus, et habeat Infusi Senmv Compos. ~viii. Sulp. Magnesi~e. Tr. Sennm Composite, as. ~i. Solve.

Surest Cyathum Vinosum 3 qr. hera ad solutionem alvi plenam. Repr. Haustus Anodynus hera somni.

30th. In consequence of the medicines not having ope- rated on his bowels until six o'clock this morning, he did not take the anodyne, but had some sleep in the beginning of the night. Five stools; pulse 80; tongue cleaner; no pain in the incision or tumour. Temperature at axilla 93 ; bend 92 ; palm 93 ; in the palm, under bandage 94. No heat of skin.

Repr. haustus Anodynus.

31st. Had a good night, but complains of pain in the wound to-day; opened the arm, and found the edges of the

of the Braehial Artery. 415

incision adhering at both ends, and looking healthy, an obseure pulsation could be felt at the right side, as if a small vessel passed over the tumour, which is diminished in size ; pulse 80 ; bowels regular ; tongue clean ; tempera- ture at axilla 96 ; at palm 92 ; applied fi'esh adhesive strips and roller.

Repr. Haustus.

September Ist. Slept well last night without the draught ; tongue white; pulse 75; bowels eonfined; temperature as yesterday.

Repr. Medieamenta Cathartiea et Haustus ; si opus sit.

2nd. Had two stools, and afterwards, at night, took the anodyne; slept well ; tongue rather foul ; pulse 72 ; tempe- rature as yesterday.

Repr. H~mstus Anodynus.

3rd. On removing the flannel roller off the limb, a tolerably strong pulsation was discernible in the radial artery at the wrist. The suture, which appeared to pro- duce some irritation in tile neighbourhood of the ligature, was removed; the edges of the wound uniting for the greater part ; two stools ; tongue clean ; pulse 7o ; tempera- ture at axilla 95 ; at palm 92 ; tumour diminishing ; wound dressed with fi'esh adhesive strips; compress and bandage as Usual ; to have fowl broth and toast.

4th. Every thing going on well ; pulsation at the wrist more perceptible ; requires no medicine.

5th. Tongue whitish ; bowels confined; in other respects the same as yesterday ; temperature at axilla 96 ; at palm 91 ; broth stopped.

Repr. Mistura Cathartics.

6th. Feels better; two stools ; pulse 80 in both arms ; temperature as yesterday; a sauious discharge~ tinged with

416 Dr. Wall 's Case of circumscribed fidse AJ~eurism

blood, from the wound; dressing renewed, allowing an orifice of exit for the matter.

Repr. Haustus.

7th. Going on very well ; pulse 72 ; bowels reguIar. 8th. Arm opened; discharge purulent and healthy ;

tumour subsiding fast; dressinff renewed; bowels con- fined.

Repr. Mistura Cathartiea.

10th. On inspecting the arm, I perceived a lengthening of the ligature, and having pulled it gently, found a resist- anee ; wound healed, except where the ligature hangs out ; simple dressing; compress and bandage as usual, with light ~ourishment.

I2th. On examination of the wound, and taking hold of the ligature, it came off without any force this day, Being the sixteenth since I tied tile artery ; the tumour is almost gone, and the patient in tile highest spirits. From this forward every thing got on rapidly; some fungoid granulations only shewed themselves in the part occupied by the ligature, which required to be occasionally touched with the nitrate of silver.

On the 3rd of October the wound was perfectly healed, and there remains no trace of the aneurismal tumour, save a little induration of the surrounding cellular tissue; the pulsation of the radial artery of the affected arm continues feeble, but equal to the other in celerity. I saw him on the 27th of October, and found that on the previous day he had been ploughing, and felt as if nothing had ever hap- pened to him.

Although the foregoing case exhibits no great novelty in the morbid appearances, o1" mode of treatment now gene- rally adopted, for the cure of circumscribed aneurism at the bend of the arm ; nevertheless, deeming that its publication may be useful to medical science, I have recorded its details

of the Bravhial ArlerIj. 417

with I trust sufficient brevity, and at the same time minute- ness, as an additional contribution to the knowledge in progress of accumulation upon the subjeer. And here I would beg to point attention to the fact, that during the time the ligature was on tile artery, I took the precaution of keeping a tourniquet on the l imb; not that I much approve of its use in these cases, but as a guard against the meddling of the patient, or his fi'iends; a practice too common out of hospital. I ha*'e, in more than this in- stance, observed the remarkable influence exercised by atmospheric air in diminishing the size and pulsation of the large, as well as of the small arteries ; which should be borne in mind where these vessels are closely accompanied by large nerves. It would appear also, that the aecompanyingveins of large arteries in the living subject often bear the same proportion, in size, to the arteries, that the latter do, in the injected state, to the former in the dead subject; the inner vena comes, in this case, being as large as the external jugular of a child in croup, whilst the artery was of the diminished size already mentioned. There was no varicose enlargement, or apparent connexion, between the wounded vein and the aneurismal sac. It will be also seen, that the temperature in the axilla of the affected arm became increased for the first few days, owing to the unusual quantity of blood suddenly thrown on the inosculating branches. Dr. Harrison, speaking of circumscribed aneu- rism from puncture of the brachial artery, at the bend of the arm, says, " I have known several cases of this species of aneurism, and fi'om the same cause, in youug persons, in whom a perfect recovery was accomplished by the applica- tion of gentle pressure on the part ; by bandaging the fingers, hand, and forearm ; by rest, and suitable constitu- tional treatment: I should, therefore, recommend in almost every recent case of this disease, a trial of this practice before having recourse to an operation; at the same time,

418 Dr. WaiFs Case of eircumscrlbed false Aneurism, 8;c.

however, it is right to observe, that pressure ought not to be indiscriminately applied, nor too long persisted in, as in some eases it may induce absorption, or ulceration in the integuments, and expedite the progress of the turnout to the surface; and in others it may convert a circumscribed into a diffused aneurism, and thus aggravate the disease." Mr. Hodgson, on the other hand, says, " compression has been strongly recommended in the treatment of circum- scribed aneurisms arising from wounded arteries; and nmnerous instances are recorded, in which it is said to have been advantageously employed. The records of sur- gery abound in descriptions of instruments invented for the purpose of compressing this kind of aneurism, with the intention of preventing the passage of the blood through the wound in the artery. A perusal of many of those cases in which compression is said to have effected the cure of this disease, has, however, convinced me that this mode of treatment cannot be relied upon with a greater prospect of success for the cure of aneurisms arising from wounded arteries, than when the disease is the consequence of a morbid condition of the coats of the vessel; and from the observations contained in a former part of this treatise, I think it is evident that compression is rarely capable of effeeting the cure of this disease." All I can say is, that having tried both methods, I am convinced had I perse- vered in the use of pressure much longer, ulceration of the sac would have been the result, without any chance of producing union of the coats of the artery.