COLUMBIA LIBRARIES OFFSITE ,.t*.^A'r.T.H,Sp'ENCES STANDARD HX64052575 RDi 4 W97 Essays in surgical a iiajiiiwiiin'iiirnBiiitwHifcrt TTJ 1 + ui<5>T ^ T^^^^S ^ £^^^^'y M^ '}yC>^ lyl^ iA<^-^^~t^~y^^ 4?z-'^/^i^^-«--2— -f Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/essaysinsurgicalOOwyet ESSAYS IN SURGICAL ANATOMY AND SURGERY, AN ESSAY UPON T[TE SURGICAL ANATOMY ANT) JTISTORY OF THE COMMON, EXTERNAL, AND INTEP.NAL CAROTID ARTERIES. AWARDEJ) THE FiRST PkIZE OF THE AMERICAN MeOICA^ AsHOCIATrON, June, 1878. AN ESSAY UPON THE SURGICAL ANATOMY AND HISTORY OF THE INNOMINATE AND SUBCLAVIAN ARTERIES. Awarded the Second Prize of the American Medical As.sociation, June, 1878. AN ESSAY UPON THE SURGICAL ANATOMY OF THE TIBIO-'l'ARSAL REGION. Awarded the (James R. Wood) Annual Prize of the Alumni Association OF the Bellevue Hospital Medical College, 1876. AN ESSAY UPON THE SURGICAL ANATOMY OF THE OBTURATOR ARTERY, AND NOTES UPON THE SURGICAL ANATOMY OF THE HIP-JOINT. BY JOHN A. YVYETH, M.D., (university of LOUISVILLE,) Menilier of the New York County Medical Society, the New York Pathological Society ; Honorary Member of the College of Physicians and Surgeons of Little Rock, Arkansas. NEW YORK: WILLIAM WOOD & CO., Publishers, 27 Great Jones Street. 1879. PHILADELPHIA : COLLINS, PRINTER, 705 Jayne Street. REPORT OF THE COMMITTEE ON PRIZE ESSAYS. Your Comtnittee to determine the merits of prize essays would respectfully report: That they have had three separate papers sub- mitted to their inspection. Two of these papers present subjects of very great interest and show original researclies, but are too imper- fect in the estimation of the Committee to command a prize. The remaining paper, in the judgment of your Committee, is fully up to the requirements. Indeed, the paper is so elaborate as to fill a large space in the volume of the Transactions of the Association. The paper should be considered as two^ and not as one. The analysis of 789 cases of operation on tlje carotid artery, and the careful and minute measurements of the artery and its branches in 121 subjects, showing the range of variation and the percentage of the same, fol- lowed by inferences, bold and original, naturally constitutes a paper complete in itself Another one on the same plan with reference to the innominate and subclavian, being an analysis of 300 cases, and the observation of 52 subjects, is presented to us in such a manner that we may consider the whole as one prize, or they may compete for both. Your Committee believe that both prizes should be awarded to the two essays by one person. The motto is '■'■Teynpora muiantur et nosmuiamur m illisJ'' B. M. MOORE, Chairman. THOS. LOTHROP, H. R. HOPKINS, W. W. MINER. Buffalo, N. Y., June 6, 1878. HIS FRIEND, S. S. LAWS, A.M., D.D., LL.D., M.D., PRESIDENT OF THE MISSOURI STATE UNIVERSITY, THE AUTHOR BEGS LEAVE TO INSCRIBE %\im €mp. PREFACE. I HAVE been encouraged to offer to the profession, in a complete volume, these "Essays on Surgical Anatomy and Surgery," since separately they have been received with such marked favor by gen- tlemen eminently qualified to judge of their respective merits. It is gratifying to know that they have already been accepted as stand- ard contributions to surgical and anatomical literature, and that the conclusions arrived at are taught in the lecture-rooms of some of our leading medical colleges. Three of these essays (and only three) were offered in competition for prizes given by liberal associations, and in each instance with gratifying success. I am under lasting obligations to the Committee on Publication of the American Med- ical Association, and to the Alumni Association Prize Committee for the privilege of publishing these Essays in other than their original form. The dissections embodied in these Essays were made in every instance by myself, and the measurements were noted at the time. The deductions are positive. No less positive the conviction, that " Surgical Anatomy" has not heretofore, nor does it now receive that careful consideration its vast importance demands. Plow few graduates of American colleges, who either practice surgery or put themselves in a position where an emergency may require them to undertake a dangerous surgical procedure, are equal to the occa- sion ! While it is true that for the majority of operations the prac- titioner has time and may make the opportunity to prepare himself for any given case, by special dissections, yet the time does come to all when instant and decisive action is required; when the pa- tient's life, dependent upon his skill and that self-possession which comes from a consciousness of careful preparation, hangs by such a slender thread that one mistake alone is fatal. Is it not close to the border-land of criminality to place one's self in this position? And yet I have heard teachers in great American colleges say that "too much anatomy was dangerous," and have heard it instilled into the minds of students that it was a good maxim, "to cut when it (V) VI PREFACE. was necessary, and tie what was cut." From such teachings has sprang the lack of preparation, and from both, the reckless practice which is called Surgery; a practice which would ligature a large artery for a lesion' involving an insignificant branch, the former easily performed and dangerous in its results, the latter more difficult but trifling in its consequences. In the winter of 1876, in some statements made before the ISTew York County Medical Society, upon the subject of one of these Essays upon which I was then engaged, I earnestly censured the practice of tying the commori carotid for any lesion of the external carotid or its branches, when there was one-half an inch between the lesion and the bifurcation of the primitive trunh. My conclu- sions met with the approval of two eminent surgeons, themselves Professors of Surgical Anatomy in the College of Physicians and Surgeons and the Bellevue Hospital College, and within the last year several younger American surgeons have with creditable skill ligatured the branches of the external carotid^ rather than tie the common trunk} These few instances, with those gathered in these pages, will, I hope, inaugurate a new era in the operative surgery of the neck, and will furthermore encourage younger men not to accept any procedure, no matter how high the authority which en- dorses it, unless it stands the test of a critical analysis. In gleaning from the almost boundless field of professional litera- ture the "Surgical Histories of the Great Vessels of the Neck," it has been my aim to arrive at the truth, positive and indisputable. I have accepted nothing that was not satisfactorily stated, not wish- ing to swell the manuscript with irrelevant matter. To this end I have omitted several hundred cases of deligation of these vessels, heretofore published ; those of the subclavian^ artery when from the description of the operation I was satisfied that the axillary was the vessel tied ; those of the other vessels when the results were not given, or the operation couched in uncertain terms. Besides the published cases I have been fortunate in obtaining many operations from private sources in answer to a circular letter of inquiry sent to every quarter of the civilized world. To each of these gentlemen who so courteously responded I beg to express my ' Prof. Jos. W. Howe has recently tied both lingual arteries below the posterior belly of the digastric. Dr. George F. Shrady performed the same operation upon the lingual of one side. Prof. L. A. Stimson tied both Unguals above the hyoid bone behind the hyo-glossus. 2 The subclavian is considered as terminating at the lower border of the first rib. PREFACE, Vll obligations for the generous contributions to the success of my un- dertaking. My thanks are especially due to my friend, the late Professor Alpheus B. Crosby, and to Professor Edward G. Jane- way, for the use of dissecting material under their control, which would with difficulty have been obtained elsewhere, and without which my investigations could not have been so fully completed I beg to acknowledge my obligations to the Society of the New York Hospital for the use of their magnificent library, and to the many courtesies extended to me by Dr. Vandervoort and son, the librarians ; to the New York Medical Journal Association, and to Professor A. B, Mott for the use of the private notes of operations by his distinguished father. I have received valuable assistance from the following works : "Contributions to Practical Surgery,"^ by Dr. George W. Norris, of Philadelphia; an admirable article by Dr. Ch. Pilz, "Zur Liga- tur der Arteria Carotis Communis;"^ "Ligature of the Common Carotid," by Prof. Jas. R. Wood ;3 "Des Bffets Produits sur I'En- cdphale," etc., by Dr. J. Ehrmann ;■* a " Prize Thesis on Ligature of the External Carotid Artery,"^ by Dr. Landon E. Longworth ; "Zur Ligatur der Arteria Carotis Externa,"® by Dr. Madelung; "Medical and Surgicar History of the War," by Dr. Geo. A. Otis, U.S.A.; "Ligature of the Subclavian Artery,"'' by Prof. Willard Parker; "Ueber Unterbindungen und Aneurysmen der Arteria Subclavia,"- by Wilhelm Koch; and to a magnificent paper on "Subclavian Aneurism,"^ by the lamented Alfred Poland. These various publications I have used for reference to the origi- nal article, which I have consulted when it was available; when not available I copied directly from the article accredited. I am indebted to my pupils, Drs. W. L. Wardwell and M. C. Wyeth, for much valuable assistance in reviewing the voluminous manuscript. It is impossible not to be attracted by the startling mortality following these capital operations upon the common carotid^ innowi- naie and subclavian arteries; operations which have been and are now taught and practised as justifiable procedures by many eminent men. And are we not justified in believing that this death-rate ' Lindsay & Blakistoii, Philadelpliia, 1873. 2 Archiv fiir Klinisclie Cliirurgie, 186S. 3 New York Medical Journal, 1856, *■ J. B. Bailliere, Paris, 1860. 6 G. P. Putnam's Sons, New York, 1873. 6 Archiv fur Klinische Cbinirgie. 1 New York Medical Record. 8 Archiv fiir Klinische Chirurgie, 1869. * Guy's Hospital Reports, London. VIU PREFACE. would be shown to be still greater if all of the unsuccessful cases were made public; if every surgeon was honest enough to acknow- ledge publicly his failures as we are all willing to herald our suc- cesses ? In the Essay upon the Surgical Anatomy and History of the Carotid Arteries, I claim to prove that ligature of the common caro- tid for a lesion of the external carotid or its branches, when there is half an inch between the seat of lesion and the origin of the ex- ternal carotid^ is wrong in principle^ unsafe in practice^ and should cease to he a s^irgical procedure. The deligation of the common caro- tid is and has been the almost universal teaching and practice, the objections to tying \\\e external being that the origins of the branches of this artery were usually so close together and so irregular in their relations (the anatomical objection), while the danger of hemorrhage was the clinical objection. I have proven, in the analysis of one hundred and twenty-one consecutive and carefully measured dissections of the three caro^i'c^s, that the anatomical objection has been greatly exaggerated and does not contra-indicate the ligature of the external carotid^ while the analysis of the Surgical Histories of these vessels, containing 898 carefully collected cases, shows the death-rate after ligature of the common carotid to be 41 per cent.; that of the external carotid to be only 4| per cent.! Surgery as a Progressive Science must abandon any practice which endangers human life, when a safer method is demonstrated. I hold it to be bad surgery which places a ligature upon the common carotid for a wound of the internal carotid artery. The proper procedure is given in the text. I believe it to be bad surgery which places a ligature upon the common carotid for a lesion of the vertebral artery. The method of differentiation is demonstrated in the text. In the Essay upon the "Innominate and Subclavian Arteries," I claim to prove that ligature of the arteria innominata on account of aneurism is not a justifiable operation, and that ligature of the sub- clavian arteries (more especially the right) in their first surgical divisions on account of aneurism is alike unjustifiable. Nature left to her own resources is more successful than the surgery which ties these vessels ; while the methods which belong to Conservative Sur- gery are given, which are still more successful in the alleviation of sufi'ering and the preservation of life. The very exceptional conditions in which these vessels may re- quire the ligature are mentioned hereafter. IMiEFACE. IX I believe that the mortality of 65 per cent, following ligature of the suhclavian arteries in their 8d surgical divisions on account of hemorrhage; and the mortality of 4-3 per cent, after ligature of these vessels in their 8d divisions on account of aneurism, are un- necessarily great, and that the methods of decreasing this mortality are demonstrated. The article on the Obturator Artery was originally published in the New York Medical Record^ and those on the Hip Joint in Pro- fessor Sayres' popular work on "Orthopedic Surgery and Diseases of the Joints." The "Essay on the Surgical Anatomy of the Tibio-Tarsal Region" was published in the American Journal of the Medical Sciences in 1876. I discovered that the arterial distribution in this region was not correctly described by the popular text books on anatomy, and I. believed that the frequent surgical operations at the ankle-joint based upon a wrong idea of the anatomy were not so safe as those founded upon a close and minute understanding of the relations of the vessels at this point. Subsequent reflection has not changed my convictions upon this subject. In conclusion, conscious that I have labored earnestly to arrive at the truth; alike conscious that no human undertaking can be utterly free from error, I offer these essays to the medical profession without an apology, feeling assured that what is worth enduring in them will endure, JNO. A. WYETH. Njew York, 1878, 44 West 27th Street. THE SURGICAL ANATOMY OF THE . COMMON, INTERNAL, AND EXTERNAL CAROTID ARTERIES. From their exposed position in the neck, that portion of the human body least protected from violence, the Carotid Arteries and their branches are more often the seat of lesions requiring surgical interference than any other vessels. This clinical fact, which (in connection with their distribution to the great nervous centre), makes them of most vital interest to the surgeon, together with the varying descriptions of these vessels by different anatomists, and the frightful mortality following the deli- gation of the common trunk to which my attention was called when a student ; — are among the reasons which led me to undertake the labor embodied in this essay. THE COMMON CAROTIDS. Anatomists agree, without exception, that the common carotid arteries bifurcate into the external and internal carotids, almost in- variably on a level with the notch between the two alae of the thyroid cartilage ; this varying slightly as the head is moved forward or backward. In what is known as the " surgical position" of the n€ck, that is with the shoulders slightly elevated and the head thrown back and a little below the axis of the body in the recum- bent position, there will be found nothing so constant in the ana- tomy of the arteries as the relation of the termination of the common carotid to the upper border of the thyroid cartilage. In 121 instances, 116 bifurcated at this point. In four cases the bifurcation was respectively one-fourth, one-half, three-fourths, and one inch above this line. In the fifth case the internal carotid was 10 PRIZE ESSAY. wanting, but the small common trunk took the usual distribution and relations of the external carotid} Prof. Hyrtl states, that any variation in the bifurcation of the common carotid from the point above given, will be helow this line. I cannot agree with him, since in my cases all the exceptions were ubove this point. The anatomy of the common carotids is so simple, and so much has been written concerning them, that I can add nothing of importance to the researches of others. What there may be of originality in these investigations will be found in the tioo upper anterior triangles ; namely, the trigonum colli superius and trigonum submaxillar e. Taken together they form an irregular quadrilateral, the anterior limit of which will be the median line of the neck, from the symphysis menti to the centre of the body of the os hyoides ; the superior limit cor- responds to the lower margin of the inferior 7naxilla, along the body and ramus to the condyle, then backward and downward to the middle of the origin of the sterno-mastoideus from the 7nastoid process of the temporal bone. The posterior boundary will be the median line of the sterno- mastoideus muscle down to the point of crossing the anterior belly of the omo-hyoid ; which muscle, passing upward, inward, and for- ward, forms the inferior border of this space. In this quadrilateral^ nine-tenths of the surgical operations, in which the carotid arteries are involved, are performed. The omo-hyoideus will be found to cross the common carotid, in the vast majority of cases, between one-and-a- half and two-and-a-quarter inches below the bifurcation. In a few instances it will be lower or higher than this limit, owing to the development of the muscle or the length of the loop of deep cervical fascia, which passes from its central tendon to the sternal extremity of the first rib. This irregular surgical quadrilateral is divided into the two tri- angles above mentioned by a pair of muscles intimately associated • lu the New York Medical Record, vol. xi. 1876, Dr. Eugene Peugnet, of Ford- ham Heights, gives a case very analogous to the above. See also the same case in the History of the External Carotid. Koberweiu states, he had seen a skull with only one carotid canal. In the case of Dr. Ray (see statistics of common carotid artery), is a notice of ano- malous absence of the arleria innominata ; the right carotid and subclavian coming directly from the arch of the aorta. I have seen reports of one or two cases in which the external and internal carotids on the right side were derived from the innominate at the usual point of origin of the common trunk. — ( Wien Med, Wocli. No. 96, p. 1573, cit.) SURGICAL ANATOMY OP CABOTID ARTERIES. 11 with each other, viz., the digastricus (its posterior belly), and the siylo-Jiyoideus. The first of these two, corning from the digastric fossa on the under surface of the niastoid process, passes downward and forward to he attached by a loop of Cuscia to the upper surface of the hyoid bone, the anterior belly being reflected upward and forward to the under surface of the inferior maxilla just outside the symphysis. The stylo-liyoideus, more deeply situated than the pre- ceding, is inserted into the os hyoides by two tendons whicli pass on each side of the central tendon of the dujastnctis. These two muscles vary considerably in their relation to the origin of the external and internal carotids, owing to the varying distance in different individuals between the chin and the hyoid bone. In the majority of ray dissections it crossed between one and one-and-a- half inches above the bifurcation of the common carotid. In rare instances higher than this, and in one instance of a high bifurca- tion, these muscles crossed at that point. The stylo- hyoidtus was wanting in one case. The sterno-mastoidetis, passing obliquely downward and inward, approaches the internal carotid, occasionally overlapping its outer portion, just above its origin from the common trunk; the anterior edge of the muscle descending along the common carotid obliquely crosses to its inner side completely overlapping it, about one inch and a half below the upper edge of the thyroid cartilage. It will be noticed that the common carotid in the last inch and a half of its course, and both the internal and external carotids in their entire length, are uncovered by muscles, except the delicate platysma myoides, and the conjoined bellies of the stylo-hyoid and digastric muscles (about one-half an inc-h wide), which cross these last two vessels from one to one inch and a half above their origins from the common trunk. A further examination of the surgical anat- omy of these vessels will show that in this single triangle, the trigonum colli superius, the ligature is applied to the common carotid in its upper portion, and to the external and internal carotids for all lesions of these vessels not requiring a double ligature at the seat of injury. THE INTERNAL CAROTID. From its direction this vessel seems to be the direct continuation of the main trunk. Passing upward almost directly in its first por- tion, it becomes slightly tortuous as it approaches the opening of the carotid canal. As it leaves the common trunk, it is usually 12 PRIZE ESSAY. trumpet-shaped; this dilatation being due, as I think, to this fact; the blood flowing forcibly along the main artery strikes the septum of biFarcation and is deflected with a certain degree of violence into the two smaller carotids. The pressure upon the external is in- stantly relieved by its numerous branches of distribution derived near its origin ; while the internal is distended by the constant pres- sure, which finds no relief until the blood can travel through the tortuous track of the vessel to be distributed to the brain. Anatomists, as will be seen from the extracts from various stand- ard works given below, usually describe this artery as giving off no branches. Sappey says: "In the course of this vessel from its origin to the base of the cranium it gives off no branches. Haller has, however, seen it give off once the ascending pharyngeal ' and another time the occipital.''''^ Gray says, "the cervical portion of the internal carotid gives off no branches."^ " The occipital has in some cases originated from the internal carotid P (Quain.^) Wilson says, " the cervical portion of the internal carotid gives off no branches."* "In the neck the internal carotid gives off no branches." (Leidy.^) And Hyrtl, more positive still, gives this artery as "invariably without branches."" In 120 dissections in which the internal carotid was present, the ascending pharyngeal was derived from it in seven. In three of these pharyngeal arteries came from both internal and external carotid ; in one case there were two branches from the same internal carotid. I have never seen the occipital from this vessel. All of these branches were derived within one inch and a half of the common carotid. It may be safely asserted that in j^ve per cent., the internal carotid will give off branches in the first half of its cervical portion. At the same time, the presence of these vessels offers no contra-indication to the application of the ligature in this region, since they are so small that they will be occluded by the inflammatory adhesions oc- curring at and near the ligature. In the cases of hemorrhage after excision of the tonsils, given in the accompanying Surgical History of the Common Carotid, in which this last vessel was tied to arrest 1 Traite d'Anatomie Descriptive, Paris, 1869. 2 Anatomy, Descriptive aud Surgical, London, 1870. 3 Anatomy of the Human Body, London, 1845. * Human Anatomy, London, 1858. ^ Human Anatomy, Philadelphia, 1861. 6 Haudbuch der Topographischen Anatomie, etc., Wien, 1871. "Die carotis in- erna ist vollkommen astlos." SURGICAL ANATOMY OP CAROTIlJ ARTERIES. 13 the flow of blood, the lesion was in the lo7bdllar bivanches of tVie ascendiwj pJiarymjeal. If (as is advised in the "conclusions" to this essay), the external carotid had been secured instead of tlie common^ the hemorrhage would not have ceased, and the crnarnon or internal trurdc would have been necessarily ligatured. Notwithstanding this rare anomalous derivation of these vessels, so great is the difference in the death-rate between the ligature of the external and internal^ or common carotid arteries, that the former should be tied in all cases without hesitation. If the hemorrhage is not arrested the common carotid may then be tied at the point of election. THE EXTERNAL CAROTID ARTERY. From the extensive distribution of its branches to the exposed portions of the neck and face, the external carotid artery demands a more careful consideration than any single vessel of the human body. Leaving the common trunk at the upper border of the thyroid car- tilage, well forward of the anterior border of the sterno-mastoid muscle, this vessel arches forwards and upwards (its concavity looking toward the lobule of the ear) until, on an average of .92 inch above the bifurcation, after giving off the facial branch, it turns obliquely upwards and backwards to a point opposite the in- sertion of the external pterygoid muscle into the neck of the condyle of the lower jaw, where it terminates by dividing into the temporal and internal maxillary arteries. Eight regular branches belong to this vessel (though some anato- mists, among whom are Hyrtl, Wilson, and Richardson, describe nine).' On its anterior aspect arise from below, upward, the thyroidea superior, lingualis, maxillaris externa, and maxillaris interna. On its posterior and internal aspect the pharyngea ascendens, and pos- teriorly the occipitalis, auricularis, and temporalis. THE ARTERIA THYROIDEA SUPERIOR. " This vessel originates from the front of the external carotid, just above its commencement." (Leidy.^) " Close to the external carotid, 1 These writers give the mastoid branch of the occipital as a branch of the carotid. It will be seen further on that this occurred in only 15 of 120 examinations. 2 These extracts from celebrated anatomists are given in no spirit of criticism that would reflect unkindly or unjustly upon the reputation of these great men, but to 14 PEIZE ESSAY. immediately below the cornu of the os hy aides.'''' (Qnain.) "From the external carotid just below the great cornu of the hyoid bone." (Grray.) "Its origin is so close to the termination of the primitive carotid that this last seems often to terminate by a trifurcation. It is not rare to see it originate by a trunk common to it and the lingual." (Sappey.) Wilson gives the origin identical with Quain and Gray, while Hyrtl gives nothing more definite than that it originates from the commencement of the external carotid. The average distance of origin of the thyroidea superior from above the centre of bifurcation of the common carotid (this being the centre (a Figs. 1 and 2) of a triangle, the three sides of which are drawn, two from the septum of bifurcation of the two vessels downward to the first swelling that indicates the origins of the external and internal carotids from the primitive trunk; the third line or base connecting these two), in 121 cases (in all of which it was present) was .11 inch, which point is almost exactly opposite the septum between the two vessels. (See Fig. 1.) By referring to the lines radiating from T (see Fig. 2) we will have the exact range or variation of origin of this vessel, in 121 cases, as deduced from the table of measurements. Between a point one-eighth of an inch above, and one-sixteenth of an inch below this centre already indicated, this vessel takes its origin in 68 per cent. The remaining 31 per cent, ranged between one-eighth and one-half inch above this, while 1 per cent, was below the centre of bifurcation one-half inch. (That is in only one single instance.) If to this 68 per cent, we add six cases in which this branch was de- rived one- half inch above, one case given off" one-half inch below the bifurcation, we have over 73 per cent, of cases in which, the necessity existing, a ligature could be applied to the external carotid within one-quarter of an inch of its origin without interference with the thyroidea superior, while a precautionary ligature applied to this last vessel would render the operation free from the danger of se- condary hemorrhage, as far as this branch is concerned. In four of 121 cases it was from a common trunk with other branches, viz., twice in common with the lingualisy and twice with show that the surgical anatomy of this vef-sel (the external carotid) has not here- tofore received that careful and exact study which its importance demands. In the prominence it will take in future (and to which it is hoped these labors may con- tribute to some extent), in the department of operative surgery, it is believed that a more minute analysis of its relations will be acceptable to the profession of surgery. SURGICAL ANATOMY OF CAROTID ARTERIES. 15 the lingvalis and maxiUaris externa (as sliown in Figs. 5 and 0). In one case it was from the comw.on carolid one-half inch below the bifurcation. Such is the peculiar position of this artery, that should it be wounded too close to the main trunk to allow of its being tied, the common, external, and internal carotidi^ would require the li^^ature, while on account of the free anastomosis with its fellow of the op- posite side, the peripheral end would require torsion. It ranks fourth in size of the branches of the external carotid, being largest in two of 77 cases examined as to this feature. One of the most fre- quent anomalies of the external carotid is the origin of the hyoid branches of the superior thyroid and lingual from the main trunk between these two vessels. Of its four branches (three of which are quite constant), there are: (1) The superior /orT/w^m? perforating the thyro-hyoid membrane, and distributing blood to the muscles and mucous membrane of the larynx. Hemorrhage from this artery has proved fatal in several instances ; once in an attempt to dislodge a fragment of oyster-shell lodged beneath the epiglottis, and again in attempts to relieve oedema glottidis, the hemorrhage causing death by asphyxia and not by exhaustion proper, ('i) The or ico- thyroid, wounded necessarily in the operation of laryngotomy; and (3) the cervicalis descendenSy which, crossing the sheath of the common carotid, superficially from above, downwards and outwards, is divided in the operation of liga- ture of the prin^iitive carotid above the omo-hyoideus. These three are, properly speaking, the surgical branches, the hyoid and terminal thyroid distribution possessing no special surgical interest. In two instances 1 have observed the thyroidea siijyerior turn abruptly down along the sheath of the common carotid for some distance, and then turn sharply forwards to be distributed to the thyroid body. Under such rare conditions it would probably be divided in the incision for ligature of the primitive carotid in the trigonum colli superius. In one case of goitre this artery was as large as the external trunk (see Fig. 8), seeming to be on the order of the " trifurcation" spoken of by Sappey. Operation for Ligature. — With the head in the surgical position, draw a line from the base of the tragus of the ear to the sterno- clavicular articulation. Parallel with this line make an incision an inch or an inch and a half in length, the centre of Avhich shall be opposite the upper border of the thyroid cartilage. A short incision 16 PRIZE ESSAY. at right angles to this, in the direction of and along the upper edge of the thyroid cartilage^ will facilitate the operation. Immediately beneath the skin and platysma myoides will be seen the thyroid^ lin- gual^ liyoid and other veins, which may assume either of the forms or relations shown in Fig. 9, A and B, being most common. These being tied and divided, or twisted, the artery will be found opposite the point, above so often indicated. In any case it will be found within half an inch above or below this bifurcation of the common carotid (see Fig. 2, T). LINGUALIS. Gray, Quain, Leidy, and Hyrtl agree in saying that this artery is derived opposite to and runs parallel with the greater cornu of the OS liyoides. Sappey gives it as coming between the superior thy- roid ?ca^ facial sometimes in common with one or the other. Wilson gives it as "ascending obliquely from its origin, and then running parallel with the cornu of the os hyoides." In the 121 dissections tabulated in another portion of this article, the average distance of origin of the lingualis from the centre of bifurcation (before given) was .68 inch, from the average of the thyroidea superior .57 inch (see Fig. 1). In Fig. 2, the lines radiating from L will give the range of origin of this artery from the external carotid. In 82 per cent, of cases this vessel was derived from that portion of the carotid between half and one inch above the centre of bifurcation ; in 6 per cent, between one and one and three-eighth inches; in 12 per cent, between half and one-eighth above. This leaves 88 per cent, of cases in which the lingualis is derived at a sufficient .distance above the origin of the external carotid to allow the ligature in its first surgical division, i.e., the portion below the facial, lingual, and occipital. While the eminent authorities above quoted generally agree in regard to the intimate relation of this vessel to the os hyoides (a re- lation which my dissections also show) they do not state anything definite as to the distance between it and the thyroidea superior ; a point of no little interest, since the ligature of the external carotid in this, its most important division, depends a good deal upon the average relation of these two branches. In 2 of 121 cases it was from a trunk common to it and the thyroidea superior ; in 2 other cases with this vessel and the maxillaris externa (see Fig. 6); in 31 of 121 cases it was common with the facial ; making this artery SURGICAL ANATOMY OF CAROTID ARTERIES. 17 abnormally associated in 35 of 121, or 1 in every 3^-. In 5 of 77 cases, noted as to comparative size, this vessel was largest, making it third in size. Extra liym'.d branches came from the external cciro- P. If 2i H ^8 2 If 21 2 1^ •■■8 2 93 -8 2i 2i 11 If 22- H H 2i 2i 2t 2i 3 2| 2i 2| 93 ^^4 ^8 H 2| 31 2i 3i 3 2| 2^ -^4 2i H H 95 2J H H ^2 2i 2f 2^ 93 ^4 3 2i 2| 2| H H 2| ^4 3 3 2i 3i 2| 2| 9i 2* ^4 ^4 30 PRIZE ESSAY, t3 O 2 CO bo a "3 1« be bo a a [p. O O.rH '3 "3 No. i 1 1 2 3i 82. L. 1 7 8 H 83. R. 1. 8 1 H li n 2 21 n 84. L. 1 If If li H 2i 3i 3i 85. L. 1 4 li li 1 1 3i 3i 86. L. 1 4 i If 1 4 H n 3i H 81. R. 3. 8 1 If H 2 3i H 88. R. 4 i H 1 2 3 4 7 8 2i 2^ 3 H .3 89. L. i i 3i 90. L. 1 4 1 2 1 JL 2 li If 2| 2| 91. L. Opposite. 1 li 3 4 1 2 3 3 92. L. u 1 n f If 2i 3i H 93. L. 1 1 8 1 8 JL 4 1 4 1 2 2 2i 3 H 94. R. 3 4 3 4 3 95. L. Opposite. u 1 7 8 op. 1 8 5 8 15 2f 2i 2f 96. R.* J. 8 1 8 n Q1. R. 1 4 1^ -■-8 -^8 1| 2| 3i H 98. R. 1 8 1 4 3 4 1 JL 2 4 n 2i 2i 3i H 99. R.f 1 1 2 5 8 If 5 8 If H 100. L.J 1 4 4 4 3i 101. R. Opposite. a 1 2 3 4 5 8 I i 1 2 3 4 If 2| 3 3 21 2| 102. L. 4 3 4 1 3 4 3 103. L. If If 2 3 104. L. 1 1 2| 105. R. 1 2 3 4 3 4 1 JL 2 If 3 3 3 106. L. 1 8 7 8 3 101. L. a 1 2 H op. H H 2| 2| 108. L. u 1 2 ■ 1 i. 2 1 2 2 2| 2| 109. L. ^ above. 4 1 1| 1 1 H 1| 3 31 3 110. L. 5 8 5 8 H li 3i 111. R. Opposite. 1 1 3 4 1 If 2| n 112. L. § I" below. 1 2 3 4 op. op. li 2i 2i 113. L. Opposite. 3 4 1 3 4 7 8 2 3 3 SURGICAL ANA.TOMY OF CAROTID ARTERIES. 31 ■a 'S "^ bo 3 OS '3 fcoio a =) *t5 o No. 114. L. Opposite. f 1 op. 1 2i 3 3 115. R. ^ above. i " Opposite. 1 n 1 op. 3 4 1 2 H 3 3-'- •-*8 3i 116. L. 1 1 3 111. L. 2i 2i 3^- 118. R. I above. 3 4 3 4 1 li 3 3 119. L. Opposite. 1 li 1 H 2i n 2| 120. R. -^ above. 7 • 8 H 7 8 i| 2^ H 3^ 121. L. i " 1 li li li 2i H 3i Total distance above bifur- cation 12.81 Average dis- tance 11- 82.56 110.99 67.31 115.80 221.8t 355.12 inches .68+ .92+ .60+ .96+ 1.89+ 2.93+ " * This case bifurcated ^ inch above the upper border of the thyroid cartilage. All the remaining cases were opposite this point. Total 121. On right side, 50 dissections ; on the left, 71. [Note. — Each measurement in these tables was made with compass and rule, and noted at the time the dissection was being made. It was thought unnecessary to measure below the ^ of an inch in general. ] SURGICAL HISTORY COMMON CAROTID AETERY, 34 PRIZE ESSAY. Surgical History of the Name of operator. Source of information. Cause of operation. o ■w a s »■ o o o X ^ f3 OS -2 ci re tS p. 2 P ■n pa Abernethy, 1803. Adelmann, 1841. Adelmann, lSr>3. Adelmann, 1 Adolphus, P. 1862. Alexander, C. T., 1862. Andrews, E., Chicago. Anandale, T.. 1875. Angell. do. Ansiaux. Ai'sndt, 1821. Arnold, G. C, New York, 1874. Arnott. Auchincloss, 1S39. Aubert, Moscow. Awl, Wm.L. 1827. Baizeau, 1817. Baker, J. W., 1870. Baker, W. M. 1S7.7. Von Balass 1854. Von Balassa, 1844. Ballingal,1854, East India. Norris Contributions, Pbila., 1873; Dr. C. Pilz, in Langenbeck's Archiv fiir Klinisclie Chirurg., 1868. Arch. Klin. Chir. (cit.) do. do. Med. Surg. Hist. Re- bellion — Dr. Otis, do. Letter to author. Brit. Med. Jr., Oct. 1875. Arch. Klin. Chir. do. do. Letter to author. Lancet, 1846, p. 135. Norris Contrib. Arch. KliD. Chir. Arch. Klin. Chir. Ext. Lancaster, Ohio, Gazette, March 20, 1827, kindness Prof. J. H. Pooley. Arch. Klin. Chir. 1868. Lancet, June, 1870. Am. Jr. Med. Sci., July, 1877, p. 176. Arch. Klin. Chir. do. do. Mid age. 19 Hemor'ge; wound throat ; gored by cow. Hem. of tongue. Removed cancer; tongue. Removed superior maxilla. Shot wound inf. maxilla. Fragment of shell, temporal region. Stab wound inter- nal carotid, high up. Aneurism ; arch of aorta. Epilepsy. do. Removed parotid. Aneurism anast. of face. Hemorrhage after removal, recur- rent tumor, an. gle of right inf maxilla. Hemor'ge, mouth; fall on pipe-stem. Aneurism anast. of head. Aneurism anast. of ear. Removed immense tumor of right cheek. Hemorrliage ; fis- tulous opening near ear. Hem. ; removed parotid gland. Hemorrhage; as- cend, pharynge- al ; fall on pipe- stem. Prep, resection of inf. maxilla. Aneurism of com- mon carotid. Pew hours. 5 days. 12 days 23 years. Some time. 17 days- 15 years. 3 years. 18 months. Below omo- hyoid. At omo- hyoid. Above omo- hyoid. Dec. 28, 1861. Sept. 6. Jan. 18, 1862. 1,2,3 da.ys. THE COMMON CAKOTID AKTBRY. 85 Common Carotid Artery. Date of opei'iitiou. %-. ^ Cm t. !-( ° O . ■^ ^ rt ji s. s 3 •5.SP ^■3 5.2 (=1 ■TJ =5 o p a R. Aneur. com. caro tid, high up. Hem. of int. caro tid. do. Hemorrh'ge ; stab mouth, piece of wood. Hemorrhage. Wound of throat piece of glass (ext. carotid and sup. thyroid). Knife wound of neck. Hem.; cancer. Hem.; abscess in neck. Nasal polypus. Shot w'd of face. 1 year. Removed tumor parotid. Hem.; aneur.; ext, carotid. Traum. aneur. of orbit. , Spont. aneur.; or- bit. Tumor of Diploe. Encepli. tumor ; parietal bone. Suicidal cut-thr't. Lacerated (glass) wound of angle of jaw. W'd of ext. caro tid or branches. Traum. aneur. of right orbit. Suicidal wonnd of neck. Hem. ; mouth ; in typhus fever. Aneur. anast. of head and face. Aneur.; com. caro- tid, low down. Erect, tumor of 19 y'rs. cheek. 5 mos. 20 mos. 11 days 5 days. 14 days Above omo- hyoid. May 5. June 28. July 4. 3 or 4 days. May 16. Often. THE COMMON CAROTID ARTERY. 39 Common Carotid Artery — continued. Date of oporatiou. o :^ o) QJ o c3 Recovery. Condition. Cause of death, date after op. REMARKS. Doc. 1.3, ise4. Doc.'26, J 180-1. Dec. 1SJ5. Often. 3d day, Nov. U, 1861. Dec. 14, 18(Jy. Sept. U, 1823. May 16, 18G6. June 13, 1860. 7th day. Feb. 28, 1859. June 18, 1860. 10, 11, 12 day. Dec. 21, 18.S9. July 9, 1842, July 9, 1848, May 10, 18.52. Dee. 22, 18o7. After. 63 day. 2 hours, 71 day. Feb. 23, 18)9 Feb. 19, 1824. Nov. 23, 1S6j. May 10, ism. Sept. 11, 1827. Jan. 15, 1830. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Cured. 3 days after last op. liom. and cerebral exhaustion. 2d day, exhaustion. 3d day, coma. Cured. 44 days ; cerebi-al complications. Cured. Not cured. Cured. Not cured. Cured, with loss of eye Cured. Improved. Cured ? 13th day, pyajmia. 7th day, hem. Several days coma. 17th day, hem. Diai'rhcea and hem 11th day, pysemia. 2d day ; cerebral symptoms and ex haustion. Carbollzod catgut. Had had Hyphilia. Hemorrhage and suppuration from ear» r«- poatodly. No cerebral symp- toms followed first op., loss of coiisciousncHs after second. No anajsthesia. Ext. carotid had been previously tied. Autopsy: Inflammation of dura mater. Internal carotid ' also tied, paralysis. Slight braiu trouble. Ball enterpd left side of chin, broke jaw, carried several teeih away, part of tongue and pha- rynx ; fractured transverse pro- cess 3d cervical, against which vrttbrnl artery had cut itself through causing fatal hemor- rhage. Permanent paralysis of sixth nerve. Died 11 months of hemorrhage and disease. Hem. on 71st day, ceased spon- taneously. Int. carotid tied. Facial paralysis persistent and complete. (Due to injury.) Int. carotid also tied. Fell from mast striking on feet. 5 mos. after first operation no improvement. S mos. later left carotid tied. Tumor was large and suffocation imminent. 27th day tnmor di- minished one half. 3 years later well. Bra.sdor. 40 PRIZE ESSAY. Surgical History of the Name of operator. Source of information. PATIENT. , Hti-uok on ho;nl by (.'alf. Hem. iiiiinodiato, rij^ht oar. .Tuly 28, jiain in Icl't oyi;. Sept. .'i, ulceration cornea. Feb. 1, aneurism evident. PreHHure on left carotid arrested pulsa- tion. Loss of vision left eye after recovery. Braador, 16 years after tumor began to grow agaiu. Nov. 9, 1864. Dec. 1864. July 7, 1858. Feb. 23, 1871. June 14, 1817. July 5, 1816. March 26, 1866. July 11, lSo9. 1876. Sept. 16, 1840. 5 min- utes. 13 days. Often. Recovered, Recovered, Recovered, Recovered, Recovered, 39 Recovered. Cured. Cured. 12th day; cerebral! symptoms. 1870 reported "disability J and permanent." Ball entered back of neck (left side) and passed out through cheek. 10th day after wound., internal carotid tied. Hem. followed, and common and external caro- tid secured. Hem. still, arrest- ed by styptic. Cured. Cured. Cured. 2 days ; hem. and exhaustion. 27 days. 9 days ; abscess of right hem. ; coma hemoi-rhage. 10th day. Com. carotid tied first ; hem. did not cease ; sac opened and buth ends of internal carotid tied. No cerebral symptoms followed. Well in 18.53. Hemorrhage after op. from tooth and wound of op. Memorrliogic diathesi.i. Cavern in right lung. Hem. (General bad condition may ac- count for death.) Autopsy. (See cause of death.) Autopsy: Ascending and trans- verse arch of aorta enormously enlarged. Right jugular vein, right carotid, and subclavian artery occluded. Distal; War- drop. 42 PEIZE ESSAY. Surgical History of the No. Name of operator. Source of information. PATIENT. Cause of operation. o (=1 o o o It < 6 "^ 1 j3 lOfi Campbell, 1845. Cantrell, J. Y., 1862. Carnoohan, New York. [ do. Carpul. De Castro, 1864. Catolllca, Caltolica ? Cockle, John, 1872? Coe, 1851. Coates, 1816. Cogswell, 1803. Cole, 1815. Collier, 1815. Colson, 1839. Cooper, A., 1805. do. 18CS. Cooper, B., 1840. do. Coote, H., 18.58. do. 1860. Curling, T. B., lfc.-54. Curtis, 1S57. Cusack, 1820. do. 1836. Cuveiller,1860. Cbadwick. Chapel. Arch. Klin. Chir. Med. Snrg.Hist. Reb. Am. Jr. Med. Sci., July, 1867. do. Arch. Klin. Chir., B. ix. Arch. Klin. Chir., B. xvii. Arch. Klin. Chir., B. ix. Am. Jr. Med. Sci., April, 1873. Letter from Prof. Paul F. Eve to author ; Arch. Klin. Chir. Norris Contrib.; Arch. Norris Contrib. Arch. Klin. Chir. Norris Contrib. Norris Contrib.; Arch. Klin. Chir. Med. Chir. Trans., vol. i. Med. Chir. Trans., vol. i. p. 224. Norris Contrib. Lancet, 1846, vol. i. p. 134. London Med. Times & Gaz.. vol. i. 1858. Arch. Klin. Chir. Med. Chir. Trans., vol. xxxvii. p. 221. Am. Jr. Med. Sci., 1861. Norris Contrib.; Arch. Klin. Chir. Dub. Med. Jr., Feb. 1847, p. 262. Poland in Guy's Hosp. Eep., vol. XV. 1870. Lancet, 1851, vol. i. p. 177. Arch. Klin. Chir. M. M. F. F. 48 Mid age. 34 34 E. R. L. 107 of innominate. Shot wound neck, near larynx. Elephantiasis Grsecorum. do. Hemorrhage. Aneur. of ext'rnal carotid. Traum. aneur. of vertebral. Aneur. ascend. aorta. Traum. aneur. of carotid. Aneur. of com. carotid. Turn, of parotid. Shot wound. Hem. of wound of angle of jaw. May 8. May 15. TOS 109 no m M. M. M. F. M. F. M. M. F. F. M. M. M. M. M. M. M. M. M. M. M. 31 48 55 41 37 27 63 44 60 34 64 46 49 36 20 24 13 R. L. L. L. L. L. L. L. L R. L. R. R. L. R. E. L. L. R. E. 15 mos. 1T^ n?! 1U 5 mos. 6 mos. do. 115 iifi 117 IS 5 days. IP 1?0 do. Aneur. int. caro- tid. Aneur. com. caro- tid. Hem.; suicidal cut- throat. Fung, growth of right sup. max. Hem.; removed sup. maxilla. Aneur. of orbit; traum. Shot wound of mouth. Hem.; wound of throat. Aneur. of carotid ; traum. Aneur. subclav.; bayonet wound. Lacerated scalp by circular saw ; hem. Aneur. carotid. 5 mos. 6 mos. 1 year. T^l 19^ 777) ns 1?4 Aug. 18. 1W 1?fi 2 w'ks. 19,7 1?,S l-Jfl 2 mos. 12 days. Below omo- hyoid. ISO 131 THE COMMON CAROTID ARTERY. Common Carotid Artery — continued. Date of operation. March 8, 184,j. Jan. .3,1816, Nov. 14, 1803. June 28, 1815. June 22, ISlf). 1839. Nov. 1, ISOJ. June 22, 1808. April 7, IS-iO. Aug. 22, 1S(J6. June 2, ] 8.H. April 19, 18r;7. Aug. 16, 1820. Nov. 22, 1836. 1860. 3 days. Often. 45-46, 49-57 dSys. Often. 21 days. Often. 32d day. 7th Jay. s>^ 14 4? 13 28 n .22 and 23 33 24 Recovery, Condition. Kecovercd Recovered. Recovered. Recovered. Recovered. Recovered. Recovered, Recovered. Recovered. Recovered. Recovered. Recovered. Recovered, Improved. Cured. Improved. Cured. (Improv'd.) Cured. Cured. Cured. Cured. Cured. Cured. Cause of death, date after op. 19th day, fever, de- lirium. 43d day, hem. and prostration. Hem.; sac burst. 71st day, hem. 20th day, hem. 4th day, asphyxia. 20tli day, inflam. of sac. 21st day. 3d day, hem.; cere- bral exhaustion. 2 hours, exhaustion. 60th day, hem. 10th day, hem. Antdpsy; Inflainmatiotj lunt'H. Aneurism of arcli of aoria, ('ar- otid occluded. Distal; War- drop. " 6 months after 1st op. improve- ment njarked. 8 yrars later patient was quite prcsentaljle ; could see, hear, smell, and taste well '." 3d day sac opened and external carotid was tied. AneiirisMi located on vertebral artery. Distal. 12 months after op. patient was working as farm labori-r. (Ara uuable to say whether this case is identical with Mr. Heath's or not.) 2 ligatures, vessel cut between. Hyoid bone broken. Severe la- ceration. (Ligature probably slipped over end of artery.) Pus in bronchi. Partial paralysis of left side. 2 ligatures ; vessel not divided. Inflam. of sac and pressure on larynx caused difficult respira- tion. " Died from mental disturbance and irritation of wound." This case not numbered by mistake — numbered at the last. Paralysis resulted. Autopsy: Right hemisphere softened. Cerebral symptoms followed, but gradually disappeared. No cerebral symptoms followed. Sup. thyroid tied ; 32d day after hem. and common carotid tied a second time. Hemorrhage persisted. Right subclavian tied same time. Distal. I Bones of skull were deeply in- dented by saw-teeth. 4th day, cerebral Autopsy: Breaking down of softening. 1 brain substance. 44 PRIZE ESSAY. Su7'gical History of the Nam-e of operator. Source of information. Cause of operalion. -S S Clieever, 1862. Chelius, 1836. Chaumet. Chassaiornac, 1859'. Cherry, 1858. Cliesley, 1864. Chiari, 1829. Clark, Le Gros. 18-16. Clark, Le Gros, 1860 Clarke, W. S., 1855. Glaus, 1846. Cleary, 1864. Cline, 1808. Critchett, 1854. do. 1855. Crosby, T. R., 1864. do. De Cruz, 1825. Dalrymple, 1813. Davidge, 1823. Davis, R., 1860. Debrou, 1867. Deces, 1839. do. 1850. Dehane, 1S32. Delpecli, 1831. Demme, 1859. do. Demme, 1840. do. Deguise, 1827. Delore, 1860. Despres (Sedan). Med. Surg. Hist. Reb. Norris Contrib. Arch. Klin. Chir. Traite des operations, p. 326. Ehrmann des effets. Med. Surg. Hist. Reb. Norris Contrib. do. Med. Times & Gaz., 1860, vol. 1. p. 190. Lancet, 1855, vol. ii. p. 165 ; Arch. Klin. ■Chir. Arch. Klin. .Chir. Arch. Klin. Chir., vol. xvii. p. 626. Norris Contrib. Arch. Klin. Chir., 1868. Med. Times & Gaz., lS.i5, p. 437. Med. Suvg. Hist. Reb, Norris Contrib. Med. Chir. Trans., vol. vi. p. 111. Norris Contrib. Ed. Med. Jr., Jan. 1862, p. 685. Schmidt, B. 138, S. .53. Ehrmann des effets ; Arch. Klin. Chir. do. Am. Jr. .Vied. Sci., vol. X. p. 496. Arch. Klin. Chir. Arch. Klin. Chir., vol. ix. and xvii. do. do. Ehrmann des effets, Gaz. des Hop., 1860. Gaz. des Hop., 1871, p. 362. Shot vround of left side of face. Aneur. varix. of temp, region. Removed cancer of parotid. Hem. after punc- ture of retro-pha- ryngeal abscess ; w'd of internal carotid. Erect, tumor (fungus). Shot wound sup. max. Traum. aneur. of vertebral artery. Wound of exter- nal carotid. Stab w'd of neck (carving-knife). Aneur. of carotid (angle of jaw). Suicidal cut-thr't. Shot w'd of face. 1 year. Above omo- hyoid. May 31. June 13-14. Short time. 1| h'rs 6 mos. R. Aneurism. Hem.; abscess. Hem.; aneur. of orbit. Shot w'd through left temporal bone. Same vessel tied again. Wound of throat. Erect, tumor of orbit. Fung, of antrum. Suicidal cut-thr't; angle of jaw. Stab in neck (knife). Aneur. of carotid (traumatic), do. Aneur., traum. Few hours. 1 year. lOiy'rs. Hem. of nose. Shot wound of temp, artery. Shot wound inf. max. (fracture). Aneur of carotid. 54 days. 35 days. 25 days. Erect, tumor. Aneur of carotid. Shot wound of face and neck. Sept. 30. Oct. 7. May 6. June 2 and 20. Above omo- hyoid. Sept. 1. Sept. 9. THE COMMON CAROTID AKTEUY. 45 Common Carotid Artery — continued. No. Diito of operation. W ° Recovery. Condition, Cause of death, date after op. Kii.MAUKS. 132 133 134 135 136 137 138 139 140 141 l42 143 144 14.) 146 147 148 149 1,50 Inl 152 153 154 l.')5 156 157 158 159 160 161 162 ]«3 164 Juno 14, 1S02. .Tan. IS, 1836. Aug. 1859. Oct. 7. 1864. July IS, 18-9. Oc'. 14, 18-16. Jan. 23, 1860. July 2), 1855. Dec. 31, '46, Oct. 4, 1864, Dec. 16, 1S08. June 20, 1864. 45 days later. Feb. 27, 1825. April 7, 1813. April, 1823, 1860. 1867. Feb. 2,5, 1839. Sep. 2, 1850 Jan. 20, 1832. 1831. 1859. 45tli day. 8.1th day. None. Sept. 24, 1840. Sept. 9. 9, 11, 17 days Recovered, Recovered. Recovered. Recovered Recovered. Recovered. Recovered Recovered. Recovered, Recovered, Recovered Recovered, Recovered Recovered, Recovered, Recovered. Cured. 10th day. 8th day. 5th day. 9th day. Cured. Cured. Cured. (7) Cured. Cured ; loss of eye. Cured. Cured. Improved. Cured, Cured. (?) Cured. Cured. Artery tied 3 times in succfSHion before hemorr'ge wan arr'-Hted. Cerebral symiitoms on 2d day. Hem, profuse before op. : after op. aphonia and headache for 24 hours. Autopsy: Aneurismal of vfrte- bral artery between 1st and 2d cervical. Wardrop. Autopsy: Thrombus in carotid. Ext. carotid tied 14 days after injury. Common carotid 33. 3d day. Glossitis. 2d day. 4th day. Hem. 3d day. Exhaustion 4 or 5 months. Hem. 'No cerebral symptoms. 6 weeks. Tetanus. 10th day. 49th day. Pysem. Exhaustion. Died. (7) 49th day. Hem. 5th day. Coma. Ball entered over left ear: open- ing large as two fingers ; out 3 inches anterior ; duramaternot opened. May 17, headache; 20th, comatose ; June 2, hem. ; June 20, ligature ; 45 days later hem. ; common carotid tied again. 2 ligatures, artery divided be- tween. Carotid tied between two ten- dons of origin of sterno-mastoid. Headache as a sequel. "Very much improved." Autopsy : Pus at base of brain ; inflam. internal jugular vein. Cerebral symptoms 5 days after op. ; relieved by venesection. Autopsy: Pus in sac and in tis- sues near wound. Facial paralysis 2d day after op. (left) ; 3d day paralysis body on left side. 46 PRIZE ESSAY. Surgical History of the No. Name of operator. Source of information. PATIENT. Cause of o 0.2 .3 bo o -^ ^ bD 6 bo < Ti m operation. 1fi5 Despres (Sedan). do. Dewar, 1860. Detmold, Prof. Wm., 1840. Detmold, Prof. Wm., 1842. Detmold, Prof. Wm., 1845. Detmold, Prof. Wm., 1847. Detmold, Prof. Wm., ? Dieffenbacli,'28. Dletrich.son. DolillLoff, 1837. do. Donaglie, 1856. Dudley, 1841. Duffin, 1823. ? Duke, 1847. Duncan, 1836. do. 1843. Dupont, 1814. Dupuytren 1814. Dupuytren, 1818. do. Dupuytren, 1835. Drop.sy, 1855 (Burnoth). ? Dzondi, 1824. do. 1825. Doughty, P. E., 1875. Gaz. des Hop., 1871, p. 362. do. Med. Times & Gaz., 1860, vol. i. p. 90. Personally to author. do. do. do. do. Arch. Klin. Chir. do. Eust. Mai?., 1838; Ehrmann des effets. do. Prof. Jas. E. Wood in N. Y. Med. Jr., 1857. Norris Contrib. Lancet, 1823, vol. ii, p. 200. Lancet, 1848. vol. i. p. 233. Norris Contrib.; Arch. Klin. Chir. Ediu. Med. & Surg. Jr., 1S44, vol. Ixii. p. 117. Norris Contrib. Norris Contrib.; Arch. Klin. Chir. Ehrmann des eifets ; Arch. Klin. Chir. Norris Contrib. Arch. Klin. Chir. Arch. Klin. Chir. Ehrmann des effets. Arch. Klin. Chir. do. Prof. Alex. B. Mott to author. M. M. P. F. M. F. M. M. F. M. F. F. M. F. M. M. F. M. M. F. M. M. F. M. F. M. Ififi and int. carotid, do. Hem.; pulsating tumor of tonsil. Vase, tumor of right side head. Vase, tumor chin. Aneur ; anast. of left ear Malig. tumor (to arrest growth). Eemoved sup. max.; malig. dis. Fung, of parotid. Hem. of tumor. 167 27 26 8 mos 40 R. R. L. L. E. 168 169 170 171 172 173 3 25 49 51 15 4 32 60 30 27 42 76 20 18 25 60 25 45? R.' E. E. E. E. R. R. L. E. L. E. L. E. L. L. E. L. E. 174 17,1 176 palate. Aneur., innom. Cancerous tumor of mouth. Erect, tumor of orbit. Hem of facial ar- tery. Traum. aneur. of carotid; pharynx (supposed abso.) Hem.; ulcer of throat. Aneur. of carotid at bifurcation. Aneur. of carotid. Shot vp-'d of ext. carotid and facial Aneur. of internal carotid. Erect, tumor of ear and temple. Enceph. tumor of temp, region. Aneur. of carotid, traum. Hem.; cancer of tongue. Eemoved inferior maxilla. Aneur.; root of neck (probably at bifurcation of innominate). 177 178 Several years. 179 ISO 1 year. 181 182 1S.S 6 mos. 22 days. 184 185 186 187 15 mos. 1 year. 188 189 190 191 THE COMMON CAROTID AHTEHY. 47 Common Carotid Artery — continued. Date of oporatioii. 1^ s3^ Bocovery. Condition. Cause of deatli, date after op. After. do. .Tnno 2, 1S40. 1842. 1845. 1847. 1828. May6,'is37l 1837. 1856. Jan. 1841. 1S23 ? Jxiue 10, 1S47. Marcli 29, 1836. Dec. 25, 1843. 1814. Feb. 24, 1814. 1818. April 8, 1818. Jan. 1835. June, 1855 ? 1824. July 8, 1825 Nov. 1,1875 7tliday. After. 4, 10, 1] days. 1.5tli day. None. Recovered. Recovered. Recovered. Recovered. Recovered. No improve- ment. Cured. Cured. (Growth checked. ) Recovered Cured. Recovered. Recovered. Arrested tempor'rily. Cured. Recovered. Cured. Recovered. Recovered. Recovered. Improved. Few minutes. Hem. Fatal hemorrhage from distal end. do. do. i" I/'li'morrhagie etait tellement j foiidri)yaiiti' riue j'ai en a peino I lo lemjis do decou vrir I'artere." Syjiliiiitic diathesis. " Op. made no impression on ta- moi- ; died 18 months later of plitliisis." "After ligature tumor laid open and hot iron applied." Died 6 months later from disease. 4th day. 14th day, of dis. 26th day. Cerebral 8th day after op. left paralysis, softening. i Autopsy: Brain softened. 5th day. Cerebral 3d day left paralysis. Autopsy: complications. Few hours. 5 weeks. Hem. Caries of clavicle ; hyperjemia of braiu. ' Died 4 months later exhausted by disease." ''Hem. ceased after op. Autop- sy : Ulceration of submaxillary gland." Paralysis after op. slight. (Dr. Duke did not puncture the aneurism by mistake, but was called in to tie the carotid. — Author.) 13th day. Bronchi-Hem. central end of artery; pe- tis and hemorrhge.! ripheral end was occluded. 17th day. Hem. and Tracheotomy was performed be- spasm of glottis. 6th day. Sth day. Cerebral complications. loth day. Original disease. 5th day. Cerebral comp. and disease. ISth day. Brain symptoms. fore operation. Autopsy: Sac had burst into trachea. After op. cough, difficult deglu- tition, and general insensibil- ity. Autopsy: No appreciable change in cerebrum. 3d day paralysis of left side. Autopsy: Softening of cerebrum. This patient was operated upon by Prof. A. B. Jlott one year after the above date, and the subclavian was tied in its 3d division. The author saw this man, by invitation of Prof. JMott, one year after the latter had tied the subclavian, when he was almost entirely recover- ed. A small tumor about the size of an almond, and quite hard, could be felt just b'^hiud the steruo-clavicular articula- tion. Patient told nie he was quite weak in his Uff arm for some time after the carotid was tied. Distal. 48 PRIZE ESSAY. Surgical History of the No. Name of operator. Source of information. Cause of operation. 192 193 194 Eastman, 1S73, Buffalo. Eccles, 1843. Ehrmann, A., 1858. Eliot, J., 1876. 197 19S 199 2D0 232 203 204 20 iJ 205 206 207 209 210 211 212 f Ellis, 1844. \ do. I Ellis, 183). Ensor, 1S74, Africa. Esmarch, 1857. Evan, Thomas? Evans, 1828. Eves, A., 1847. Eve, Prof. Paul F., see Z at end. Ewing. Fairfax, 1842. Fearn, S. W., 1847. Fearn, S. W., 183j. Fergusson, 1S41. Field, 1858. Von Fillen- baum, 1872. Loud. Med. Gaz., 1S32, vol. ix. p. 374. Letter from Prof. J. F. Miner to author. Norris Contrib. J. Ehrmann des effets, etc. Am. Jr. Med. Sci. April, 1877. Ehrmann des effets ; Arch. Klin. Chir. do. Norris Contrib. Lancet, 187.^ ; Am Jr. Med. Sci., 1875. Arch. Klin, Chir. Lancet, 1853, vol. ii. p. 225. Ehrmann des effets ; Norris Contrib. Lancet, 1849, vol. i. p. 556. Norris Contrib. do. Ehrmann des effets; Arch. Klin. Chir. Ehrmann des effets ; Arch. Klin. Chir.; Norris Contrib. Arch. Klin. Chir. Arch. Kliu. Chir.; Norris Contrib. Med. Times & Gaz., 1S58, vol. ii. p. 217. Schmidt Jahr., B. 156, S. 199. Schmidt Jahr., B. 156, S. 193 ; Wieu. Mediz. Woch., 1872, p. 29. 20 Mid age. L. E. Removed sup. maxilla. Aneurism. Tumor (sup. aneurism). Aneur. of ext. carotid (traum.). 2 years. Aneur. of innom. Shot w'd tongue. do. Wound of thi'oat. Aneur. of aorta and innom. Removed tumor of throat. Hem.; opening abscess of scalp. Aneur. of innom. and carotid. Suicidal cut-thr't; angle of jaw. Removed tumor of neck. Aneurism. Stab ; int. carotid. Aneur., innom. Shot wound facial artery. Aneur., innom. and subclavian. Hem.; removed sup. maxilla. Shot w'd of neck and face. Pistol w'd of face wound inter. max. art. 7 days. 11 days. 8 days. Below omo- hyoid. About 1 year. Short time. 30 y'rs. Below omo- hyoid. At omo- hyoid. 2 years. 2 days. 12days. Few hours. Above omo- hyoid. June 15. 1858. Aug. 10. Imme- diate, and 6th and 7th days. THE COMMON CAJtOTII) AHTKHY. Common Garolid ^W«rv/— continued. 49 No. Pate of oi'oratioii. ■f £'0 192 193 194 About 1873. Sept. 23, 1843. "(^>, Oct. l.'j, 1876. 1844. 4 clays la- ter. Jan. 26, '3;5. Sep. 8, 1874. Aug.9, 1S57, lethi day. Recovery. Recovered (?) Recovered Condition. Cause of death, date after op. Pyaemia. July 22, 1S2S. April 2, 1847. Feb. 11, 1832. July 18, 1842. Feb.2, 1S17, Aug. .30, 1836. June 22, 1841. June 17, 1 S.iS. 1872. Ausr. 17, 1872. Once. Slight. Recovered. Recovered Recovered. Recovered. Recovered. Recovered. Recovered. 20 Next day. 23-25 Cured. Cured. Cured. RKMARKS. Patif-nt was doing well day« after operation. Died of bron'hitiH in 4 months. AiitopHy Khowod diseaKo to bo e.nlirge.d gland. 4th day. CerebraliFew hours after op. right hr-mi- complicatious. plegia, hypora5sthe«ia left face ; oxter, strabismus loft eye. Po- I Hf.ntnn)e.r8p'.ri)'i)i>.raVn. 2.Tth day. Exhaust.; Subclavian tied same time. (.See.) hemorrhage. Not cured. Cured. Cured. Cured. 65th day. Pleuritia and hemorrhage. Recovered. Recovered Recovered. 4th day, Exhaust'n 5th day. Exhaust'n 79th day. Cured. Cured. 7th day. Pleuro- pneumonia. 8th day. Oct, 31, or Ifith day, hem. from sac 16 ounres. Died 2.jth day, loss of blood in/ormir)^clot in sac, and by external hem. ; to- tHl, 8 lbs. 3 ouiices ! Body weighed 130 lbs. Autop-y: Lig. atuie loose in wound ; floor of arch atheromatous ; opening of innominate 2 inches in diame- ter ; sac 5j inches verlif-aUy, transversely 4 inches, antero- posteriorly 3^. Distal. No cerebral symptoms except dyspurea. No cerebial symptoms noted. Patient was a Hottentot. Sub- clavian tied same time. (See.) Autopsy: Sac ruptured just be- low ligature. Persistent hemiplegia (right) after op. Patient died some months later ; cause not jjiven. Pleuro-pneumonia (slight) fol- lowed operation. " Paralysis of right (?) side fol- lowed." (Norri-.) Dis a/. Died 14 months later of gastric trouble. Paralysis after operation. Dyspnoea followed op. ; muco- purulent fluid in bronchial! tubes ; thrombus in carotid. Slight cerebral symjitoms result- ed Subclavian tied 2 years later. Distal. Autopsy : Fract. 2d and 3d cer- vical vertebrae ; abscess ; me- ningitis, etc. Solil throml)«8- on Loth sides of ligature, dbtn day. Cerebral Ball entered point of nose rajio^ complications. ] ed toward left ear. and lodged",- hem. left ear ; 30 days altt-r op- eration patient left his bed :; on 37th day pain in head ; died next day. Autopsy ; Pus at base of bram, inflammation of me- ninges, softeuin,' of left hemi- sphere Wound, of mcerual maxillary. 50 PRIZE ESSAY. Surgical History of the Name of operator. Source of Information. Cause of operation. <=* oil Fischer, 1864. do. do. Fisher, H. N. 1862. Finley, 1S21. f Foote, 1867, Cincinnati. L do. Follin. Forster, 1852. Fouilloi, 1828. Fox, 1848. Fleming, 1803 (British Navy). Freye and Botana. Fricke, 1826. Frothingham, G. E., Mich., 1875. Frothingham, G. E., Mich., 1872. Gamgee, S., 1871. Gaunit, 1827. Gensoul, 1826. Gibb, G., 1857. Gibhs, R. W., 1872. Gibson, 1832. Gibson, C. B. Goodlad. Guntner, 1872. Giinther. Arch. Klin. Chir. '•' do. Med. Surg. Hist. Eeb. Norris Contrib. N. Y. Med. Jr., March. 1869. do. Arch. Klin. Chir. do. Arch. Klin. Chir.; Norris Contrib. Am. Jr. Med. Sci., Oct. 1S49, p. 387. Norris Contrib.; Arch. Klin. Chir. Arch. Klin. Chir. Arch. Klin. Chir.; Norris Contrib. Am. Jr. Med. Sci., Oct. 1876. Am. Jr. Med. Sci. Jan. 1877. Lancet, June 3, 1871. Arch. Klin Chir. do. Lancet, 1857, vol. ii. p. 495. Charles. Med. Jr., 1874; Am. Jr. Med. Sci., 1874. Norris Contrib. do. Med. Chir. Trans., vol. vii. p. 112. Schmidt Jahrb., B. 158, p. 35. Arch. Klin. Chir. Mid .... Shot ■wound. Mid age. 17 35 Mid age. do. Hem.; removed thyroid body (sup. thyroid). Shot w'd inferior maxilla. Fungus antri. Traum. pulsating tumor left orbit. do. Kemoved carcino- ma of tonsil. Punct. w'd mouth (fallonumbr'la) Removed tumorof pai'otid. Aneur. of external carotid. 3 days. Some months. Suicidal cut-thr't Aneurism of both carotids. Cancer of parotid. Traum. aneurism common carotid. Pulsating tumor of orbit. An. of com. caret., high up (spont.). Carotid aneur. Rem. inf. max. Hem. (fall on dish, and carotid di- vided). Shot wound ; an- eurism of left submax. region. Medul. tumor of neck. Osteo- sarcoma of jaw. Immense tumor of pai'otid. Removed tonsil. Stab of int. max, artery. Short while. 8 days. Below omo- hyoid. Below omo- hyoid. Below omo hy Few hours. 5 years 6 years 6 days. At omo hyoid. 2.5, 26, 27 Deo. Aug. 16 1S75. THE COMMON CAIIOTII) ARTERY. 51 Common Carotid Arte/nj — continued. No. Date of operation. Hemorrh'ge occurred, after op. Sdg" "9 RESULT. REMARKS. Condition. Recovery. Cause of death, days after op. 214 April IS, 1S64. do. June 12, 18')4. Dec. 27, 1862. July 27, 1824. r Juno 22, 1867. 1 [1867. L July 20, Once. 2d day.' 2d day; hom.; coma. Luni; iiiiurcd also. 215 210 11 9 Recovered. Cured. Several days. 10th day. ConvulsionB on tightening liga- •^17 ture. Autopsy: No thrombus at lig. ?1S Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Not cured. Cured. •^ll After Ist operation hruit ceased, liut returned in 2 hours. After 30 days, symptoms being unfa- vorable, the rii;ht carotid was secured; the bruit ceased, but again returned ; ultimately cured. Discharged patient in 3 weeks after last operation. ?,?n w,i No symptoms of interest fol- lowed. Paralysis of right side for 9 months. fm 1S52. 1S28. Oc'.21, 1848. Oct. 17, 1S03. Cured. Cured. Cured. Cured. Cure of one. 223 15 20 7 ?,1^5 lowed, which gradually disap- peared. '^■^fi IStli day. Cancer. ginal wound. Abernethy, Flem- ing, and CoM'eswell tied the carotid in 18U3. ^17 ?I'^S Sept. 7, lS7o. March 29, 1872. 1871. 1827. 1826. AuiT. 30, 1857. 1872. Nov. 20, 1832. June 12, 1844. Sept. 5, ISlo. June 27, 1S72. 12 18 Recovered. Recovered. Cured. Cured. Internal jugular vein also tied ; no cerebral symptoms noted; 2 ligatures to artery ; voice per- manently impaired. Cerebral symptoms for several weeks ; pulsation returned ; growth of tumor retarded for 3 years, then began again ; ex- tirpated with eye ; hem. fol- lowed, and orbit was tamponed with liut in Monsell's solution. No cerebral symptoms followed. ?,^9 ^sn 6th day. (Cancer of rectum ?) 15th day. 231 Recovered. Cured. 232 ^33 6th day, slight. sup. 35 inf. 48 Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Cured. Cured. Cured. Cured. Cured. Cured. Cured. Difficult deglutition for several days ; both ends of artery tied. Paralysis right side after opera- tion, which was much dimin- ished after lapse of 1 year. 234 235 236 237 36 22 n 238 measured 20 inches : removed after ligature was applied. After ligature of the common trunk the hemorrhage persist- ed and the iuternal'maxillary was tied, which arrested hem. The ligature to the common trunk was then removed. (It is likely that the tightening of the ligature by dividing the in- ternal coat of the vessel oblit- erated its trunk as in ligation.) ?,39 52 PRIZE ESSAY. Surgical History of the No. Name of operator. Source of information. Cause of operation. « I o.o o ^- 240 241 242 243 244 245 246 247 248 249 250 251 252 253 255 2S6 259 2eo Gunderlach. 1S31. (MoUer), L 1832. Guthrie. Gurlt. do. Von Graefe, 1829. Von Graefe, 1821. Green, 1831. Green, Isaac. Greene, F. C, 1863. Graudchamp (Pinel), 1839. Greig, 1S62. Griffith. Gruening, E. N. Y., 1875. Hall, J. Z., 1864. Halsted, 1857. do. 1858. Arch. Klin. Chir. Lancet, 1850, vol. ii. p 143. Arch. Klin. Chir. do. do. do. Norris Contrib. New York Med. Jr. July, 1857. Med. Surg. Hist. Keb. Arch. Klin. Chir Edin. Med. Jr., 1862, p. 446. Med. Surg. Hist. Eeb. Archives Otology and Ophth., vol. V. No. 1, 1876 ; note to author. Med. Surg. Hist. Eeb, New York Med. Jr., March, 1869. do. do. 1839, New York Hosp. or Halstead. Notes, vol. iv. C. 496. Hamilton, 1838 (of Ohio ?). L do. 18.39. Hamilton, Prof. Frank H., 1853 Arch. Klin. Chir. do. Notes of cases from Prof. Hamilton. Mid age Mid age L. Aneur. anast. of frontal and nasal regions. do. Suicidal cut-thr't common carotid at bifurcation Hem.; shot w'd. Hem. of external carotid. Wound of neck. Removed lower jaw. Aneurism, Suicidal cut-thr't; w'd of superior thyroid. Shot w'd of face. Pulsating tumor of face. Aneurism of orbit (fall on head). Shot wound of su- perior maxilla. Vascular proiru- sion of both eyes (fall). SJ y'rs. 5f y'rs. 8th day. 2 years 14 days 3 mos. Shot w'd of face. Aneur. of orbit traumatic. Euceph. tumor of outer canthus of left eye. Enceph. tumor of diploe. Epilepsy. Sarcom. antrum of Highmore. 3j y'rs. From child- hood. do. Over 7 months. May 27. June 15, Above omo- hyoid. Above omo- hyoid. Above omo- hyoid. Aug. 21 June 16. Sept. 4. Often for 2 or 3 w'ks. THE COMMON CAROTID ARTEKY. Common Garoiid Artery — continued. Date of operation. a Condition. Recovery. CauHe of death, day8 after op. KEMARKS. Sept. l.S, 1831. Jan. 18, 1832. Auff. 23, 18(iB. 1866. 1829. July 26, 1S21. April 15, 1831. June 16, 1S63. 1839. March 30 1SC2. July 10, 1S64. June 8, 1875. Sept. f 186-1. 1857. 1858. 1839. Au?. '38. L Mar. '39. Dec. 24, 185!. Recovered. Recovered. Not cured. ? Next day. Recovered. 3 weeks. 3d day. Coma. Recovered. Recovered. Recovered. Recovered. Recovered. Cured. 10th day. Recovered. Cured. 2d day. 7th and 14th days, severe. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Cured. Cured (loss of eye). Not cured. Improved. Cured. Cured. Patient died later of variola. Ligature to cnmmon trunk did not arrf'st hem.; internal car- otid tied, and «till hcmorrhaco roKulted, uliinh ceaHKivilh the lipntiirfof the. fixlernol cor'ilirl. Internal jutfiilar vfin tied with lateral lif/aturo. For other cases of Guthrie see last page. Autopsy; Brain inflamed. 3d day, paralysis of right side. 'Patient became imbecile and died some months later of cho- lera." During previous year, the two facials, the transverse facial, infra-orbital, and temporal ar- tery of the affected side were tied, with no effect upon tuinor. No cerebral symptoms followed ligature of common trunk. '■ Fell down stairs." "Disease caused by fall. .Sup- posed fracture at base of cra- nium, with communication be- tween carotid artery and ca- vernous sinus." "Sight impaired in affected eye." Tumor diminished at first, but began to grow again, and 10 months later it was removed with the eye. " Died several months later from disease and hemorrhage." Although attributed to Prof. F. H. Hamilton by many writers, was not performed by him. I have his authority for this cor- rection. — Author. Polypus in right antrum causing protrusion of eyeball, depress- ing roof of mouth, and closing rightnostril ;patient weak from loss of blood. After operation patient complained of slight pain in right side of head ; hem. from wound on 7th day3 pints ; arrested by pressure in wound ; on 14th day vomiting caused hem. from nose ; tumor staii m- ary for some time ; cure com- plete. 54 PRIZE ESSAY. Surgical History of the Name of opevator. Source of iaformation. Cause of operation. "=.2 O ;3 261 Hamilton, Prof. Frank H., 1854 do. do. do. do. 1860. do. 1865. do. 1866, do. 269 do. 1869 270 do. 271 do. 1877 Notes of cases from Prof. Hamilton. do. M. Aneur. facial art- 6 w'ks. ery (traum. false; stab pen-knife) Medul. sarcom. of 2 years, angle of right jaw (tumor re- moved). Hem.; polypus of nose and antrum. Medullary sarco- ma of right an- trum. Erect, tumor of outer angle of right eye. 5 years. Several years. 6 w'ks. Hem. of ranine| 5 days, artery. Medul. sarcoma of superior maxilla (recurrent). Removed left sup. maxilla for me- dullaiy sarcoma. do. do. 12 y'rs. 6 mos. Below omo- hyoid. Above omo- hyoid. Above omo- hyoid. Above omo- hyoid, do. do. July 4. At time of in- jury. Often and profuse. Often. July 10. Often, but slight. THE COMMON CAROTID ARTERY. DO Common Carotid Artery — continued. Date of operation. W 30 o Condition. Recovery. Cause of death, days after op. 261 , Aug. 15, ' I8r)4. 1 262 Nov. 10, ISoo. 263 264 266 267 All?. 29, lSu7. Aug. 1.859. Feb. 12, 1S60. An?. 15, 1865. Sept. 5, 1866. None. After. do. Recovered. None. Next day, slight. 271 May 12, 1869. Feb. 25, 1877. 10 Recovered. Recovered. Recovered. -28 None. Had not come away 3 mu's after oper, Cured. (Temporary improve-^ ment.) No benefit. Not cured. Recovered. Recovered. Recovered. Recovered. 10 hours. Shock, hem., aniesthetic. 39th day. Ilemor'ge, exhaustion. 16th day. Anaemia ; exhaustion. Not cured. Not cured. No cerebral symptoms noted ; pulsation in tumor ceased im- mediately. Tumor ^rnw very slowly until last 2 inonthH ; size of coeoanut ; over a lartje portion of face and neck ; was excised ; hem. to 2or 3 pts. ; several ligatures in w'd ; no symp's of cerebral disturb'e. Br. Axtreo liad attempted to re- move tumor, but had to desist on account of hemorrhage ; ex- treme suffering ; no symptoms of cerebral disturbance. 7 y'rs previously dentist broke a tooth on right side, followed by intense pain ; 3 years before op. hem. 1 y'r before eyeball began to protrude; after op. eye aud tu- mor removed ; hem. profuse but easily controlled. Disease ret'd some time later and proved fat'l. Tumor covered right temple, had pushed eye out and destroyed it; soft, elastic, with distinct bruit; tumor returned later and patient died from it. On July 4th, patient had lower jaw broken on both sides; ab- scess formed and the attending surgeon (not Dr. H.) accident- ally divided the ranine artery, in open'g the abscess. — Author. " 3 months previously tumor had been removed by Prof. Lewis A. Sayre, but returned in a very malignant form. Day after lig- ature of carotid, paralysis ou left side of face and right side of body ; comatose and slight hem. from roof of mouth ; pa- tient died 2 mos. later. Autopsy: Granular dei;eneration of kid- neys and cancerous deposit in various organs." (The coma and paralysis were doubtless due to ligature of the ^carotid. Death iu great measure due to disease. — Author.) Patient died 6 months later of disease. Patient died several mos. later of disease. " Patient of hemorrhagic diathe- sis. Sharp pain down neck to collar bone some b"rs after op." Submaxillary gland removed; "^vouud healed nicely ; 3 months later disease seemed on the point of returning ; patient lost siyht of after this. Prof. Ham- ilton has furnished me notes of one other case which occurred on McCIellau's retreat after the "Seven Days' Battle." The common carotid was tied to ar- rest hem. from guushot wound of the ext. carotid; the hem. ceased, but the case was lost sight of in the confusion of the retreat. In every instance he has used his own "aneurism needle." which is described in his work upon the -'Priu. and Prac. of Surgery." — Author. 56 PRIZE ESSAY. Surgical History of the No. Name of operator. Source of information. PATIENT. Cause of operation. o .2 2 "S 'i Q o .2 'a "=^ .| to .25 fi.a t« to 6 bo 2 9.1'?. Hargrave, 1849. Hart, 1861. Heath, Christo- pher, 1865. do. 1872. Heine, 1869. do. 1871. do. 1873. Hebenstreit. Hendricks, 1864. Herpin, 1844. Hewson, 1850. do. 1867. Von Hippel, 1873 ? Hobart, 1857. Hoda;son, ZSoO. Holscher, 1819. Holmes, T.,1S75 (London). do. 1S7U-2? Holmes, E. L. (Chicago). Holt, 1860. Arch. Klin. Chir. Lancet, 1862, vol. i. p. 271. Lancet, Jan. 1867. Brit. Med. Jr., Feb. 1877. Long-w'orth, Prize Thesis. Wien. Mediz. Woch., 1874, p. 661. Wien. Mediz. Woch., 1874, p. 679. Arch. Klin. Chir. Med. Surg. Hist. Reb. Arch. Klin. Chir. do. Am. Jr. Med. Sci., July, 1876, p. 20; Dr. Thos. G. Morton. Schmidt Jahrb., B. 163, S. 59. Med. Times & Gaz., 1830, vol. i. p. 64. Arch. Klin. Chir. Norris Contrib. Am. Jr. Med. Sci., April, 1877. Lancet, 1872. Schmidt Jahrb., B. 172, p. 70. Lancet, 1861, vol. i. p. 560. M. M. F. M. M. M. M. M. M. F. M. M. M. M. F. M. F. M. M. M. 61 11 30 21 32 50 L. L. K. L. E. E. Hem.; puncture wound. Aueur. anast. of upper lid and or- bit. Supposed aneur. of innominate. Aortic aneurism. Hem'ge ; removed cirsoid aneur. of ear and scalp. Removed sarcoma of right tonsil (prepart). Recurrent sarco- ma of neck. Eemoved tumor of parotid (wound of facial). Shot w'd of face and neck. ^73 ?,74 4 mos. Above omo- hyoid. ^ys ^7fi 5 days. Several years. 277 Above omo- hyoid. Below omo- hyoid. 27S 279 280 25 59 48 51 21 L. L. E. E. L. Above omo- hyoid. 2S1 282 Aneur. of external carotid. Aneur. of innomi- nate. Traumatic pulsat- ing tumor orbit. Traumatic aneu- rism of carotid. do. Aneurism. Aortic aneurism. Innominate aneu- rism. Intra-cranial an- eurism (of pitui- tary body). Aneurism of caro- tid (low down). 283 Some time. 10 w'ks. 284 ■285 6 mos. •286 287 23 21 50 21 30 K. L. E. L. R. ■288 289 "290 Some time. 2 mos. 291 Below omo- hyoid. THE COMMON CAROTID ARTKRY. 57 Common Carotid Artery — continued. Date of operation. !-. tj >- O P (P a o o "t^S. Kecovery. Condition. Cause of death, date after op. KKMARK.S. Jan. 2.j, 1840. 1861 1 1865. Feb. 1872. is;9. Dec. IS, 1864. July 26, 1844. June 19, 1850. 1867. Sept. 3, 1857. 18.50. Sept. 27,'19, Oct. 21, 1875. 141 h day. Nov. 20, 1860. After. 28,29 2 or 3 times. After. do. 18 After 14th day, of bronchial catarrh Recovered. Recovered. Cured. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered, Recovered. Recovered. ISth day. Improved. Cured. Improved. Improved. Cured. Cured. Cured. ? Cured (?) 10th day. 90th day. Hem. No «yrnptomH of cerebral disturb- ' Subclavian in .Id div. tied Harne time ; tumor reduced in Kize and patierit much improved, thouijh of di»Holute habitB." niKtil. (In Lanrot, July 2, 1870, is notice of death of this patient on Dec. 8, 1869, from I'uptnre of aortic anenrism. The intiominate was not in- volved in tlie disease. — Author.) Died 4 years later from rupture of sac. Distal. ' Ext. carotid tied when tumor was removed; 5 days later hem. and lif;. common carotid." (See Surgical History oi' the Ext. Carotid Artery.— yl7///(or.) Not a particle of hemorrhage! " Operiite man so trucken wie an der Leiche." 6th day pa- ralysis left sidn and delirium ; osteo-plastic resection of lower jaw durinsr operation. Autopsy: Thrombus above and below lig- ature, continuous clot from, enroti'^ into ri'.ht siihclnvi"n ' 14 ligatures in wound of extir- pation." Hera, resulted from ulceration of wall of internal j ugular vein. 10 months later pulsation was noticed in opposite eye ; arrest- ed by cold application. 12th day. (Serous effusion in lungs.) 57th day. rhage. Distal. No symptoms of cerebral disturb- ance noted. Afi er operation tumor increased, was opened, and to arrest hem. a small artery was tied. Oct. 9, another hem., and a second liga- ture was applied (to carotid), which came away on Nov. 4. Hodges. Hobart, 2d case. See appendix. Patient was alive after 13 months had elapsed Right subclavian tied same time and tumor treated by gnlvnno- puncturK ; carb'd catgut used ; sac sloughed causing death. Died 3^ years later of disease. Autopsy : Tumor of pituitary body large as hen's egg, pressed upon carotid, causing aneuris- mal dilatation of this vessel and atrophy of both optic nerves. "After operation pain in head and retention of urine. (Feb. 4, much better and sent to Mar- gate?)" 58 PRIZE ESSAY. Surgical History of the Name of operator. Source of information. Caiise of operation. 0.2 M3 292 Horner, 1S32. Hueter, 1864. Hunt, 1862 (Fortress Mon- roe) . Hunt, Wm., 1868. Hunter, 1843. do. Hutchinson, 1856. Hutchison, Prof. J. C. (Brooklyn). do. 1866. do. 1877. Hutton, 1842. Isaacs, C. E., 18.i5. Jaeger, 1836. Jameson, 1820. Jobert, 1836. do. 1839. Johnson, C. H., 1850. Johnson, 1842. Jiingken. Norris Contrib. Arch. Klin. Chir. Letter to author from Prof. Alfred C. Post. Am. Jr. Med. Sci., July, 1876; Dr. T. G. Morton. Arch. Klin. Chir. do. Med. Times & Gaz., March, 1856, vol. i. p. 209. Letter to author from Prof. H.; Am. Med. Times, April, 1861, p. 20. Letter to author ; N. Y. Med. Record, Aug. 1867. Operation witnessed by author ; notes from Urs. H. W. Kand and J. E. Richardson. M. 34 Arch. Klin. Chir. N. Y. Med Jr., July, 1857. Arch. Klin. Chir. Norris Contrib. cit. Arch. Klin. Chir. Norris Contrib. Lancet, 1S50, vol. ii. p. 118. Norris Contrib. Arch. Klin. Chir., 1868. 58 Mid ige. 28 60 29 60 Wound of throat. Hem., secondary. Shot w'd of neck (high up). do. Aneur. in mouth. Aneurism of com- mon carotid. Hem. ; cancer of left submaxil'ry gland. Puncture wound by iron rod (w'd of internal max- illary). Aneurism of in- nominate. Neuralgia of 3d division of trifa- cial nerve. "Not long." Pew hours. 13 days. 7 years R. Innominate an- eurism. Hem.; shot w'd of angle of jaw ; suicide (single ball;. Hemorrhage after surgical opera- tion. Fungous tumor of antrum. Erect, tumor in temporal region. Anenr. of orbit. Hem. of pharynx ; umbrella driven through fauces. Aneurism. Hem,; aneur. anastomosis. 1 year. Below omo- hyoid. Below omo- hyoid, 1 inch above innomi- nate. 13 mos, 4 mos. 3 years, Sept. 11. 11 and 24. THE COMMON CAROTID ARTERY, 59 Common Carotid Artery — continued. Date of opiiratiou. Juno 18, 1832. Doc. 23, 18C4. 1362. Aug. 3, 1843. Sept. 2i, 1860. Jan. 16, 1866. June 30, 1877. June 27, 1842. 1855. May, 1S36. Nov. 11, 1820. Ausf. 22, 1836. Hemorrh'ge occurred, after op. 13 Recovery. Condition. CauHO of death, date after op. KEMARKS. May 12, 1850. Jan, 22, 1842. 22d day. None. 28 Recovered. Rocovorod. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Cured. Cured. Cured. Cured. Next day. Shock ; oxliaustiou. 4th day. 10th day. Cured. Cured. Cured. Cured. Cured. Cured. Not cured. 41st day. Asphyxia, reth day. 16th day. Hem. 2d day. " Slight cerehral diHturbanco. Internal carotid tied also. 3 days hefore death symptoms of paralysis on right side. " 14 hours afteroperation patient seized with epileptic convul- sions, which ceased later." Subclavian was not tied owing to its displacement and obliter- ation by tumor. Autupsy : An- eurism of aich of aorta and in- nominate. Both enrnlidn, right vert Aral and suhct avion artery occlutie.d, and nn symptnma of cerehral a^immial Distal. Upon two previous occasions, several teeth had been extract- ed, the alveolar processes re- moved, and once the dental branch of ?A division of ;'jth nerve had been exsected but without result. Carbolized cat- gut and antiseptic dressings used. Dr. Jno. D. Rushmore writes me, Aug. 18,1877, ''the operation was followed by com- plete cessation of pain ; wound healed by first intention ; pa- tient discharged cured." Tumor diminished almost en- tirely after operation ; epileptic convulsions before death. Au- topsy : Risfht subclavian also occluded although not included in ligature. Distal. No cerebral symptoms. No cerebral symptoms. Cure complete 27 days after op- eration. In Laneenbeclv's Archives. Dr. Pilz gives a 3d case by Jiing- keu, but as the S''x. side, civse, and result of the two opera- tions are identical. I suspect this industrious compiler has accidentally repeated this case. It is my purpose to admit no- thiug in this history that is not clear and positive. — Author. 60 PRIZE ESSAY. Surgical History of the Name 9f operator. Source of information. PATIENT. Cause of operation. O d 6 ft o o a "S "ox ^:2 6 t^ ho 6 60 < T3 .d ■^^^ .liingken. Karatscharoff. Keen, W. W., 1S63. Kerr, 1S40. Key, Aston, ■]830. Key (?), 1S24. Key & Grouse, 1811. Koch, 1866. - Kuhl, 1S43. do. do. 1836. Kluyskens, 1840. Knagges, 1863. Knapp, H., 18.58 (Heidelberg). Knowles, 1867. Arch. Klin. Chir., 1S6S. Med. Zeit. Russ. 1846, S. 39 : Arch. Klin. Chir. cit. Med. Surg. Hist. Reb.: Otis; Am. Jr. Med. ' Sci., 1864. Edin. Med. Journ., 1844, vol. i. p. 119. Lond. Med.Gaz., 1830, vol. vi. p. 702. Korris Contrib. Schmidt Jahrb., B.41, ■ S. 75. do. Ehrmann, No. 13 ; Norris Contrib.; Arch. Klin. Chir. do. Arch. Klin. Chir., 1868. do. Lond. Med. Times & Gaz., 1863, vol. ii. p. 8. Letter to author from Prof. Knapp. Lancet, June, 1869. Arch. Klin. Chir. Gunther, 199; Arch. Klin. Chir.. 1868. Norris Contrib., 1868. Ehrmann des eifets, p. 41. Arch. Klin. Chir., 1868. do. do. do. Lancet, 18.52, vol. ii. p. 57. M. M. M. F. F. M. F. M. M. M. F. M. M. M. M. F. F. M. M. M. M. M. M. 33 33 67 61 40 53 38 53 53 43 23 15 9 mos 40 48 49 29 48 36 58 65 30 L. R. L. R. R. R. R. L. R. R. L. R. L. R. L. R. R. R. R. R. L. L. Stab wound of ex- ternal carotid. Short while. '^^'>, 313 Shot wound of superior max. Vascular tumor; supposed aneur. Aneurism of in- nominate. ' Aneurism. Aneurism of caro- tid. Hem.; shot w'd. Aneurism anast. oecip. traum. do. Vascular tumor of frontal region. Aneurism, traum. Aneurism of caro- tid, traum. Intra-cranial turn. Aneurism of caro- tid (low down). Headache. Removed tumor of neck. Aneurism of caro- tid (at root). Above omo- hyoid. Julyl. July 8. ii.i =!lfi 5 mos. ^17 ?1S ^19 24 y'rs. 520 do. 4 mos. 3 mos. 4 mos. ?21 ?22 323 Below omo- hyoid. Above omo- hyoid. 324 325 3W 3?7 Labat. Lambert, 1S27. Von Langen- beck, 182.5. do. do. 1845. do. 18.J9. do. Lane, 1852. 3?8 329 330 perior thyroid artery. Hem. carcinoma. Traumatic aneur- ism of carotid ; shot wound. Removed epithe- lial cancer of neck. do. Aneurism of caro- tid (low down). 5 days. 14 days. 3S1 339, 2 years. 333 334 5 w'ks. Above omo- hyoid. THE COMMON CAROTID APwTEKY. 61 Common Carotid Arlery — continued. Dato of operation. !■ « ■ Ph ia S c. 5>^ • o s S " b« a ge Kecovery. Condition. Cause of death, date after op. REMARKS. July 16, lSJ:i. April :iO, 1810. July 20, 1S30. Jan. 24, 1824. Sept. 9 1S41. July 22, 186(3. r May 24, I 1S43. j Au!.'. 4, 1 1834. Sept. 16, 1836. Aug. .5, 1840. Jan. 16, 1863. 1858. 3,4, slight. Several times. 3d day. Eecovered Kooovered Cured. Cured. 4th (lay. Corehral complications. Rocoverod. 4 hours. Coma. 10th day. Recovered. Recovered. Recovered. Recovered. Cured. Cured. Not ciired. Cured. 2d day. 22 Recovered, 34 March 1, 1827. ? 1845. Jan. 13, 18o9. May 30, 1859. July 7, 18j2. 11,49, 61st day. No better. 14 Recovered. Eecovered Recovered. Recovered. Improved. (?) Cured. 44th day. Next day. Disease. 35th day. Coma. Sujipuration in sac whicli had to be opened. Paralysis .35 days after opera- tion. Autopsy: Abscess in brjiin. Patient died months after op- eration from pneumonia. Autopsy : Mouth of hft carotid was about one-tonth size of rest of vessel ; both vertebrals small. Distal. No had symptoms. Ball entered at infra-orbital for- amen, s]iin. process, 2d and 3d cervical vertebrje. One year after a fall from a horse on occiput ; disease began 72 days after 1st operation. The 2d carotid tied ; no mark- ed cerebral symptoms follow- ed the 2d operation, although convulsions occurred after the 1st. Cerebral symptoms followed ; unconscious 4 hours. Autopsy : Tuberculosis of lungs ; pneu- mogastric nerve injured by inflammation of surrounding structures ; right .luhclnvion ■includtd in ligature hy mistake. Died 4 years; rupture of sac ; supposed aneur. of vertebral. Sterno-mastoideus divided in op- eration ; was well united. Au- topsy: Suppuration of sac. Autopsy: Vascular tumor in convexity left hemisphere, large as a man's fist, pressing brain to right; parietal bone outward. No cerebral symptoms until 34th day, when paralysis of left side complete. Died J 3 months from rupture of aortic aneur. Autopsy showed above and also varicose condi- tion of left choroid plexus. 62d day. Hem. ; ex-; (Distal.) haustiou. 34 hours. Coma. Autopsy: Left hemisphere con- gested ; right ausemic and se- rous effusion. 12th day. (?) No cerebral symptoms. Autopsy: No brain lesion. (Note. — Int. jugular vein also tied.) Id day. Lost consciousness before death. Autopsy: No brain lesions. (In this case also the int. jugular vein was tied.) 6Sth day. Inflam-'' Progressed favorably up to 6th mation lung. i day.' Distal; Bras'dor. 62 PRIZE ESSAY. Surgical History of the Name of operator. Source of inforiuation. Cause of operation. Lane, L. C, 1873. Lane, Jas., 1871 do. do. Larrey, 1828. Lavocherie. Laub, H., 1874. Lauda, 1838. Lawrence, 1867, England. Lawrence, M. Lee, H,, 1864. Legouest. Lenoir, 1851. Lerylier, 1846. Lewis, J. B , U. S. A., 1884, do. Lick and Hop- mann. Lisfranc, 1827. Listen, 1841. California State See. Trans.; Am. Jr. Med. Sci., Oct. 1874. Lancet, Jan. 13, 1872. do. Oct. 14, 1871. Wien. Mediz. Woch., 1875, p. 630. Clinique Cliir.,vol. ii. p. 130. Arch. Klin. Chir., 1868. Schmidt Jahrb., B. 167, S. 266. Schmidt Jahrb., B. 30, S. 371. Arch. Klin. Chir. (cit.). Schmidt Jahrb., No. 139, p. 221; N. Y. Med. Jr., March, 1869. Arch. Klin. Chir., 1868. Lancet, Nov. 1864, p. 523. Lancet, January and March, 1839. Arch. Klin. Chir., 1868. do. Ehrmann des effets, p. 48; Pilz (cit.). Med. Surg. Hist. Reb. Otis. do. Berlin Klin. Wochen., Aug. 1871, p. 419. Arch. Klin. Chir., 1868; Norris (cit.). Norris Contrib. Sol- dier Mid age Mid age Neuralgia follow- ing removal of parotid. Aneurism of caro- tid, root of neclj. Traumatic aneu- rism of occipital artery behind ear. Hem.; stab w'd with sabre in duel, right side of neck, high up. Hem. of carotid. Hem. ; removed part of submax- illary gland. Traumatic aneu- rism of carotid ; stab wound of neck. Hem.; aneurism, traumatic. Traumatic aneu- rism of orbit. Hemorrhage. Hem.; opening ul- cerating tumor of neck. Traumatic aneu^ rism of carotid low down. Traumatic orbit, aneurism. Erect, tumor of temporal region. Aneurism of caro- tid. Shot wound of left side of face, do. Shot w'd of face. Fungus hrematod. (supposed aneu- rism). Hem.; puncture of supposed ab- scess. 8 days. 1 day. Below omo- hyoid. Above omo- hyoid. July 24, do. Aug. do. Near innom. THE COMMON CAROTID ARTERY. 63 Common Carotid Artery — continued. No. Date of operation. t< S ° Recovery. Condition. Cause of death, date after op. 335 336 337 338 340 341 343 344 345 346 347 1S73? Sept. 20, 1871. June 28, 1871. 348 349 360 351 352 353 355 1874. 1838. 120tli day. 21 Recovered. Recovered. Recovered. Recovered. Recovered. 1846. Aug. 10, 18(34. Aug. 14, lb64. 4 days. Oct. 21, 1841. 2 days. After. 14 days- Recovered. Recovered, Recovered, Recovered Cured. Not curod. Cured. Cured. Treatment faillntf, it wan acci- dentally dlHCovered tliat preg- Kure uiKiii the carotid gave re- lief. After ligature of the car- otid it was cured. Tumor at flrHt diminiHhed, after- ward mucli enlarged; Kuhcla- vian tied Hanie time. Distal. No cerebral .symptoms ; temp. 1° higher iu auditory meatus of right (lig.) side than opposite. Pulsation ceased after op. ; re- turned 3 days ; cure in 9 mos. Hem. profuse before operation, and was arrested by ligature ; Larrey supposed tiiis a case of both external and internal car- otids arising by separate trunlts from innominate. — Author. Cured. Cured. Cured. Cured. Cured. Died. 3d day. 2d day. 15th day (about). Cerebral complica- tions. After operation blind and deaf on left side. Recovered (?) Recovered, Not cured. Cured. Uied. llth-12th day. Coma. 9th day. 1st, 5th, 2d Autopsy: Wounded vessel not found ; brain normal. Above ligature adherent throm- bus. Paralysis of riglit side face im- mediately afteroperation ; tem- perature right side 2^ higher, sweating profusely on 1/ft s\A&. Dr. Jno. W. Ogle says, " want of equilibrium in muscles of face, result not of paralysis of the light side, but spasm of the muscles of the left," and " that the symjiathetic nerve was in- jured by ulceration." External carotid tied at same time. No hemorrhage noted. Wth day paralysis of left side. Ball entered left malar hone, out beneath left mastoid process. 18th day. disease. 15th day. Hem 2 mos. after operation aneurism developed at seat of ligature (diffuse), cured by compress af- ter 6 weeks' trial. Hem. ;'Fungiis of left cerebral fossa; petrous portion tempural bone carious; internal jugular vein obliterated. A tumor in neck, thought to be abscess, was opened; hem. fol- lowed. Autopsy : Proximal end of artery open ; no attempt at thrombus. 64 PRIZE ESSAY. Surgical History of the No. Name of operator. Source of information. Cause of operation. %-. o o o O ^ .^^ ^ ■-5 3 a d -S 3 •3.2P 3 ft. a o 13 Listen, 1841. do. 1S17. Lizars, J., 1827. f Longmore, I 18S3 Love, W. S., 1861, U. S. A. do. Liicke, 1865. do. 1866. Luke, 1829. Lancet, 1844, vol. ii. p. 276. Ed. Med. Surg. Jr., 1820, p. 72. Poland in Guy's Hosp Report, vol. xv. 1870. Lancet, April 10, 1830, Lancet, .January, 1864 p. 90. Med. Surg. Hist. Eeb.; Otis. do Gaz. Hebdom , March 29, 1837; Arch. Kiln. Chir., 1838. Schmidt Jahvb., B. 141, p. 202. Norris Contrib. do. 1848. Lancet, 18^0, vol. ii. p. 109. Luzenherg, 1S34. Lyford, 1818. Lynn. Macaulay, 1812 (Calcutta). Macgill, 1823, Maryland. Maclarhlan, 1825. Mac Manus. Mageadie, 1827. Mahon, A 1838-9 Mahon, M, 1864. D., Malgaigne, 1845. Norris Contrib. Norris Contrib.; Arch. Klin. Chir. Arch. Klin. Chir., 1868. Norris Contrib.; Ehrmann des effets ; Arch. Klin. Chir. (cit) do. do. Norris Contrib.; Arch. Klin. Chir. Arch. Klin. Chir., 1838. NoiTis Contrib.; Arch. Klin. Chir., 18S8. Schmidt Jahrb., No. 1.50, p. 307. Am. Jr., vol. xlviii. p. 276, 1864, Dr. Made- lung ; Arch. Klin. Chir., vol. xvii. p. 626. Arch. Klin. Chir., 1868. Mid age. 25 45 Mid ,ge 23 Vascular tumor of neck. " Beating pain on left side of head and face." Subclavian aneu- rism. Prep, resection of superior max. ; medullary sarco ma. Shot w'd through lai'ynx ; epiglot- tis carried away. Hem'ge from lin gual artery. Shot w'd of inf. maxilla. 6 mos. L. Shot w'd of left side of face. Traumatic aneu rism of vertebral (supposed caro- tid). Spontaneous pul sating tumor of forehead. Hem.; ulcer thr't. Suicidal wound (knife). Parotid tumor. Aneurism of caro- tid, common. Second, hem. re- mov. carotid. Aneurism of int. maxill., tranm. Pulsating vascu- lar tumor of both orbits. do. Vascular tumor of scalp, following arteriotomy. Cervical tumor ; carcinoma ; sup- posed aneurism. Tumor of antrum high. Stab of carotid at bifurcation. Hem.; shot w'd of lower jaw. 7 years. 4 days. Short time. 20 y'rs 3 w'ks Above omo- hyoid. Above omo- hyoid. May 3, 1863. Aug. 13. Sept. 19. Sept. 30 At omo hyoid. Aug. 21. 1,3,4 day. 5 days. E. Aneurism of caro- tid, innominate, and subclavian. Nov. 25. Day be- fore op- eration. Nov. 29. THE COMMON CAROTID AUTEUY, 65 Common Carotid Artery — continued. Datfl of opei'atioii. J3 13 o u a o a ij ^ ho ^ k. m Tj Recovery. CaiiHO of death, date after op. REMARKS. ,Tuno 22, 1H17. 1S38. May 12, 1,S63. May 18, L 18(33. Sept. 4, 18W. Oct. 7, 1804, An^. 4, 18(35. Aug. 9, IStfU. Oct. 4, lS2f). Sept. 6, 18i8. Oct. 30, 1S18. Dec. 16, 1812. 1823. 1 montli later. "July 10, 182"). March 4, 1S27. April .3, 1S45. After K'thday. Horn nth day. 14, 16, IVth day. 3d day. 4th and 10th. Often. 22 Recovered. Kolicf only temporary. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Cured. Cured. l.Tth day. Hera. 38 hours. Next day. Cured. Cured. Not cured. Improved. Worse. Cured. Slight im- provement. 2.ith day. Hemiple- gia. Coma. 19th day. Hem. ; de- lir. 49th day. Coma. I'ith day. Exhaus- tion. 4th day. Plenritis, pysemia. Pth day. Diarrhoea. Ah pain coawed on prn«Bnre ap- plied to left carotid, thiH vesHol was tied. lielief was not of lonu duration. Subclavian tied same time. Aii- topj-y : f'arotid and innominate obliterated ; subclavian open. Dixt'il. Died 17 months after of disease. Both vessels were closed ; brain symptoms noted. Hemiplegia supervened on 23d day. Autopsy: Left hemisphere soft ; tumor was in vertf-bral be- tween atlas and occiput. Delirious after operation. Au- topsy: Ulcerated hole in carotid at ligature. Erysipelas in face; violent dr. lirium after oiieration. Autopsy: Arachnoid sliyhtly injected; brain normal. 2 ligs., vessel divided between them ; 4th d. light side slightly paralyzed, which disappeared slowly. " Several months after operation she is said to be doing well and tumors subsiding." — Nurrif.-, Autopsy: Pus in pleural sac and mediastinum. n days paralysis rig^ht arm ," con- vulsions ; paralysis improved later; mind impaived. After operation stupor, which passed off in 2 days. Ball entered angle left inf-mav. fractu'ing it; passed beneath tongue ; exit right side of hyoid bone. On account of continu'^d hem. after lig. of common caro- tid, ext. carotid was ligatured. Ten weeks after this ope:atioa subclavian was tied lor was supposed to have been tied). AutoPsy showed carotid obli'- erated, but subclav. pervious. 66 PRIZE ESSAY. Surgical History of the Name of opetator. Source of information. Cause of operation. 380 Maiaonneuve. Arch. Klin. Cliir., 1868. do. Mandt. Marchal, 1835. Marquardt, 1869. Marjolin, 1814. Maunder, 1861. do. 1867. Mayer. Maunoir. Mayo, Ch., 1827. Mayo, H., 1828. do. 1834. do. 1833 Mayo, E., 1829. McClellan, 1825. do. do. do. Norris Contrib.; Arch. Klin. Chir., 1868. Allg. Med. Zeit.; Lancet, Jan. 1870. Norris Contrib.; Arch. Klin. Chir., 1868. Arch. Klin. Chir., 1868. Lancet, Sept. 1867. Arch. Klin. Chir., 1868. do. Norris Contrib.; Arch, cit. Norris Contrib.; Arch, cit.; Ehrmann des effets. do. Norris Contrib.; Arch. Klin. Chir. (cit.). Arch. Klin. Chir., 1868. Norris Contrib.; Arch Klin. Chir., 1868. do. do. Maurin, 1829. McCullough. McMurdo, 1846, Norris Contrib., 1868 Am. Jr. Med. Sci., April, 1864, p. 334. do. Y'g m'n 5 mos Varicose aneur- ism of parietal reg., traumatic. Kemov. of parotid gland, prepara- tory. Prep, to removal of fungus of pa- rotid. Hera.; puncture aneurism mista- ken for abscess. Stab wound of ex- ternal carotid angle of jaw. Hem.; shot w'd. Second, hem. after removal of inf, maxilla. Innominate an- eurism (sup- posed). Prep, to removal of inf. max. Cirsoid aneurism Tumor of neck. Hem.; ulcer thr't; lingual artery. Hem.; knife w'd of throat. Erectile tumor of face. Hem.; abscess of thr't (after punc- ture). Erectile tumor of orbit. Erectile tumor of cheek. Vascular fungus of dura mater. Aneurism of caro- tid, traumatic. Shot wound. Hem.; abscess. 2 mos. 6 days. 8 days. ii y'rs. 1 m'nth 3 days. 1 day. THE COMMON CAROTID ARTERY. 67 Common Carotid Artery — continued. No. Dato of operation. a o o " t>. ri ts ^ h-i a Recovery. Condition. Canse of death, date after op. KEMAHKS. 381 382 383 384 385 3S6 387 388 389 390 391 392 June 19, 1835. 1S14. March 30, 1861. (?) Before 1821 Oct. 19, 1828. 1834. Once. 395 396 398 399 Twice. Jan. 10, 1825. 1825. Nov. 20, 1829. Dec. 1,1845 5, 6 days. 3d day. Recovered. Cured. Recovered- Recovered Recovered Recovered No improve ment. No better. Cured. 8 Recovered. Recovered. Recovered. Recovered. Recovered. Recovered, Recovered Improved. Cured. Cured. Cured. Cured. Soon. Cereb'I com- plicatioas. Sth week. Return of disease. 6th day. Hem. ; cerebral complica- tions. Several days. Hem. meningitis. 5thi day. 13th day. of brain. Inflam'n Cured. Cured. External carotid was tied first; this li^. foil liith day. The Slip, thyroid w;ih tied at this time. Hem. af,'ain occurrinjf, the int. and common carotids were tied, followed by complete homiplei,'ia (L). Autoj)-sy : Right hemisphere softened, tlie sym- pathtitic nervti inclu/iedin both the internal and common car- otid ligatures. — Pilz. External carotid was first tied, but not arresting hem. common carotid tied ; 2d day convul- sions. Attempt to tie ext. carotid a fail- ure ; no cerebral symptoms fol- lowed. Pain right side of head for sev- eral weeks. Subclavian also tied. Autopsy : Aneurism of aorta — not of in- nominate. Died in 7 months, of hem., dis- ease ; cerebral complications ; epilepsy followed operation. Patient died 5 years lat'^r. Au- topsy showed lingual artery to have been wounded. 6 days after 1st lig. hem. oc- curred and a deeper lig. was applied ; paralysis of left side. Autopsy: Abscess in right hemi- sphere. 7th day. tion. Dr. C. Pilz of Breslau accredits McClellan with a 4th case un- der the head of " Epilepsy,'" the patient " M. 16 R., and vascular tumor over right ear," leads me to believe that the case is iden- tical with this case. I have omitted it on this account, with many others 1 have found about which an uncertainty exists. — Author. Two ligatures, vessel divided between. Exhaus- Autopsy : Varicose aneurism — int. jug. vein and int. carotid artery. PRIZE ESSAY. Surgical History of the Name of operator. Source of information. Cause of operation. IS 3 p s McGraw, T. A., Michigan, 1S73 McKee, J. C, lS6i, U. S. A. McMahon, A., U. S. A., 186S. ? U. S. A., 1863. Mettauer, 1842. do. 1829. Michaux, 1846. Michels, 1835. Miller, 1825. do. 1836. Moon, W. P. Molina, 1828. Montgomery, 1829. Moore, J. H., 1862. 416 Moreland, 1861 Lavallee. Morrison, 18i2. Moirogh, 1849. Morton, T. G.. Pliila., 1864.' do. do. 1869. do. Letter to author from Prof. McGraw. Med. Surg. Hist. Eeb. Otis. do. Ehrmann des effets, Paris, 1860, p. 88. Am. Jr. Med. Sci., Oct. 1849, p. 349. do. Norris Contrib.; Am. Jr. Med.Sci.,Oct.lS49, p. 349. do. Norris Contrib.; Ehrmann des effets ; Arch. Klin. Chir. Arch. Klin. Chir., 1868. See Morton, T. G. (a). Ehrmann (cit.), p. 43; Arch. Klin. Chir. (cit.) Lancet, 1833, p. 421 ; Norris Contrib. Med. Surs. Hist. Reb.; Otis. Arch. Klin. Chir., 1868. Am. Jr. Med. Sci., vol. xlx. p. 324; Norris Contrib. New York Journ. Med & Coll. Soc, May, 1852, p. 419. do. Am. Jr. Med. Sci., January, 1868. Am. Jr. Med Sci., April, 1876. do. 18 Mid age. Mid age. Prep, toremov. of pulsating malig- nant tumor of su- perior maxilla. Shot w'd of left mastoid reg. Shot w'd of right malar reg. Shot w'd of cra- nium through frontal bone. Some time. Aneurism, traum. Aneurism anast. antrum of nose. Prep, to remoT. of polyp, throat. Aneurism anast. of face and occi- put. Wound of neck. Erectile tumor of orbit. Aneurism, fusi- form ; superior thyroid. Aneurism of as- ternal carotid. Aneurism of caro- tid. Several years. About 1 year. 2 years. 27 days. 18 mos. Shot w'd of left temporal bone. Pulsating fungus of dura mater. Aneurism of in- nom. and carotid. Epilepsy. Spontaneous an. eurism of orbit. Hem. 2d day after attempted remo- val of tumor of neck. Hem.; lacerated wound of face. Supposed intra- cranial aneu- rism. Pulsating of orbit. 8-9y'rs. Few days. Above omo-hy. do. Aug. 21. April 9. Nov. 25. Feb. 14. I5: inch above innomi- nate. March 2d, Sth. Several times. THE COMMON CAROTID ARTERY. Common Carotid Artery — continued. 09 Dato of oporatiou. o t^i o Hod Recovery. Cause of death, date after op. KEMAHKS. May 17, 1873. Aug. 27, 18U4. May 7, 1865. Dec. 17, 1803. 1842. May 12, li29. Nov. 8, 1846. March 12, 183.0. Oct. 1825. 1836. March 10, 1829. March 22, 1862. Ang. 7, 1851. Nov. S, 1832. Feb. 23, 1849. Dec. 4, 1864. 1864. Oct. 15, 1869. 1874. Jan. 8,1876, 12th day. Several times. Kecovorod, 6 days. 19 days. 2 days. 12 days. Coma ; he- miplegia. 12 days. Cerebral complications. Recovered. Recovered. Recovered. Cured. Cured. Cured. 8 days. Cerebral complications. 4 days. Recovered. Cured. 12.5 days. ( ? ) Recovered. Cured. 11 days. Pyaemia. Recovered. Recovered. Not cured. Improvem't only temp'y 10th day. Pyaemia. 21st day. Rupture jug. vein ; hem. in- direct. 24 hours. Cerebral complications. Few hours. Serous apoplexy. Ball entered frontal bono 1^ in. above tlie supraorbital ridge, through right orbit, out near angle of inf. maxilla. Hemiplegia (left) in eleven h'rs. Autopsy: Right hemisphere Kol'tcnod. Paralysis (right) 24 hours after operation ; 8th day coma ; death in convulsions. Died 2 y'rs after from carcinoma. Patient was 3 months pregnant at time of operation ; did well. For 3 days after operation patient was unconscious. 2d day ; paralysis of left side. Died suddenly ; no autopsy. Moeller, see Gunderlach. Tumor disappeared ; cause of death not given. (Probably py- aemia. — Author.) (There was suppuration of the tumor, and at autopsy the int. jug. vein was found involved in the disease. DUtril?) Six years after operation there was facial paralysis. (In all probability due to direct injury to 7th nerve (portio dura^ by missile. — Authnr.) Autopsy : Lower thrombus ad- herent, upper not. Died suddenly 20 mouths after; cause not given. Distal. Partial paralysis of left side fol- lowed operation. Mediate transfusion practised 5 days after operation ; patient did well until 19th day, when int. jug. vein ruptured ; died 2 days later. Although the bruit was distinct- ly heard by Dr. JI.. no aneurism was discovered at the autopsy. Intense inflammation at apex of orbit and firm clots in the si- nuses. Autopsy: Arachnoid opaque and cloudy ; large amount of serum beneath; patient had been struck in this eye by snowball 29 years previous. 70 PRIZE ESSAY. Surgical History of the Name of operator. Source of information. PATIENT. Cause of operation. o Cl CD c3 eS o.S t3 Z El oJ.-r, P.2 'i u o 'eH are neces- sarily omitted. Th': author is indebted to Valentino Mott, Esq., for valuable aid in collect- ing his father's and grandfath- er's cases. Carholized catgut lit-'atnre, com- pression of carotid had been tried forlOwoekH without fffect; patient left bed 6 days after op. 34th day. Cerebral Several days after operation con- complications, vulsions. Autopsy : Varicose I aneurism of internal jugular vein and carotid artery ; left hemisphere softened. No brain symptoms. 16th day. Exhans-!Convulsions day after operation, tion and cerebral complications. Not cured. Cured. Cured. ? No benefit in either of these three cases; pro- bably in- creased vio, lence of the malady Autopsy : Left hemisphere soft- ened. Very much improved on October 10th following. Paralysis of left side followed 5th day. 2d day. Exhaust'n. No brain symptoms 3d day. Hem. 9th day. Apoplexy jlOth day. Hem. Loss of sensibility in right arm for 14 days. Nerve resected at pame time ; 12 hours after operation paralysis of left side ; recovery complete. No bad symptoms followed op. Convulsions continued, seeming in some instances to be exagge- rated. In one case the j ugular vein was wounded and was tied or stitch- ed around some way to arrest hemorrhage ; pysemia followed with pleuritis ; partly recov- ered ; "die heftige 'Blutuiig wurde durch die umsehlum- gene naht gestillt." Pressure over carotid arrested hemorrhage, hence ligature. (It is probable the vertebral was compressed with carotid. — Au- thor.) Autopsy : Wound of ver- tebral . Autopsy : Carcinoma ; brain not examined. Autopsy : Rupture of aneurism of aortt ; innominate almost OD- literated. 76 PRIZE ESSAY. Surgical History of the Name of operator. Source of information. PATIENT. Cause of operation. Packard, J. H.^Med. Surg. Hist. Reb.; M 1864. Pallau, Prof. M. A., 1861. Palmer, H., 1863. Parsons, 1846. Partridge, 1864, Patruban. do. do. do. do. Pauli? Butcli- ev? Geigens? Parker, Prof. Willard, 1848. do. 1851. do. 1S54. f do. do. do. 18.'55. Otis, Verbal com. to author (army of W. Va.). Arch. Klin. Chir., 1868. Med. Surg. Hist. Reb. Otis. Am. Jr. Med. Sci., 1848, p. 3o0. Lancet, Dec. 1864, p. 6.59. M. AHg. Wien. Med." F Zeit., 1876, No. 48, SO; Am. Jr. Med. Sci., April, 1877. do. do. do. do. do. do. do. Schmidt Jalirb. No. 134, p. 308. From notes of cases kindly furnished author by Prof. Parker. do. do. do. do. Mid age. 19 21 Girl 63 41 37 Y'g m'n 23 Shot w'd of right jaw. Buckshot wound; fracture of ra- mus of inf. max. Prep, remov. inf. maxilla. Shot w'd of right side of neck and ear. Pain in head. 2 years. Stab with knife ; 6 days", wound of left ex- ternal carotid- Tic douloureux. do. do. do. do. do. do. do. Shot wound of oc- cipital artery. Epilepsy. Fibroid tumor of nose. Malig. tumor of face. L. Malig dis. an- trum. Hem. ext. caro- tid. 14 days 6 mos. 7 mos. Sept. 30. July 2, 1863. Above omo- hyoid. do. do. do. Below omo- hyoid. July 12. THE COMMON CAROTID ARTERY. 77 Common Carotid Artery — continued. Date of operation. a o o o S <^ " c-'* (=^ Recovery. Condition. Sept. 1 6, 1800. Aug. 21, 1829. Sept. 22, 1838. 1842. ? April 1, 184.5. 1S4.'5. 1862. Jan. 9, 18\>i, or 1816. Sep. 5, 1862. Nov. 22, 18:W. Feb. 4, IS.Sl. r Aug. 23, I 1831. Nov. 14, 1831. f Sept. 2, 1831. 563 I LOct.lO,'.31 Oc- curred. After. Sth, 14th, loth day. 16-18 Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Slictht im- provomeut do. Cured. Cured. Cause of death, date after op. RKMAUK3. 3 weeks. Cerebral complication.s. intb day. Hoin. ; as- phyxia. Cured. Cured. Temporary improvem't Improved. Not cured nor inipr'd. Improved temporarily 6 week.s. Hem. Died. Phlebitis ; pya3mia ; delirium 3d day. Disease ; cerebral oomplica. A few hours. Ex- haustion. Autopsy: One hemi-pViero soft- ened partially. Autopsy: Polypus in larynx. The arrow was driven throu)?li left sup m-.ix. and was extriict- ed with (lifficulty ; :'> week* la- ter, on account oi' hem. tho car- otid was lied ; the "unfleasaut fulness" remained after reco- very until death of the patient (Gen. Bayard) in the battle of Gcttysliui'g, 3 years later. Sao burst about 4 montlis after ligature. 20th day. Hem. Recovered. Improved Autopsy : Two phlebolitbs were found in tumor, l^h ebitii of int. jugular, although vein was not wounded in the operation. Pus in vein. Paralysi^ ensued. Int. carotid also tied at same time ; hem. arrested ; patient exhausted by previous hem. No cerebral symptoms followed. No cerebral symptoms noted. Died 2 or 3 years later from iri- j tation of larynx by pressure of I tumor. Autopsy: Tumor was an enlarged gland and was rest- I ing on the carotid. Aut'psy : Vertebral wound at edge of foramen magnum. April 13th, no return of attacks ; patient much improved in gen- eral health. On the ]-)th of Feb. 1832, he was again admitted in a state of in- sensibility aud had been speech- less for 14 days. Jan. 1833, suf- fering from paralysis agltaus. 2.T days after 1st opei-ation, this man walked r> miles ; on ac- count of heat (it is supposed) the disease returned, and the 2d operation was performed. Preston is accredited with oje other case of double ligature for epilep.-^y. but I am of the opinion that it is a repetition of one of the cases here given, at least the comparison is suspi- cious and details are lacking. — Authur. 6 82 PRIZE ESSAY. Surgical History of the No. Name of operator. Source of information. Cause of operation. %- o <« d a 6 >> ■-E B d SJ 5 =1 ^a fi tS pa 564 565 568 569 570 671 573 574 575 576 Randolph, 1833. Ray, E. R., 18B4. Raynaud, 1871, Remer (Breslau). Reese D. M., 1S23. Reyburn, Robt. 1866. Reynold, W. B. U. S. A., 1861. 578 579 580 581 582 583 684 685 686 687 Richardson, W. F., 186J. Ricliet. Kichter. Reed, F., 1854. Rigen, 1829, Amsteidam. Rivington, W., 187."). f Robert, 1846 Norris Contrlb. Med. Times & Gaz., M. Feb. I8B0, p. 171. Gaz. des Hop., 1871, p. 425. Arch. Klin. Chir., 1S6S. N. Y. Med. Jr., 1857; Jas. R. Wood. Am. Jr. Med. Sci., July, 1868. Med. Surg. Hist. Reb. Otis. do. Arch. Klin. Chir. (cit.) Med. Surg. Hist. Reb. Otis. Ehrmann, de.* effets Arch. Klin. Chir., 1868. do. do. do. do. 1847. 1857. Robbins, N. A., U. S. A., 1864. Robertson, 1837. Robinson. r Rodgors, J. R., 1844. I (Van Buren, J 18.50.) Rogers, D. L., 1832. do. Med. Chir. Trans., vol. Iviii. Ehrmann, des effets, etc.; Arcli. Klin. Chir. (cu.). do. Arch. Klin. Chir., 1868. Med. Surg. Hist. Reb.; Otis, Norris Co'ntrib. Arch. Klin. Chir., 186S. Schmidt Jahrb., B. 98, S. 77; Archiv fiir Klin. Chir do. Norris Contrib. Mid age. 62 42 11 Anenr. varix. Hem.; malig. tu- mor. Hem. ; shot w'd neck ; ext. or int. carotid. Hem.; cancer of neck and face. Rem. turn. neck. Aneur. (near bi. fur. com. caro- tid). Shot w'd mouth. Shot w'd neck. Hem. ; remov. turn, parotid : f-icial artery. Shot w'd neck be- hind left ear. Shot w'd parotid region. Hem. (after arano plastic op.). Tumor neck and face. Innom. aneur., supposed. Intraorbital aneu- rism, traumatic. Aneur.. cir.^oid, frontal region. do. Aneur., cirsoid. Shot w'd near left ear. Aneurism. Hem. from ab- scess. Aneur. by anast., head. do. Erect, turn face. 4 days. 7 days. 1 year. 19 y'rs. 19i years. 2 mos. 8 mos. Below omo- hyoid. Above omo- hyoid. 11th and 14(h month. Nov. 30. Dec. 6 Oct. 7. Below omo- hyoid. Oct. 16 Before opera- tion, exces- sive. THE COMMON CAROTID ARTKRY. Common Carotid Artery — continued. Dato of operatiou. s = s " >'S Recovery. Condition. Nov. 14, 1S04. Dec. 6,1871, 1823. 1866. Sept. 19, 1864. Oct. 9, 1864. Feb. 22, 1865. Nov. 20, 1865. May 31, 1854. Feb. 21, 1829. 1875. Jiine 5, 1846. Feb. 22, 1847. 1857. Oct. 29 1864. March 21, 1837. r 1844. 687 Dec. 12, 1 1832. Doc. 2d. 2d & 3d days. Noue. Profuse After. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered, Cured. Cured. Cured. Marked im- provement. Cured. Not cured. Not cured. Cured. Cause of death, dato after op. REMARKS. No.xtday. Corobral Coma soon after operation. compUcatiouH. I 17th day. Iloiii. ; Autopsy ; No clot in the artery erysipolaH. | below lii^ature ; no artoria in- noiniiiata, the carotid and Hub- clavian direct from the aorta. (I liavc nover seen this anom- aly. — Author.) 4th day. E.xhans- No cerebral syinptomK ; patient tion. was tranHfused aft'T Hu(r<;ring from severe hemorrhage, Ur. Raynaud, with gcnerou.s devo- tioii to duty, furnisliing the blood from liis own arm. 24 hours. Exhaus- tion and disease. 17th day. Next day. Actual cantery had to be used to arrest hem. after operation. Hemorrhage before operation had been very profuse. Same day. Exhaus- Hemorrhage for 4 days before tion, liem. operation. 2d day. Cerebral complications. Sth day. A few days. 4th day. 4th day. Exhaust'n. Autopsy: No thrombi in artery ; brain ansemic. Tth day, paralysis of right leg. Autopsy : Extravasation of blood at base of brain. Patient died of another disease 4 months later: tumor was on arch of aorta, was diminished in size, hard, and filled with a firm coagulum. Patient was operated upon for hernia in May, about one month before his death. No cerebral symptoms. Slight cerebral symptoms fol- lowed each operation, but pass- ed away. In May, 1850. there was no pul- sation in the tumor. Temporal artery was also tied. See Van Buren. 84 PRIZE ESSAY. Surgical History of the No. Name of operator. Source of information. PATIENT. Cause of operation. o Is ^M >< a CO !J0 < 6 m ft a j3 588 Eompani, 1841. Romaglin, 1S34. ? Arch. Klin. CMr., 1868. do. M. M. 70 20 R. L. Aneur. carotid. Stab wound verte- bral. 589 590 Roser, 1852. Eossi, 1844. De Rouleurs. do. Ehrmann de,s effets ; Arch. Klin. Chir, (cit.) M. M. 55 L. R. Hem. after resec- tion. 591 See Ossieur. 592 Koux, 1830. Quarante annees de Prat., vol. ii. p. 401. M. 30 R. Shot w'd ext. car- otid or branches, through month. 8 days. 593 do. 18.«. do. p. 325. P. 46 L. Hem. ; w'd ext. carotid ; fell on June 23, 1852. 594 do. 1837. do. 1829. do. do. do. Arch. Klin. Chir., 1868. do. do. F. M. M. M. 30 26 45 33 R. R. R. glass vase. Remov. tumor of parotid. Aneur. orbit. Rem. turn. neck. Rem. tum. of an- trum, prep. 2 years. 595 596 6 mos. 598 Sands, Prof. H. B., New York, 1868. New Yorlf Med. Rec, Dec. 1869. F. R. Aneur. root of neck (supposed innom.) 699 do. 1869. do. do. 1870. Notes of cases kindly furnished by Prof. Sands. do. do. M. F. F. 50 R. Recur, epithelial cancer in right cheek. Above omo- hyoid. 601 40 R. Second, hem. after remov. tumor of neck. 602 do. 1871. do. P. 28 R. Aneur. com. caro- tid. Below omo- hyoid. 603 do. 1872. do. M. 53 L. Secondary hem.; removal of inf. maxilla. Just be- low bi- furca- tion. 601 do. 187.0. do. F. 39 R. Tumor orbit. Below omo- hyoid. 605 do. THE COMMON CAKOTID ARTERY. 85 Common Carotid Artery — continued. No. Date of operation. Hemorrh'ge occurred after op. RESULT. UEMAKKB. Recovery Condition. Cause of death, date after op. fi88 Oct. ,30, 1S44. 1834 I 1852. 1S44. 1830. June 2,<5 1862. June 19, 1837. 1829. 3 times. After. 20tli day. \\<-m. Diod. Hem. 6th day. 6th day. riSQ (Some authoTK think the ligature wiiH removed after il was dis- coverod that the hemorrhHffe was not controlled by it. The ligature once apfilied tlglitly would act as does Prof Fleet Spier's conntriolor, milking the case practically a ligation. — Avthiir ) Paralysin of right side. Autop- sy: Cancerous deposits in lungs. Mn .wi fifl^ 14-18- 19thday once. 18 18 Recovered. Recovered. Cured. Cured. top.sy: Left carotid and right vertebral also occluded ; only vessel going direct to bi ain was left vertebral. (Analogous to Dr. Hutchison's case, which see.) Difital. No hemorrhage until 8 days after injury; actual cautfry ; 2 liga- tures applied ; no bad symp- toms. Hem. on July Tth, beyond liga- ture ; also on the ISth and 19th days ; compress. ws ,')!)4 ]4th day. 7th day. Purulent infection. ( ? ) 60 hours. fiP,-) Recovered. Not cured. fiPfi fi97 Lig. was taken off after 48 hours. Autopsy: Congestion of right hemisphere. Died 13 months after operation. Autopsy: Aneurism of arch of aorta in front of origin of arte- ria inuominata. This last ves- sel not involved. Dista'. Sub- clavian tied same time, 3d divi- sion. Hemiplegia of opposite side 12 hours after operation. -iflS July 16, 1868. May 23, 18o9. 42dday. 23 Recovered. 599 4th day. Cerebral complications. Few hours. Hem.; exhaustion. fion Recovered. (?) KOI April 29, 1870. June 23, 1871. Nov. 1, 1872. April 14, 1875. After. None. Autopsy : Ulceration of common carotid near bifurcation. (Note. — The hem. had been very pro- fuse before Dr. S. arrived ; no anaesthetic.) "Patient recovered with slight paralysis, which came on 19 days after operation." 602 25 14 21 Recovered. Recovered. Recovered. 603 rism. Slight paralysis of op. side. Cured. " Tumor continued to grow." fl04 22, the external tarntid was tied, Nov, 10, alarming hem, from ulcerated opeuing of in- tf.rnal caroVd. This was tied above and below opening, and the common carrtid j ust below bifurcation Ligature from int. carotid came away 9ih day. The internal jugular vein was tied with a lateral ligature. 2 days after operation pulsation in tumor returned. Patient had tumor removed from orbit in If 64, and a second tumor and the eye removed in 1873 : 6 mos. after this the third appeared. 605 86 PRIZE ESSAY. Surgical History of the Name of operator. Source of information. Cause of operation. Santesson, 18.53. Savory, 1871. (?) Sedillot, 1842. Sisco, 1829. Solly, 186? (& Garroway). do. 1853. South, 1856. do. ? Southam, 1864. Surrage, James. 1840. Sykes, 1821. Syme, 1832. do. 1835. do. 1842. do. 1859. do. 1860. do. Schiess, G emus- sens, 1868. Sohort, 1857. Scarpa, 1828. Schrader, 1820. Arch. Klin. Chir., 1S6S. Lancet, Sept. 30, 1871, Norris ; Ehrmann (cit.). Ehrmann des effets. Norris ; Ehrmann. Brit. Med. Jr., 1862, p. 489. Lancet, 18.53, vol. ii. p. 666 ; 1854, vol. i. p. 91. Med. Time.s & Gaz., August, 1S56, vol. ix. p. 441. Arch. Kliii. Chir. (cit.). Med. Chir. Trans., vol. xlviii. p. 65. Lond. Med. Gaz., vol. xxviii. p. 392. Korris Contrib. ; Lond. Med. Gaz., vol. xxviii. p. 392. do. Arch. Klin. Chir., 1 868. Norris ; Ehrmann. Arch. Klin. Chir., 1868. do. Brit. Med. & Surg. Jr. 1848. Schmidt Jahrb., No. 146. Arch. Klin. Chir., 1868. Norris Contrib. Arch. Klin. Chir., 1868. F. L. Eem. parotid tu- mor. Hem. (after open- ing " sanguine- ous tumor of neck"). Hem. w'nd ext. carotid. Rem. parotid. Aneurism, traum. Wound face and temporal region thrown from car- riage. Aneur. carotid (at bifurcation). Aneur. ext. carot Aneur. vertebral (supposed caro- tid). Aneur. by anast. head. Aneur. int. max.? Aneur. carotid, traum. Hem. ear and mouth. Aneur. carotid, traum. Aneur. int. caro- tid. Aneur. carotid, traum. Aneur. orbit, spont. Abscess of neck (supposed an- eurism). Orbital aneur. traum. Aneur. ext. caro- tid. Aneur. carotid. do. 12 y'rs A few- min- utes. 13 days 3 w'ks. 1 m'nth 8 years 3 years 7 mos. 5 mos. 7 w'ks. 1 year. 8 years. May 9. 1862. ' 3 years. THE COMMON CAROTID ARTERY. 87 Common Carotid Artery — continued. Date of operation. .a ?; a> o OS Nov. 14, 18r)3. April, 1S42. May 23, 18ti2. Oct. 22, 18.5.?. July 6, 18)6. May 20, 18')4. Oct. 28, 1840. June 20, 1821. Sept. 1832. Feb. 18, 1 83.5. April, 1842 June 17, isr)9. Julys, 18ljn. None. Stli day. 11th day Once. 3d day. ■5th day June 15, 1S6S. Nov. 5, 1857. M;iy 23, Ih-J.s. Nov. 14, 1620. '^^ Once, fatally, Several times. Recovery. Condition. Recovered. Recovered Recovered Recovered Recovered Cured. Cured. Cured. Cured. Cured. Cured. Cnred. Recovered. Kecovered. Recovered. Recovered Recovered, Recovered. Cured. Cured. CauBo of death, dato after op. No better. Cured. Cured. Not cured. Next day. Exhaus- tiou. 9th or 10th day. 14th day. Cerebral complications. nth day. Complica- tion.s and hem. 2Pth day. Hem. ; cerebral complica- tions. 3d day. ( ? ) 14th day. Hem. asphyxia. 30 hours. The internal carotid waH torn in two ; liffature to coinriioii caro- tid incrcasi'd the hoili., and liga^ turo en rnri.HHe wa« applied. IJ year later patient was well, al- I hough Hie tumor wa8 not en- tirely ri'moved at above opera- tion. Internal and external car- otids must have been included in the ligature "n rnaSH' . Patient had lost 3 pints of blood. Hemiplegia, 3 hour.f after opera- tion, of loft side of body, right side face. Autop.sy. Softening of right anterior lobe. 8th day abundant hemorrhage ! 12th day right hemiplegia. Au- topsy : Left hemisphere soft- ened and purulent ; right con- gested. Patient lost the use of left eye, and hearing of same side im- paired. Patient shaved himself on 7lh day ; paralysis of right side be- fore deatli ; uuconsciousne''8. Autopsy : Carotid closed by thrombus. 23d day suffocation, sac opened ; 26th day hem. and paralysis of left arm. After ligature partial paralysis of left side. Afler ligature tumor rapidly in- creased : burst Hth day in tra- chea. Autopsy : Aneurism wa.s between trans, proc. 4th and .5th cervical vert. No ansesthetic ; ulcerated, and hemorrhage before operation. Sac suppurated. 2 lig. of catgut ; artery divided between them. Syme could give no reason for death. Died. Hem. Method of Antyllus. The tumor was found to be a cyst in intimate relation with the sheath of the carotid. Strange to say, it diminished notably in size after operation. Patient was kicked by a hor.se. Attempt to tie the remaining carotid some months after was abandoned on account of hemor- PRIZE ESSAY. Surgical History of the Name of opeiator. Source of information. Cause of operation. o o Schuh, 184S. do. 1856. Schwartz, 1S44. do, 1850. Scott, 1S31. do. 1832. Smith, J. A., 1865. Smith, Prof. Stephen, 1876. do. 1857. Smyth, A. W., New Orleans, 1864. Spence, IS do. 1842. do. Shipman, 1844. Staude, 1861. Stedman, 1830. Stevens, 1826. Stanley, 1859. Stromeyer. do. Szokalsky,1864. Arch. Klin. Chir. 1868. do. do. do. Med. Chir. Trans., vol, xxii. p. 134 ; rep. by Geo. Busk. Norris Contributions : Ehrmann. Med. Time,s & Gaz., April 8, 1835, p. 358. N. Y. Med Jr., June. 1S76. N. y. Med. Jr., July. 1857. New Orleans Med. Press, May, 1866 ; Guy's Hosp. Kep., vol. xvii. Schmidt Jahrb., No. 144, p. 87. Norris Contrib. Arch. Klin. Chir. ISdS. do. Am. Jr. Med. Sci., July, 1847, p. 264. do. Norris Contrib. New York Med. Phys. Jr., vol. V. p. 811. Arch. Klin. Chir. (cit.). do. do. do. M. 18 M. Boy Shot w'd of facial. Hem. int. max. Secondary hem. (internal maxil- lary) . Shot wound. do. Hem. from nose ; exophthalmos. Remov. tumor face. Hem. int. carotid. Cancerous tumor inf. max. 1 day. 4 mos. 5 days. To arrest malig. di-ease left sup. max. Aneur. subcla- vian. Hein. ulcerat. face. (Suicidal stab w'd carotid at bifur- cation.) Aneur. carotid. Prep, remov. pa- rotid. Remov. parotid. Parotid tumor. Remov. tumor. Hem. after punc- ture of tonsil. Stab wound. 35 days. 4 years. 2 years. VI y'rs. Shot wound max- illaris interna. Aneur. orbit, traum. 5th day before, and day of op. Above omo- hyoid. THE COMMON CAROTID ARTEKY. 89 Common Carotid Artery — contimied. Date of operation. -g £ o a sc RESULT. REMARKS. Keoovory. Condition, Cause of death, date after op. fi'>S Nov. 14, 1848. Dec. r), 18.5U. July 26, 1864. May 4, 1840. ISC-O. Nov. 10, 1834. Feb. 4 1832 8th day. Cerebral complications. .3d day after operation, paralyslH of leftside; 4th, coma. AiitopKy; Pleura and liingM contfi^sted ; riKht hemisphere softened. After lit', of common carotid H inch of' the jaw was resected, and the int. maxillary tied. Patient died 3 months later from iiercosis of vertebral col- umn and tubercnlosis. (The first operation was made to ar- rest hemorrhnge caused by tre- phining jaw in neurotomy for facial neuralgia.) Paralysis of right side day after operation with aphasiii. li yr. after operntion all unpleasant symptoms had disaiipeared ex- cept difficulty of motion in right leg. No cerebral symptoms of note. No cerebral symptom* of note. Fell through a ship's hold ; 38th day after accident hem. from nose and protrusion of eye ; hem. was arrested and the ex- isting exophthalmos disappear- ed ; loss of vision. fi?0 30 16 28 6'^n Recovered. Recovered. Eecovered. Recovered. Cured. Cured. Cured. Cured. fi'ii (i32 633 42 hours. Convul- sious. In a few hours. ? 634 635 Feb. 11, 1 865. 1870. April 24, 18,57. May 15, 1864. 1869. May 24, 1842. 636 14 20 13 Recovered. Recovered. Recovered. Not cured. Not cured. Cured. Carbolized catgut lig. Tumor continued to grow. 637 638 6^t» 4th day. Coma. 61st day. Exhaus- tion. 10th day. Pysemia. 19th day. Hem. tied at same operation. ,54 days later the vertebral was tied. (Died 10 years later of same aneurism.) 640 after operation paralysis en- sued. Autopsy: The "lig. was found to have slipped, and it was thought the renewed cur- rent had washed the plug in the vessel into the cerebral cir- culation. No cerebral symptoms noted. 641 642 Julv 25, 1865. May, 1844. 12th after. ligatured at same time. 643 644 28 Recovered. Recovered. Recovered. Recovered. Not cured. ? Cured. Cured. Disease returned, and patient died ia 2 years. 645 646 Sept. 7, 1830. June 3, 1826. Oct. 24, 1854. 27thday hem. After. After op. 26 14 14 647 61 days. Cerebral complications. Died instantly. Hem.; exhaustion. Died. Hem. time. Hemiplegia on 31st day : abscess and softening of left hemi- sphere. 648 640 6,')0 1864. C.u i-pd No cerebral symptoms. 90 PRIZE ESSAY. Surgical Hiatory of the No. Name of upera.tor. Source of information. PATIENT. Cause of operaiion. o o i B Q c o 13 1^ 03 01 be n3 "S s fi a J3 fial Textor, 1826. Tilanus. Tyerman, 1834. Todd, G. R. C, 1876 (South Carolina). Von Thaden, 1864. do. 1836. Thebaud, J. S., 186.5. Travers, 1815. do. 1826. do. 1809. Trier, 1834. Triboli, ISto. Tschansofif, 1867. do. do. T\vitcliell,1807. f Unknown, J 1823. 1 Ullman, L 1824. Unknown. do. (Crimea). Unknown, 1864. do. do. 1863. do. 1864. do. 1862. do. 1865. do. 1864. do. do. 1863. do. do. 1864. do. 1863. do. Ehrmann des effets, p. 38 ; Arch. Klin. Chir., 1868. Velpeiiu ; Ehrmann des effets p. 38; Arch. Klin. Chir., 1868. Norris Contiib. Am. Jr. Med. Sci., Jnly, 1877, p. 112. Arch. Klin. Chir., 1868. do. Letter from Dr. J. B. Reynolds, with Dr. Thebaud's notes. Norris Contrib.; Archives etc. do. Med. Chir. Trans., vol. ii. p. 1. Arch. Klin. Chir., 1868 (cit.). do Arch. Klin. Chir., Bd. xi. p. 203. Arch. Klin. Chir., p. 204. do. Norris ; Arch. Klin. Chir. (cit.). Arch. Klin. Chir. do. Norris Contrib. Arch. Klin. Chir., 1868. Med. Surg. Hist. Reb.; Otis. do. do. do. do. do. do. do. do. do. do. do. do. M. 40 L. Knife wound ext. carotid. Aneur. aorta (sup- posed carotid). 12 days. fi.i?, 658 M. M. M. F. M. M. F. M. M. F. M. 35 25 22 66 6 mos 33 34 R. Ii. R. R. . . . . R. R. L. fin4 Aneur. ; pistol shot wound at bifurcation. Stab wound. Of w'd, 17 days; of au- eu-.,2-4 4hours. Below omo- hyoid. 6.-)n fi-ifi fii7 of nerve (max. int.). Aneur. anast. face and eye. Hem. fung. tumor of cheek. Knife wound ext. carol. Erectile tumor orbit. Knife wound sup. thy. Knife wound. Epithel. turn, of parot. Epithel. cancer lower jaw and mouth. firiS fial Short while. fifin fifil fifi? 27 50 60 R. R. fifi'^ 5 years. RB4 6fi5 fifiR M. M. M. F. M. M. M. M. M. M. M. M. M. M. M. M. M. M. 20 19 20 R. L. R. Shot wound int. carotid (neck and face). Erectile tumor in region of left ear. do. Aneur.; face w'd. Hem.; shot wound external carotid. Shot wound lower jaw. do. do. Shot wound face. Shot w'd mouth. Shot wound lower ja,w. Shot wound face (right). Shot wound face. Shot wound inf. max. Shot wound sup. max. Shot wound face. Shot wound left mastoid process. Shot wound inf. max. 10 days. 6fi7 fifiS fifi<» 6 w"ks. fi70 671 Mid asje. do. do. do. do. do. do. do. do. do. do. do. R. R. L. ■rV R. L. R. L. 67?, 678 674 67 T 676 677 67S (Near bifur.) June 19. July 1. 679 Above omo- hyoid. 680 681 Below omo- hyoid. Above omo- hyoid. 68'^, 6S8 Dec. 30, 1862. THE COMMON CAROTID AHTKIiY. 91 Common Carotid Artery — continued. ])ato of oporatiou. o g £ Recovery. May, 10, 1S2(). OtU day. Aug. 14, 18:i4. Sept. 26, 1864. Jan. 20, 18t)6. Nov. 13, ISl.!. Jan. 27, 1826. May 23, 1809. 1834. 184,^. Oct. 1867. Oct. 18, 1807. 1S23. 1824. 20th day and aft. Twice. 1864. July 8, 1864. June 7, 1863. June 19, 1864. 1862. April 11, 1S65. i July 4,'64 L" 6, " June 2.3, 1864. July 18, 1863. June 7, 1863. May 16, 1864. Oct. 10, 1863. Condition. Cause of death, date after op. REMARKS. 10 1.5 13 11&22 Recovered. Recoverod. Recovered. Recovered. Recovered. Recovered Recovered. Recovered. Recovered. Recovered 30th day. Cerebral complications. Cured. Cured. Not cured, hut bene- fited. 4J days. 16th day. Menin- gitis. 56th day. Hera. Cured. ? Cured. Recovered. Recovered. Recovered. Recovered, Cured. 14th day. Tubercu- losis. (?) 8th day. 20th day. 3d day. Exhaust'n 4 hours. Exhaus- tion. 2 days. Next day. 3 days. Died. 1st op. 2 days. 2d op. same day. 2 days. 8 days. Same day. Same day. 14 days. Died Jan. 15, 1863. 23d day, paralysis of ri^ht side. Autopsy: abhccss in left hemi- sphere. Patient died suddenly 5 months later. Autopsy: Tho an>Miiism of aorta was full of solid flbriii. 'Comparatively good healtli." Tumor long since disappeared. "Collapse and unconsoionsness day alter opovatioii. Autopsy : Both hemispheres congested." 19th day, patient was wild with delirium. Two ligatures applied. The trachea was also wounded. Autopsy: No thrombus in ^ea- tral end, in distal small clot. Died 3 mos. later of some other disease. On account of hem. a second lig. had to be applied lower down. Hem. ceased with application of ligature. ■ Disability J and permanent, April, 1867." This artery was tied a second time. The same vessel was religatured on July 6, on account of hem. 92 PRIZE ESSAY. Surgical History of the Name of opera4;or. Source of information. PATIENT. Cause of operation. "5 g 6 3 Q o 2 'a '^ o ^° t3 «.-. bo >< bo < 6 y a O fi a fiS4 Unknown, 186-t. do. do. 1863. do. 1862. do. 1863. Med. Suri?. Hist. Reb.; Otis. do. do. do. do. do. do. do. do. do. do. Arch. Klin. CMr., 1868, 173. do. 174. do. .'^06. do. 442. Madelung ; Arch. Klin. Chir., Bd. xvii. p. 616. Lancet, 1859, vol. i. p. 559. Med. Surg. Hist. Reb.; Otis. N. Y. Med. Jr., July, 1857, Prof. Jas. R. Wood. do. N. y. Hosp. Notes, kindness I'rof. H. B Sands. N. Y. Med. Jr., July, 1857, Prof. Jas. R. Wood. do. Arch. Klin. Chir., 1868. Med. Sure. Hist. Reb.; Otis. Arch. Klin. Chir., 18W. Norris ; Ehrmann ; Arch. Klin. Chir., - 18^8. M. M. M. M. M. M. M. M. M M. M. 22 21 Mid age do. do. do. do. do. L. L. R. R. L. Shot wound lower jaw. Shot wound neck, internal and ex- ternal carotid. Shot wound neck, high up. Shot wnd mouth and neck. Shot wound neck and face (r.) Shot wound neck and jaw. MavlO, 1864. 685 6Sfi fiS7 May 30. May 3. April 12 fore op. fiS8 R89 May 5. 690 ( do. 1862. \ do. do. 1864. R91 do. Shot wound head aud neck. . Sfti^ May 5. May 12 to 21. fiP.S fi94 do. 1864. do. 1S55 ? 23 R. Shot, ■wniinH fi-an'. R9-) ture of riifht pa- rietal bone cut- ting middle me- ningeal artery. fi9R M. 35 L." glands. Hem. of mouth. R97 fi9S (supposed caro- tid). Tumor (carcino- ma) of temporal muscle; supposd aneurism. Cirsoid aneurism of scalp. Hem. of mouth ; fell with pipe- stem in mouth. Shot wound ; r. mastoid process. Malignantdisease of right nasal fossa. Cirsoid aneurism of scalp. Aneurism of orbit, left traumatic. Hem. of external carotid ; removal of parotid tumor. Enceph. tumor of right orbit. R99 do. Hotel Dieu. Ure, 1859. Valk, N. N., 18S4. W. H., 1849. do. 18.30. do. 1854. do. 1852. do. 1857. Vanzetti, 1865. Vansant, J., 1865. Vargus, 1823. Velpeau, 1835. M. jvi. M. F. F. M. P. M. M. M. F. M. 20 35 21 40 17 23 L. R. R. L. L. 7nn 7 hours. Above omo- hyoid, do. 701 702 Aug. 25. Sept. 7. 703 704 70') 70R 25 60 Mid age. 30 16 R. L. L. L. 707 708 Shot wound left side of head. Aueur. carotid. Feb. 6. Feb. 15. 709 713 temporal region. THE COMMON CAUOTTI) ARTERY. P3 Common Garoiid Arlery — continued. Date of operation. E !- fc, o c ® age 4> O C4 X Sog' KESCI.T. RKMARKB. No. Condition Recovery. Cause of death, days after op. «S4 June 2, 1804. ( June in, { 1864. ( Julys, '64 Oct. 10, 1863. June 18, 1862. May 16, 1863. Mays. (?) ( May 17,'62 May 21, lb64. Next day. 17 days aftfr Ist op. 2 " " last " Next day. 4 days. Died May 1.1. Same day. Same day. Next day. 13 days. Hem. Internal jugular vein bcini; fiSi July 2. wounded in operation wa8 aUo tied. Tlio veHsel vtslh tied a Bccond 68(5 fiS7 19 Recovered. 7 time on account of hem. 1.3 days alter Int operation. Lingual was also tied. fiS8 Ball entered neck, right side, tra- fiSO versed antrum and out at no^e. (iqn mi 603. Recovered Recovered. Recovered. Cured. Cured. 694 May 13, 1864. After. .30 days. Details not given. Details not given. Paralysis of right arm resulted. Autopsy: Aneurism of veriebral between 2d and 3d cervical vert. fiflfi m7 20th day. Died. (?) fits fiW Recovered. Recovered. Ijnproved. Cured. ? Temporal, auricular, and occi- pital tied at same time. No cerebral symptoms; symp- toms were favorable on 31st ult. 700 May 21, lSo9. Sept. 9, 1864. 1849. 1850. June 24, 1854. 1S52. 1857. 1865. Fel). 15, '65. Kelig. 21. Aug. 18, 18-23. 1st and 2d day, slight. 701 nth day. 60 hours. Cerebral complications. 70? Hemiplegia in 24 hours. Autop- sy : Right hemisphere softened. Disease latent ; right carotid had been tied 6years previously ly Dr. J. K. Kodgers. No cere- bral symptoms followed. 7ns 14 15 Recovered. Recovered. Recovered. Not cured. Not cured, but iuipr'd Cured. 704 70i day. IS months later patient improved and condition good. Pressure on right carotid slops pulsation in tumor. Superior thyroid also tied Pain ceased on tightening lig. Autopsy : Healthy clot in boTh central and distal ends ; orbit and zygomatic fossa filled wiih canci-rous matter. 70fi 13th day. Pyjemia. 8th day. ^'^^l 4 •'• hem. 16th day. Hem. 707 70S Once. Hem. recurring same vessel was 70<» Recovered. Cured. tied 6 days after 1st operation. 710 Often. 94 PRIZE ESSAY. Surgical History of the Name of operator. Source of information. PATIENT. Cause of operation. o 1=1 S u a t3 S =1 ,^ bo CO bo 6 -a * 2 711 Velpeau, 1S39. Verneuil, 1863. do. 1871. do. 1870. Vilardebo, 1847. Vincent, 1845. do. 1829. do. 1818. Voisin. ■Wagstaffe,1872. Walton, 1851. Walt her, C, 1830. Von Walther, P. Watson, J., ' 18.53. (?) Warren, 1 827. do 18S0. r do. 1843. ■i do. do. do. 1837. do. 1836. do. 1827. Wardrop, 1818. do. 1826. do. 1827. do. 182.5. do. 1826. Wattman, 1823. Webster, N., 1864. Weber, G. 0., 1853. Norria Contrib.; Arch. Klin. Chir., 1868. Arch. Klin. Chir., 1868. Gaz. des Hop., 1871, p. 442; Lancet, Nov. 4, 1871, p. 644. Gaz. Hebdom., Nov. 10, 1876, p. 709. Arch. Klin. Chir., 1868. Norris Contrib. Norris Contrib.; EhrmauD (cit.). Norris Contrib. Eve Collect. Remark. Cases ; Arch. Klin. Chir. (cit.). Lancet, June, 1872. Med. Times & Gaz., lS.i4, vol. i. p. 185. Arch. Klin. Chir. (cir.). do. N. Y. Med. Jr., July, 1857. Norris Contrib. (cit.). do. Am. Jr. Med. Sci., April, 1846. do. Norris Contrib., etc. Arch. Klin. Chir., 1868. do. Lancet, vol. xii. p. .394. Norris Contrib. Lancet, vol. xii. p. 762. Norris Contrib. do. Ehrmann des effets ; Arch. Klin. Chir. (cit.). Med. Surg. Hist. Reb.; Otis. Arch. Klin. Chir., 1868. M. M. M. M. M. M. M. M. F. M. M. F. M. F. M. M. M. F. M. F. M. F. m"." M. M. 28 41 30 32 70 28 48 52 5 mos 29 38 Y'g 42 18 23 23 52 45 60 6 WliS 5 mos 22 75 57 55 Mid age. 63 R. E. R. E. R. R. R. R. L. L. L. L. R. L. R. R. L. L. L. L. L. R. R. E. R. An eur.orb . ,traum. (of both sides). 6 mos. ^^9. 713 tumor of parotid. Hem. shot wound of cheek. Hem. foUowiut; lii;-. ext. carotid. Aneurism of caro- tid and innom. Hem. wound of tongue. Aneurism. do. St lb wound ver- tebral. Aneur. of orbit. 21 days. May 23. 714 15-30 and after. 71.') 716 8 days. 8 mos. 3 w'ks. 717 71 S 719 720 7?,1 3 mos. 722 723 724 carotid. Stab wound ver- tebral. Aneurism. Erect, turn, orbit. Erect. turn, mouth, face, neck. do. Scirrh. tum. neck. Remov. tum. thy- roid. Prep, removal of glands of neck for malig. dis. Erect, tum. cheek. Erect, tum. face. Erectile turn, face and head. Carotid aneurism, low down, do. 72o 7m 727 7'>8 729 7M) 30y'rs. 2 years. 1 year. 6 w'ks. 7'?1 732 73.S 734 73f) 12 y'rs. 73fi 737 738 739 gland. Shot w'nd (flesh) face. Hem. after opera- tion for exlirp. Mays. 740 THE COMMON CAROTID ARTERY 05 Common Carotid Artery — continued. No. Date of operation. ni |s1 COO KEBULT. RE.MARKS. Recovery. Condition. Cause of death, date after op. 711 July 1839. Recovered. Recovered. Improved. ? PresHuro of right carotid arront- 712 20 42 hours. Coma. Next day. 21st day. 6th day. Hem. 7th day. Cerebral complications. 33d day. Inflamma- tion of sac. Died. ed pulsation in tumor of left orbit comiiletcly and l<>HH'-ned jiulsation In tliat of ri^'ht eye, and vice vfrita. .\flor operation tumor of left side ci-ased to pul- sate, and sight was diminished. 6 months later improved, not cured. 718 July 2, 187). Feb. 5 1870. Two ligatures to carotid ; hemi- plegia immediate. Autopsy: " Right hemisphere prufonnri'ly altered." (flute.— 'Ry: I. and int. carotid also tied in a 8ini,'le loop of ligature.) 714 715 716 April 16, 1845. July IS, 1829. Dec. 19, 1818. Once. 717 Autopsy: Softening of right hemisphere. 718 22 719 720 721 June 5, 1851. 1830. 23 14 Recovered. Recovered. Recovered. Cured. Cured. Cured. No cerebral symptoms. 722 7?8 3d day. Cerebral symptoms. 7-H 2 days after operation paralysis (rig'ht) ; internal jugular vein was also tied. Autopsy : Brain softened. 725 Oct. 26, 1827. Jan. 2, 1830. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Cured. Cured. No better. Improved. 796 727 f Oct. 5, 1845. J Nov. 9, 1845. March 7, 1837. Sept. 14, I'^SS. 1827. 1818. March, 1826 Oct. (?) 1827. June, 1825. 728 half after 1st ligature, but there was no positive improvement. 729 730 by removing a portion and plunging needles into the re- maining parts. Cured. 7th day coma; parn lysis of left arm. which disappeared. 7S1 ? 732 Patient died 1 year later from re- 73:^ 14th day. Exhaus- tion. turn of disease. Tumor ulcerated freelv after op- 734 11 25 Recovered. Recovered. Recovered. Cured. Improved. Improved. eration. 733 Died 103 days after operation ; psoas abscess. (Distal.) \(Di.itnl.) 736 737 23d day. Died. Brain com- plications. S days. [62d day. Hem. ) 738 1825. June 22, 1864. Nov. 11, 1853. Day after operation paralysis of j left side. 7.39 740 Twice. 14 1 96 PRIZE ESSAY. Surgical History of the No. Name of operator. Source of informatiou. PATIENT. Cause of operation. o O " :c S3 ^ en 3 "o o "n «* 13 5:2 '^ y. < ^ s 741 f Weber, G.C.E.,1857. do. Weeker, 1S6S. Weinlechner, 1861. do. 1863. Weir, R. P., 186;?. do. 1864. do. do. 186.3. do. 1862. do. 1863. do. 1876. Wickham, 1829. Williams, 1825. Williaume, 182 >. Wood, Prof. J. R., 1839. do. 1840. do. 1842. do. 1843. r do. 1855. j do. do. 1847. do. 1S54. do. Wciodward, A. T., 1860. Am. Jr. Med. Sci., April, 1860, p. 574. do. Schmidt Jahrb., No. 144, p. 200. Arch. Klin. Chir., IStiS. do. Med. Surg. Hist. Reb.; Oiis. do. do. do. do. do. Letter to author. Norris Contrib. Arch. Klin. Chir., 1868. Norris Contrib.: Arch. Klin. Chir., 1S68. N. Y. Med. Jr., July, 1857, Prof. Jas. R. Wood. do. do. do. do. do. do. do. do. Letter to author. M. M. P. P. P. M. M. M. M. M. M. 20 20 63 40 41 y>rs Mid age do. do. do. do. 25 L. R. L. R. R. R. L. R. L. R. R. R. Epilepsy. do. Pulsating tumor of left eye. Secondary hem. (facial). Hemorrhage. Shot wound right sup. max. Shot wound inf. max. (lingual, verteiiral, and oesophagus). Shot wound inf. max. Shot wound left side of neck. Shot w'nd spinal cord and neck (aneurii-m). Shot wound face. 5 years. 742 743 Several months. Short time. 15 days. 744 74.'-. 746 Sept. 17 Aug. 25 July 9. Jan. 1. About Sept. 24. July 3. Sept. 25. Sept. 3. July 19. Jan. 1 747 748 749 Below omo- hyoid. 750 7o1 Below omo- hyoid. and after. July 9. 7o2 7o.S M. M. M. P. P. M. M. M. M. M. M. M. P. 55 Aneurism innom. 7o4 7/)fi 21 Mid age 36 6 mos 37 53 53 36 .23 Mid age do. L. L. R. R. R. R. L. R. L. L. L. 7fifi Suicide ; knife wound of throat. Aneur. carotid at bifurcation of innominate. Aneur. auast. of cheek. Epilepsy. Malig. disease of antrum, do. Aneurism of ext. carotid . Malig. disease of antrum. Malignant tumor of left jaw. Aneur. anast. of left ext. carotid. 757 6 mos. Above omo- hyoid, do. 75S 759 7fin Some time. Above omo-hy. do. do. do. Below omo-hy. 7fi1 7fi^ 7fi3 7fi4 765 THE COMMON CAROTID ARTERY. 97 Common Carotid Artery — continued. No. Date of operation. U ^ '_. o a> e be W 1^1 t3 RESOLT. REMARKS. Kecovery. Condition. Cause of death, date after op. 741 r Dec. 2, 1857. - Dec. 19, 1857. Juno 20, 1868. May 19, 1861. 12 Recovered. Recovered. Interval of 17 days between the 2 oporatioriH ; 6 woekg after laft operation no attack, but mind weaker. Paralysis of right side followed operation. 742 743 Improved. 52 hours. 6 days. 744 745 8-9 Recovered. Recovered. Cured. (?) No cerebral symptoms. 746 Nov. 14, 1863. Sept. 3, 1864. July 20, 1864. Feb. 26, 1863. Sept. .30, 1S62. July 10, 1863. 1876. Sept. 26, 1829. Next day. Hem. 32d day. 747 Once. 38,41 days. 748 On account of hemorrhage the artery was religatured on Aug. 30th. 749 750 2 days. None. Once. 3d day. Hem. 3d day. 11th day. Hem. ; asphyxia. a little below thyroid notch, passing out left of occipital pro- tuberance. 751 7.'J2 Antiseptic ligature ; no cerebral symptoms ; subclavian tied at the sume time. Autopsy: Sac bursted in trachea. (Distal.) 753 Recovered. Recovered. Recovered. Temporary improvem't. (?) Improved. 754 33d day. Hem. rupture of the sac. Subclavian was tied on 3d December. 755 756 June 26, 1829. June 26, 1839. Dec. 13, 1840. March 2, 1842. Sept. 2, 1843. f July 2, J 1856. 1 Sept. 26, L 1856. ■ Dec. 6, 1847. Dec. 7, 1854. Several times. 21 12 12 9 15 14 " Hem. caused by patient tear- ing wound open with her own hands." Patient complained of queer feel- ing in head, which passed off in an hour. {Distal.) 3 years after operation bat little change in tumor. No cerebral symptoms. 757 Recovered. Recovered. Recovered Recovered. Cured. Not cured. Marked im- provement, do. 758 759 760 761 38th day. Exhaus- 762 13 13 Recovered. Recovered. Cured. tiou. 763 common carotid was also tied. 764 4th day. 4th day. sloughed after operation and brought away by a ligature ; 6 months after operation patient fell into hands of a quack and died. Paralysis on opposite side a few hours after operation. Dr A T Woodward kindlv sent 765 me another case where he tied the right common carotid foi" shot wound of face and neck. Patient was living several days after operation, but as the Dr. lost sight of him. and the result is uncertain, I have thought best to omit this case. 1 98 PRIZE ESSAY. Surgical History of the Name of operator. Source of information. PATIENT. Cause of operation. O o o •3.2> t3 ft. 9 6 be < 6 •2 u cS o p a J3 Vfifi Woodward. G. F., 1857. Wynkoop, G.H. "Wutzer, 1847. White, 1861-5. WMto, 1846. Wright, W., 1855. Zeiss. Z6rnroth, L.H. N. Y. Med. Jr., July, 1857, Prof. Jas. R. Wood. Notes of case, courtesy of Prof. Willard Parker. Arch. Klin. Chir., 1868 (cit.). Letter, Dr. J. H. Erskine (Med. Direc- tor Army of Tennes- see). Lancet, 1846, vol. i. p. 149. Lancet, 1856, vol. i. p. 711. Norris Contrib. Arch. Klin. Chir., 1868. M. M. M. 33 li y'r. 25 R. R. R. R. L. R. Cancerous tumor orhit and brain. 7fi7 7fi8 face (ulcerating). 7fiP carotid. 77n M. M. 34 70 15 mos Anenrism,carotid, near bifurcation. Aneurism, innom. Erect, tum. face. Aneurism tempo- ral artery (arte- riotomy). 3 mos. 771 77"^ 77-? Appendix to History of the No. Name of operator. Source of information. PATIENT. Cause of operation. o 3 " - 9 P-l > -2 3 =1.9 0) < 6 •p m ft i 774 Guthrie. Eve, Prof. Paul F. (Nashville, Tenn.). do. Cooper, B. (See 122-3). Hodges, 1S6S. Hobart, 1839. Nash. Jr. Med. Surg., Feb. 1874. Letter to author. do. Boat. Med. Surg. Jr., Aug. 6, 1868. Guy's Hosp. Rep., vol. xvii. F. 53 775 of neck. 776 777 778 M. F. 35 25 R. R. Innominate aneu- rism. Aortic aneurism (supposed in- nominate). 779 THE COMMON CAROTID ARTERY, 99 Common Carotid Artery — continued. Date of operation. o [3 5 o:" o rt ■a BBStTLT. KEMARKS. Recovery. Condition. Cause of death, date after op. 766 April 18, 1857. Nov 1 1868 Eopeat- edly. 1 50th day. DiseaHe,'Paralv«lH reHulted on loft Hide- 767 21 18 Recovered. Recovered. Cured. Cured. hem., and cerebral coraplicationij. 42d day. Tumor continued to grow. 768 769 both endH bein« cut off and left in vround ; the loop worked out on 'Mat day. 3 days. 1 88th day. 114 days. Cerebral complications. going Into tumor, it was deemed irniiracticalile to tie the ext. carotid. 770 771 Aug. 28, 184.^. Oct. 1, 1855. 6, 10, 11 days. 10 Recovered. Cured. Paralysis (left) followed opera- tion ; absc(^ss of brain at autop- sy. Distal. 772 8 77S Once. Recovered. Cured. Common Carotid Artery. No. Bate of operation. CD If? f-l 2 P-l O S OJ o ■ P< RESULT. REMARKS. Recovery. Condition. Cause of death, date after op. 774 Recovered. Not cured. 775 was tied, but did not arrest hem. The external was then secured above the wound, and this did not arrest hem. The internal carotid was nest se- cured, and hemorrhage ceased. The disease returned, and pa- tient died 6 months later. (For Dr. Eve's 3d case see Mott, V.) 776 Recovered. 11th day. Exhaus- tion and hem. ISth day. Hem. 777 778 April 11, 1868. 1839. sth day. 16th day. Distal. The subclavian wa* tied 779 in its 3d division at pame time. Sth day, internal jugular vein burst and was tied. in 1st division at same time. Patient did well until 16th day, when in a fit of passion she sprang from her bed and threw a pillow and some books at the attendant. Hem. from carotid ensued, and death. Autopsy: Subclavian closed, carotid open, although the aorta and not the innominate was the seat of the disease, the pulsation in the tumor had ceased before death, and the process of cure had begun. 100 PRIZE ESSAY. Appendix to History of the Name of operator. Source of information. Cause of operation. 780 Parker, Prof. Willard, 1863. 781 782 786 787 Bickersteth, 1864. Little, Prof. Jas. L. Speir. S. Fleet, Bruotlyn, N. Y. Harwell, Rich- ard, 1877. Paul, .lolin, 1830. Stimson, D. L. Cooper, S. E. Bradley, E., New Yor.t City. 1877. Notes of case to author from Dr. Par- ker. Mr. T. Holmes in Lancet for 1872. do. Notes from Dr. Little. Notes from Dr. Speir in Birmingham's Archives of Clinical Surgery. Lancet, Nov. 17, 1877; Am. Jr. Med. Scl., Jan. 1878, p 275. Lond. Med. Gaz., 1838, vol. viii. p. 71. Dr. Stimson to author. Amer. Med. Times, June 24, 1862. Notes of case from Dr. Bradley to author. M. I 32 I Subclavian aneu- rism. Innominate aneu- rism. Aneur. aorta and innominate. do. Aortic aneurism ( supposed innom- in ate). Aneurism aorta, carotid, subclav. , and innominate. Pulsating tumor ove ear. Aneurism of com- mon carotid. Tumor of parotid and submaxil'ry glands. Hem. during re- moval of vascu- lar tumor of pa- rotid and sub- maxillary region (Angioma). 19i years. Near clavicle 1 Mr. Richard Barwell. Am. Jr. Med. Sci., Oct. 1S7S, p. 570, and January, 1878, p. 27.5. M. ; 45; R. Aneurism of aorta, innominate, subclavian, and carotid arteries. Carotid tied Aug. 14, 1H77, and subclavian a few minutes later in 3d division. Tximor diminished rapidly in size and consolidated. Nov. 14 patient left the hospital. '' On the 22d November, he walked two miles through snow and sleet, thinly clad, sat four hours in wet clothes, without a fire, and died Nov. 24, 1877." Autopsy : " Bronchitis, redema, and hypostatic pneumonia. Muco-pus in large and small bronchi. Arterial blood was dark. The innominate, right carotid, and subclavian were obliterated. No vessel opened out of the aneurism, which was much diminished in size and consolidated." fit is probable this patient would have lived comfortably for a much longer time if he had acted more prudently. The reader is referred to the summaries for results of these double distal ligatures. — Author.'] THE COMMON CAROTID A H T E K Y . 101 Common Carotid Artery — continued. No. Dato of oporalion. Sept. 2, 1863 7S1 7o2 786 787 78S 10,21,35, and 42 days. None. 18C4. f 1875.' Auff. 6, 1B74. Aug. 14, 1677. July 29, 1S30. 1877. Dec. 6,1877, U !-' O o 3 S a vC QJ O ci P< a /I o ^ t-. bn \f >. 1-1 rt OS t3 Eocovory 26,27,28, 30,31, 3i days. 3d week. Recovered. Recovered Recovered. Recovered Condition. Ciiuse of death, date Hl'ter op. 42d day. Hem. 0th day. 10 weeks, tion. Marked im- provciiifnt to date. Shock. Suffoca- 34th diiy. Hem. ; dyspnoea. Much inip'd on JNov. 13, 1877. Cured. Cured. Several weeks. CEdema of glottis. REMARKS. Wardrop. Tho Bubclavian in iHt divJBion and v^rtel'ral wct. and common carotid also tied. Common carotid wan first tied ; hem. not arrested ; IJr. B. cut into sac and tied b'lth ends of wounded internal caroiid. Hera, not ceasing with lig. of internal carotid, Iho common and ext. carotids were also tied. Common carotid first tied but did not arrest hem. ; internal next tied, still no arre>t oT bleeding ; external carotid ti<^d, hem. stop- ped. Int. jug. vein was also tied. Common carotid was also tied. Only one ligature, and that on proximal side of wound. Hem. was coiitroUcd by pressure on cjm. car. until the int. was tied. Common carotid tied, no arrest of hem. ; external then tied on distal side of wound : hem. still continued, and did not cease un- til internal carotid was .-secured. Patient died 6 months later from return of disease. Ext. carotid was tied same time. The common carotid was first tied, but hem. was not arrested until ligature of inter'l carotid. The internal jugular vein was tied at the same time. There was no cerebral disturbance. In operation for removal of tu- mor internal jugular vein was wounded and tied wiih lateral ligature; 10 days later hem. from ulceration of internal ciratid, which was tied above and below bleeding point, ard common car ot I '< tied just below bifurcation. The extornal car- otid was secured at the first op. The internal carotid was torn in two during operation ; c •m- mon carotid tied, increasing hemorrhage ; the vessels were ligatured then e.n mouse. External carotid also tied ; no cerebral symptoms. Disease returned and patient died some months after. Common carotid also tied. [Common carotid also tied; ext. . and internal in single ligatuie; \ hemipTa immediate. Autop>y: I Lea hemis. profoundly altered. 106 PRIZE ESSAY. Ligature of the No. Name of oiierator. Source of information. PATIENT. Cause of operation. o a 6 .2 " 11 3 ^ a o o (It's 13 -2 '5 9 oil CO < 1 Bertherand, 1860. Ehrmann des effets. Dr. Madeluns ; Arch. Klin. Chir., vol. xvii. F. 4^ mos L. Erectile tumor of temporal region. 2 Boeckel, 1861. Arch. Klin. Chir., 1868; Gaz. Med. de Strasbourg, 1862, No. 6, p. 100. F. 50 E. al enchondroma near angle jaw. 3 Burchard, T.H., 1873. Letter to author. M. 60 L. Hem. pistol w'nd neck, high up (suicidal). ^ inch above bif. of com. 4 ' Busch, W., 1872. Schmidt Jahrb., Bd. 167, p. 66 ; Dr. Made- lung (cit.). F. 29 R. Pulsating vascu- lar tumor back of head. 24 y'rs. • fi L do. do. 1856. Bushe, G., 1827. Byrd, W. A. (111.), 1876. F. M. F. M. 29 34 2^ Mid age. L. L. R. L. 6 Longworth Prize The- sis ; Dr. Madelung (op. cit.); Schmidt Jahrb., vol. xcviii. p. 341. Lancet, 18-28, vol. ii. p. 413 ; Longvrorth Prize Thesis. N. Y. Med. Jr., Aug. 1876. Eetro-pharyngeal tumor (prepar. to remove). Above digas- tric. do. 7 g pulsating tumor temporal region. Shot wound ext and int. carotid angle of jaw. 7 hours. 9 10 f V. Bruns, 1 1856. - do. do. 1859. Arch. Klin. Chir., vol. xvii.; Dr. Made- lung. M. 25 R. L. R. Vascular tumor left cheek, lip, and nose, do. Tumor of parotid. Arch. Klin. Chir., vol. xvii.; Dr Made- M. 56 12 do. Bramblett, W. H., 1864. lung. M. M. 23 47 L. L. Fibroid tumor of parotid. Shot w'nd cheek. 13 N. Y. Med. Record, June, 1869. 10th day after injury. 14 De Castro, 1864. Gaz. Med. d'Orient, 1864, p. 166; Dr. Made- lung. M. 31 R. Hem. after Ms,, of common carotid for aneur. exter- nal. 10 Corradi, Italy, 1874. N. Y. Med. Jr., Sept. 1876. 58 L. Tumor of parotid. 16 Cleary, 1864. Arch. Klin. Chir., vol. xvii. p. 626, Dr. Madelung. M. Mid age. E. Shot wound face. 17 Demarquay, 1867. Gaz. Hebdom., 1858, p 6SS. M. 62 R TT■,rr.or•^t.,^TllTO• nf Above digas- tric. parotid. THE EXTERNAL CAROTID AHTEIiY. 107 External Carotid Artery. No. Date of operation. a Sii a> o rt 5 O o .SP(s i». Recovery. Coudition. Sept. 1873. f Aug. 25, I 1872. do. 1856. Once. Noae. 7 1827. May, 1876. f 1856. March 12, 1859. Aug. 2, lS.")f). Dec. 1861. 1864. None. Noae. (Oc- curred.) Recovered. Recovered Recovei-ed. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Cured. Cured. Not cured. Cured. Cured No benefit. Cured. Cured. Cured. Cured. Cause of death, date after op. About .0 days. Coma; cerebral exhaust REMARKS. 20minutes. Exhaus- tion from previous hem. Died in fewminutes. Hem ; exhaustion. Recovered.! Cured. 35 days. External carotid flrnt tied HOino hourH before common As the effect on t)io tumor wag not marked this last vf^sfol was tiod aiKi tho ligature nirnovfid from thi; external. (As th'; lie- ature was tightener! and re- mained several hours in xttu, the vessel can prop'-rly be con- sidered as obliterated by the operation, tho inner coat being cut and turned in as is the rule in such cases.) — Avthor. After ligature of />xt/-rnaf earn- tiii, hemorrhage T?hifh was ar- rested by liyature of C"mmiin and internal carotid. Paralysis resulted after these last two vessels were secured. No bad symptoms followed. In- ternal carotid tied same opera- tion. Patient writes Dec. 20, 187.3, "Aai not able to work; appetite good; sleep badly; pulsation in tumor place is not so well as when I was discharged." Hem. from the sloughing tumor some time after op., only very slight. External ea,rr>tid as large as common trunk. Pressure aad hot iron had been tried to arrest hem. before liga- ture. No hem. after operation. Hemorrhage had been immense before Dr. Byrd arrived. Inter- nal and common carotid were also tied. 10 days after wound internal carotid tied ; hemorrhage per- sisting, common and external carotids also tied. Hem. still followed, though not so severe, arrested by pressure of cloth soaked in tinct. ferri chloridi. Hem. not ceasing after ligature of common carotid, the sac sup- purated and external tied. Died immediately from previous hemorrhage. (No details of this case.) External c.irotid tied 14 days after injury; 3.3 days later, on account of hemorrhage, com- mon carotid was tied. Died 2 days later. 108 PRIZE ESSAY. Ligature of the No. Name of opera'tor. Source of information. Cause of operation. 0.2 •5 1 A a 18 I Dolbeau, 1864. 19 iDiimdnil, 1872. 27 Ensign. W. A. 1864. Fouoher. Giinther, 1845. Gutlirie. 26 Hamilton, Prof, F. II., 1838. Heine, C, 1869. Longworth (op. cit.); Madelung (op. cit.). Schmidt Jahrb., Bd. IGO, p. 16ti. Schmidt Jahrb., 39-10, p. 212 ; Arch. Klin. Chir., vol. xvii. p. 624; Longwovth ; Made- lung. Med. Surg. Hist. Reb.; Dr. G. A. Otis. Longworth ; Made- lung ; Gaz. des Hop., 1852, p. 518. Madelung (op. cit.). Nash. Jr. Med. Surg., Feb. 1874. Arch. Klin. Chir., 1868 : Pilz. Notes of case from Prof. Hamilton. Schmidt Jahrb., 147, p. 69. Jones, J. C, 1S64. Lannelongue, 1873. (?) Legouest. Lizars, Jno , 1830. Mahojn,M.,]864 Maisonneuve, 1849. do. 1855. do. do. 1856. do. do. M. M. F. Med. Surg, Hist. Reb.; M, Otis. Schmidt Jahrb., Bd. 166, p. 149. Arch. Klin. Chir., 18BS ; Pilz (cit.). Longworth Prize The- sis (cit); Madelnng (op. cit). Am. Jr. Med. Sci., vol. xlviii. p. 276 ; Madelung (cit.); Lan- cet, 1829-30, vol. ii. p. 64. Bull, de la Soc. de Chir., vol. i. p. 4J0 ; Longworth (cit.); Madelung. Mem. de la Soc. de Chir., 1864, tome vi. p. 211 ; Longworth ; Madelung (cit.). do. Mid ,ge. 21 Mid age. 17 Hem. abscess sub- max. region. Hem. polyp, nose. Below digas- tric. Suicidal wound near angle jaw. Shot wound orbit and int. max. artery. Hem. after ampu tating tongue by ecraseur. Hem. after remov. of parotid. Hem. removal of tumor of neck Knife wound int. carotid (suicid- al). Scirrhous tumor of parotid. Hem. cirsoid turn, scalp and ear. Shot fracture of right inf. max. Sarcoma of tongue and face. Traumatic aneur, of orbit. Prep, to removal tumor sup. max, Shot wound inf. max. 5 days. Above digas- tric. Below digas- tric. Above digas- tric. June 3. June 14. Several years. Aneurism anast. temporal region. Carcinoma of tongue. do. Cancer of left inf max. and tongue. Cancer of tongue, jaw, and phar- ynx. Below digas- tric. Below digas- tric. i inch above origin. Below digas- tric. Dec. 14. Nov. 29. THE EXTERNAL CAROTID ARTERY. 109 External Carotid Artery — continued. ]>ato of operatiuu. 1864. o H » 3 O c3 Recovery. Occnr'd fi-oui nose ; none from liga- ture. None. July 16, 1SG4. March, 1838 Dec. 14, 1S61. Dec. 3, 1864 Oc- curred Recovered, Recovered. Condition. Cured. None. Severe. None. None. Jan. 21, 18.31. Nov. 23, IS.'j). 18ot3. Recovered. Recovered. Recovered. CauHe of death, date after op. Died on table. E.k. haustion. Cured. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered fromopei''n. Recovered Recovered. Not cured. Cured. Not cured. Cured. Cured (?) Cured. KEMAUKS. Died. Hem. exhaustion. Died. Coma; not on accouut lig. ext car. The ligature did not arroHt hern.; tlMTo viaa no liera. from seat of ligature. Wound from angle of jaw to larynx, oponing into pharyu-X, Horn, before operation was im- mense. (Ligature of the external car- otid was performed too late, as patient could not rally from previous and e.\hau.stiug hem.) Hem. after ligature stopped by ice and compress. Common carotid first tied ; did not arrest hem. ; external tied above wound ; hem! not arrest- ed until internal carotid was seoure^l. Internal jugular vein tied (la- teral lig.) and common carotid same time. 8 days later ext. carotid tied ; internal carotid also. Disease returned and patient died later. days after lig. of ext. on ac- count of hemorrhage the com- mon carotid was tied. Hem. from seat of ligature. Died of disease some time after operation. Common carotid tied same time. Several polypi were removed from the ethmoid bone during operation. Ball entered angle left iuf. max. fracturing it ; passed beneath tongue, out right side hyoid bone ; common carotid first tied. Hem. not arrested ; external was ligatured 4 days after eom- mon. 21 days after lig. of external carotid, hem. ; 26th and 27th hem., then lig. of common and internal carotid ; sympathetic nervt included in last lig. Hemi- plegia ensued after lig. of com- mon trunk. Patient died 1 month later from violence of disease. Died 60 days after operation from violence of disease. Discharged in 1}^ month. 110 PRIZE ESSAY. Ligature of the Name of operator. Soui-ce of infoimation. Cause of operation. Maisonneuve, 1854. do. do. do. do. do. L do. 5 do.isse. \ do. do. Marchal, 1835. Mastermann. Moses, J., 1863 Mott, v., 1831. McClellan,1871, do. 1845. McGraw, T. A. Michigan. do. Nfelaton, 1858. lfoir,1861. Pancoast, G. L. 1864. Parker, Prof. WiUard, 1838. do. Peugnet, Eugene (Fordham). do. L Post, Prof. A.C. 1855. do. 1876. Richard, 1855. Mem. de la Soc. de Chir., 1864, tome vi. p. 211; Longworth. Dr. Madelung in Arch Klin. Chir., vol. xvii. p. (J-28. do. do. do. do. do. do. do. Norris Contrib. (cit.^ Madelung. Arch. Klin. Chir., Bd. 17, p. 616 ; Madelung Med. Surg. Hist. Eeb.; G. A.Otis. Am. Jr. Med. Sci., vol. X. p. 17; Dr. Madelung (cit.). Am. Jr. Med. Sci., Oct. 1S72. McClellan, System of Surgery. Letter to author. do. Arch. Klin. Chir., Bd. 17, p. 620 ; Madelung. do. p. 624. Med. Surg. Hist. Eeb. Letter to author. do. N. Y. Med. Rec, vol. xi. 1876 ; Letter from Drs. Katzenbach & Peugnet. Letter to author. do. Arch. Klin. Chir., Bd. 17, p. 62ii ; Madelung ; Longworth. Mid age 35 Mid R. Carcinoma phar- ynx and tongue, do. Carcinoma of tongue. Unknown. do. Carcinoma of tongue. Carcin. of tongue. do. Unknown. Hem. puncture of aneur. (mistaken for abscess). Aneur. anast. ear. Shot wound face. Melanotic tumor of parotid. Recurrent tumor of right parotid. Removal of tumor of parotid. do. Hem. after remov. parotid tumor. Hem. facial art. Shot wound inf. max. Enlarged parotid. Disease parotid. Osteo-aneurism of lelt inf. max. Prep, removal of tumor of parotid. do. Traumatic aneu- rism near paro- tid. 20 y'rs. 1 year. About digas- tric. Sept. 20 About digas- tric. At di- gastric. Near bifurca- tion. do. 5 inch ab. bif. June 18, 1864. i inch above bifur. of com. Ab.Jin. from origin. THE EXTERNAL CAROTID ARTERY. Ill External Carotid Artery — continued. No. Date of operation. E »- u o 3 © © o « loo -3 BUBULT. REMARKS. Recovery. Condition. Cauae of death, date after op. 38 .39 40 41 ( March 11, \ 18C4. ( do. March 21, 1804. J 1854. \ 1804. r March 28, 18(54. y do. ) 18.56. \ 1856. 15 15 18 Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Cured. Cured. Cured. Cured. Cured. ? ? Not cured. Not cured. Cured. 4'^ 48 (This ca.se is reported as cured, but as the patient was lost Biglit of 33 days after operation, f think it is not safe to consider it aH a cure. — AiWior.) 44 4.') 4fi 47 18 (It is not certain that this case belongs to Maisouneuve. — Au- tkor.) Lig. of external narotid did not arrest hem., and common trunk viras tied ; 2d day after this cou- vulsion.s, and death in 6 days. Part of tumor liffatured also, and part cut away and nitrate of silver applied. Ext. carotid tied, hut failed to arrest hemorrhage ; 19 days after, common was tied, and death followed in 2 days. Died 1>^ year later from disease. In removal of tumor the jug. was tied and facial nerve divi'ded. Internal carotid was also tied, and it was thought that the spinal accessory and pneumo- gastric nerves were divided. 4R Jane, 1836. After. Died. Hem. and ce- rebral complica- tions. 49 5 Recovered. Cured. .-in Nov. 26, 1863. 1831. After. 21st day. .'il 12 17 Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Not cured. ? ? Cured. Cured. Not cured. !S7. IS?. ,14 .'),') .in 1S5S. 10,11,18, 19 day aft. op. 21 ^1 3d day. applied, and vessel divided be- tween them. iiS June 27, 1864. July 12, 1838. 59 fin None. 16 Recovered. Recovered. Cured. Cured. fii r July 16, 1875. July 28, 1875. 1855. 1876. 18.35. 5, 6, 7, 8 and 9 days. After. None. None. After 1st operation hem. from aneurism on 21st, 22d, and 23d July, aud/rom seat of ligature on 24th, which was controlled by pressure on common carotid of same side. Next day there was hem. again from the aneu- rism in mouih, and the common carotid of the opposite side was tied ; the hem. was not arrested and the patient died. Autopsy showed that the internal caro't- id on right side was absent, the common taking the distributio 'I of the externa?, which it in re- ality loas. (There is but one other such anomalous arrange- ment of the carotid on record. This I found in the dissecting room in 1876. — Author.) fi2 2 days. Hem. 63 64 Recovered. Recovered. Recovered. Cured. Cured. Cured. 112 PRIZE ESSAY. Ligature of the No. 67 Name of operator. Source of information. Richet, 1861. Eoser, 1856. do. do. clo. do. Sands, Prof. H. B.,1872. do. 1874. Santesson, 1S53 Sedillot, Scott, 1S.30. Smith, Prof. Stephen, 1864. Unknown, 1863. do. 1862. do. do. 1864. do. hy Larry. do. Vanzetti, 1846. Verneuil. do. 1870. Wallace, 1833. Weber, C. 0. Wldmer, 1838. Wutzer, 1841. do. 1847. L'TJnion Med., xii. p. 4.5,1861; Dr.Madelung. Arch. Klin. Chlr., Bd. 17 ; Madelnug (cit.). do. do. do. do. Personally to author. Arch. Klin. Chir., 1863; Dr. C. Pilz. Longworth Prize The- sis ; MadeluQg (op. cit.). Lond. Med. Gaz., vol vii. p. 286. N. Y. Med. Jr., Jan. 1874. Med. Surg. Hist. Reh.; M. Dr. G. A. Otis. Cause of operation. .9 wj 53 L. Parotid tumor. Varicose aneur. of left ear. Carcinoma of pa- rotid. Facial neuralgia. do. do. Secondary hem. rem. inf. max. do. do. do. Longworth Prize Thesis. Madelung (cit.). Arch. Klin. Chir., Bd. 17, p. 720 ; l)r. Made- lung. Lancet, Nov. 4, 1871, p. 644. Gaz. Heh., Nov. 10, 1876, p. 709. Arch. Klin. Chir., Bd 17 ; Madelung; Long- worth ; Lancet, 1833-4, vol. i. p. 849. Dr. Madelung. Dr. Madelung; Long- worth (cit.). do. Mid age Secondary hem. removal of dis eased parotid. Removal of tumor of parotid ; hem. Vascular growth of head and face. Prep, to removal of sup. max. for osteo-sarcoma. Hem. cancer, dis- ease. Shot wound inf. maxilla. Shot w'nd malar hone. Shot wound sup. maxilla. Shot wound zygo- matic region. Wound of exter- nal carotid. Removal scirrhus of ear. Enlarged parotid. Shot w'nd cheek. Prep, to removal of osteo-sarcoma of inf. maxilla. Nebvus of right cheek. Parotid tumor (during remov- al). do. Fung, of palate. Fung, of neck and fauces. Few minutes Below digas- tric. =s 2 fi a At di- gastric. Just above origin. 21 days Sept.l4 Sept.l4. Sept.l ,Tune 6. 6th and 7ih. 5 inch above origin. Below digas- tric. THE EXTERNAL CAROTID ARTERY. 113 External Carotid Artery — continued. Dato of oporatioii. Oct. 22, 1872. Jan. 28, 1874. Nov. U, 1853. Nov. 17, 1830. Jnly 5, 1863. July S, lSti3. Sept. 22, 18(32. Sept. 1.5, 1832. June 7,1864. Jan. 19. 1870. la CD P< None fi'om ext. carotid None. None. None. Once ; arti-ry retied. 16,17 days. None. Once. (2) 19-22 Kocovery. Kocovored Kocoveiod. Recovered llecovered Recovered Rocovereil. Kecovei'ed. Recovered Recovered Recovered. Recovered. Recovered. Recovered Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Condition. Cured. Cured. Cured. No relief. No relief. Cured. Cured. Cured. Cured. Cured. Cured. Improved. Cured. Cause of death, dale after op. 12 days. ? 42 hours. Coma. 19th day after ext. 2d day after com. RKMAKKS. Several Hmaller veHselH tied Hame time. Patient wont home 6 days after operation. During removal of lower jaw for malii,'nant disease, the external carotid and internal jugular vein were secured. About 10 days later severe hemorrhages occurred from ulceration of in- ternal cnrntid, and it, with the common, was liiiatured. The lingual was also tied. Ligature enma*4ewith internal caroti'1. Two ligatures ; artery divided between them. Internal carotid tied same time. Patient died of extension of di — ease. Artery tied on account of hom. Patient was rated as " totally disabled." (In all probability he was disabled from wound, not from the ligature of the ex- ternal carotid.; — Author. (Note. — Dr. Madelung gives one other case by an unknown sur- geon, in which the common and external carotids were tied. As Dupuytren thinks this case is uncertain, I have left it out. — Author.) Internal and external in com- mon loop. The common carotid tied same time. Hem. 17th day. Common tied ; death. 2 ligatures to artery. Hem. after operation from the occipitalis. SUMMARY OF THE SURGICAL HISTORY COMMON, EXTERNAL, AND INTERNAL CAROTID ARTERIES. SECTION 1. Sex. — The statistics contain 789 cases of ligature of the Common Carotid. The sex is stated in 712. Males, 538. Females, 174:. Three males being exposed to accidents, or suffering from lesions, necessitating this operation, to one of the opposite sex. Age. — The age is stated in 5-1:2 of 789 instances as follows: — Under 1 year old 16 22 57 151 106 89 55 40 6 542 The oldest patient was 75 years; the youngest 6 months of age. In the period of life from 20 to 40, about one-half of the opera- tions were performed. Side. — Of the 651 cases noted as to this feature — 361 were tied upon the I'iglit side. 290 " " left " The difference in favor of the right side may be explained, inas- much as the carotid of this side is often involved in lesions of the right subclavian, which last vessel is often the seat of injuries result- (115) From 1 to 10 years 10 " 20 " 20 " 30 " 30 " 40 " 40 " 50 " 50 " 60 " 60 " 70 " 70 " 80 " 116 PRIZE ESSAY. iug from the use by preference of the right arm, also in aneurism of the innominate. The jj.omi of deligation was at the omo-hyoid muscle (its anterior belly) in the vast majority of cases, although not stated. It is given as — Above the omo-hyoid in 56 At " '• " 4 Below " " " 25 The remainder not definitely stated. In one case (No. 789) the left carotid was reached from behind the sterno mastoid. Hemorrhage is given as occurring after the operation of deligation in 144 instances. Unfortunately meagreness of detail in the pub- lished reports renders it impossible for me to specify whether the bleeding was at the seat of ligature or beyond it, in every instance. In 27 instances it is specified that no hemorrhage occurred after the ligature was applied. If there was or was not hemorrhage after deligation, in the 618 remaining cases, it is not specified. If we admit that in these 618 cases no bleeding took place^ we would have only 18 per cent, of hemorrhage after ligature of the common carotid. But when we are reminded that many cases proved fatal so soon after the operation that secondary hemorrhage had not the time to occur (the dates of death, in which 288 of the 323 fatal cases are given, show that y'j died on the day of operation, \ within the third day after, and | within the first week), and that the hemorrhage did occur in a fair number of cases in which it is not reported, it is evident that this accident after ligature of the common carotid will occur in a much larger proportion of cases than 18 per cent. Hemorrhage was immediate after deligation in ... 3 cases. " occurred in from 1 to 5 days " . . . 19 " 5 " 10 " " ... 13 " " 10 " 20 " "... 23 " " 20 " 40 " " . . . 10 " " 40 " 80 " " . . . 7 " " 80 " 100 " " . . . 1 " " " on 120th day "... 1 " " " " 11th, 14th, and 61st day in . .1 " " " with no date given in . . . . 66 " 144 S U 11 a T C A L HISTORY OF C A R O 'I' [ D A R T K \i T K S . 117 LIGATURE CAME AWAY. The date of separation of the ligature is obtained in 287 instances as follows : — On tlie 41h flay 1 n the 23(1 day 9 5 " 1 24 " 4 7 " 4 25 " 5 8 " 5 26 " 3 9 " ^ 27 " 5 10 " 10 28 " 7 11 " 12 29 " 3 12 " 19 30 " 3 13 " 25 31 •' I 14 " 34 33 " 2 15 " 16 34 " 1 16 " 12 35 " 2 17 " 14 36 " 1 18 " 17 39 " 1 19 " 7 45 " . . 1 20 " 9 48 " 1 21 " 23 60 " 1 22 " . . 11 96 " 1 One is given as not having come away at the end of three months. In some few of the later dated cases the "Lister carbolized catgut" was used as the ligature, and these never came away, being cut off, left in the wound, and absorbed. In two cases the artery was "con- stricted," once with Dr. Speir's constrictor and once with a thread.^ EESULT. Of 789 cases in which the common carotid was tied for all causes, 323, or 41 per cent., died. Condition after Recovery. — 466 patients recovered, as reported by the operator, and the condition is stated in 371 of these, as follows : — As cured . 253 '• improved 49 " temporarily benefited . 14 " not cured 33 Cured of original disease, but with paralysis of opposite side as a result of the ligature 2 As not benefited 19 " worse than ever ......... 1 Of the reported cases 68 per cent, were cured, in the true sense of that term, and it is probable that this percentage will represent the -correct proportion of ewes in the entire number of recoveries. ' In Porcher's case (see Appendix to Common Carotid Statistics), catgut ligature w as used, which became loose, and ihe artery was not occluded. 118 PRIZE ESSAY. DATE OP DEATH AFTER DELIGATION. Of 323 fatal cases in the total of Immediately ("upon the table") in On the same day of the operation in From 1 to 3 days after in " 3 " 7 " u 14 u 21 " " 21 " 28 " " 28 " 35 " " 35 " 42 " « 42 " 50 " " 50 " 60 " " 60 " 70 " " 80 " 90 " "100 " 120 " "120 " 150 " " Several weeks after • No date given . 789 ', death occurred — 4 instances. 18 43 64 57 40 12 10 9 9 3 9 4 1 2 2 . 1 35 323 Or 7f per cent, died within 24 hours, 23 per cent, within 3 days, 45 per cent, within 1 week, 64 per cent, within 14 days, and 75 per cent, within 21 days of the date of operation of deligation. CAUSE OF DEATH. In only 200 of the 323 fatal cases is the cause of death stated. From cerebral complications alone, following the ligature, there died .... . . 54 cases. From cerebral complications, with ' ' exhaustion" . 4 " . U (f hemorrhage . 6 " u a injury or shock 1 " 11 <( pyaemia 1 " •■<( << original disease 2 " (< « gastric fever 1 " From meningitis . 1 " " " with hemorrhage . 1 " Thus of 200 fatal cases, 27 per cent, died from interference with the functions of the cerebrum alone, by cutting off the supply of blood through one or both common carotids. While in 15 additional instances (7|- per cent.) interference with the cerebral circulation was an important factor of death. SURGICAL HISTORY OF CAROTID ARTERIES. 119 This point demands the most earnest consideration. I do not think it has heretofore been empliufiized sufficiently. I hold it to be an overwhelming argument against tying the common carotid^ wlien tlic lesion is in the external curotid ox its branches, at a point suffi.- ciently removed from tiie bifurcation of the p-imiiive carotid to allow the ligature on the cardiac side. This will be more fully shown in the comparison of the sum- maries of the external, with that of the common carotid. HEMORRHAGE AS A CAUSE OF DEATH. Of 200 cases in which the cause of a fatal result is stated — Died from hemorrhage alone from the carotid 44 " " with " exhaustioa" 12 " . " " shock 2 " " " inflammation of thoracic viscera . . 2 " " " erysipelas 1 " " " spasm of the glottis .... 1 " " " diarrhoea ...... 1 " " " asphyxia 3 66 This gives a ratio of mortality of 22 per cent, from hemorrhage alone after the ligature, while in 33 per cent. (22 additional cases) bleeding was a factor of death, following the deligation. (Indirect and fatal hemorrhage came from the vertebral in several instances, from the jugular vein iu 2, and from the lungs in one instance.) " EXHAUSTION" AS A CAUSE OF DEATH. From exhaustion alone there died 23 cases. This vague term may imply cerebral interference, hemorrhage, suppuration, etc., and is necessarily useless, unless the particular cause of the exhaustion is also given. (See Hemorrhage and Cere- bral Complications for other cases in which " Exhaustion" is noted as a factor of death.) The original disease for the cure of which the operation was per- formed was the cause of death in ..... 7 cases. Intercurrent disease was the cause of death in . . . 3 " PyiBmia alone " " " ... 12 " " with pleuritis " " . . . 1 " 120 PRIZE ESSAY. Inflammation of thoracic viscera alone was the cause of death in 4 capes. Tetanus alone " " " 1 Glossitis alone " " " 1 OEdema of the glottis alone " " " 2 Diarrhoea .alone " " " 1 Asphyxia alone " " " 3 Inflammation of aneurismal sac " " " 2 CASES IN WHICH SYMPTOMS OF CEREBRAL DISTURBANCE WERE NOTED AS A RESULT OF TYING THE COMMON CAROTID ARTERY (FATAL AND NON-FATAL cases). Hemiplegia opposite to side of ligature is noted in . . . 43 cases. " " " " with aphasia . . 1 " " on same side as ligature is noted in . . . 1 " Paralysis of face on same side, and of body on side opposite to that of ligature, is noted in . . . * . 2 " Paralysis of opposite arm (none of leg) in . . . . 5 " Imbecility as result of ligature in 1 " Delirium, convulsions, headache, and other light symptoms of cerebral disturbance (not counting difficult deglutition which was in most cases a mechanical hindrance) occurred in 18 other instances. If then it is accepted that paralysis followed ligature of the com- mon carotid in only 52 of the 789 given cases, we have not quite 7 per cent, in which we may expect this danger to ensue. It is very important in this connection to remember that 7| per cent, of the 323 fatal cases terminated within a few minutes to 24 hours after the deligation ; 23 per cent, inside of three days ; 45 per cent, within one week ; 6i per cent within 14 days ; 75 per cent, within 21 days, and that after either of these dates paralysis might have resulted. Secondly, remember that paralysis very likely did occur in some of the cases to which no history proper is attached. Thirdly, that paralytic symptoms would probably not be recog- nized in patients operated upon in conditions of extreme prostration, when both motion and intelligence were suspended. Taking these points into consideration, I am of the opinion that a larger percentage than that given in the foregoing summary should be present in the mind of the operator who has the choice between deligation of the common and external carotids. In exceptional cases paralysis will remain after recovery from the operation as a permanent malady. In 42 cases of the entire statistics it is noted that there were "no symptoms of cerebral disturbance." SURGICAL HISTORY OF CAROTID AIITKIMIOS. 121 REPORT OF AUTOPSY. Post-mortem examinations were reported in only 85 of tlie »323 fatal instances. In 18 of these the brain was not examined. The points of interest in connection witli this organ are as follows : Brain, softened in 16 " inflained 8 " anaemia of . 1 " extravasation of, blood . 1 " abscess of 7 " " and softening 1 34 Showing that in 67 examinations of the brain 51 per cent, de- veloped important changes to have occurred. SYNOPSIS OF LIGATURE OF THE COMMON" CAROTID WITH ONE OR MORE OF ITS BRANCHES, OR OF THE INTERNAL JUGULAR VEIN. Common, external, and internal carotids tied in the same patient. Died 2 ; cured 2 = 4 cases. Common, external, and internal carotids, and the internal jugular. Died 1 ; re- covered 1 = 2 cases. Common and internal carotids in same case. Died 4 ; cured 2 = 6 cases. Common and external carotids in same case. Died 5 ; recovered 4; cured 3 = 9 cases. Common carotid and internal jugular vein. Died 7 ; recovered 2 ; cured, 1 = 9 cases. Common carotid and external and internal carotid and sup. thyroid. Died 1 = 1 case. Common carotid and sup. thyroid. Died 1 ; cured 1 = cases 2. " " " lingual. Died 1 = 1 case. " " temporal, auric, and occipital. Recovered 1 = 1 case. " " and internal maxillary. Recovered 1 ; cured 1 = 2 cases. " " " temporal. Recovered 1 = 1 case. RE-LIGATURE OF THE COMMON CAROTID. The same vessel was twice tied in 8 instances. Of these 6 died. The same vessel was tied a third time to arrest hemorrhage. It proved fatal. 122 PRIZE ESSAY. SYJfOPSis OF Cases in which both Common Carotids were tied. CAUSE. Age, y'rs. Interval. Result. Cause of death. Operator. Malig. dis. antmm. 53 2| mos. Died 38th day. Exhaustion. Wood. 11 i( 45 1 " Rec. (Not imp'd.) Parker. (t (( 38 28 days. " improved. " (( a 21 8 mos. 11 u V. Mott. " nose. ? 10 " " cured. " " orbit. ? 5 » Died 4th day. (t " parotid. ? 15 min. " 48 hours. Coma. (( Fungus hferaat. 15 3 weeks. Recovered. Blackman. Aueur. anast. H 4 mos. i( Gundelach and Moeller. " occiput. 53 H " " cured. Kuhl. U (( 20 1 year. " " Pirogoflf. Pulsat. tumor, orbit. 20 28 days. K ) Innominate aneurism, in which — (1) The carotid alone was tied. (2) The carotid and subclavian were tied, (1) Total 17. Died 12, or 71 per cent. Of 5 recoveries^ 2 are cured^ and 2 improved, and 1 not cured. [Nos. 80, 176, 203, 210, 283, 300, 302, 315, 417, 434, 435, 542, 543, 544, 550, 715, 771.] ' See notice of death of Bai'well's case, which termiuated fatally since writing above. 130 PRIZE ESSAY. * (2) Total 14. Died 10. Of the 4 recoveries^ 2 are most probably cured ; 1 improved ; and 1 improved temporarily, dying in five months. [Nos. 191, 196, 200, 208, 2b9, 379, 591, 752, 753, 778, 781, 782, 783, 784.] (The aorta was involved also in some of these.) (c) Subclavian aneurism. Total 5. Eecovered 1 (No. 638). In 2 cases the innominate was also tied (Nos. 638, 473). In 2 others the subclavian was also tied (Nos. 129, 358). The case (No. 638) died, about ten years later, of the old aneurism, which had disappeared and then reformed from the recurrent collateral circulation. {d) Aneurism of the carotid. Total 5. Died 2. [Nos. 77, 328, 736, 737, 757.] Cured 2 ; improved 1. (e) In 1 other case the subclavian was also tied. Eecovery (No. 336), ''not curcdP Summnry of Cases of Ligature of the Common Carotid. On account of aneurisms. Total 166 cases. Died 76, or 46 per cent. Cured ^Q^ of 90 recoveries. On cardiac side of aneurism. Total 106. Died 37, or 35 per cent. Recovered 69 ; cured 60. On distal side of aneurism.^ Total 60. Dzec? 39, or Qb percent. Recovered 21 ; cured only 6. LIGATURE OF THE COMMON CAROTID ARTERY FOR THE RELIEF OF KEttVOUS DISORDERS. Subdivided into — 1. Epilepsy. 2. Neuralgia. 3. Hemiplegia. 4. Headache. 1. Epilepsy. Total 20, Died 1. Mortality 5 per cent. Of the 19 recoveries^ 3 are reported cured ; 10 improved (three of these only temporarily); and 3 not benefited. 2. Neuralgia (of Head or Face). Total 14. Died 1. Of the 13 recoveries^ 6 were cured, 4 temporarily improved, 1 not benefited. ' I have included here the five cases in which the vertebral was the seat of the aneurism. SURGICAL HISTORY OF CAROTID ARTEIUKS. 131 3. Hemiplegia. Total 4, All rooovorod ; throe of those arc improved ; 1 not hencJUed. 4. Headache 2. Both recovered. Improved I. No bonofit 1. Summary of Ligatures for Nervous Disorders. Total 40. Died 2. Mortality 5 per cent. Of 38 recoveries, 9 were cured; 18 were henefUc'l ; no benefit in G; condition not given in rest. (The fact that so few of these patients died from an operation of such magnitude is probably due in great measure to the healthy condition of the artery at the seat of ligature, and also to the fact that these patients had not been exhausted by hemorrhage.) SECTION 3. SUMMARY OF THE SURGICAL HISTORY OF THE INTERNAL AND EXTERNAL CAROTID ARTERIES. (a) I have found only 18 cases of ligature of the internal carotid in which definite results are given. From these, nothing reliable as to the practicability of this ope- ration can be deduced, since in only one^ instance was this vessel alone the subject of deligation. In this case (No. 9) the operation was successful. The common and internal carotids were tied in 6 cases; 3 recovered and were cured ; 3 died. The external and internal carotids were tied in 3 cases. All re- covered ; 1 was cured. The common, internal and external carotids were tied in 6 cases; 3 recovered ; 2 of these were cured; 3 died. The internal jugular YG\n and the internal carotid wqvq iieiWn 1 case. Recovered, The common, internal Q.n^ external carotids and the internal jugular vein were tied in 1 case. Recovered. Summary. Total 18. Died 6, or 33 per cent. Of the 12 re- coveries, 8 were cured ; 1 not cured; rest noted as recovered. The cause of the operation was — ■ Hemorrhage in 14 cases, of which 5 died. Erectile tumor 1 case, 1 " Aneurism 1 " 16 6 Not given in 2. ' Since writing this a second case has been reported of ligature of this vessel alooe. Recovered ; cured. See foot-note under Statistics of Internal Carotid. 132 PRIZE ESSAY. The cause of death as given is — Pyaemia in 1 case. Exhaustion and heraorrhage in 1 case. " " shock in 1 case. Hemorrhage alone in 1 case. Coma alone in 1 case. (The operation will be considered in the closing summary.) (h) Summary of the ligatures of the external carotid. The statistics give 91 instances in which the external carotid artery has been ligatured. Of these 14 died, or 15 per cent.; but in 10 of these fatal cases the common carotid was also tied, leaving only 4 deaths out of 81 cases in which the ligature of the external was not complicated with that of the common carotid. If however we exclude all complications, and select only those cases in which the external carotid alone was tied, we will have a better idea of the result of this operation. Of these the statistics contain 67 cases,^ with three deaths. Rate of mortality 4| per cent. These three fatal cases were gunshot wounds in military practice^ ac- companied hy prostration and extensive injury. One died on the table from loss of blood before the operation ; the cause of death is not given in the other two. Of 64 recoveries, 31 are reported cured ; 12 as not cured; and 1 as improved. Remainder not noted as to condition. Hemorrhage after ligature in these 67 cases occurred in 5, none of luhich proved futal. It was from the seat of lesion beyond the ligature in 4 ; the location not noted in 1 case. Of these 67 cases the sex is given in 47, of which 34 were males; 13 females. l}\iQ side of body \s given in 49 instances.^ Upon the right side in 31; the left in 18. Age — Between 1 and 10 years of age 1 case, 4 cases. 10 ' ' 20 20 ' ' 30 30 ' ' 40 u 40 < ' 50 50 ' ' 60 60 ' ' 70 1 On account of the peculiarly abnormal arrangement of the bloodvessels I have omitted Dr. Peugnet's case from this summary. 2 The artery was tied on both sides in the same patient in 6 instances, all of whom recovered. SURGICAL HISTORY OF CAROTID ARTERIES. 133 The ligatures came away as follows (being tlio only cases noted as to this feature in the entire 91 histories). 5th day . 1 17tli clay . . 1 7 " . 1 18 '• . . 4 8 " . 4 19 " . . 1 10 " . 2 20 " . . 1 12 . 2 21 " . . 1 13 . I 22 " . . 1 14 " . 1 — 15 '' . 4 Total . 26 16 " . 4 • In the 67 cases of ligature of the external carotid alone, the causes of operation were, as far as given, as follows : — On account of tumors of the i^cLTO^-id gland (before, during, or after removal of). Non-malignant 17 ; all recovered. Cured 15 ; not cured 1 ; noted as recovered 1. Malignant 3 ; all recovered. Not cured 2 ; cured 1 = 20 cases. For affections termed malignant (other than those of parotid). Fungus of palate ; recovered 1. Fungus of neck and fauces ; recovered 1. Sar- coma of tongue and face ; recovered, not cured, 1. (Jarcinoma ;' I'ecovered, cured, 4 ; recovered, not cured, 2 ; noted as recovered 3 = 12 cases. [If to these 12 cases are added the 3 other " malignant" cases of the parotid, we have 15 instances in which this artery was tied to relieve or cure so-called malignant growths, with 5 cures and no deaths.] Gunshot wounds of lower jaw 3; recovered 2; died 1. Gunshot wounds of malar region and sup. max. 3 ; recovered 2 ; died 1. Gunshot wounds of orbit 1 ; died 1 = 7 cases. For wound of external carotid " " facial artery Hemorrhage, removal of tongue " abscess of submax. region . " polypus of nose . . . " remov. pulsating tumor temp. " " tumor pharynx Aneurism in the parotid Varicose aneurism of ear Vascular growth (nsevi, etc.) of cheek . " " " head and face " growth^ back of head " growth^ cheek, lip, and nose Removal of sup. maxilla osteo-sarcoma . 2 Re ^covered, cured 2 " (( li It a 11 11 11 11 II II II fi " improved. " " not cured. " no better. " cured. 11 ' In three of these both carotids were tied. 2 Both carotids tied. 134 PRIZE ESSAY. Facial neural^'ia Cause unknown' 1 Recovered, no improvement. 1 1 " cured. 1 " cured. 1 HEMOREHAGE. Of the 91 cases given in the table, hemorrhage is stated to have occurred after ligature of the external carotid either at the seat of ligature or beyond it in 12 instances, or about 13 per cent.^ In 6 of these 12 it was deemed expedient to tie the co^mmon or internal carotids or .both, afterwards. In one case the external carotid was re-ligatured successfully. The remaining cases were treated by cold, astringents, or compress. [On a previous page it is stated that hemorrhage occurred in only 5 out of 67 cases in which the external carotid alone was tied.] COMPARATIVE SUMMARY AND CONCLUSIONS. The rate of mortality after ligature of the common carotid artery, as given heretofore, is 41 per cent. After ligature of the external carotid the death-rate is 4| per cent. There can be but one conclusion to this comparison. The common carotid shoidd never he tied for a lesion of the external carotid^ or its branches^ when there is room enough hetween the lesion and the bifurca- tion of the primitive carotid to permit the ligature of the external. I am led to this conclusion not only by the comparison of the analysis of 7b9 cases of ligature of the common trunk, with the 91 instances in which the external carotid was tied, but also from the analysis of 121 dissections of these vessels, made to determine the relations of these arteries and their branches to each other. It would be a waste of time to cite the eminent authorities in surgery who advise the ligature of the co7nmon trunk instead of the external. The teaching and practice is almost universal. It is as wrong as it is general. It is as false as it is dangerous. It is 41 per centum of deaths in the one, to 4| per centum in the other. • Double ligature. 2 Dr. Peuguet's case is not included on account of the abnormal arrangement of tbe Vessels. SURGICAL HISTORY OF CAROTID ARTKRIES. 135 Tliis "History" carries its own proof of the generality of tliis practice. I have selected out of the statistics all the instances in which the common carotid was tied when the external carotid might have been secured between its origin from the common trunk and the lesion. I have omitted all cases in which raeagreness of detail leaves the least doLibt as to the seat of lesion, and furthermore, all the cases of malignant growths of the antrum, where, owing to the exaggerated nutrition of the diseased structures, the anastomosis had probably been very freely establislied between the ophthalmic nnd the internal maxillary, facial, and temporal arteries, so that ligature of the com- mon trunk became the surest method of "starving out" the disease. With these numerous omissions there were 251 out of a total of 789, and of these 108 died (or 43 per cent.). [They are Nos. 2, 3, 4, 5, 6, 11, 13, 15, 16, 17, 19, 21, 24, 25, 27, 28, 29, 30, 40, 45, 46, 48, 49, 50, 61, 62, 63, 67, 68, 76, 78, 82, 86, 87, 88, 91, 92, 94, 99, 102, 103, 116, 123, 124, 132, 133, 134, 137, 143, 147, 148, 151, 158, 159, 168, 169, 170, 172, 173, 177, 179, 184, 186, 187, 189, 190, 192, 197, 198, 202, 209, 211, 213, 217, 223, 227, 232, 234, 237, 239, 240, 241, 246, 249, 250, 252, 254, 257, 261, 263, 265, 266, 267, 268, 269, 270, 271, 276, 279, 298, 299, 306, 313, 319, 320, 321, 338, 341, 349, 351, 352, 353, 359, 360, 361, 362, 363, 365, 368, 370, 371, 374, 378, 380, 381, 382, 384, 386, 388, 391, 393, 397, 398, 401, 403, 406, 408, 415, 416, 421, 424, 425, 428, 429, 436, 442, 443, 448, 449, 450, 451, 457, 458, 464, 468, 469, 471, 472, 486, 496, 498, 510, 512, 513, 519, 520, 525, 528, 533, 534, 535, 541, 546, 551, 653, 554, 572, 573, 575, 579, 580, 585, 586, 587, 594, 599, 603, 606, 609, 611, 615, 616, 628, 630, 634, 636, 640, 643, 644, 645, 646, 649, 656, 657, 658, 663, 664, 667, 668, 671, 672, 673, 674, 677, 678, 679, 680, 681, 683, 684, 694, 698, 699, 703, 705, 708, 710, 712, 713, 716, 733, 734, 735, 738, 739, 744, 746, 748, 751, 755, 758, 764, 765, 767, 768, 772, 773, 786, 788, 789, in the statistics.] CONCLUSIONS. 1. In all intra-cranial lesions involving alone the internal carotid or its branches, this vessel should be tied. If this procedure is not successful, then the external carotid &ho\i\A be secured at the crossing of the digastric. If the fascial be given off below this point, it should be secured by a separate ligature. Since one of the dangerous results of ligature of the common caro- 136 PRIZE ESSAY. tidi?, cerebral anaemia, it is evident that this danger will be partially avoided bj leaving the anastomotic channel, between the facial^ in- ternal maxillary, and temporal branches of the external carotid, and the branches of the oj^hthalmic from the internal carotid, uninter- rupted. If this collateral current should, however, prove to be an impediment to a cure, it should be stopped. For lesions of the internal carotid in the neck (excepting aneurism) it should be tied alove and helow the lesion in all cases. The opera- tion on the cardiac side alone, be the common or internal trunk the seat of the ligature, is not justifiable, death having occurred in many instances through the descending current from the circle of Willis. In aneurism of this artery the single ligature on the cardiac side will suffice. 2. When the lesion (excepting aneurism) exists within one-half inch of the bifurcation of the common carotid, involving this vessel, or the external or internal or both, the common trunk must be tied on the cardiac side, and the other two arteries upon the distal side of the lesion. The s^iperior thyroid and any other branches of the external carotid, between the ligature upon this vessel and the bifur- cation, should also be secured. In case of aneurism in either of these points the single ligature on the cardiac side will usually suffice. 3. In erectile or pulsating tumors of the orbit (intra-orbital aneu- rism) ligature of the common carotid is to be advised. The vessel should be secured at the omo-hyoid, a double ligature applied, the artery divided between, and each end twisted ("torsion" of Bryant). If the disease is malignant the entire contents of the orbital cavity should be removed. Since the anastomoses between the terminal branches of the ex- ter7iala,Y\d internal carotids, through the orbit, are more or less exag- gerated in intra-orbital aneurism, and since in the 52 recorded instances of this operation (in non-malignant conditions) the death- rate was only llj per cent., I am of the opinion that the ligature of the common carotid is the surest and safest operation. If, however, the operation of enucleation be determined upon (the eye being already destroyed), it may not be necessary to tie the common carotid. Pressure upon the artery of the affected side will in most cases control the hemorrhage, until the operation is completed, when the compress in the orbit will most probably con- trol the bleeding ; the danger of interfering with the intra-cranial circulation being thus avoided, or deferred until the necessity exists. SURGICAL HISTORY OF CAROTID ARTERIES. 137 4. Wounds of the superior thyroid artery, too near its origin to permit a ligature on the cardiac side of the lesion, require deligation of the common, external^ and internal carotids^ and torsion of the distal end of the wounded vessel. 5. In incised^ punctured, lacerated^ and gunshot wounds of the ex- ternal carotid^ or its branches, where it is deemed inexpedient to secure the vessel at the seat of injury, the external carotid of one or both sides should be secured^ below the origin of the liri,fju(d (the point of election, see Anatomy). If the linrjiial or any other branch is in immediate contact with the ligature, it (or they) should be also secured. The common trunk should never be tied under such circumstances except as a last resort. 6. Hemorrhage of the tonsils and pharynx, if not arrested by liga- ture of the external carotid, as advised, will require either the sepa- rate ligature of the pharyngea ascendens or of the common and inter- nal carotids. 7. It must be assumed that when ligature of the external carotid below the origin of the lingual does not arrest hemorrhage from the pharynx, the bleeding is from the ascending pharyngecd, and that this branch originates from the bifurcation or the internal carotid. (See Surgical Anatomy.) (The history gives one or two deaths from hemorrhage from the tonsils after ligature of the common trunk alone.) 8. Aneurism of the external carotid or its branches (excepting the superior thyroid) demands deligation of the external carotid alone, when a sufficient space exists between the tumor and the bifurca- tion to admit the ligature with safety. 9. Aneurism of the internal carotid should be treated by ligature of this vessel alone, when there is sound artery enough between the tumor and the bifurcation to admit the ligature with safety. 10. Aneurism of the common carotid (if digital compression shall have been abandoned) should be treated by ligature of this vessel as far from the tumor (on its cardiac side) as possible. 11. Ligature of the common carotid for aneurism of the arch of the aorta is of doubtful propriety. In deference to the opinion of the eminent surgeons who advise it, it may be considered as sub judice. From my own researches I could not conscientiously advise or perform the operation. 12. Ligature of the common carotid alone, for the cure of innomi- nate aneurism, is an exceedingly dangerous procedure ; 12 of 17 cases proved fatal from the operation. Only 2 were cured. 138 PRIZE ESSAY. I cannot justify the operation. 13. The common carotid and the s-nhclavian artery were both tied for tlie relief of innominate {comhined with aortic aneurism in some instances) amiirism- in 14 cases. Died 10. This operation is only justifiable when every more conservative method sliall have been exhausted. (See conclusions to History of the Subclavian, where result of different methods is given.) 14. Ligature of the carotid artery alone, or with the innominate^ for aneurism of the snhclavian artery is not a justifiable procedure. Nature left to her own resources is safer than this. Conservative surgery (see History of Subclavian) is superior to both. 15. In case of aneurism of the carotid alone, too near the bifur- cation of the imnorninate, or the arch of the aorta, to permit the ligature being placed on the cardiac side, the deligation of the carotid on the distal side would be advisable, provided the conservative method o^ direct (elastic) pressure tqion the tumor ^ comhined with per- fect quiet and careful dietetic treatment, had been previously and persistently tried and had failed, (An element of danger in interrupted pressure upon an aneurismal tumor of the carotid is, that particles of the newly formed clot may escape into the cranial circulation.) 16. In epilepsy, while the danger of death as a result of the ope- ration is comparatively slight (5 per cent.), the proportion of cures or improved cases is not great enough to commend this procedure to the profession. (Since dilatation of the arterials and capillaries of the medulla oblongata is accepted by Scliroeder van der Kolk, Niemeyer^ and others as the most constant lesion in epilepsy, I would suggest, and would perform if the opportunity presents, deligation of both vertebral arteries. This would arrest the direct and probably irritating flow of blood through this ganglion, leaving the recurrent flow from the carotids (through the posterior communicating arteries) to supply the necessary amount of nutrition to this portion of the encephalon.) 17. In persistent and exhaustive neuralgiao^ the fifth nerve, when all other methods have proved ineffectual, ligature of the common carotid should be practised. The external carotid of one or both sides should first be tied, below the lingual (the point of election). If this fails the common trunk upon the affected side may be secured. The operation is contra-indicated when pressure upon i\\e common carotid of the affected side does not arrest the pain. SURGICAL PIISTORY OF CAROTID ARTKRIES. 139 18. In liemiplegia or li,eadache the ligature of the common carolil is not justi liable. 19. Ligature of both common carotids simultaneously is not justi- fiable. Ligature of both vessels, with an interval of from oue week to one year, is not as dangerous as might be expected, the danger being less as the interval is greater. When the importance of tyiwj the external carotid for all lesions of the regions to which it is distributed is fully apjweciated and prcLctlsed by surgeons, the double ligature of the pri)nitive carotids will probabl/j not appear in the future records of surgery ; while ligature of the com- mon carotid, with its startling mortality of 4:1 i^er cent., will be confined to tJtose emergencies in laliicli it alone is involved. Fig. 1. Aiitoridi- and posterior tomporalin. Aiiricularis. Occipitalis. ~ Phavyngea ascendPns. The relation of the brauches of the external carotid to each other (the average of 121 dissections). (Life size.) Fig. 2. Showing range of origin of the thyroidea, lingualis, and pharyngea ascendens. (Life size.) Fig. 3. Showing range of origin of the occipitalis and naaxillaris externa. (Life size.) Fig. 4. Showing range of ovigiu of auricularis and range of length of the external carotid. (Life size.) Fig. 5. Fig. 6. Fig. 7. The lingual and facial, from a commou trunk. (31 in 121.) (Life size.) The thyroid, lingual, and facial, from a common trunk. (2 in 121.) (Life size.) Showing the dangerous relation of the first five branches of the external carotid to each other. (Life size.) Fig. Middle meningeal. Temporal, Auricular. Ascending pharyngeal. Occipital. Facial. Internal maxillary. ^ Superior thyroid of man witli goitre. An unusual arrangement. (Full size.) FiGi. 9. Relation of the veius to the carotids. (Life size.) SURGICAL ANATOMY AND OPERATIVE SURGERY OF THE INNOMINATE AND SUBCLAVIAN ARTERIES AND THEIR BRANCHES. THE ARCH OF THE AORTA, AND ITS RELA'IIONS TO THE .SUR- GICAL ANATOMY AND OPERATIVE SURGERY OF THE NECK. While that portion of the arteria magna leading directly from the heart is usually described as the arch of the aorta, it is not usual for it to form one continuous and unbroken curve, but to consist of three segments of circles joined together, each differing from the other in the length and intensity of its curvature. THE ASCENDING SEGMENT. This portion commences at the most inferior surface of the semi- lunar valves; in the great majority of subjects opposite to and be- hind the left edge of the sternum^ and about half way between the costo-sternal articulations of the third and fourth ribs, this point (that is the centre of the aortic valves) being usually on a level with the junction of the sixth and seventh dorsal vertebras {at the end of expiration) and about one inch and a half from the internal surface of the sternum. From this point the aorta travels obliquely upward and to the right, a distance varying from two to three inches, and terminates in the transverse segment near the right border of the sternum, and the costo-sternal articulation of the right second rib. If a subject (who has died from other than lesions of the thoracic viscera) be taken, the left ventricle laid open in situ, and a straight probe passed into the aorta and pushed directly in the axis of the ventricle, the end of the instrument will be seen to impinge upon the convex surface of the aorta at the point where the ascending joins with the transverse segment. At this point is situated the bulging known as the sinus magnus, and here is the surface upon (141) 142 PRIZE ESSAY. which the column of blood, driven bj the systole of the ventricle, impinges with the greatest violence, accounting for the clinical fact that atheromatous degenerations and aneurismal dilatations are most frequently seated at the junction of these two segments. It is evi- dent that no exact spot can be selected as in the actual axis of the left ventricle, since this axis is shifting in the rotation of the heart from left to right and from hehind forwards xoith each systole, yet the weak point is near the place represented by the arrow point [a) in Fig. 1. The semilunar valves^ the sinuses of Valsalva^ the coronary arteries^ and the constriction at the bases of the valves are the points of interest in connection witli the first portion of the aortic arch. In a number of measurements of the ascending segment, made after the vessel was fully distended with injection matter, the average cir- cumference around the sinuses of Valsalva was four inches; the constriction just above, three and one-fourth to three and one-half inches; while at a point two inches from the ventricle the circum- ference is greater than that of the sinuses. As to the valves, I found the anterior to be largest, the left pos- terior next, and the right posterior smallest. It is not usual for any branches other than the coronary arteries to be given off from this portion of the aorta. In twenty-five con- secutive examinations as to this feature, there were found no anoma- lous branches, yet, in a capacity where I have examined a great many subjects in connection with demonstrations of the thorax, I have in several instances observed small abnormal branches originating here. Of the coronary arteries^ the right comes from the sinus of the an- terior valve, usually within (^. e. below) the edge of the semilunar fold, and, when the blood is rushing through the aorta, after the systole, the mouth of the artery is occluded by the valve. The left coronary is from the anterior aspect of the left posterior valve, and usually within the sinus. It follows, from the unique situation of tliese two vessels, that they do not pulsate with the heart's systole, and that they are only filled with blood, (1) by gravity, when in the upright position ; (2) by the expansion of the heart muscle in dias- tole ; (b) and principally by the contraction of the elastic aorta. The presence of these arteries accounts for the larger development of the two valves with which they are associated. It can be readily imagined that when the heart is contracting, the blood is squeezed out of both veins and arteries in its walls, and that the last few drops would remain in the sinuses connected with the two coronary INNOMINATE AND SUBCLAVIAN AliTKlifKS, 1J3 arteries. This pressure, iiowever little it may be, would serve to precipitate the closure of these two valves before the otlier (the I'ight posterior), hence their development larger than the one having no coronary 2)7'essure exerted against it. The constriction at the bases of the semilunar valves is caused by the aggregation of white fibrous tissue at this point greatly in ex- cess of the elastic fibres found in all other portions of the aorta. The function of this fibrous band is to prevent dilatation of the aortic orifice and consequent regurgitation of blood after the systole is complete. I have not been able to measure the amount of pres- sure sufficient to rupture the aorta here, as, in the various experi- ments made, tlie valves would either yield or the pressure would be relieved by rupture of the artery beyond this point. THE SECOND SEGMENT. This, the transverse portion of the aorta, varies in length from three to four inches in different subjects, and extends from near the costo-sternal articulation of the right second rib, obliquely to the left and backward, until in the neighborhood of the upper portion of the third dorsal vertebra it turns quite abruptly downward as tlje descending portion. From the convexity of the second segment, a little anterior to its middle line (as looked at from above), arise in quick succession the three great vessels — the innominate^ left carotid^ and subclavian arteries. The arteria innominata, usually the first branch (larger in itself than the combined calibres of the left carotid and sichclavian), comes off' in the majority of subjects itnmediately in front of the trachea, just behind the middle of the sternum, at a level varying from one- half to one and one-half inch below the upper margin of the manu- brium. (It is exceedingly rare for the arch of the aorta to be found above or below the points above indicated.) From this origin the innominata travels obliquely upward, back- ward, and to the right (crossing the trachea from its centre), and bifurcates, near the upper margin of the clavicle, between the sternal and clavicular origins of the sterno-mastoideus into the carotid and stibclavian arteries, the first of these coming from its anterior aspect, the last a direct continuation of the arch of the innominate. (The innominata in rare instances originates to the left of the trachea, more frequently it is given off before it reaches the windpipe.) The following Table (I) gives a synopsis of 28 consecutive measure- 144 PRIZE ESSAY. ments to obtain the average distance of the centre of origin of this artery from the most dependent portion of the semilunar valves {i. e. the commencement of the aorta). TABLE I. Showing' length of aorta from most dependent portion of the semilunar valves to centre of origin of the arteria innominata. (JVIeasurements made along the centre of the arch.) No. Males. 1 3|in iches, 2 3i 3 H 4 H 5 H 6 3 7 H 8 , 3i 9 3i 10 4 11 31 No. Females. 1 H Inches, 2 4 3 3i 4 H 5 3 6 3i T H 8 n 9 H .0 3i STo. Sex not noted. 1 u inches. 2 4 .( 3 3f (( 4 4 (( 5 3| i( 6 3* u 11 3 " Total number 28. Total of measurements, 97.50 inches. Average distance of centre of origin of arteria innominata from most depend- ent portion of semilunar valves = 3.48 + inches. It will be seen, that, while it varies between 3 and 4 inches, the average distance is 3.48-1- inches, this origin being in the majority of cases one inch below the upper margin of the manubrium. In table (II.) is given the result of 37 consecutive measurements of the length of the innominata. The shortest instance is f inch, the longest 2 inches, the average 1.51 -f inch. * TABLE II. Showing the result of 37 measurements of the arteria innominata. No. Males. No. Females. No. Sex not noted. 1 Ix inches. 1 If inches. 1 H inches. 2 li 2 H u 2 3 H 3 2 u 3 If 4 li 4 If (i 4 2 5 H 5 If u 5 1^ 6 U 6 u u 6 1 7 u 7 li u 7 1 8 Ij 8 H u 8 If 9 li 9 i| u 9 1| 10 1 10 2 u 10 u 11 li 11 u u 11 ^4 12 2 12 li u 13 u 13 li u Total No. = 37. Total length = 56.12 4- inches. Average length = 1.51 -f- inches. In 5 of 34 cases this vessel gave origin to abnormal branches. In the three cases where the thyroidea inferior was derived from the arteria innominata, there was no thyroid branch from the axis of this name. INNOMINATE AND RUBCLAVIAX AllTKIUKB. 145 The presence of abnormal branches from the innominate will be again referred to in the "Surgical History" of this vessel.' The left common carotid originates, on an average. 3.02 inches distant from the commencement of the aorta, and, as shown in the following Table III., its centre of origin is .43+ inch from that of the innominate. In 6 of 31 cases I have marked it as com- mon with the innominate. I do not mean that in 1 of 5 cases it will be found to come off from this last vessel, without being in intimate relation with the arch of the aorta, but that in this proportion of cases they are so intimately associated in their origins that, while their outer walls originate from the arch.^ their inner or adjacent walls are fused together, and this septum does not extend to the level of the aortic curve, being removed upward from I to I inch. TABLE III. Showing the distance betweeu the centres of origin of arteria innominata and carotis sinistra. No. Males. No. F emales No. Sex not noted. 1 1 inch. I 1 inch. 1 ^ inch. 2 Common. 2 c. ommon. 2 i " 3 ^ inch. 3 (( 3 Common. 4 3 U 4 4 i inch. 4 ^ inch. 5 2 5 c ommon. 5 2 6 i " 6 3 4 inch. T Common. 7 1 2 u 8 \ inch. 8 2 u 9 2 9 1 2 u 10 3 (( 10 i. 2 u 11 1 " 11 2 a 12 1 U 2 12 1 2 (( 13 1. » 9 13 a Total No. = 31. Total length = 13.37 inches. Average = .43 -|- inch. The left subclavian artery^ the second in size of the three great vessels coming from the arch of the aorta, arises to the left of and (as looked at in situ from the front) somewhat behind the preceding vessel. Its distance from the commencement of the arteria magna and its relation to the carotid will be seen in Table IV. ' See Surgical Anatomy of the right thyroid axis, and Fig. 3, for arrangeiuent of anomalous branches of the iunominate. 10 146 PETZE ESSAY. • TABLE lY. Showing the distance between the centres of origin of the carotis and suhdavia sinistra, and the distance of the latter from the commencement of the aorta. Jfo. Males. 1 i 2 inch, 2 3 4 3 1 2 4 1 5 3 4 6 1 t 3 4 8 1 9 3 4 10 1 11 3 4 12 i 13 1 " No. Females. 1 li inch. 2 1 (( 3 3 4 (( 4 1 (( 5 3 4 u 6 1 u 7 3 4 u 8 1 u 9 1 u 10 f u 11 1 u 12 3 4 (( 13 3 4. (( No. Sex not noted. 1 3 4 inch. 2 u 3 1 i; •4 1 u 5 1 (( 6 f u 7 3 4 (( 8 1 (( 9 3 4 u Total No. = 35. Total length := 27.75 inches. Average = .79-f-, or about four-fifths of one inch. 'I'his gives the distance from the beginning of the aorta to the centre of origin of the suhdavia sinistra as a little less than four and four-fifths inches. The average distance of the centre of origin of the suhclavian being .79 -H inch from the carotid, and 4,72 inches from the com- mencement of the aorta. The descending segment, or the third portion of the arch, begins from I to 1 inch beyond the origin of this last artery, when the aorta turns sharply downward near the upper border of the third dorsal vertebra, and is continuous as the thoracic aorta beyond the body of the fourth dorsal vertebra. The Arch of the Aorta as a Whole. In Fig. 1, I have sketched roughly, yet accurately, the life size and average arrangement of the aortic arch and the great vessels coming from it. It has already been stated in connection with the first portion why the junction of this with the second portion should be the seat of lesions demanding the interference of the surgeon.^ The situation of the innominate just beyond this weak point, and in direct range of the blood pressure that is bearing upon the roof of the arch, will also explain why this vessel is involved in lesions, next in frequency to, and almost always in connection with, the lesions of the ascending-transverse junction. The position of the left carotid brings it next in order, being often involved with the • See Resume of Surgical History. INNOMINATE AND SUBCLAVIAN AUTKRTKS, 147 innominate; while the origin and direction of the left suhclavian ex- plain why it is rarely the seat of aneurisrnal disease. Tn a number of cases in which I measured the angles of incidence and reflection, from the point a, Fig. 1, I found that the line of reflection im- pinged upon the arch of the aorta beyond the mouth of the left suh- clavian. While this law of equality of the angles of incidence and reflection is not practicably applicable to the movements of liquids (nor to the aortic arch, which is an elastic and fluctuating cylinder), yet a glance at the direction of the axis of the left subclavian (at almost a right angle to the axis of the arch), will explain the im- munity of this vessel from lesions resulting from pressure, as com- pared with the vessels heretofore named, and as compared with the descending portion of the arch just beyond, upon which the blood current must impinge with more force. Clinical facts are in accord with this explanation, based upon the anatomical relations. Of less interest to the surgeon, perhaps, is the occasional interference with the circulation in the coronary arteries by adhesions of the semi- lunar valves to the sides of the sinuses of Valsalva in some instances of aortic resfurffitation. The largest portion of the aorta is at the sinus magnus (see Fig. 1), and the diminution in the calibre of the third segment is not in proportion to the combined calibres of the three great trunks given off from the second segment. In 3 of 20 cases examined as to this feature, small abnormal arteries were derived from the anterior aspect of the transverse segment. THE SURGICAL ANATOMY OF THE SUBCLAVIAN ARTERIES. In order to arrive at results as positive as possible, I selected 13 male and 13 female subjects just as they were brought to the dis- secting rooms, and the fifty-two dissections given hereafter are from these subjects. . The right subclavian.^ larger, shorter, and more superficial at its origin than the left, is derived from the innominate behind the origin of the carotid, about the level of the upper margin of the clavicle (more frequently above than below this line), behind the interval between the two tendons of the sierno-mastoideus. It is the direct continuation backward, upward, and outward of the arch of the in- nominate, and is continuous with the axillary artery, at the lower edge of the first rib. The left subclavian, derived 1.23 inch beyond, to the left of, and more deeply situated in the thorax than, the innominate, travels 148 PRIZE ESSAY, almost vertically upwards, until it mounts above the upper surface of the first rib, when it curves very abruptly outward and down- ward, passing behind the scalenus anticus and thence to the lower edge of the first rib. The comparative length of the two sub- clavians is shown in the — TABLE Of measurements of twenty-six subjects, as to the length of the subclavia dextra and sinistra. (The length of the innominata appended.) FEMALES. MALES. No. Left Sub. Righ t Sub. Innom. No. Left Sub. Righ t Sub. Innom. 1 ^ inches. 3 nches. H inch. 14 31 inches. 2|i nches. 11 incl 2 H 2| u If (( 15 3| u 2| u If " 3 3| 3f u 2 16 31 a 92 u 1 X u ••2 4 3f 96 (( If 17 31 u 2| (( 1 1 'i ^2 5 4f 3 a If 18 4 u 21 u ^2 6 3f 3 u H 19 4^ (( 3| u ^2 n 3* 2| u H 20 31 u 21 u U " 8 2| 2* u H 21 2| u 2* li n " 9 3| 2-1 u n 22 31 u 2f u U " 10 4f 3| u 2 23 4| (( 2f ii li - 11 4| 4 li H 24 4f it 3| a 1 " 12 4 02 a H 25 4| kl 3 a 2 " 13 H op. u H 26 H u n u IJL u ^2 As shown b}' these figures the average length of the 7^iyht sub- clavian is 2.83 inches; of the left 3.74 inches. The average length of the innominate in these 26 instances is the same as that given in the table of 37 cases on a previous page, ^. e. 1.51+ inch.^ The length of the right subclavian plus the innominate is .60 inch more than the left, since this last vessel is given off well to the left of the median line. Each subclavian may be said to have three surgical divisions. The first division of the right artery is from its origin from the innoini- nate to the inner border of the scalenus anticus. That of the left artery, from its origin at the arch of the aorta to the inner border of the left scalenus anticus. The second and third portions of both vessels are identical as re- gards direction and relation, being different in the origins of their respective branches. The second surgical division of each is entirely to the inner side of the inner border of the first rib. The third 2^or- Hon, resting chiefly on the upper surface of the first rib, is in many ' The innominate is somewhat lonster in females than in males. INNOMINATE AND SUBCLAVIAN ARTEHIES. 149 instances partly within tlic inner margin of tlio rib, owing to tlie obliquity of the scalenus anticus as it passes downward and out- ward to be attached to the inner margin of this bone. The follow- ing tables give tlie average lengths of the various divisions of these two arteries. TABLE. Suhdavia dcxtra — Length of its three surgical divisions. MALES. FEMALES. No. 1st Div. 2d Div. 3d Div. No. l8t Div. 2d Div. 3d Div. 1 1 inch. 1 2 inch. U inch. 1 li inch. ^ inch. 1 lllcll 2 H a f (( H u 2 1 f U u 3 H u 2 u 1 u 3 ll 3 4 li a 4 f a 1. 2 (( 1 a 4 u 1. 2 U u 5 1 u 5 8 a i 14 5 1 i. 2 1 u 6 1 u 1 2 u 1 u 6 8 2 3 4 u 1 H u 1 (( H u Y li 1 2 1 a 8 n u i u 1 u 8 li 5 8 u i( 9 1 u 1 u H u 9 li 2 li u 10 1 u 1 2 u I u 10 1t\ 1 2 IxV" 11 H u 1 2 u I u 11 1 1 li (( 12 H u 1 2 u 7 8 u 12 li 1 2 li u 13 1 u i 2 (( 1 u 13 Tot'l, U 1 2 - li (( Total ,14.6 t.37 13. 25 15.31 7.62 15.5 6 Suhdavia sinistra MALES. TABLE. —Length of its three surgical divisions. FEMALES. Total, 27.50 7.25 13.37 No. 1st Div. 2d Div. 3d Div. No. Is t Div. 2d Div. 3d Div. 1 2f inches. 2 inch. u inch. 1 2 inches. 1 9 inch. 1 incll 2 n u 1 u li u 2 If u 1 u u u 3 3 u 2 (( 1 u 3 2f u f u u u 4 ll u 1 2 u 1 u 4 2| (( JL 2 u li u 5 If u f u 1 2 u 5 If (i i u 1 u 6 2 (( 1 2 u 3 4 (( 6 li u 1 2 u 4 (( 7 n l( 1 u U u 7 If u 3 4 (( 1 u 8 H u 2 u 1 u 8 If u 5 8 u li u 9 2i u 1 2 u li u 9 2i u i u If u 10 1| (( i a 1 8 u 10 2 u 8 u li u 11 2i (( i 2 u 1 u 11 1| (( 3 4 u li lli 12 2 u 1 2 u f a 12 2i u i u n u 13 H u 5 8 u 1 (( 13 2i u i u n li Total, 26.12 7.50 15.62 150 PRIZE ESSAY. While the first portion of the right subclavian varied in 26 cases from f to 1|- inch in length, the average length was 1.154- inch (being. a little greater in females than in males). The ^rs^ .portion of the left artery varied from IJ to 8 inches, the average length being 2.06+ inches (or in males 2.11 inches, in females 2.01). The second portion of the right subclavian averaged .58 — inch; the same division of the left subclavian being .56+ inch in length. (This slight diiierence may possibly be accounted for in the develop- ment of the right muscle more than the left.) The tJiird portion o^ i\\Q right artery is a little less; the same divi- sion of the left subclavian a little more than 1.11 inch in length. SURGICAL BRANCHES OF THE SUBCLAVIAN ARTERIES. Nine important arteries arise directly or indirectly from the sub- clavian arteries; the vertebral^ ijiternal mammary, transversalis colli, suprascapular, inferior thyroid, cervicalis ascendens, superior iritercostal, profunda cervicis, Sixid posterior scapular. Upon the right side the vertebral was derived from the 1st divi- sion of the subclavian in every one of 26 consecutive cases. It arises from the superior and posterior aspect of the main trunk, and' passes upward to the vertebral foramen in the 6th cervical vertebra (often to the 5th, less often to the 4th). As the relation of this vessel to the bifurcation of the innominate is considered a point of no little importance in the ligature of the first division of the sub- clavian, I have given in Fig. 2 the range of origin of the vertebral. Radiating from Y, the lines show that, while this branch may range from f of an inch to 1 J inch distant from the innominate, 4 per cent, will be found between J and f of an inch, 87 per cent, between | and 1 inch, and 8 per cent, between 1 and 1| inch from the origin of the subclavian. I give below the exact parts of' an inch in which this vessel was in 20 cases removed from the bifurcation: — 10 males, f, |, J, f, 1, 1, |, |, |, |; average .75 inch. 10 females, f, |, |, f, |, |, |, 1^, 1|, |; average .81 inch. Average distance of all cases .78 inch. Since the average length of the 1st division on this side is 1.15 + inch, the origin of the vertebral will be .37 inch (or about ^ of an inch) to the inner side of the inner border of the scalenus anticus. It should be looked for and secured without exception in ligature of this division of the main trunk. (See Surgical History.) INNOMINATE AND SUBCLAVIAN AKTKUIKS. 151 The left vertebral w^s derived from the 1st division of the sub- clavian in 24 of the 26 cases, and in 23 of these 24 it was given off (as represented in Fig. 1) just where the subchivian bends so ab- ruptly to the left in arching over the first rib. It is thus almost a direct continuation of the axis of the main trunk, a fact which accounts, as I believe, for the larger size of the left vertebral as compared with the right, which is derived from the main trunk at a rifjht angle to the blood current, and is thus unfavorably situated. In 22 cases examined the left was larger in 12, they were equal in diameter in 5, the right the larger in 5 instances.' (See Fig. 2.) 8 per cent, originate from the aortic arch close to the subclavian, 12 per cent, within If inch from the aorta, and 80 per cent, between If and 2| inches. In 2 of 26 cases it was from the aorta, by the side of the main trunk. Ligature of the vertebral should be prac- tised in ligature of the subclavian within the scalenus, though it is a more formidable operation on account of the dangerous prox- imity of the thoracic duct. It can be most safely reached in the 5th intervertebral space. The internal mammary artery is the most regular in its origin of all the branches given off from the subclavian. Arising from the anterior and inferior aspect of this vessel just to the inner side of the inner border of the scalenus, it passes downward (a little inward at first) behind the costal cartilages, parallel with the edge of the sternum and from \ to f of an inch distant from it. In 47 of 52 cases this branch was from the first portion of the main trunk, in 3 of 52 from the thyroid axis (twice on the right side), and in the re- maining 2 of 52 cases it was from the second division of the sub- clavian^ just behind the scalenus near its inner border. (This last anomalous origin was on both sides of the same subject.) The phrenic nerve is intimately associated with the origin of the internal mammary. In 21 cases examined as to this feature, the nerve crossed in front of the artery in 17, and behind it in 4 instances. In Fig. 2 the lines radiating from I M indicate the range of origin of this branch, being in 90 per cent, of cases within \ of an inch of the inner edge of the scalenus on the right side and not varying more than J inch to the inner border of this muscle on both sides in 52 cases (a regularity of arrangement exceedingly rare in human anatomy). As shown in Fig. 1, its origin is in the majority of cases intimately associated with that of the thyroid axis. • Hyitl says all of the branches of the right subclavian are larger than those of the left. With the above exception this is correct. 152 PRIZE ESSAY. The thyroid axis is derived from the anterior superior aspect of the subclavian just at the inner margin of the anterior scalenus. In most subjects this axis is about J inch long, and gives origin to the inferior thyroid, transversalis colli, and suprascapular. This arrangement existed in 34 of 52 cases, the variations from this order being about equal upon the two sides. In 2 of 52 examinations the axis was wanting (both on the right side), the branches being derived from different points. The inferior thyroid artery, the largest branch of the axis, passes upward (inclining at first a little inward), until it arrives at a point between the third and seventh (incomplete) rings of the trachea, where it turns abruptly inward, going behind the comrtion carotid and jugular, in front of the vertebral, and is distributed chiefiy to the lower portion of the thyroid body. In 45 of 52 cases it came directly from the axis. Of the 7 ano- malies of origin 6 were on the right side. It was a branch of the innominate, as shown in Fig. 3, in 3 instances, two from its posterior, and one from its anterior aspect. In 4 other cases it came directly from the subclavian. In Fig. 4 is given the range of origin of the inferior thyroid. Upon the right side it is within J inch of the scalenus in 89 per cent., and from the upper portion of the innomi- riate in 11 per cent, of cases. (In ligature of the first portion of the subclavian on the right side, this vessel should be tied, and also on the left side when the ligature is near the scalenus.^) On the left side the lines radiating from T, Fig. 4, show the marked regularity of origin of this branch. The cervicalis ascendens, a small branch of little surgical import- ance, is very irregular in its origin, as shown by the following synopsis : — It originated from the inferior thyroid in 38 " " transversalis colli in ..... 8 " " thyroid axis (direct) in . , . . .4 " " superior intercostal in . . . . .1 " " subclavian (direct) in 1 Cases 52 The most usual origin is therefore from the inferior thyroid, and just where this vessel turns abruptly toward the median line. The transversalis colli passes outward in front of the scalenus ' It is best to tie the vessel on the left side, well away from the main trunk, on ac- count of the thoracic duct. INNOMINATE AND SUBCLAVIAN AllTKIURS. 153 muscle and the phrenic nerve^^ underneath the oino-liyoid, and between the cords of the brachial plexus, and is distributed to the iTapezius muscle, sending a branch in the direction of the posterior border of the scapula, which anastomoses with the posterior scapular artery; and when tliis last vessel is not present, this descending branch is continued along the border of the scapula to anastomose with the sub- scapular branch of the axillary. The iransversalis colli was missing in 3 of 26 cases on the rirjJU side^ being derived from the axis in 22 of 26, and from the subclavian in common with the suprascapular in 1 of 26 instances. On the left side it was from the a.xis in 24 of 26, by a common trunk with the suprascapular alone in 1, and was absent in 1 of 26 cases. This branch will be found wanting in the pro- portion of 4 out of 52 cases, or 1 in 13. The cervicalis ascendens was a branch of this artery in 8 of 52 cases. In every one of the 48 instances in which it was present, it was within a radius of J inch extending inward from the inner border of the scalenus anticus muscle. The suprascapular artery, intimately associated with the preceding, travels suddenly downward and outward from its origin near the inner edge of the scalenus a7ilicus, passes between the subclavian artery and vein, in front of the phrenic nerve, crosses in front of the third division of the main trunk, and goes to the suprascapular fossa under the protection of the clavicle, anastomosing with the dorsalis scapulse of the sub scapular is. It gives off a branch (fre- quently wounded in operations in this vicinity) which passes be- hind the sterno-mastoideus and along the upper border of the manu- brium. (It is not usually mentioned.) The suprascapular was from the axis in . . . . . 46 cases. From the subclavian in common with the transversalis colli in . 2 " From the internal mammary in .,,... . 1 " And was absent in 3 " of 52. (Twice absent on the right side.)^ The superior intercostal artery on the right side was present invari- ably. It was derived from the 1st division in only 6 instances; in 20 of 26 from the 2d division. On the left side it was from the 1st division in 19 of 26 (as against 6 of 26 on the right side) cases, and from the second division in 7 of 26 cases. Its usual origin on both sides is from ih.Q posterior in- ' I have seen the nerve in front of the artery but once. 2 Anomalies occur much more frequently in the right subclavian. 154 PRIZE ESSAY. ferior aspect of the suhclav{a7i, and close to the inner edge of the scalenus anticus. (The range of origin is shown in Fig. 4.) The profunda cervicis was a branch of the superior intercostal in 35 of 52 cases; i.n 15 it came direct from the subclavian, and in 2 of 52 it was a branch of the thyroid axis. This vessel is usually yqyj small. I am led to believe that its importance as a collateral chan- nel after ligature of the common carotid or first portion of the sub- clavian has been overrated. On the right side, when this branch was not common with the superior intercostal^ its origin from the main trunk was to the outer side of the intercostal branch. (See Fig. 3.) On the left side, under above circumstances, this branch was nearer the inner edge of the scalenus anticus. l^he posterior scajjular^ one of the most important branches of the subclavian in a surgical view, since it must be in dangerous prox- imity to a ligature applied (as is most often done) in the 8d surgi- cal division (not given in many standard text-books, except as an occasional branch of this artery'), was present in 36 of 52 dissections, or 69 per cent. It was present in 19 of 26 on the right side ; and in 17 of 26 on the left. In 23 of the 36 cases in which it was present, it was derived from the 3d division; in the remaining 13, from the 2d division close to its outer limit. In Fig. 4 the range of varia- tion is shown in the lines radiating from P S. On the right side 74 per cent, came from the subclavian within ^ of an inch to the outer and inner side of the external border of the scalenus muscle; 26 per cent, external to this. On the left side 82 per cent, were within | of an inch to the outer and inner side of the line dividing the middle and external thirds of the main trunk ; 18 per cent, were to the outer side of this. The tendency of this important branch is to originate near the scalenus, i. e. within one-fourth of an inch of its outer edge. When tiiis ves- sel is present the transversalis colli is small, and when absent the de- scending branch of the transversalis takes its distribution. Passing outward behind the most superficial cords of the brachial plexus, it turns sharply downward, along the posterior border of the scapula, to anastomose with the subscapular branch of the axillary. Small anomalous branches were observed in only 9 instances — 1 from the 2d division of the left side, 4 from the 3d portion, and 2 from the 1st portion. On the right side only 2 small branches were observed, both from 1 Wilson, Gray, Morton, Monro, Winslow, Cloquet, Paxtou, Richardson, Leidy. INNOMINATE AND SUBCLAVIAN ARTERIES. 155 tbe neighborhood of the internal mammary. (One of tliese was the comes nervi phrenici, the other n j)ericardiac branch.) None of these had any surgical significance, being so small that they would not, if present, contraindicate the application of the ligature. OPERATIVE SURGERY. From the foregoing dissections I would advise the following methods of procedure in ligature of the great vessels at the base of the neck. Ligation of the Innominate. From the centre of the interclavicular notch, make an incision about three inches long along the clavicle. A second incision, commencing at the inner border of the sterno-mastoideus about two inches above the clavicle, is made to unite with the first incision at the middle of the interclavicular notch. Dissect the flap upwards, until the sterno-mastoid muscle is exposed, which should be divided over the sternum and clavicle upon a grooved director carefully in-- troduced. Superficial to the muscle some small veins will be found, and underneath its clavicular portion is the junction of the subcla- vian and jugular, in dangerous proximity. (It is best to leave some of the outer fibres of this muscle attached to prevent its retraction after the operation.) The anterior jugular veins will be seen imme- diately beneath this muscle, and should be tied and divided. Dis- secting carefully, with the handle of the scalpel, the connective and areolar tissue in which these veins are imbedded, the origins of the sterno-hyoid and sterno-thyroid muscles will be reached, and, when these are divided carefully upon the director, the arteria innominata will be seen pulsating just behind the sterno- clavicular articulation. Being exposed with the scalpel handle, or any dissector not likely to wound the vessel, the aneurism needle should be passed from right to left behind the artery, care being taken to avoid wounding the right vena innominata and the pneumogastric nerve, or punctur- ing the pleura, which the artery rests upan and is partly imbedded in, and (if the ligature is applied low down upon the vessel) the left innominate vein which crosses in front. When the aorta is situ- ated low in the thorax, it may be necessary to remove the sternal end of the clavicle and a segment of the sternum, as was done by Cooper, of San Francisco, in two instances. (See History.) From the remarkable results after torsion of large vessels (Bryant's 156 PRIZE ESSAY. Surgery), and in consideration of the frightful mortality which has heretofore accompanied this operation, I would advise that the in- norninate, carotid, and subclavian be sionultaneously ligatured near the junction of these three trunks, divided between the ligatures, and each well hoisted. Torsion of the innominate would increase the area of resistance to the heart's action, would cause apposition and adhesion of the walls of the artery close to the aorta, and avoid the great risk of the ligature cutting through, as a result of the constant pulsation and pressure brought against it. Torsion of the subclavian would occlude the vertebral, internal mammary, and the thyroid axis, ■which would obviate the necessity of their being tied (which should always be done when torsion is not practised), since a study of the causes of death in the ligature of these large vessels has shown that these branches are among the most important factors of death when left open.^ Torsion of the carotid is not so essential, but should be performed. Ligature of the Right Subclavian in its 1st Surgical Division, or of the Right Common Carotid at the Root of the Neck. Operation the same as for the Innom^inate. The subclavian vein will be found from J to f of an inch below and in front of the artery. The internal jugular vein crosses the artery in front of the thyroid axis at the inner border of the scalenus. Between this and the common carotid is the vertebral vein, and the pneitmo gastric nerve in front, while its recurrent branch is looped underneath and passes up behind the vessel. The internal jugular vein should be drawn to the side most convenient, the outer side being safest on account of the right lymphatic duct being at its junction with the subclavian vein. The phrenic nerve should not be forgotten, as it crosses the subclavian in front of the last portion of the 1st division, being in front of the scalenus anticus muscle and behind the iransversalis colli and suprascapular arteries. (In one instance I noticed a communicating filament from the brachial plexus join the phrenic in front of the artery.) The vertebral, internal mammary, and thyroid axis or its branches, may be secured by the same operation as for the ligature of the 1st surgical division on the right side. The vertebral will be found J of an inch to the inner side of the inner border of the scalenus anticus muscle in the vast majority of ' See Resume of Surgical History, INNOMINATE AND SUBCLAVIAN AkTKIilKS. 157 cases. It is the only vessel coming fronn t})e posterior inferior aspect of the main trunk in its 1st surgical division (excepting the superior intercostal occasionally seen on the right side, oftener on the left, but in all cases much smaller than tlio vertebrals). The thyroid axis and its branches are in contact with the inner border of the salenus anticus. The internal mammary will be found just beneath and opposite to the axis. It can be secured in either of tlie 5 upper intercostal spaces by making an oblique incision, the centre of which will be between ^ and f of an inch distant from the margin of the sternum. Care should be taken not to wound the pleura in passing the aneu- rism needle around the vessel. Ligature of the Suhclavian Arteries in their 2d and 3d Surgical Divisions. The scalenus a7iticus muscle on both sides of the neck is the guide in these operations, and it can be found as follows: From the mid- dle of the interclavicular notch, measure alorig the clavicle to the acromion process. One-fourth of this distance from the median line will be opposite the centre of the scalenus anticus. Drawing the skin well down upon the clavicle, make an incision through it upon this bone, the incision extending one inch toward the median line, and two inches toward the acromion process, from the middle of the scalenus. Make a second incision at right angles to this, about IJ inch in length in the axis of the scalenus, terminating in the first incision at the point indicated above as the centre of this muscle. The outer fibres of the clavicular origin of the mastoid muscle are then divided upon a carefully inserted director (the large suhclavian vein is almost in contact with this muscle here). The internal jugular vein seen in the anterior portion of the wound will be care- fully drawn to the inner side, the operator keeping well above the junction of this with the subclavian and thus avoiding the lymphatic duct. A prominent plexus or group of veins, viz., the external jugular, transversalis colli, and suprascapidar, will be seen traversing the wound coming from their respective origins, toward the subclavian near the jugidar. These should be secured and divided. Dissecting carefully, the su^orascapidar and transversalis colli arteries will be observed running in general in the direction of the first incision. The posterior belly of the omo-hyoid may be found in the upper margin of the wound, crossing the scalenus at about a right angle. 158 PRIZE ESSAY. The transversaJis colli and the suprascajndar may be secured or held to one side, the finger passed along the scalenus until the rib is felt, when the artery will be found just behind the muscle. If it shall have been determined to tie the artery in its second portion, the scalenus anticus muscle will be cut upon a director, the operator being careful to avoid the phrenic nerve which crosses the muscle in front, coming from above downwards and inwards. (It is between the layers of the sheath of this muscle.) The ligature is next passed around the artery from before backwards, care being taken not to wound the pleura. In all cases of ligature in this division, the posterior scapular (if present and within one inch of the ligature), the branches of the thyroid axis, the vertebral, and the superior intercostal should be tied, in order to remove the too constant cause of secon- dary hemorrhage which the resume of the surgical history of this operation will show to be one of the prime factors of death. If the third division of the artery is to be secured, the part of the above operation relating to the division of the scalenus and ligature of the branches will be omitted. m-\Q posterior scajmlar artery alone will require the ligature, with the common trunk. In this last operation the nearest cord of the brachial plexus must be carefully excluded, posteriorly to the artery; the subclavian vein in front and below. Depression of the shoulder and clavicle and extension of the head backward and slightly to the opposite side will facilitate ligature in the first and third divisions and in ligature of the iniiominctta. Ligature of the 2d and '6d divisions of the left suhclavian is accom- plished by the same procedure as for the opposite side. The operation for ligature of the 1st portion of the left subclavian is more difficult and dangerous, since the vessel is more deeply situated and has the thoracic duct in dangerous proximity. Find the anterior scalenus muscle by the rule heretofore given. One inch external to this point, commence an incision (the integu- ment having been pulled down as before) which is carried along the clavicle to the sterno-clavicular articulation. Divide the sterno- mastoid, and after this the sterno-hyoid and ster no -thyroid muscles. The subclavian artery will be seen ascending almost vertically just behind the sterno-clavicular junction. The internal jugular vein will be drawn outward, and, passing the finger along the inner border of the scalenus muscle, the artery will be felt to pulsate. The thoracic duct usually is to the right of and a little behind the artery oppo- site the upper border of the sternum. On a level with the insertion TNNOM[NATE AND SUBCLAVIAN AP.TRRTES. 159 of tlie scalenus it arches to the left, crosses in front of tlie suhclavian, in front of the scalenus^ behind the internal jugular, and curves downward to empty into the subclavian at its junction with the jugular to form the left innominate vein. On account of the intimate relations of the thoracic diict to the left subclavian artery as this ves- sel goes behind the scalenus^ the ligature should not be attempted ch)se to this muscle, nor should the dissection be carried fully to the scalenus. The artery should be tied as low down as possible, the duct being less likely to be injured here, since in passing behind the aorta it is deeper than the artery. It will be found behind and to the right, the pneumogastric in front and to the right, the left vena innominaia crossing in front, while the pleura is directly be- hind. (I consider this operation the most formidable in the domain of operative surgery. It has been undertaken only once (by J. K. Eodgers, of New York^); the case terminated fatally.) Ligature of the thyroid axis and internal mammxiry artery near their points of origin on the left side is not justifiable, on account of the proximity of the thoracic duct, which by virtue of its difficult recognition renders operative procedures in this quarter exceed- ingly dangerous. In very rare instances an anomalous origin of tbe right subclavian artery, with absence of the innominate, may occur. As seen in Fig. 5, the order of origin is : first, right and left carotid (usually from a common origin), then the left subclavian, and lastly, and from the third portion of the aorta, the right sub- clavian. From this origin the subclavian passes behind the oeso- phagus and trachea to the right, and assumes its normal position behind the scalenus anticus. In still rarer instances the aorta is reversed, and with it the order of origin of its branches. ' See History of Ligature of Subclavian in 1st Surgical Division. SURGICAL HISTORY INNOMINATE AND SUBCLAYIAN ARTERIES. 11 162 PEIZE ESSAY. Ligature of the No. Name of operator. Source of information. Cause of operation. S.-I o <« El **-> d ^ .2 ^ -2 s ;3 ft .a O Ti Mott, Valentine, New York, May 11, 1818. New York Med. Re- pository, vol. i. 1818 ; Norri^ Contributions to Practical Surgery ; Guy's Hosp. Reports, vol. xvii., Poland. Aneurism of sub- clavian, from fall on shoulder. 79 days. i inch below bifurca- tion. Feb. 21. 1S18. ■ INNOMINATE AND SUBCLAVIAN ARTERIES. Arteria Innominata. 163 No. Pate of operation. o 3 as-. 11 P. Fl o O , , k a bo 'S-. M C5 03 t3 Recovery. (.'oiidition. Cause of death, (late after op. May 11, 1818. 23,24,2.'-. and 2G days. 26tli day. Hem. REMARKS. Feb. 21, 1618, patient (a sailor) slipped and fell on deck, Htrik- ing on right arm, shoulder, and back of head. Not Hpecially in- convenienced by fall. Two days later BwoUing and intense pain in shoulder. Entered New York Hospital March 1, 1818. Turnor thought to be indolent, and treated by blisters. May 3, felt something give way in tumor, which increased in sine and be- gan to pulsate, both above and below the clavicle. Symptoms increasing to May 11th, opera- tion for ligature was made. Tumor had an elevation of 2 inches, and its diameter was from 4 to .0 inches in every di- rection- It was intended to tie the subclavian in its firni ■por- tion, but being diseased, the innominate was tied on€-half an iQcii below the bifurcation. The ligature was of silk, and the ve— sel was notcntirely occluded by tli« operator at first until some minutes had elapsed in order to arrest the column of blood gra- dually. Operation lasted one hour; tumor reduced one-third in size; wound ■ closed by su- tures ; arm wrapped in cotton ; l«ft carolid became very much dilated and patient was bled l^i ounces ; 2d day doing well ; .Sd, ditto; 4th, suppuration began and continued to separation of ISgature on Hth day; on 16th and after 2M day, patient was so far improved that he walked alone about the hospital wards ; 28d, -ciemoiThage from wound, and on 24th, 2,5t}i, and 26th con- tinued, and he died on 26th day after operation from loss of I)lood. Autopsy; Innominate not closed on central side of lig- ature ; on distal side the ulcer- ative process had carried away the remainder of the vessel and portions of the carotid and sub- clavian, which last two vessels opened into wound ; the sub- clavian was pervious through- out ; the carotid was not quite occluded ; the clavicle was worn through about its middle ; there was no inflammation of the pleura, nor of the serous coat of the aorta. (In the ope- ration a vessel was divided about a half-inch Irom the in- nominate on the lower border of the subclavian. It is probable that this was either the comes ne.rvi plirenici (see anatomical notes accompanying this essay) or the sternal braiich from the supra-scapular, which traverses this region. .\n abnormal branch, was found to he derived from the arteria innominata near the ligature. I found this anom- alous vessel iu 5 of .34 consecu- tive examinations. — Author.) 164 PRIZE ESSAY. Ligature of the No. Name of opei'atoi". Source of information. Graefe, Berlin, 1822. Norman, Batli, 1824. Arendt, St. Petersbui'gh, 1827. Hall, Baltimore, 1830. Graefe & Walthers' Journal, Bd. iv. ; Guy's Hosp. Reports (cit.); Noi'ris Contrib. (cit.). Fergusson's Surgery, p. 429, Phila., 184.5; Norris Contrib.; Guy's Hosp. Reports (cit.). Chelius, System of Surgery ; Norris Con- trib.; Guy's Hosp. Reports (cit.). Norris Contrib.; Dupuytren, Lemons orales ; Guy's Hosp. Reports (cit.). Norris (cit.); Balti- more Med. & Surg. Journ., vol i.; Guy's Hosp. Reports (cit.). Cause of operation. «.- o <« fl (._. ' rt 6 o o o !» S. 5 ■-C s a !? (xi 5.3 fi '^ Aneurism of sub- clavian. About 1 year. ? do. Aneurism of sub- clavian, caused by blow on shoulder. Spontaneous an- eurism of sub- clavian. About 1 year. About 9 mos. 1 inch from aorta. ^ inch below bifurca- tion. INNOMI?fATE ANT) SUBCLAVIAN ARTERIES, 165 Arteria Innominata — continued. No. Date of operation. March 15, 1822. Dec. 24, 1827. Sept. 7, 1830. O ^ 'U After few weeks, and on 6G and 67 days. 60 t'rs. Oc- curred, During opera- tion, and im- medi- ately after. Uocovory. CauHO of death, dnto after op. 67th day. Hem. hours. Hem. Sth day. Exhaus- tion. (Pyaemia?) Hemorrhage. REMARKS. On March l.'i, 1822, the oporati-n was made, intending to tie ilio subclavian in linjirxt ptirliuii, hut as in the caee of Mott, this vessi^l was so involved in the disease that the innominate was tied one inch from the aortic arch. '1 he ant-urism had exist' d about one yi^ar. Imuiediately after operation, tumor diniii- ished in size, and patient did well for first few weeks. Hem- orrhage occurred later and was repeated until death ensued on the 67th dny. Autopsy showed that the centrril, ea oz. He continued to grow. weaker on 25th, 26th, 27th, and 2sth of Dec. days afteroperatiou, pus in wound, which increased in quantity. Patient died 8 days after operation, from exhaus- tion. Autopsy: Cellular tissue in region of wound infiltrated with pus. Innominate closed, ligature not being separated. Circumscribed pneumonia of right long. (Pysemia. ?) No details of tnis case. .oth day. Exhaus- Operation Sept. 7, 18^0 ; innomi- tion from hemor-! nate diseased and dilated ; after rhage, venesection ligature hem. from wound con- (possibly pyajmia), trolled by compression with and pericarditis. sponges ; 1st and 2d day doing well ; was bled l.i ounces ; 3d day, patient walked a good deal, and went intotheyard ; 1th diiy, sudden change for worse, and died oth day after the operation. Autopsy: Pericarditis: aorta enlarged ; innominate, carotid, subclavian, and aorta athero- matous ; large clot in sac ; an- eurism needle had partially- transfixed artery, accounting for hemorrhage. 166 PRIZE ESSAY. Ligature of the No. Name of operator. Source of information. Bland, 1832. Lancet, vol. i. p. 97, et seq.; Guy's Hosp. Keports (cit.). Norris Contrib.; Lancet, vol. ii. p. 44.'5 ; Guy's Hosp. ileports (cit.). Cause of operation. O tfl u u D Spontaneous an- 2 years eurism of sub- clavian, of about 2 years' dura- tion. Subclavian aneu- rism, fall on right arm ; frac- ture of left clav- icle. Some months. INNOMINATE AND SUBCLAVIAN AKTEKIES. Arteria Innominala — continued. 107 Date of operatiou. 9 oC a o a W ? O o March 26, 1832. Oc- curred. May, SI, 1837. 20 and 22 days. Recovery. Condition. Cause of death, date after op. 18th day. Hern.; ex- hauation. 22d day. Hemor phage ; exhaustion. REMARKS. AnouriHm had cxiRtcd for abont 2 yearn. Openttion, Marcli 26, 18:i2. Soon after operation, ve- nesection 18 ounceM ; 2d day, venoHection 10 ounces ; Hd day, patioiit easy, vencKOctlon \H ounccK, and purgatives, and on same day, venesection again 11 ouuces ; 4th day, venesection .3 ounces ; .0th day, doing well, venesection 2^ ounces, and agaiu 2 ounces ; Hth cay, vene- section 8 ounces ; 7th, 9 ounces ; 8th, 12 ounces; 9th and 10th, doinf,' well, and bled .') ounces ; 1.1th, 12th, and 1.3th, doing well ; 14th, bled 3 ounces ; l.Oth, some fever, and bled 14 ounces, re- lieved; 16th, not so well ; 17th day, hemorrhage from wound about .5 ounces, and in evening of the same day, venesection 6 ounces, and again of 14ounce»< ; 18th day,hem jrrhage repeated- ly, and death. Autopsy : No injury to neighboring parts by operation ; central eud of in- nominate closed ; carotid closed completely; snhclnviaTt open. (The patient was bled a total of about 83^ lbs. and lost about 1 lb. by accidental hemorrhage.) 4 months before operation, pa- tient fell on left shoulder, breaking clavicle. 15 months before operatiou he had fallen heavily upon right arm and el- bow. Tumor not observed until a few weeks before op., which occurred May 31, 1S37. While clearing the innominate, the thyroidea ima, or some anom- alous branch was found, as in the case of Mott. In Lizar's operation it was divided. Few hours after operation sense of suffocation and piiin in chest ; 2d day, better and easy ; 3d, in- ability to pass water, catheter ; 4th day, pulsation returned in tumor; 5th, 6th, 7th, and 8th, progressed favorablv; 9th, 10th, 11th, doing well: 12th, 13th, 14th, not so well, vomited ''Si'J- ioMs - looking " fluid; 16th, wound discharging pus ; 17th, ligature loose; did well until 20th day, when there was slight hemorrhage from wound ; vene- section -0 ounces, digitalis, hy- oscyamus ; 22d day, death from hemorrhage. Autopsy : hemor- rhage into pleura ; lung soften- ed : central end of innominate not entirely closed ; the sub- clavian was pervious, and the hemorrhage was supposed to be from this and the vertebral. 168 PEIZE ESSAY. Ligature of the No. Name of operator. Source of information. PATIENT. Cause of operation. .:=: to PL, -3 pE Gore, Bath. Erichsen ; Guy's Hosp. Reports (cit.). 12 Cooper, E. S , 1869, San Fran- cisco. do. 1860. Pirogoff. Hutin (Oran). Smyth, A. W., New Orleans, 1864. Mott, A. B., New YorIs;,1868. Guy's Hosp. Reports (cit.). Allgemein ; Krieg's Chir., 1864, p. 4.'59 ; Guy's Hosp. Reports (cit.). Guy's Hosp. Reports (cit.). New Orleans Med. Press, May, 1866 ; Guy's Hosp. Reports. Note to author. Spontaneous suh- clavian aneu- rism. Aneurism of ca- rotid, subclavi- an, and innomi- nate. Aneurism of ca- rotid or subcla- vian, or both. Aneurism of sub- clavian (trau- matic). Punctured wound of branch of ax- illary, and after ligature of sub. clavian. Subclavian aneu- rism ; violent stretching of arm. Subclavian aneu- rism. About 2 years. Several years. About 3 mos. INNOMINATE AND SUBCLAVIAN A ii'J' K li 1 E S. 109 Arteria Innominata — continued. No. Date of oporatioM. i> Condition. Kecovory. Cause of death, days after op. Sept. 24, 1850. 17 th day. 1859. None. Oc- curred. Not clearly stated. 14th day, 15, le, 51. Recovered. Aug. 13, 1868. Oc- curred. 17th day. Iletnor- rhago. 91h day. Exhau-s- tion (ijrohahly from uvajmia and pya:- mla). .34th day? Hemor- rhage. 48 hours. Pyaemia. 11 hours. Exhaus- tion from hemor- rhage before ope- ration. Cured. ? 23d day. Hemor- rhage iu thorax. Operation, Sept. 24th, 18.00. Did well until 5tli day, wlicn o-y- KipelaM ensued ; lltli day, phle- bitlH ; 17th day, r-lot ol blood eKcaped from wound ilniin(< a fit of coughing, aud wan follow- ed by terrible hemorrhage and deatli in a few minute«. Autop- sy : Cardiac end of artery only partially closed ; both Kubcla- vians closed ; carotid of riprht side open ; purulent iiiflltratiou of tissue.-i in neighborhood of wound. Sternal end of clavicle and up- per portion of sternum removed to facilitate operation ; liitatnie close to aorta ; did well for 5 days, then difflculty of breath- ing, retention of urine ; flth day. death. Autopsy: TuberculoMs of right lung ; pus in right kid- ney. Operation same as above ; pa- tient did well for several weeks, when hemori hage occurred re- peatedly ; patient becomingdis- couraged Iroui his hopeless con- dition, removed the compress, and died on 34th (?) day from hemorrhage. No autopsy. After operation, pain in right side, difficulty of breathing : :id day, paralysis of left side of face; death in 48 hours. Au- topsy: Purulent infiltration of pleura and mediastinum, oede- ma of lungs, and lobular pneu- monia. Patient received a punctured wound in a duel (thoracic branch of axillary was divid- ed) ; subclavian was tied ; 9 days later, to arrest hemor- rhage, the innominate was tied; died in 11 hours. Autopsy: Hera, from thoracic branch of axillary. Aneurism resulted from violent stretchiug of the arm ; A months later, innominate and carotid were tied simultaneously; did well until 14th day, when hem- orrhage (16 ounces) occurred, which was controlled by com- press ; loth and 16th days, con- tinued slight hemorrhage ; 17th day, wound was filled witk S7nnll shot; 51st day, terrible hemorrhage ; .'J4th day, verte bral tied : .^oth day, shot re- moved from wound ; patient continued to do well, and re- covered. (Note. — After finish- ing this essay, I learn from the New Orleans Med. and Surg. Journal for Ju'y, 1S7-5, p. 27, that this patient died ten years later from hemorrhnge from the original sac. Dr. Stone reports case.) The carotid was tied same time : sac was found to have burst into pleural cavity. 170 PKIZE ESSAY. Ligature of the No. Name of operator. Source of information. PATIENT. Cause of operation. o O Jj "S CI ft o .2 'SI ■S3 !>. 1:1 6 ^ bo CO bo <1 te 16 Bickersteth, E. B., 1SG8. Lancet, Dec. 1872. M. 40 .... Subclavian aneu- 6 w'ks. rism(traumatic); (strain). Ligature of the Subclavian Artery No. Name of operator. Source of information. PATIENT. Cause of operation. l| Ph "3 13 -•1 IS •« bo 01 bo 6 CO ft " 1 CoUes. Arendt, 1826. Mott, v., 1831. Bayer, 1829. Hayden, G. T., 1835. O'Reilly, 1836. Partridge, 1841. Listen, 1830. Rodgera, 1845. Edinburgh Med. & Surg. Journ., vol. xi.; Norris Contrib., Phila., 1873; Arch. Kliu. Chir., Bd. x. Arch. Klin. Chir., Bd. X. Am. Jr. Med. Sci., vol. xii.; Norris (cit.). Guy's Hosp. Reports, vol. XV. Arch. Klin. Chir., Bd. X. Norris Coutrib.; Am. Jr. Med. Sci., 1838. Norris ; Guy's Hosp. Reports, vol xv. Arch. Klin. Chir., Bd. X. New York Med. Jr., March, 1846; Guy's Hosp. Reports (cit.). M. 33 R. Traumatic aneur- ism of subclavi- an. 2 mos. 1st divi- sion. do. do. do. do. do. do. do. do. 9. S F. M. P. M. M. M. M. 21 21 57 39 38 32 42 E. R. E. R. R. L. Subclavian aneu- rism. Subclav. axillary aneurism. Subclavian aneu- rism. do. do. do. do. 1 or 2 years. About 10 w'ks. 11 mos. 5 mos. 7 w'ks. 4 w'ks. 4 6 6 7 8 9 INNOMINATE AND SUBCLAVIAN ARTERIES. 17] Arteria Innominata — continued. No. Date of oporatiou. Hemorrli'ge occurred after op. en. Ball entered thorax and wound- ed lung ; gangrene had resulted before the ligature was applied. Autopsy: Jlultiple abscesses in both lungs ; clot in subclavian. Patient had a fungous growth in left axilla ; attempt to remove it ; hemorrhage so profuse, it was thought to be an aneur- ism ; ligature behind scalenus ; death. Ball entered at insertion of del- toid, and lodged between cla- vicle aud first rib ; patient did not rally ; ball cut out at ope- ration. Aneurism caused by strain of arm in catching from a fall : on. account of nearness of tumor, the outer fibres of the anterior scalenus were divided, and the ligature placed in the 2d divi- sion. On the day of operation, venesec- tion 10 oz. ; 2d day, vomited greenish fluid; ordered 2 grs. of calomel every 2 hours ; died comatose. Autopsy: Serous ef- fusion beneath arachnoid: brain slightly softened : purulent in- filtration in region of wound. 176 PRIZE ESSAY. Ligature of the Subclavian Artery in its Second No. Name of operator. Source of information. PATIENT. Cause of operation. o g 6 S § ft "" 9 c.o 'a 'Si PL. -3 ■a o \^ .2S P.S 6 bo -■ t) t. o :^ « Feb. 8 1841. Nov. 5, 1862. Nov. 14, 1866. March 29, 1871. 44, 46, 47, 68 days. Condition, Recovery. Recovered. Cured. Recovered. Cause of death, date after op. 4tli (or nth?) day. A grocer in jmrHvil of a ciiHto- llcmorrliage. riier wlio liiu] pa-Kfid ii coutiier- feit note ir trade with }iim,waK Htiililied from Miinii tlirougb ri^'lit scaiuihi; Iioiiiorrlia«e iiii- iiiodialc and frij-'litfiil; for next few (lays, do.; on 121 h diiy, Hoiix tied the axillary; 2 days later. heniiirrliHge not beinK control- led, he tied HUliclavian behind scalenuK; hernorrhaj/e agiiiii on 4th diiy; amputation at shoul- dir; death in .i'i lionrH. Dill well until 2lHt day. whfn profuse venouK hemoiiliage of- curred to amount of 1 pint; pressure; 22d day, iineuiin nia .supervenfd; pulse returned in radial artery on 3Hlst day. 6th day. Pneumo-' Diffuse aneurism resultin,' from nia. rupture of circumflex artery iu attempt at reduction of shoul- der; tumor size of man's head; 3d day after operation, partial unconsciousness ; 6th, pneumo- nia and death. 9th day. Pysemia. 4 days after operation, fever and rigors, and on 9th d:iy, death : tlirombus formed on either side of ligature. Autopsy: Adhp- sions between pleura and lung on right side, bloody serous ex- udation in left pleural sac. 43d day after operation, abundle of nerves from brachial plexus sloughed away; 44th, frightful hemorrhage; pressure and per- salt of iron; 46th and 47th. also hemorrhage; 4Sth, gangrene of arm evident ; 5-Sd day, ligature of subscapularis ; 6-'th day, amputation of arm at upper third ; 6Sth day, hem. again : 90th day, removal of humerus at shoulder-joint. 9th day. Bronchitis; There was no pulsation in the pulmonary conges- subclavian when reacheil in the tion. operation. Autopsy: Clavicle partly absorbed; 2d and 3d ribs cut into by al)sorpfion from pressure; thrombi on both sides of ligature; lung inflamed. the outer edge of the Scalenus Anticus and the loiver border of First Bib). 33 Nov. 9, 1809. 1811. 181-') or 1813? 5th day. Exhaust'n. 4th day. Exhaust'n? 6th day. Exhaust'n. Autopsy: Firm thrombus on both sifle.s of ligature; 2 lbs. of clot- ted blood iu sac. 34 3") Delirium and rapid ean^rene of limb followed operation. Au- topsy: No clots had formed whicli occluded the artery ou proximal or distal side of liga- ture. 12 178 PRIZE ESSAY. Ligature of tie Subclavian Artery in its Third Surgical Division (between Name of operntor. Source of information. Cause of operatiun. o ft o .2 t3 3d divi- sion. 1 m'nth. do. 4 moB. do. do. 2 mos. do. do. 3 mos. do. do. 1 m'nth. do. do. do. 5 days. do. do. 3 w'ks. do. 6 w'ks. do. «a 36 Galtie, 1S14. Blizard, T., ISlo. Warren, J. M. 1847. Pirrie, 1838. Skey, F. C, 184'J. Mackenzie, 134.i. Travers, 1823. Bullen, Thos., 1823. Langenbeck, C. J. M., lS2;i Sawinkoff, 1823. Datmold. Wm. New York. Ch-amberlaine, R. Post, 1817. Wisliart, 1823. Norri.t Contrib.; Arch. Klin. Chir. Bd. X. Am. Jr. Med. Sci., January, 1819, p. 13. Am. Jr. Med. Sci., July, 1858, p. 229. Lancet, 1840, p. 376. Arch. Klin. Chir., Bd. X. p. 229. Guy's Hosp. Reports, vol. XV. p. 69. Lond. Med. Repos., 1823, vol. XX. p. 190. Norris Contrib., p. 222. Arch. Klin. Chir., Bd. X. p. 222. Guy's Hosp. Reports (cit.), p. 73. Verbally to author. Abevnethy in Med. Chir. Trans., ISI.% p. 128 et seq. Cooper in Med. Chir. Trans., 1818, p. 18.1. Guy's Hosp. Reports, vol. XV. p. 73. Mid age M. L. Hemorrhage after disarticulation of humerus for shot fracture. Axillary aneu- rism(traumatic). Snbclav. axillary aneurism (strain while drawing a cork). Axillary aneu- rism (strain). Subclav. axillary aneurism. Hem. (thrust of red-hot poker in axilla). Subclav. axillary aneurism. Subclav. axillary aneurism (tar barrel fell on shoulder). Axillary aneu- rism Punctured w'nd axillary artery. Subclav. axillary aneurism. Shot wound of axilla. Axillary aneu- rism (punctured by a cutlass). Subclav. axillary aneurism. do. Oct. 5, 1814. Imme- diate and pre fuse. INNOMINATE AND SUBCLAVIAN ARTEUIES. 179 outer edge of Scalenus Anticus and lower, border of First Bib) — continued. Date of oporaliou. a O o 1-3 cs ce Aug. 1814. Jan. 10, Ihlu. Dec. 24, 1*47. 18.58. ? 1840. Nov. 19, lS4y. April 2.3, 1S23. Feb. 8, 1822. 1822. Jan. 17, 1815. Sep. 8, 1817, Auff. 22, 1823. Oc- curred Oc- curred. 16,17, 26. 75. 2,3. None. 5,6. Recovery. Recovered Recovered, Recovered, Recovered, Recovered. Recovered. Recovered. Recovered Recovered, Recovered Condition. Cause of death, date after op. Relieved. (Small tu- mor per- sisted.) Cured. Cured. Cured. 3d day. Hem. 8th day. Cerebral symptoms (proba- bly pyjBinia). 4th day. Exhausfn. Cured. Cured. Cured. Cured. Cured. Cured. Cured. After rcftoction. iimpiitJition and ligature of axillary ; hem. and ligature of Hiibdavian ; death 3(1 day. Antopxy Hljowed ulcer- ated hole in axillary one inch to central Hide '<( flr«t ligature, accounting for hemorrhage. 2 days after ojieration sujipura- tion of sac eiiHued ; 7tli day, rupture and diHcharge of con- tents of sac. Autopsy: Throtn- burt on Vjoth sides of ligature. Radial pulse returned on 4th day ; aneurism very much re- duced in size, but a small tumor containing fluid persisted for some time after operation. Phlebitis resulted after opera- tion. In passing needle the sac was penetrated ; hemorrha^'e, which did not cease with the ligature, but was controlled by conipi ess. (No anaesthetic.) Radial pulse, which was scarcely perceptible before ligature, wns very dis- tinct after ; 2d day, venesec- tion 12 oz.; Ifith, hem. from wound; 17th, do.; 18th, tumor began to increase in size ; 26th, it was punctured ; day before patienthad coughed upcontents of sac ; 75tli, hem. ; numbness of arm during convalescence. Severe hemorrhage followed wound ; ligature of the axil- lary; new hem. and ligature of subclavian ; right arm remained weak after convalescence. Load of bird shot entered axilla at close range (2 feet); uth day after injury, subclavian tied as it crossed 1st rib (incision be- low clavicle); 2 days after ope- ration, arterial hemorrhatre; pressure;3d, hemorrhage a.L'ain; recovered; fixation of fingers in flexed position as a result of in- jury to nerves by shot. Below clavicle, at first rib. Artery tied behind clavicle ; Ab- ernethy gives it as subclavian, as "shoulder was pushed up." No bad symptoms. Below cla- vicle, at 1st rib. otb day, hfmorrhage (slight) from wound ; tith, do.; 9th, sac bursted, discharging 3 oz. dark coagulated blood ; 12th, do. 4 oz.; \M)x, 14th, loth, febrile paroxysms ; slight numbness in arm and hand during convales- cence. Did well until 10th day, when febrile symptoms ensued ; ab- scess in axilla after convales- cence. 180 PRIZE ESSAY, Ligature of the Subclaman Artery in its Third Surgical Division (between Name of operator. Source of information. PATIENT. Cause of operation. o O X •^ a o o a 'S S 3 o| w a br. 3 ^ 51 Mayo, 1821. Stanley in Med. Cliir Trans., vol. xii. p. 12. M. 38 L. Axillary aneu- rism (rheuma- tism). 3d divi- sion. R', Wells, W., 1828 (Maracaibo) . NorrisContrib.,p.222; Am. Jr. Med. Sci., 1828, p. 28. M. 61 R. Axillary aneu- rism. 7 mos. do. SS Listen, Robert, 1820. NorrisGontrib.,p.222; Edin. Med. & Surg. Jr., vol. xvi. M. 35 L. Subclav. axillary aneurism. 5 mos. 2d or 3d.? M Key, Chas. Aston, 1823. Med. Chir. Trans., vol. xiii. p. 1 et seq. M. 36 R. Axillary aneu- rism (muscular 3 mos. fif) do. 1822. Gibbs, H. L., 1823. NorrisContrib. p. 222. exei'iion). Aneurism, Subclav. axillary aneurism (struck with rope). fifi B. C. Brodie in Med. Chir. Trans., vol. xii. p. 531. M. 35 L. 1 m'nth 3d divi- sion. fi? Brodie, 1831. Guy's Hosp. Reports, vol. XV. p. 69. M. 50 R. Snhclav. a.xillarv 2mo<. do. aneurism. fiS Baroni, 1 823. Mem. Med. Soc. de Bouloifne ; Norris Contiib. M. Wound of axilla. A few days. do. fi9 Arendt, 1826. Thorpe, Robert, 1827. Arch, fiir Klin. Chir., Bd. X. p. 222. Am. Jr. Med. Sci., vol. il. 1828, p. 136 ; MeJ. Chi'-. Rev., 1828; Norris Contrib. M. M. 30 36 R. R. Axillary aneu- rism. do. Im'nth. 14 mos. do. do. 60 61 Wardrop, 1826. Lancet, 1826, vol. xii. p. 471 ; Arch. Klin. Chir., Bd. x. p. 223. F. 45 R. Innominate aneu- rism. 11 mos. do. 69, Cooper, B., 1827. Gibson, W., 1828. Norris Contrib , p. 224; Am. Jr. Med. Sci., 182S. Am. Jr. Med. Sci., vol. ii., 182S, p. 136. M. M. 38 35 R. L. Axillary aneu- rism. Wound of axilla- ry (reduction of shoulder-joint). 3 mos. 2 days. do. do. 63 INNOMINATE AND SUBCLAVIAN ARTKUIES, 181 outer edge of Scalenus Anticus and lower border of First Rib) — continued. No. Dato of operation. Hemor occur after J ^ m '^ Recovery. CiiuHo of death, date after op. 5S March 19, 1S21. Alirin2, 182S. April 3, 1820. Sept.. 19, . 1823. 1822. Jail. 5, 1823, 1831. Jan. 17, 1S23. June 6, 1826. June 21, i827. July, 1S23 1,10,11, 12. Dec. 4, 1827 March 17, 1S2S. Repeat- edly. Recovered. Recovered. Recovered. 12th day. Horn. Cured. Cured. Cured. Cured. Recovered. Cured, Recovered, Temporary relief. th day. Inflamma- tion of siic ; pl«u- ritis ; pericardits. 7th day. Exhaus- tion. (Pysemia.)? 60th day. Exhau; tlou and hem. from sloughing of sac. 6th day. Exhaus- tion ; gangrene (Pysemia?) PulKe returned In 8ac 2d day, and vem^Hcction to 18 oz.; 3d day, vnesction KJoz. and leech- es ; 6th, hern, from wound (over a pint) ; loth, venftsi'ction 16 07,., and calotriel. jalap, and salts, also liemorrhaL'e 1/; pint; 11th day, hem. from wound; 12th, do. and death. Autopsy; Artery divided hy lii^atiire; central end open ; distal clused by clot; slight pleuritis and adhesions; first three ribs partly absorbed Patient thought aneurism -was caused by severe horseback ex- ercise ; arm remained weaker than the other; patient died three year.s later of ulceration of the bladder. (As the scalenus anticus was partially divided, this might be classed with the 2d division group ; practically it is in place here.) Violent hem. from the external jugular occui'red on 5th day: controlled by com- press. No unfavorable symptoms super- vened. (Details not given further.) Preparatory treatment by vene- section and cathartics ; no bad symptoms noted. Suppuration about wound and high febrile symptoms. Autop- sy: Coagala on both proximal and distal side of ligature: pur- ulent infiltration near wound. (In the Gazette Medicale, ]8?5, is a simple not'ce of this case as here given ; I can find no fur- ther account.) Same day of operation, venes-^c- tion 24 ounces ; 2d day. hemor- rhage 30 oz.; 17th day, venesec- tion 12 oz.; 4 months after ope- ration, no pulsation in radial. Symptoms of dyspniBa which had existed previous to operation in a severe form, disappeared after operation ; patient died of the aneurism 2 years later ; cause of dea^h, bronchitis, anasarca, diarrhoea, and aueurism. Au- topsy: Subclavian oeclud^'d : aorta and great vessels athero- matous ; large aneurism of in- nominate extending into neck. This operation is stated to have lasted only l-i minutes : rei'eat- ed hemorrhage followed. 4th and -ith day arm mmh swol- len ; gangrene ensued ; deliri- um. Autopsy : Extensive in- flammation of axilla ; cardiac end of artery was not filled with clot. 182 PRIZE ESSAY. Ligature of the Subclavian Artery in its Third Surgical Division (between Name of operator. Source of informatiou. PATIENT. > 5 3 64 Textor, 1828. 65 i De Haen, 1828. 66 Baker, 1828. 67 Balardini, 1828. Porter, 1829. Crossing, 1830. Bland, 1830. Delpech, 1830. Buclianau, M., 1830. ? Mott, v., 1830. Roux, Pli. J., 1830. Mayo, 1831. Brodie, 1823. Fergusson, Wm., 1831. Porter, 1831. Blasius. Buenger, 1S32. Lallemand, F., 1833. Arch. Klin. Chir. Bd. X. p. 223. Dr. Jones in Lancet, vol.xvi., 1S28-9, p.210, Norris Contrib.; ircli. Klin. Chir., Bd. X. p. 224. Dublin Hosp. Reports, vol. V. p. 198 ; Guy's Hosp. Reports, vol. XV. p. 73. Med. Chir. Trans., vol. xvi. p. 344. Norris Contrib., p. 224, Arch. Klin. Chir., Bd. X. p. 224. Lancet, 1830-1, p. 452. Notes from Prof. A. B Mott; Am. Jr. Med. Sci., 1830, p. 309. Arch. Klin. Cliir., Bd. X. p. 224. Norris Contrib., p. 224, Arch. Klin. Chir., Bd. X. p. 222. Ed. Med. & Surg. Jr., vol. xxxvi., 1831, p. 309. Norris Contrib., p. 224 Arch. Klin. Chir., Bd. X. p. 225. Arch. Gen., 1835, t. 7, April, p. 477 et seq. M. 20? R. M. P. 18 R. P. 60 R. M. 40 L. M. 46 R. M. 63 R. M. L. M. 55 M. 28 R. M. 22 L. M. 49 L. M. 56 L. M. 60 R. M. 63 L. P. 33 R. M. Y'g M. R. Aneurism, axilla- ry (traumatic?). Aneurism, axilla- ry. Fungus of axilla (supposed aneu- rism) . Aneurism, axilla- ry (result of fracture of hu- merus). Subclav. axilla- ry aneurism (id- iopathic). Axillary aneu- rism(idiopathic). Aneurism. Axillary aneu- rism). Hemorr'ge (after amputation). Axillary aneu- rism (strain). Hemorrhage after 9 days, ligature of axil- lary. 3d divi- sion. do. do. Aneui-ism. Subclavian aneu- rism. Axillary aneu- rism. Sarcomatous tu- mor of mamma. Punctured wound of axilla. Sword thrust in axilla. Im'nth, 2 years. 5 -w'ks. 1 year. do. do. do. do. do. do. do. do. do. do. Feb. If 1833. INNOMINATE AND SUBCLAVIAN ARTERIES. 183 Older edge of Scalenus Anticus and lower border of Firal Uih) — continuod. Datn of oporation. QJ O 03 Id July 28, lb28. Aug. 1S28. 182S. Nov. 24, 1S2S. 1S29. June 2.3, 1S30. Dec. 17, 1S:W. 1S:50. May ], 1830. Aug. 30, 1830. Aug. 2,5, 1830. March 26, 1831. March 7, 1S23. May 12, 1831. Dec. 31, 1831. 1831. 1832. Feb. 19, 1S33. Oc- curred, Oc- curred. 16, 17, Recovery. Kecovorod. Recovered. Recovered. Recovered. Recovered.? 32 Recovered. Recovered. Cured Condition. Cause of death, dale after op. REMARKS. Cured. Cured. Cured. Cured. 4th day. ? Exhaust'n; disease. 30th day. Suppura- tion of sac; exhaus- tion. Recovered. Recovered. Recovered. Recovered. Cured. Cured. Cured. No Hpecial caiiBn of death ih given. At tlio autoi'ny a cord of the liriichial plwxiiH wan fouiid witliin the ligature. Tumor dimininhed in nize imme- diately after ripoiation, but waH not cured. Autopsy: Sulcla- vian ohl iterated by tlie ligature. Aneurism aftor fracture of the huitierns; venesection and ice did not arrest its development. Autopsy: The central end of the subclavian was found oblit- erated (condition of the distal end not given). Inflammation and suppuration of sac on 2.5ih day; large abscess opened on 4.ith day. 13th day, slight hemorrhage from wound and vene-ecticn Iti oz. ; 1-tth day, venesection again 1 6 oz. Patient fell in vat of lye, which necessitated amputation of arm aljove elbow : hemorrhage en- sued ; ligature of subclavian ; death 6 days later. Discharged cured 27 days after operation. 27 days before operation, disar- ticulation of hnmerub for gun- shot wound ; 19ih and -0th days before operation, hemorrhage ; subclavian tied bplow clavicle; hemorrhage again, and subcla- vian tied npar scalenus ; on ac- count of hemorrhage, patient was transfused, but died in a few minutes. Autopsy: Pleuro- pneumonia ; thrombi above and below the first ligature. oth day. EKhaus- Autopsy: Thrombi on both sides of ligature. 6 weeks before operation tnmor had grown rapidly ; a good sized segment of the artery came away with the ligature; 33d day, sliaht oozing hem. ; 34th, do.: 37th, large abscess in axilla punctured. 6th day. tion. Few minutes. Ex- haustion from hem. before op. above clavicle. tion; gangrene. 20th day. Septice- mia. Tumor result of blow ; 3th day, fever and rigors, and suppura- tion ; difficult breathing, es- hanstiou. death. -Autopsy; Pus infiltration in region of wound ; artery still closed by ligature ; no clot on cardiac side. Sth day, diarrhoea ; 12th, do., and on this day the large abscess in axilla was punctured, giving escape to an enoruiou- quant' ty of bloody pus : radial pulse re- turned ;iOtli dny. 18J: PRIZE ESSAY. Ligature of the Subclavian Artery in its Third Surgical Division {between Name of operator. Source of information. PATIENT. Cause of operation. o 11 .- bo 13 a!2 V, bo CO bo < 3 CO .a 82 Kuhl, 1834. Arch. Klin. Chir., Bd. X. p. 225. M. 22 R. Axillary aneu- rism, punctured wound. 15 days. 3d divi- sion. Feb. 10. 11-25. f^3 Nicol, Jno. I., 1834. Ed. Med. & Surs^. Jr., vol. xlii., 1834, p. 1. M. 68 L. Medullary sarco- ma of humerus (supposed aneu- rism). do. S4 Seutin, 1834. Guy's Hosp. Reports, vol. XV. p. 72-3. M. 44 L. Subclav. axilla- ry aneurism (syphilis). do. S.i Lizars, 1S34. Lancet, 183.3-4, vol. ii. p. 717. F. Mid age. L. Axillary aneu- rism. 10 y'rs. do. Sfi Earle, 183;). Hobarr, 1836. Montani, 1836. Rigaud, 1836. Michaelis, 1836-7. Mussey, 1837 (New Hamp- shire). Norris Contrib., p. 224; Arch. Klin. Chir., Bd. X. p. 224. Guy'.s Hosp. Reports, vol. XV. p. 74-). Arch. Klin. Chir., Bd. X. p. 223. Archives Generales, t. xii. 1836. Arch. Klin. Chir., Bd. X. p. 226. Am. Jr. Med. Sci., 1837, p. 390. M. M. M. M. M. M. 54 38 21 31 L. R. R. E. Subclav. axilla- ry aneurism. do. Axillary aneu- rism (punctured wound). Axillary aneu- rism (punctured, thought to be ab- scess). Punctured wound of axillary ar- tery. Removal clavicle and scapula for osteo-sarcoma. 10 mos. 4 mos. do. do. do. do. do. do. 87 88 89 90 91 June 12. Imme- diate. 40 92 Jobert, 1837. Guy's Hosp. Reports, vol. XV. p. 73. M. 61 R. Subclav. axilla- ry aneurism(car- rying weight on shoulder). 4^ mos. do. 93 White, 1838. Norris (cit.), p. 226 ; Arch. Klin. Chir., Bd. X. p. 227. M. Y'g, L. Aneurism, axilla- ry (punctured wound). 2 w'ks. do. INNOMINATE AND SUBCLAVIAN AltTEUIES. 185 outer edge of Scalenus Antiaus and lower border of First Rib) — continnod. Bate of operation. g 5c « o te W Recovery. Condition. Cause of death, date after op. REMARKS. Feb. 25, 183i. Jan. 17, 1S.J4. April 27, 1S34. April 1,8, 1835 ? 1S36. June, 1836. 1S36. Sept. 28, 1837. Sept. 17, 1S3S. Cth. 26 and after, and 35. None. Recovered. Recovered Recovered. Cured. Cured. Cured. Recovered. Recovered Cured. Cured. Recovered. Cured. Otli day. Hem. 2.') til day. Diar'hcea; liciii.: exhaustion. 3Jtli day. Hem. 15 dayH before operation, Hword thriiHt in duel ; hem. next day, andHwoUlnjf in axillary region; 2Jth Feb., ligature : 2d day, ab- HceHH opened, and 4 IhH. of blood and pnM CHcaped ; fjth day. vio- lent hem. from wound of liga- ture, and patient died before Dr. K. arrived. Autopsy : Nothing of intele^t. 5th day, patient became lethar- gic ; Kith day, inflammation of wound and sup)iuratioJi ; vene- section 8 oz.; after this did well until 2lKt day. when after for- bidden exertion he was '' de- luged in blood." Auti'psy Car- diac end of artery closed by clot, dintal mfl opfu. Tumor full of fibrin; 2d rib eroded ; purulent infiltration of parts above wound ; no clot on cardiac or distal side of ligature. Last six months before operation, tumor had grown rapidly; 8 days before, "felt something give way in the axillary le- gion;" pulse in ladial in lO hours ; operator thought the subclavian was in front of scalenus anticus ; was nut pos- itive ; tumor at last account had diminished i in size. Suppuration of sac after opera- tion. 46lh day. Exhaus- Venesection in course of treat- ment after operation ; IMh day, large abscess formed in sac. 29th day. Hemor- 19 years previously, metacarpal bone had been removed for dis- ease ; 11 years later, arm ampu- tated at shoulder for same affec- tion ; 6 years after last opera- tion, subclavian tied in opera- tion for removal of olavicle and scapula; wound united by 1st intention; during the operation, subclavian vein was wounded and air entered. \5 days after operation, aneurism hage, exhaustion. ] developed on cardiac side of ligatui-e ; abscess formed on shoulder. Autopsy: Purulent infiltration among tissues: both euds of artery open and in pus : general atheromatous condition of vessels. Following the wound, severe hemorrhage which was arrested by compression ; 4 days later, aneurism appeared : after the ligature, the abscess in axilla was punctured with great re- lief. 186 PRIZE ESSAY. Ligature of the Subclavian Artery in its Third Surgical Division [between Name of operator. Source of information. Cause of operation. rt" o iiO ^ o t3 fi.a Nott, Josiah C. (Mobile), 183S. Syme, 183 9° 1 HuUon, J. P., ! 1841. Am. Jr. Med. Sci., vol. ii. n. s., 1841. Arch. Klin. Chir., Bd. X. p. 227. Lancet, 1810-1, vol. ii. M. p. 377. Pfister, 1840. Gross, Prof. S. D.. 1841. Hutin, 1S41. McDougall, 18-12. Arch. Klin. Chir. Bd. X. p. 227. Am. Jr. Med. Sci., vol. X., 1815, p. 19; Norris, p. 226. Guy's Hosp. Reports, Bd. X. p. 138, vol. xvii. NorrisContrib.,p.226.! M. 22 Aneurism, shot (.small-sized shot) wound ax- illa. Axillary aneu- rism (after fall). Axillary aneu- rism (fall, and catching violent- ly by arm). 2 mos. 3d divi- sion. Axillary aneu rism (punctured wound). Some weeks, 3? Axillary aneu- rism. Wound of axilla- ry, scissors- 12 days. Aneurism (shot wound). do. Sept. 23. 12th day, 13-16- Extra- vasat'n immedi- ate. Dec. 17. 1840. Several times. Oct. 28, 1831 INNOMINATE AND SUBCLAVIAN ARTERIES. 187 outer edge of Scalenus Anticus and lower border of First Bib) — continued. No. 97 Hato of operation. Nov. 27, 1838. Oct. 2S, 1838. Jan. 8, 1841. Jan. 8, 1841. Feb. 18, 1S41. Nov. 9, 1841. 101 Dec. 12, 1S41. 0, at So often that S. had to ampu- tate at shoul- der. Oc- curred. Recovery. Kocovered. Recovered. Recovered. Condition. Cause of death, date after op. Cured (with loss of arm). Cured. lotli day. Hem. 30th day. Exhaus tion, rupture of sac into pleura. 10th dny. Exhaus- tiou, hem. ith day. Hem REMARKS. fiun dlBcharped in axilla at rIo«e range ; hemorrhage on 12th, KUh, and Ifith days ; com[TO»s ; in 2 nioiitliH annurintii aippeared ; operation miccoHKful in all re- Kppcts ; 2 ynarK after operation patient wll. ThefriKhtful hernorrhaffe occur- red through thetinbHcapularis of axillary, which was found to be torn. 3 weeks after fall and strain of arm, aneurism appparod ; HO days after ligature the sac, which had diminished in size, began to inciease rapidly ; punctured and discharged pus. (Although the incisions were made, and the artery reached ahove the clavicle, the operator says the artery was tied 2 in- ches below this bone ! Such a procedure is scaicely possible. — Author.) 3 weeks before oper'n, wounded with pointed instrument in ax- illH (from behind) ; on account of hemorrhage attempt to tie ax- illary, whi'hbeing wounded by the aneuiism needle, the sub- clavian WHS secured ; hemor- rhage, rigors, and death. Au- topsy showed hemorrhage to have come frum cardiac e d of subclavian n en r ligature, whi h had partially cut through the 3 coats of the artery. After ligature the tumor became solidified ; 2")th day. fever, tu- mor red with inflammation and painful ; 2(ith, severe pain in chest ; 2Sth day, patient felt as if fluid was passing from pleura iuto aueurismal sac ; died 30th. Autopsy: Between 1st and 2d ribs sac communicated with pleura by free opening: 3 qts. of bloody serum in right pleural cavity. " Soldier, fighting duel with scis- sors blade attached to end of stick," was wounded in ax'.Ua: 12 days, ligature of subclavian; 6 days after ligature, patient got out of bed, contrary to or- ders, went to water closet, and in act of defecation hemorrhaLC from axilla; compress : 9th day, on account of continued hemor- rhage, H. tied the inni'mh'atn; died next morning. Autopsy: Tlie only source of hemoirhage w:is found to be one of the tho- racic branches of the narillary ; no other points of interest. 188 PRIZE ESSAY. Ligature of the Subclavian Artery in its Third Surgical Division {between Name of operator. Source of infoimation. PATIENT. Cause of operation. o 03 cS fl.3 >M bo bo 6 CO o3 O OS 101 Post, A. C, lS4i. N. Y. .Tr. Med., vol. iv., March, J 84.5. M. 37 R. Hem. (wound of) axilla (scythe- blade). 21 days. 3d divi- sion. Nov. 15. Imme- diate. ^o?. Cooper, B. B., 1.S41-9. ? Gny's Hosp. Reports, vol. XV. p. 70-1. M. 50 L. Subclav. axillary aneurism. 6 w'ks. do. 108 Wattman, 1843. Arch. Klin. Chir., Bd. X. p. 228. Subclav. axillary aneurism (shot 10+ Mott, v., 1844. Knorre, 1845. Dr. A. B. Mott to author ; N. Y. Jr., Jan. 184.5. Arch. Klin. Chir., Bd. X. p. 229. M. M. 35 22 R. R. wound). Axillary aneu- rism (shot w'd). Hem (abscess in axilla). 22 days. 3d divi- sion. do. 10.5 106 Green, 1844. Guy's Hosp. Reports, vol. XV. p. 70-1. M .So R. Subclavian aneu- do. rism. 107 Vanzetti, 1P46. Syme, 1847. Arch. Klin. Chir., Bd. X. p. 229. Ed. Monthly Jr., 1848, p. 217. M. M. 40 34 L. R. Axillary aneu- rism. Axillary aneu- rism. 17 mos. do. do. lOS 109 Manec, 1848. Arch. Klin. Chir. M. 18 L. Subclav. axillary aneurism (shot wound). 7 days. do. June 24. Soon after, and July 2. 110 Hancock, 1848 Lancet, 1849, p. 126 et seq. M. 34 Axillary aneu- rism (sack of beans fell on shoulder). 2 years. do. 111 Linhart, 1848. Arch. Klin. Chir., Bd. X. p. 229. M. Mid age. R. Shot wound (shoulder-joint). A few hours. do. 11'^ Ci-ompton, 1849. Syme, 1849. Unknown, Scblesswig- HolsteiQ War, 1S48-.50. do. do. Parker. Prof. Willard, 18i9. do. p. 230. Ed. Monthly Jr., March, 18-50, p. 240. Arch. Klin. Chir., Bd. X. p. 230. do. do. Notes of cases fur- nished to author by Prof. ParKer. M. M M. M. M. M. 49 50 Tf Axillary aneu- rism. Axillary aneu- rism (thrown from carriage). m R. is days. 3d divi- sion. do. do. do. do. 114 ITi neighborhood of axilla. do. do. Traumatic aneu- rism and hemor- rhage of axilla. IIR 117 31 R. Feb. 5, 1849. INNOMINATE AND SUBCLAVIAN AUTKRIES. 189 outer edge of Soalenua Anlicus and lower bot-der of First liib) — continued. naio of operation. u o r; t. ^ o S a> to ■a i Recovery. Condition. CauHe of (loath, date after op. Dec. (), 181;3. 1841 ? 1843. April 11, 184i. April 6, 184). Aug. 17, 1S46. July ^9, 1&47. July 2, 1848. 1848. March 23, 1849. Oct. 23, 1849. 1S4S-J0. do. do. Feb. 23, 1S49. None. Oc- curred, None. 26 Recovered. Cured (Iosh of arm). Recovered. Recovered. Recovered. Recovered. Recovered. Recovered. Recovered, l.Oth day. Pleuritis, pneumonia, empy- ema. Hemorrhage. ? Cured. Cured. Cured. Cured. 37th day. Hem. Next day. Exhaus- tion, pneumo-tho- rax. Cured. Cured. Pysemia. do. do. Cured (with loss of use hand from ulceration). I"im<'iliatf!ly after wound, axil- laiy artrry lied by Dr. Cox of WilliamnburKli, N. Y. ; next day, arm amputated by Or. PoHf, 2 inohoH below head of liumerus ; in tliiK operation, ax- illary tied } inch above l)r. C.'h ligature ; 14 days alter amputa- tion, arterial hemorrliage 12 oz.; 21 days after amputation a pro- fuse arterial henjorihage neces- sitating ligation of subclavian ; external jugular vein divided, and oir entered w.in ; recovered with no unusual symptoms. No autopsy. 11th day after operation, tumor discharging freely ; no bad symptoms. Absiess had been opened and hemorrhage resulted for seve- ral days ; recovery very slow, hut without bad symptoms. In operation, nerve of brachial plexus was included in liga- ture ; ou account of the intense pain, ligature was removed and re-applied ; recovered without a had symptom. 16 years previously, patient fell down stairs and strained his arm ; 10 months before opeia- tion, tumor increased rapidly; no had symptoms followed ope- ration. During ofieration, external jug- ular vein was cut and air en- tered ; recovery slow ; bull en- tered just below clavicle and was cut out of the infra-spinous fossa. Was bled on admission : 27th day, sac opened and dischar^'ed quite a quantity of offensive blood and pus : 37th daj-, hem. and death. Autopsy : Artery closed by clot on both sides of ligature; fatal hemorrhage from branches between ligature and sac. Resection of humerus immedi- ately after injury. Autopsy: Ball had entered thorax in 3d intercostal space. Erysipelas supervened about 23d day : no other unfavorable (■yojptoms noted. Patient was well and a useful man many years after operat'n. 190 PRIZE ESSAY. Ligature of the Subclavian Artery in its Third Surgical Division (between Name of operator. Source of information. Cause of operation. o X u Parker, Prof. Willard, 1859. do. 1S60. do. 1S61. Goetze, 1850. Lohmeyer, 1850. Notes of cases fur- nished to author by Prof. Parker. do. Arch. Klin. Chir., Bd. X. p. 230. Holt, Barnard, Lancet, 1852, vol. i. p. 1851. 120 ; 1853, vol.i. p. 13:^ Mackenzie, E.J. Gore, 1851. Van Buren, Wm. H., 1S52. Hamilton, Prof. Frank H., 1852, Miller, 1853. ? Ed. Monthly Jr., Jan. and March,1852, p. 110. Guy's Hosp. Reports, vol. XV. p. 72-3. Contnb. Pract. Surg. V. B., 1865. Notesofcaseto author Arch. Klin. Chir., Bd. X. p. 231. Aneurism axilla. do. Shot wound under clavicle. 15 days Axillary anenr. Subclav. aneur. Aneurism, stab wound. 3d divi- sion. do. do. do. 23 days. do. 5 w'ks. 3 w'ks Removal of large sarcoma from ax- illa. Axillary aneur. do. do. Oct. 4, 1850. INNOMINATE AND SUBCLAVIAN ARTERIP:^, 191 Older edge of Scalenus Anticus and lower border of First Rib) — continued. No. Date of oiieration. 120 121 122 125 126 127 Doc. 13, 1809. Nov. 13, 1860. Oct. 2, lS(il. Nov. 2, 1S50. Nov. 3, 1850. June 19, 1851. Nov. 19, 1851. 1S51. 1852. June 23, 1852. 18.'i3. ? o s 0) So .*•' OJ o « Noae. None. Oc- curred. Oc- curred Recovery. Coadltion. Cause of death, date after op< 15 sliglit. None. Eecoverod, Kecoverod, Eecovered, Recovered. 4tli day. Shock. Cured. Cured. Cured. Recovered. Cured. 5th day. Hem. Hemorrhage. 27th day. Hem. pysemia. ? Cured. Cured. Thi« m!in liad KyphiliH, and wa» of l.ail and illHKi|.at(;d hul.itK, a lid could not rccovr from the Kliock of HO foimidablc an ope- ration. No bad HyrnptomM are noted In the course of recovery. The aneurism was caused. after ting a bag of grain. Ball (iutorod two fingers' breadth below nii'ldlo of clavicle, and p'riHscd throngb axilla and out through scapula; hcinorrliMge on 15th day after injury, which recurred 5 times; 4th day after operation, 2 severe heni'jrrhaaes and death. Autopsy : Hemor- rhage from distal end of artery, which was found open. Ball entfred below clavicle, passed through axilla, and out through scapula near spina scapulaj ; wound healed nicely until 23d day ; hemorrhage ; 4 days later, hemorrhage again ; after ligature, hem. ceased un- til 3d day ; on 4th, recurred, and death. Autopsy did not re- veal the source of the hr-rn. During the operation a large branch thought to be transver- salis colli (more probably the posterior scapular — Author) was mistaken for the subcla- vian. After the lik'ature was applied to subclavian, pulsa- tion in sac ceased, but the con- tents remained fluid for some time. 6th day, rigors, bronchitis ; ISth, slight hemorrh'e from wound; 19th, do. slight; 20th day, do. profuse, arrested by compress ; death, 27th. Autopsy: Subcla- vian vein behind scalenus anti- cus ; large abscess in pleural cavity extending fi-om 4th rib upward ; cardiac end of artery open ; distal end closed. Hem. profuse immediately after injury; arrested by pressure; 2d day after ligature, symp- toms of gangrene ; 4th day, line of demarcation ; 7th day, one pound of coagulated blood es- caped from sac; 15th, erysipelas and slight hemorrhage ; within next mouth, erysipelas reap- peared several times, and pa- tient was at times delirious. Dr H. writes: ''Whether the tumor returned I do not know, as I lost sight of patient some months after the operation."' 192 PRIZE ESSAY. Ligature of the Suhclaman Artery in its Third Surgical Division {between Name of operator. Source of information. Cause of operation. Caccioppoli, Dom., Xaples, 1S53. White, 1853. Coppin, 1835. Blaker, 185") Stanley, 1856. Gregg, 1837. Soule, M. E., Arch. Klin. Cliir., 1857. Bd. X. p. 232. Clarke, LeGros. Lancet, 1859, vol. i. p 159. Gaz. Med. de Paris, 1854, t. ix. p. 62. Ed. Med. & Surg. Jr., 1834, vol.lxxxl. p.417. Arch. Klin. Chir. Bd. X. p. 231. Guy's Hosp. Reports, vol. XV. p. 70-1. Arch. Klin. Chir., Bd. X. p. 232. Guy's Hosp. Reports, vol. XV. p. 72-3. Drayton, H. E., 1859. Torelli, 1859. Arch. Klin. Chir., M Bd. X. p. 232. Am. Jr. Med. Sci., M. Oct. 1859, p. 402 Arch. Klin. Chir., Bd. X. p. 232. Axillary aneur. (spontaneous). Shot wound of ax- illa : aneurism. Aneurism, axilla- 3 w'ks. ry (punctured wound). Suhclav. axillary 2 years, aneurism (rheu- matism). Subclav. axillary 6 mos. aneurism. R. Punctui-ed wound of axillary. Axillary aneur. Suhclav. axillary aneurism. Suhclav. axillary aneurism (fall). Axillary aneur. (punctured w'd). 3d divi- sion. 2 mos. Aneu- rism ex- isted 15 days. 10 days. do. do. do. do. do. do. 3 weeks before opera- tion. Immp- diate. March 25, 1859, April 24 INNOMINATE AND SUBCLAVIAN AUTEKIES. 193 outer edge of Scalenus Anlicus and lower border of Firal Rib) — continued. No. 135 136 137 13S Date of oijoration. Feb. 13, 1863. April 24, 18j3. .*"'^ <: f £& O C! S "fc-^ i"s .£!'f*|i a, o « J is « H -o Eecovery. Condition 1855. Aus. 4, 185ti. Dec. 1.3, 1857. 1858. Feb. 1858. April 22, 1869. April 24, 1859. None. 9,12. 13 Recovered. Recovered. Recovered. Recovered. Recovered. Recovered Cured. 12tli day. Hem. 3d day. Pleuritis. Cured. Cured. Cured. Cause of death, date after op. RiiMARKS. Sth. day. Pneumo- nia; pysemia. Im- mediate cause hemorrhage. ISth day. Hem. Anenriurn had been faithfully troati'd by f!li^otro-))unotiire, Ijiit of no avail ; alter ligature, pul- Hatiou irj tumor disappeared, but ri'turrjed in 24 bourn ; C. tlien introduced an ivory probe between ligature and loop of ligature, and left it there for some days. No bad symptomo noted. Ball entered left axilla in front, lodged, and was cut out of in- fia-s])iiious fossa ; hemorrhage immediate and profuse, con- trolled by pressure. A hot iron was tlirust into ax- illa and wounded tlift artery ; hemorrhage immediate and pro- fuse ; 3 weeks later, aneurism was discovered ; no bad symp- toms noted during recovery. Patient did well until fitli, when hemorrhage occurred, which proved fatal on 12th. Autopsy: 1st and 2d ribs eroded ; large clot in sac ; proximal side of artery healthy to near ligature, where it bad sloughed and was open ; distal side was full of purulent matter and uuhealtby. Autopsy : Pint and a half of ex- udation in le.ft pleural cavity; purulent infiltratiou of tissue-s around wound. Pneumonia, abscess, symptoms of pysemia, and delirium en- sued, and on Sth day, during fit of violent and delirious exer- tion, fatal hemorrhage. Autop- sy: Cardiac end of vessel closed; distal end open and a large sized branch opened here {sd. to he iniernaL mammary /) which was cause of hem. Did well to 13th day; patient quarrelled with a fellow pa- tient, and in shaking his fist hemorrhage ensued which was controlled by pressure ; on loth day, repeated hemorrhage, digi- tal pressure ; 1.5th, coughing and hem. ; 17th, delirium and hem.; ISth death. Autopsy: Cardin c end of artery open ; dis- tal end only partially occluded. 22d day. Phlebitis; On ?th day after operation, fever and delirium ; jumped from bed and tore wound open ; no hemorrhage. Autopsy: Artery closed on both sides of ligatured point. 10 days after injury aneurism formed rapirtly : hemorrhage on 24th of April. 'and ligature ; 24 days later, thumb and part of index finger amputated on ac- count of gangrene ; recovered with partial anchylosis of elbow joint. 194 PRIZE ESSAY. Ligature of the Subclavian Artery in its Third Surgical Division (between Name of operator. Source of information. Cause of opei-ation. R.S Paget, 1860. Buscli,"W.,lS61. do. 1S62. do. 1864. Methner, 1862. Bennett, H. N. (Conn.), 1862. Turner, 1863. Armsbv, Prof. Albany, N. Y.. 1863. Knorre, 1864. Vanzetti, 1864. Venning, Edgecomb. Eichet, 1864. Browne, R. K. Segond, 1834. Unknown, C. S. A., 1863. Guy's Hosp. Reports, voi. XV. p. 70-71. Arch. Klin. Cbir. Bd. X. p. 233. do. p. 234. do. Am. Med. Times, Dec, 27, 1862, p. 348. Dr. Rodgers in Loud, Med. Timps & Gaz., vol. ii., 1863, p. 485. Am. Med. Times, 1864. p. 54. Arch. Klin. Chir. Bd. X. p. 234. do. Lancet, 186.'}, vol. ii. p. 672. Arch. Klin. Chir. Bd. X. p. 234. Am. Jr. Med. Sci. Worris Contrib., p. 224; Arch. Klin. Chir. Bd. X. p. 241. Dr. H. L. Thomas, C. S. A., in Med. & Surg. Hist. Reb., Part I., p. 538. M. 54 R. F. 17 L. F. 43 L. F. 42 R. M. 54 R. M. 20 L. M. 27 L. M. 28 R. M. 25 L. M. 40 L. M. Mid age. R. M. 39 L. M F. 40 M. 25 L. Subclav. axillary aneurism (rheu- matism). (Before removal head of humerus and scapula for cancer.) Hem. removal of mammary gland Remov. humerus for carcinoma. 3d divi- sion. Hem. (after rem. humerus for car- cinoma). Punctured knife- wound axilla. Axillary aneur., lifting weight. Aneur., subclav. axillary (after amputation near shoulder). Hem. abscess in axilla. Axillary aneur. (punctured w'd). Aneurism, axilla- ry (fall). Hemorrhage (re- moval of head of humerus). Aneurism axilla (pistol shot wound). Aneurism axilla (fall, dislocation, and wound of shoulder). Shot wound lung, chest, and sub- clavian artery at lower border of 1st rib. 10 w'ks, do. do. do. do. do. do. do. July 3, 1863. INNOMINATE AND (SUBCLAVIAN ARTEItlES. 195 outer edge of Scalenus Anticus and lower border of First liib) — continued. Diitn of operatiou. April, 1861. Feb. 8, 1S62. July 13, 18(54. Oct. 12, 1S62. June 18, 1863. Nov. 19, 1863. May 19, 186-t. July 27, 1864. Sept. 1864. April 5, 1831. July 3, 1863.? 13-23- 41-62- 65. None. None. None. None. None noted. Condition. 20 Recovered. Recovered. Recovery. 6")th day. Iloin. Cured. 3d day. Pleuritis. .Tth day. Septicae- mia. 3d day. Exhaustion. Cured. Cured. Recovered. Cured Recovered. Recovered. Recovered. Cured. Cured.(?) Cured (Anchylosis of elbow.) Cured. Paralysis of left arm Cause of death, days after op. REMARKS. 4tli week, tion. Died. ? Exhaus- Did well till 13th, horn.; 23d, hem. and pyajinlc t.'e most prol)al)ly from branches comtiiu- riicating witli sac.) 4 years later patient wan per- fectly well. Breast was extirpated on 2Sth January, for carcinoma that had returned a thinl time ; Feb. 3d, severe hemorrhage. Patient died, in all probability, from effects of disease with loss of blood before the ligature. Hemorrhage after wound imme- diate and profuse; 2d hemor- rhage in a few days, necessitat- ing ligature. A large bianch running parallel with subclavian was also tied; a small sized tumor per.sisted some time after recovery. July 7th, arm shattered by acci- dental discharge of cannon ; amputation near shoulder 3 dnys later ; .5 mouths, aneurism having ajipeared, burst and dischurg'd 3 qts. of blood. Digital compression had been tried but failed ; after reeoveiy, tumor diminished iu size, but was filled wiih liquid. Hemorrhage occurred after ope- ratiou in October; pyaemia also ensued. (Author read notice of this case and took notes at time as given, but failed to note date of jour- nal. The case as given is reli- able.) — Aiithnr. Patient slipped and fell upon an earthen vessel, dislocated arm, and wounded axilla with frag- ments driven in ; humerus re- duced by non-professioual ; 4 or 5 days later, profuse hemor- rhage, and one month later, aneurism. 'One of the nerves of the bra- chial plexus, ]irobably. having been included in the ligature." (Although this accident has happened in several instances, the paralysis iu this case could equally have been due to injury from missile. — Author.) 196 PRIZE ESSAY. Ligature of the Subclavian Artery in its Third Surgical Division {between No. Name of operator. Source of information. PATIENT. 6 6 bn CO o '6| Recovery, Condition. Cause of death, date after op. REMAICKS. 155 156 159 160 April 14, 18b2. July 17, 1863. May 7, 1865. Sept. 19, 1864. Dec. 11, 1864. May .31, 1864. July 25, 1864. 5tli day. Three times. 2 days. Oct. 11, 1863. June 17, 1864. June IS, 1864. Imme- diate. None. None. 12tli day. None. Recovered, Recovered, Recovered. Partial diH- il)ility of left arm. Total disa- bility of aim. Not cured of aneu- rism. 5th day. Hem. 50 hours. Exhaus- tion; hemorrhage. 'Ball entered near collar bone, cut out lower ed>{e of Hcapula, atropliy of niiiscles of arm and shoulder. JJiKability one-half torniiorary. Still a pensioner in 1872." Great tumefaction in region of wound ; aw h^morrhaf^e did not coase with ligauire of subcla- vian, tho siipra-«cai)ular was also tied ; ligature from supra- scapular on Kith day: no bad symptoms followed ; ball enter- ed 1)4 inch below left scapula, ranj^ed forward, and lodged. Musket ball through the light shoulder and axilla ; disability total ; still pensioned in 1872. Ball entered one inch below cen- tre of right clavicle, and passed directly through. In 1867 "no use of right arm, total disability from arienrifim alone, liable to death, by rupture, upon any ex- ertion." In 1872, still a pen- sioner. Hem. occurred from sloughing of axillary artery. Minnie ball, in through pecto- ralis major, and out 2 inches above posterior f( Id of axilla; 2 days after ligature of subcla- vian, a vein was tied at .seat of wound. Autop.sy: slough had destroyed portion of supra-sca- pular artery and axillaiy vein. Ball entered right shoulder pns- teriorly and lodged in axilla, passing through scapula just below spine ; 17 diiys after wound, hemorrhage 3 pints, ligature of axillary : 10 days later, hemorrhage, and on the next day, 2S days after injury, ligature of the subclavian. Au- topsy uot given ; hemorrhage reported as from riistal side of ligature aud irova. distal end of nxillary. Ball fractured head of humerus, near coracoid prucess, and pass- ed out above spitia scnpvlcB. Fever and suppuration follow- ed; after ligature of subclavian (9 days) gangrene supervened. Patient was of hemorrhagic dia- thesis aud was suffering from a cough ; artery gave way 12th day, and death was almost in- stantly the result. "There were slight fibrinous exudations on either side of where the liga- ture cut through."' (I judge from this that the hemorrhage was at the seat of ligature, and pi-obably from cardiac side — I Author') 6th day. Gangrene; Ball entered under spine of left exhaus'n; pyaemia, scapula and rauged toward chest ; gangrene and hemor rhage followed ; after ligature of subclavian, no hemorrhage, but rigors and pyaemic symp- toms. 16lh day. Exhaus tion; hemorrhage. 10th day. Gangrene; exhaustion. I2th day. Hem. 198 PRIZE ESSAY. Ligature of the Subclavian Artery in its Third Snrgical Division (between No. Name of operator. Source of information. PATIENT. Cause of operation. O S 3 p. 2 0) 6 "2 ft s W < JB p -d ,0 165 Browa, F. H..? Med. Surg. Hist. Keb., M. Mid L. Shot wound arm 23 days. 3d divi- May 31, June] 9. 1S62. p. 540. age and axilla. sion. 1862. 166 Hodsren, J. T., 1862. do. M. 19 L. Shot wound left axilla. 19 days. do. Oct. 3, 1862. Oc- curred. 167 Sheldon, A. V., 1S64. do. M. 22 E. Shot wound righ arm and shoul- der. 11 days. do. May 8, 1864. May 29. 168 Allen, Harrison, lS6i. Med. Surg. Hist. Reb., Part. I., p. 541. M. 28 R. Shot wound right axilla andshoul- der. 9 days. do. Oct. 27, 1864. Oc- curred. 169 Gross, Prof. Dr. Jno. J. Eeese in M. Mid L. Shot wound left 8 mos., do. June 25, M'ch 14. S. D., 1863. Med. Surg. Hist. Eeb., p. 541. age. axilla; hemor'ge diffuse aneurism 20 days. 1862. 170 McClellan, E., ? 1863. do. M. 39 L. Shot wound left shoulder ; aneu- rism. 58 days. do. April 2, 18B5. Several times. 171 Baylor, J. C, 1863. Dr. P. F. Browne in Med. Surg. Hist. Reb., p. 541-2. M. Mid age R. Shot wound right axilla. 38 days. do. Nov. 8, 1863. 172 Selden,Wm., 1864. Surg. Hist. Eeb., p. 542. M. 29 L. Shot wound left axilla. 39 days. do. June 14, 1864. Imme- diate and profuse. INNOMINATE AND SUBCLAVIAN ARTERIKS. 199 outer edge of Scalenus Antious and lower border of First Bib) — continued. No. PatGof operation. n ° 1^ ri « Eocovery, Condition. Cause of death, date after op. REMARKS. 166 107 Juno 23, 18U2. Oct. 22. May 29, 18()4. Nov.5, 1804. March 1.5, 1S63. May 30, 18S5. Dec. 16, 1863. July 23, 1S64. None. 7-9 ? 17-21. 10, 11. 13days None. Next day. None. 4th day. Pya3nila.(?) 0th day. Exhaus- tion; hemorrhage. 21st day. Hem. 13th day. Hem. 2d day. Exhaustion (shock ?) 12th day. Exhaus'n IS hours. Exhaus- tion ; hemorrhage. Sth day. Hemor- rhage ; erysipelas pleuritis. Ball entered left arm at del- toid inKcrtion, out at poHterior border of axilla; bone not in- jured ; ureat proHtration at time of operation, from previous hemorrha!,'c. No autopsy. 21 day« after injury, hem. 40 oz. occurred ; hem. w)if!n ligature came away; arresti'd by com- ])res»ion, but recuircd fatally. No autopsy. Tied beneath the clavicle. Ciiven as subclavian. Ball enti'red near lower edge of clavicle and emerged at ujiper angle of scapula; extensive slongh and suppuration ; did ■well for 10 days aft-r ligature, then on ligature coming away, slight hem.; compression. Au- topsy : Nothing of interest. (Tied below clavicle. From di- rection and location of wound it is evident that the subclavian was tied on first rib, and very likely in the wound of entrance — Aiiihiir.) Three months after injury, both wounds (of exit and entrance) ■were healed; Feb. 1st, swell- ing in axilla began ; March 1st, there was perceptible fluctua- tion, but no thrill ; March 14, profuse arterial hemorrhage: after ligature extreme prostra- tion. " Reaction never fairly set in." No autopsy. Ball entered just below clavicle, emerging at inferior angle of scapula; secondary hemorrhage several times ; after ligature, tumor decreased very rapidly ; 9th day, hemorrhage. Autopty: Ligature still on artery, and clot on either side ; no clot in sac. (Fatal hemorrhage was very probably from vessels com- municating with sac. — Author ) About one month after injury, aneurism appeared; after the ligature, the sac was opened and clot turned out, and ineffec- tual attempts made to secure the bleeding vessels ; tampon ■was used. Autopsy: Ligature was firmly tied aro'ind artery; hem. had occurred through col- lateral circulation through sac.) Although axillary artery was divided, patient rode 8 miles, closely pursued for 3 ; hem. profuse but ceased spontaneous- ly ; did well, suffering only slightly from aneurismal swell- ing until 2Jd day. when hem. took place, 1 pint ; 3 days after ligature, erysipelas ensued; 6th. day, pleuritis; died Sth day. Autopsy: Axillary vein and artery cut in two by ball ; no clot on either side of ligature; copious effusion in left pleura ; no fibrinous clot in aneurismal sac ; pericarditis. 200 PRIZE ESSAY. Ligature of the Subclavian Artery in its Third Surgical Division (between Ko. Name of operator. Source of information. Cause of operalion. o >, Lidell, Jno. A., 1863. Med. Surg. Hist. Reb., Part I., p. 543^. M. 174 Coolridge,R.H., 1863. Isaac Norris, Jr., in Med. Surg. Hist. Eeb. p. 545. 177 179 Morton, J. C, 1864. McLean, C. E. 1863. Morton, T. G., 1864. McKee, J. C. Humphrey, 0. M. Dr. C. Wagner in Med. Surg. Hist. Eeb., Part II., p. 440. Dr. J. Hopkinson in Med. Surg. Hist. Reb., p. 440. Dr. W. S. Hendric in Med. Surg. Hist. Eeb., p. 441. Med. Surg. Hist. Eeb., Part il., p. 468. do. p. 634. Mid M. Aneurism, shot 23 days ■w'nd left axilla. Aneur., axillary, shot wound. June 21, 1863. June 21. 67 days. June 9 1863. Shot ; flesh w'nd 21 days, of right arm. 51 days. do. Shot wound and amputation at shoulder-joint. Solid shot wound shoulder-joint ; amputation. do. 27 days. 8 days. do. do. Sept. 30. 1864. July 2, 1863. June 4. 1864. May 28. Jan. 30, 1863. Wone noted as im- mediate Doubt- less it occurd 66th day. Oc- curred. July 23; Aug. 1-23. June 2.')-30 ; July 1. INNOMINATE AND SUBCLAVIAN ARTE It IKS. 201 outer edge of Scalenus Anticus and lower harder of First liib) — continued. No. Dato of operation. 174 176 July 14, li<63. 24,28,29 Aug. 17, 1863. Oct. 21, 1804. Aug. 23, 1863. July 1,1864 178 Sept. 1,1864. »H )r. > a bo E5 >-. J a T3 Becovery. None. gtliday, Oc- curred during and prob'ly after Not noted. Condition. Cause of death, dato after op. 4'ith day. Hemor- rhage ; Huppura- tiou. 6 hours. Hem. he fore ope' n. Shock? Dyspnoea. KEMAUKS. 31st day. Hem. he- fore op'n ; exhaus- tion. 9th day. Hem. 1 hour. Exhaust'n hemorrhage. 2d day. Cause ? 20th day. Exhaus- tion. Ball cnlorod axilla from in front, wounding a.xillary artery and Kome of hracliial ple-vun; hem. immediate to nyncope ; ceaHcd spontaneouHly : lf)th day aftpr wound, aneurism was noticed, MO thrill: had felt soiriething " give wiiy" on moving liis arm; 21 days after wound, ligature of finbchivian : tumur dimlni^hi'd immediately ;.Tth day, xacburst, and on lliis and following day discharged several onncs of liloody pus ; 18th day, ligature loose ; 24th day, lirofuso hem. from sac; liq. ferri pfrrsulph. locally arrested hern.; 2Sih and 29th, hemorrhage; 4fth, 41st, and 42d days, suppuration as- sumed very offensive character; death, 46th day. Autopsy : Firm clot on both sides of ligature ; cicatiices (seeming y tubercu- lous) on apices of lungs. Autopsy: Large nerve included in ligature; (Patient had died with symptoms of great dys- pnoea.) (It is most probable that this nerve was the posterior thnrrific, which had been press- ed by the aneurism toward the scalenus. Simple ligature of a cord of the brachial plexus go- ing to the arm would not pro- duce such symptoms of dys- pnoea. This last accident has happened quite frequently. — Author.) Hemorrhage twelve days after wound ; brachial tied ; 9 days later, hemoirhage again ; sub- clavian tied ; patient improved for a while, but died of exhaus- tion 31st day. July ?:^d, hem. from brachial, and this vessel tied ; Aug. 2, amputation of arm for hem.; Aug. 23, hem. from axillary, and ligature of subclavian; did not do well, and died from hem. Sept. 1. Autopsy : Proximal side of ligature c used by clot ; hemorrhage was distal. Below clavicle. Hem. from brachial June 2.i, and axillary tied : June .^Oth, hem. and compression; July 1, hem. from axillary at ligature: sub- clavian tied ; lo.st 30 oz. blood in operation, and died in one hour. Dr. W. P. Moon tied the axillary. Autopsy not given. Below clavicle. Shot passed through left axilla and aneurism resulted ; sub- clavian tied at amputation. iCases Nos. 17S to 184. inclusive, were most likely ligatured be- neath the clavicle. — Author.) Kight arm torn off by shot ; pro- fuse hem.: immediate amputa- tion by Dr. G. C. Harlan: 7 days later, profuse hem.; Feb. 7, lig. of subclavian, by Dr. Humphrey. 202 PRIZE ESSAY. Ligature of the Subclavian Artery in its Third Surgical Division (between Name of operator. Source of information. Cause of operation. u- o V. 1=1 ^ 6 o >, "■2 =1 o3 03 r third. Amputation at upper 3d, on June 18; (?) hemorrhage from and ligature of axillary July 2.ith, by Dr. G. B. Boyd ; Aug. 8th, hemorrhage from ligature, and ligature of subclavian over 1st rib ; hem. again on 7th day, controlled by pressure; (Dr. T. H. Squire amputated arm;) af- ter ligature of suhilavian. iire.s- sure was continued for 6 weeks. Shot fracture head of left hu- merus, much destruction of tis- sues. After excision, arm amputated at shoulder, by Dr. J. (!. Jlor- ton ; 10 days later, hemorrhage and ligature of subclavian. Ball wounded spinal cord, cans ing paralysis. 29th day. Exhaus- Arm amputated at middle third ; tion. hemorrhage recurred and liga- ture of subclavian. Died Aug. 30, 1864. January 17, amputation at upper third humerus; 6 days later, hemorrhage ; 7th, do.: 14th. do. profuse ; Feb. 1, ligature of sub- claviau ; no unfavorable symp- toms except slight surgical fever. I infer that this case will appear in the 3d ^^urgical volume of tlie Jled. aud Surg. History, as Dr. Otis has given one case by Dr. H. from same source. 204 PRIZE ESSAY. Ligature of the Subclavian Artery in its Third Surgical Division (between Name of opecator. Source of information. Cause of operation. g 03 a 196 do 198 199 do do do iiUU 201 do do 204 Uuknown. Med. Surg. Hist. Reb. do. M do. M do. M do. M do. M do. M Thiersch, 1865. Arch. Kliu. Chir. Bd. X. p. 236. Busch, W. do. 1865. Church, W. H. 1865. do. p. 237. do. p. 236. do. p. 241. Dr. H. G. Piffard in Am. Jr. Med. Sci., Oct. 1865, p. 393. M. Subclav. axillary aneurism (punc- tured wound). Hemorrhage after opening abscess of axilla. Hemorr'ge (after punctured w'd). Shot wound of axilla. Suicidal shot w'd of axilla. 9 days. 3d divi- sion. Imme- diate, and Jan. 16. 23 days. July 3. June 3, 1865. June 3, slight ; June 13, profuse. INNOMINATE AND SUBCLAVIAN ARTKItlEB. 205 outer edge of Scalenus Antious and lower border of First Rib) — continued. No. Date of oporaliou ? ■2 r^ ° fc. -- t^ ase .Si'is^ OJ o d H -a 196 197 198 199 200 201 202 Recovery Condition. CauHe of death, date after op. Jan. 17, 1865. 204 203 17th- 29th Jan'y. Unknown. Sept 11, 188.3. July 26, 1S66. June 13, 1865. Died. Recovered. Recoveied. Recovered. Oc- curred. Oc cuired. Recovered Cured. do. do. do. 14th day. Pysemia; hemorrhage. 6th day. Pysemia. 11th day. Pyamia; hemorrhage. At the foot of page .047, of IhI unvi^. vuluDio of hiH ma>.'niflcent bintory. Dr. G. A. OtiH wayw : '' I shall ('nuincrate a total of .02 cases of ligature of the subcla- vian (in a future volume) with 41 deaths." I have been able to And, and have given lieretoforo (Iroiu the 1st and 2d voluniei, 4.') cases, 37 of which were fatal. There is left to be reca|iitulated in the 3d volume, an additional nuiiiber of 7 cases, of which 4 (_|_;^7 = 41) were tatal, and 3 recovered. I have (in order to be as exact as possible) included Dr. O. M. Humphrey's case, as I am sure Dr. Otis will have this case in the 3d volume. 1 could not obtain from the Surgeon- General's office advance copies of these cases, on account of the labor requisite to hunt them out in advance. I am under many obligations to Dr. Otis for prompt answers to inquiries and otlier courtesies. — Author. In this category I might include 4 fatal cases of ligature of sub- clavian for shot wounds, by Hopkiuson, Wells, Kennedy, and Andersou, given by Prof. T. G. Morton, in Am. Journal Med. Sci., July, 1867. These are doubtless included by Dr. Otis in the above .02 cases, and I have so considered tliem rather than incur the risk of counting them twice. 4th and oth days, symptoms of pneumonia ; 6th and 7th. rigors and pysemic symptoms ; uafa- vorable couditions increased, a diarrhoea occurred, and death on 14th day. The ligature of the subclavian did not arrest the hem. completely, and ope- rator could not tie bleeding vessels in wound on that ac- count. Patient was in 6th week of a spell of low fever, and was consequently much exhausted. Abscesses in various parts of body. Gangrene of forearm just before death ; numerous abscesses in lungs ; artery firmly closed on botli si'fes of ligniure ; both axillary artery and vein wound- ed, the "latter most so. Arm slightly paralyzed from in- jury to nerves by missile. 3d day. Exhaust'n ;1 Before operation, hemorrhage 16 hem.; gangrene. oz. ; 3d day, do. 6 oz. Autopsy: Axillary wounded in 2d divi- sion ; diffuse aneurism ; gan- grene of arm (slight). 206 PEIZE ESSAY. Ligature of the Subclavian Artery in its Third Surgical Division (between Name of operator. Source of infoimation. Cause of operation. C 33 >« bo 207 210 211 212 213 215 216 217 218 219 220 221 223 Schauerburg, isee. Asch, 1S66. Demme, Sr. Forster. ' Chassaignac. do. Arch. Klin. Chir. Bd. X. p. 236. Schmidt Jahrbuch., Bd. xcvli. p. 3il, 1858. Arch. Klin. Chir. (cit.), p. 237. do. Chassaignac traits Clin, et Pratique, Paris, 1S61, t. i. p. 316. do. Lannelongue, Bordeaux. Legouest. Middeldorpf. N^laton. Pelican. Nussbaum. do. do. O'Reilly, Dublin. Pirogoff. Schmidt Jahrbuch., Bd. cxv., 1862, p. 376, Legouest Chir. d'armee, 1863, p. 421; Arch. Klin. Chir., (cit.), p. 238. Arch. Kliu. Chir., (cit.), p. 238. Schmidt Jahrbuch., 1856, Bd. Ixxxix. p. 225 Arch. Klin. Chir., Bd. X. p. 239. Arch. Klin. Chir., Bd. X., 1869, p. 238. do. Cyclop, of Anat. Phys., vol. iv. p. 616-17. Arch. Klin. Chir. (cit.); Pirogoff's Military Surgery, p. 4-19. M. iSol- R. dier Sol- dier M. M. M. I Sol dier Sol- dier Sol dier Hemorrhage (shot wound slioulder- joint fracture). Axillary aneur. (shot wound). Subclav. axillary aneurism. Punctured wound of axilla. Hemorrhage after excision of hu- merus. Hemorr'ge (after division of cica- tricial contrac- tions in axilla?). Aneurism of ax- illary (traumat- ic). Hemorrhage (re- section of hu- merus). Aneurism (sub- glenoid disloca- tion). Hemorr'ge (after disarticulation of humerus). Hem. during rem. cancerous tumor of axilla. Hem. punctured wound axilla. Immense tumor of axilla. Diffuse aneurism Hemorr'ge (after ligature of bra- chial for traum. aneurism). 3d divi- sion. do. do. do. do. do. do. 3d divi- sion. Pro- fuse.. Occur" d often. Often. I N N O M I N A T K AND S U ]1 C L A V I A N A K'l' K li I JO S . 207 outer edge of Scalenus Anticus arid lower border of Fir d Rib) — continued. No. Dato of operatiou. t1 (H 1^ o ci 3 OJ o c« w -a RESULT. REMARKS. Recovery. Condition. Cause of death, dato after op. 207 July, ISGC, 1S66. ? ? ? r ? ? ? ? ? ? ? ? ? ? 1833. 7 2d day. Pnenmo- tliora.v ; pneumo- nia. Ilomorrhage. 22d day. Hemor- rhage; pneumonia. 8th day. Gangrene. Panctiire of pleura dnring pas- sage of noodle aroiiml Hrtory; violent influx of air to pleural cavity. AiitopHy: Right lung coniplotoly collapsed and proH--- ed against vortoliral column ; pleiiritis ; pneumonia of left lung. 208 Oc- currod. 13, 14 209 Pneumonia accompanied with cough Hupervonod and homor- rhage occurred l.'Uh and J 4th days after operation. Auto)>.sy : Pneumonia; rupture of artery at seat of ligature. 210 Recovered. Cured. 211 None. Did well until 4th day, when gangrene ensued, causing death on 8th day. 212 One I'ecovered. Cured. 213 One died. Died. Pyasniia. Several days. Hem. Died. Died. concerning these two cases than this short extract in Chassaig- nac's work cited- "Deux lois 2U j'ai pratique la ligature de la soiis-claviere ; une fois avec succes chez un malade qui avoit subi le disarticulation de I'epaule suivie d'hemorrhagie consecutive. Une autre fois chez un homrae qui apres la section d'uu bride inondulaire de I'aisselle a volt en des henior- rhagies recidivtes." — {Author.) (1 could not obtain the Journal de Bordeaux, where a full ac- count of this case is given. The Jn.hrbv.ch only contains an- nouncement. — author.) 215 Once. Recovered. Cured. 217 Once. Rupture of sac ; death. Autop- sy : Arteria dorsalis scapulse opened into sac. 1^1 S 219 Recovered. Recovered. Cured. ? Cured. ?,?0 ?!?1 (Dr. Wilhelm Koch gives this as a fatal case. Kusbaum says the operation was unauccess- fnl. As the probability is that Dr. N. lold Prof. Gurlt it was fatal (see Archiv), I have so marked it. — Atithoi-.) Thrown by runaway horse dis- location of shoulder; reduction; aneurism appeared (due to in- jury by fall or reduction?); 4th and" 6th fingers were destroyed by gangrene. 222 Recovered. Recovered. Cured (lost two fin- gers.) Cured. 223 208 PRIZE ESSAY. Ligature of the Subclavian Artery in its Third Surgical Division [between Name of operator. Source of information. PATIENT. Cause of operation. o Pi m .2 ^ Hi ^ bo 'A IB m 6 be < 03 fi a ■",-( Pirogoff. do. do. Broca, 1862. Seyppel, 1880. Langenbeck. Graf, E., 18a6. Holthouse,1864. Pereira, 1826. Vianna, 1S45. Almeida, 1846. Texeira, 1847. Barbosa, 1832. Bryant, Thos. Biirt, W. (On- tario), 1873. Bennett, E. P. (Conn.), 1867. Butcher. Busch, F., 1872. Bickers teth, 1864. Cledoux, 1875 ? (Navorreux). Arch. Kliu. Chir. (cit.); Pirogoif's Military Surgery p. 449. Surg. Anat. Arteries. do. Military Surgery. Lancet, July 2, 1870, p. 11. Arch. Klin. Chir., (cit.), p. 241. do. do. p. 242. do. Arch. Klin. Chir., (cit.); Journ. Med. Soc, Lisbou, 1862, p. .S86. do. do. do. do. System of Surgery, Phila., 1873, p. 204. N. Y. Med. Jr., Oct. 1873. N. Y. Med. Record, Nov. 1837. Schmidt Jahrbuch., Bd. cxxxiv. S. 359. Archiv fur Klin, Chir., Bd. xv. p. 475. T. Holmes in Lancet, 1872, vol. ii. p. 37. Gaz. Ae^ Hop., 1876, p. 237. M. M. M. Sol- dier Mid age Sol. dier E. R. L. Hemorr'ge (after liirature of bra- chial for traum. aneurism). Malignant tumor of axilla. Hemorrhage shot wound subclav. axillary. Innominate aneu- rism. Axillary aneur. after punctured wound. ? Hemorrhage after ulceration arm. Aneurism (trau- matic). Axillary anetir. do. do. do. do. Innominate aneu- rism. Hemorrhage after amputation of shoulder. Pulsating tumor of axilla in hu- meral region. Aneurism. Wound axillary (fracture of hu- merus). Aneurism of aorta and innominate. Aneurism, axilla- ry (gored by a cow). 3d divi- sion. '>,'>?> '>p,f, 9.91 13 days. 10 days. 3d divi- sion. do. do. do. do. do. do. do. do. do. do. do. do. do. do. do. do. mR M. 24 Wt 9M M. M. M. M. M. M. M. M. M. M. M. M. 32 33 37 51 41 50 41 33 35 30 42 43 E. 7 L. R. E. L. L. E. L. ? E. 231 9:n Before. 9,SS 9M 93n 9,Sfi 1^37 238 939 Often. 940 241 9,49, Oct. 7. 14,15, 23, 24. 243 M. 32 L. INNOMINATE AND SUBCLAVIAN AIlTEIilES. 209 Older edge of Scalenus Anlicus and lower border of First Itib) — continued. Dato of opoi'iitioii. O P CJ * O 1« Sept. 30, 181)0. Feb. 10, 1826. Mar. 184'). Oct. 28, 1S46. 1S47. April 2, 1862. Aug. 1871. July 1873. 239 1867. Oct. 24, 1S72. Oc- curred Oc- cun-ed. 3-13. Oc- curred, None? 1864? l&l^. Slight. 14 Recovery. Condition. Cause of death, date after op. IlKMARKS. Recovered, Recovered. Recovered. Recovered Recovered. Improved I Cured? Cured. Cured. Cured. Cured. Cured. Improved. Cured. Not cured. Recovered Cured. Hemorrhage. 6th day. Thlolatis. Hem.; pyajmia. 13th day. Hem. 16th day. Hem. Died. Several days. 7th day. Exhaus tion (pysemia?). 21st day. tion. SufFoca- Patient died a good while after operation, of pulmonary v;a.n- grene. The rarotid artery, which was not tied liecauKe thi;re wa» no pulsation in it, was found at autoppy to bo pervinuH, though mncii diminished in calihre. Nov. 17, patient was stabhcd in an affray ; hem. and marked infiltration of a.xilla ; 24th Nov. puncture of abscns.'*, severe ar- terial Iiem. and lii/ature of sub- clavian. Recovered slowly. 6 weeks after fracture of fore- arm, amputation of upper third humerus ; 2 weeks later the stump became greatly infiltrat- ed and swollen, and was punc- tured ; profuse hem. resulted, and littature of subclavian. Recovered within a yeai-. Suppuration and rupture of sac just before ligatuie. This patient recovered in 40 days. Recovered in 50 days. Patient still living. Rapid con- valescence followed, witli great dimioutioa and consolidation of the aneurism. Drunk ; run over by locomotive, crushing both arms. Right, amputated middle 3d forearm ; left, at shoulder-joint. Hera- orrliage profuse. Ligature of subclavian. Tumor ceased to grow, but did not decrease in size as result of operation. Probably connected with exostosis. Transfusion after ligature imme- diately. Autopsy: Lungs ge- latinous. (Query: Carcinoma or infarction?) Pus in medias- tinum. Carotid had been tied 7 weeks previously. Hemorrhage, immediately after accident, was arrested by tam- pon. Several days after, aneu- rism appeared. Slight hemor- rhage after operat'on, arrested by compress. 210 PRIZE ESSAY. Ligature of the Subclavian Artery in its Third Surgical Division (between Name of operutor. Source of information. Cause of operation. fi} Lane, James, 1871. Lancet, Jan. 13, 1872. F. 40 E. do. 5 mos. 3d divi- sion. w, Lang, Ed., 1873. Wien. Medizin.Woch., 1874, p. 770. M. 19 E. Hem. (fracture of OS humeri ; hem. after resection). do. do. 9m Morton, T. G., 1868. Am. Jr. Med. Sci., July, 1876. M. 37 E. Crushed shoulder (railroad acci- dent). A few hours. do. INNOMINATE AND SUBCLAVIAN ARTERIES. 215 outer edge of Scalenus Anticus and lower border of First Rib) — conUnucd. No. 2.J7 258 261 262 Date of operation. (H tj fJ O P ^""^ ^ t! *- t^ o g £ 0^ O cd a -a Recovery. Condition. Cause of death, date after op. 280 Deo. .'!, 1S2!). Nov. 28, 187G. 284 Aug. 6, 1874. None. 2()-27-2.s 30-31-32 Aug. 14, 1877. 1874. 1S72. 15 rem'd llccovored. Recovered. Recovered. Recovered. Cured. Much ina- proved. (?) Cured. JJiod aliout 3 iuoh. i2d day. Hemor- rhage; dyspnoea. Died after 3d day. Carotid waH tied Sept. 20,182:/. No bad Kymptoms followed. In Marcli previou.s iiaticnt first felt piiiu in sliouldor ; in .June, flrnt appearance of tumor; carbol- izcd catgut ligature used. 2 days before ligature of suhclu- vinn, tlie right carotid had been obliterated by means of Dr. Speir'a " conntrtctor." The carotid wound healed by firHt intention ; the subclavian went on to suppuration ; 2d day, tumor decreased one-half in size ; 4th day, neuralgia ; 7th, tumor increasing and looks red; 18th day, inflammation increas- ing, difficulty of deglutition ; 23d, intense pain through aneu- rism ; 2.5th, swelling spreading to right of sternum, with rnarlf- ed "bruit;" 26th, hemorrhage from tumor; 27th, do. and pul- sation noticed first time in ra- dial ; 2Sth, .30th, 31st, and 32d days, hemorrhage from sac ; death. Autopsy: Displacement of riirht clavicle, erosion of manubrinm ; liver waxy ; left kidney do. ; aneurism from transverse portion of arch : neither innominate nor carotid involved ; carotid closed by co- agnla, on both sides of constric- tion ; internal coat divided and tii.rned in; subclavian tied on both sides of the ligature ; thrombus in right subclavian vein ; sac full of clot. {Noteby^ author. — The " constrictor" of Dr. Speir seems to bid fair to prove a successful innovation in surgery, having been applied to all the large arteries with success, by the inventor.) Carotid tied simultaneously. Carotid tied same time; subcla- vian in 3d division ; 3 months after operation, patient was considered out of danger, and aneurism consolidated. Died 3 months after operation. See foot of page 100. 2 ligatures — Distal. This case is not considered in the sum- mary. Removed scapula and part of clavicle for disease after ampu- tation at shoulder. This case is not considered in the sum- mary. I SUMMARY OF THE SURGICAL HISTORY INNOMINATE AND SUBCLAVIAN ARTERIES. SUMMARY OF THE CASES OF LIGATURE OF THE ARTERIA INNOMINATA. I HAVE accepted as reliable 16 cases of ligature of this vessel. The case of Peixoto was not a ligature proper, as the thread was only passed around the artery and was not tightened. I have no reason to doubt the two cases of Bujalski reported verbally to Vel- peau, but, as I have been unable to find anything definite concerning them in the literature of this subject, they are noted and not included in the table. Porter's was a case of acupressure of this vessel. Of the 16 cases all were males. All died except one, and he re- covered, temporarily cured of the aneurism, which returned and caused death ten years later (see Table). The ages given are 57, 36, 52, 31, 30, 52, 46, 27, 40, and 32. Of the causes necessitating the operation there were — Aneurism of subclavian — Traumatic . 6 Idiopathic 3 Cbaracter of aneurism not stated o Hemorrhage' of the ligature of subclavian 1 Cause of operation not given ........ 1 Total . . . 16 Point of Ligature. — Location indicated in only 3 instances. Once " near the aorta." Once only h inch below the bifurcation of the innominate. Once 1 inch from the aorta. ' The case of Hutin. (221) 222 PRIZE ESSAY. Hemorrhage after Operation. Hemorrhage in 12 cases — . On cardiac side of ligature in 3 On distal side of ligature in 5 Source not stated 3 Into lungs (A. B. Mott), rupture of sac . . . 1 — 12 No hemorrhage in 3 cases — Death 8th day 1 " 2d " .1 " (date not given) 1 — 3 15 Not definitely stated (probably none) ; death 11 hours . . 1 Ligatures came away in only 4 cases, respectively on the 20th, 17th, 14th, 14th days. Recovery^ 1 case ; condition temporarily cured, with slight and probably temporary debility of right upper extremity. Causes of Death. Hemorrhage alone after operation 10 " with pericarditis 1 Exhaustion (with probably pysemia) 1 " ( " " " urasmia) 1 " from loss of blood before operation .... 1 Pyaemia (alone) 1 15 Complications loith Ligature. Ligature of innominate and carotid simultaneously . 1 A, B. Mott. Ligature of innominate and carotid simultaneously, and vertebral on 54th day 1 Smyth. Ligature of subclavian (3d division), and innominate 9 days later 1 Hutin. Ligature of innominate alone 13 Total 16 In the cases of Lizars and Valentine Mott, an anomalous branch (probably the inferior thyroid) was from the innominate near the ligature. In 5 of 34 consecutive cases examined as to this feature, I found this anomaly ; 3 of these 5 were branches to the thyroid body (the thyroid branch from the axis being wanting in 2) and two were pericardiac branches. In the cases of Lizars and Mott, the hemorrhage was from the seat of ligature. (I do not doubt that these abnormal branches were partial causes of the non-closure of the innominate.) INNOMINATK AND SUBCLAVIAN ARTERIES. 223 Dales of Dealh after Operation. Days. 26, 67, 8, 5, 18, 22, 17, 84, 23, 6, 9, 2, 2^, ^; not given 1. Total, 15. Condition of Vessel as shown hy Autopsy. V. Mott. Innominate not occluded on cardiac side of ligature. Portion beyond ligature had disappeared by sloughing, but the ends of carotid and subcla- vian were open. Graefe. Cardiac end of artery occluded, distal end open. Bland. Cardiac end occluded, distal end open. Carotid was closed by clot, but subclavian was open. Lizars. Both ends open. Gore. Both ends of innominate open. The carotid Avas open, but subclavian was closed. Arendt. Died 8th day. Ligature still in situ. Hall. Died 5th day. Ligature still in situ. Bickersteth. Died 6th day. Ligature still in situ. Clot in subclavian, none in carotid. Mott, A. B. Aneurism burst into thorax. Ligature separated on 20th day. No hemorrhage at seat of ligature. Conclusions. To arrive at a just conclusion as to the propriety of cleligating the innominate artery, it will be instructive and necessary to com- pare with this operation other and more conservative methods of treatment. Of the 16 cases given in the history, 14 were for relief of suh- clavian aneurism. In 1 the cause of the operation is not given. In 1 other (Hutin's) the cause of operation was hemorrhage. In this last case, a punctured wound of the thoracic branch of the axillary artery was the cause of ligature of the sulclavian, and, hemorrhage again occurring, of the innominate. It seems that to have enlarged the original wound and secured the bleeding vessel should have been the first step, instead of liga- ture of the sxilclavian. And after hemorrhage occurred again (as suggested by Dr. Otis in the Medical and Surgical History of the Rebellion), amputation at the shoulder would have been safer than ligature of the innominate. In 14 operations for subclavian aneurism we have 18 immediately fatal, and one "temporarily cured," which proved fatal, from the original aneurism, which reformed in the reversed collateral circula- tion^ about ten years later. 224 prize essay. synopsis of 22 cases of subclavian aneurism in which " no treatment" was undertaken. 18 deaths ; 4 spontaneous cures. (After PolandO 18 fatal cases. Dates of death after tumor was noticed (and when surgical interference might have been undertaken). 1 case. Aneurism had existed for " some time." Died 12 weeks after admission to hospital. 1 case. Not known how long aneurism had existed. 1 case. Lived " some months." Died of exhaustion and suppuration caused bj pressure of sac. 1 case. Died of rupture of sac 24 years after recognition of aneurism.- 1 case. Died from asphyxia caused by pressure of sac, 8 years. 1 case. Died from external rupture of sac 2 years and 8 months after recognition of aneurism. 1 case. Died from exhaustion from pressure of sac, 2 years after recognition. 1 case. Died from dyspnoea from pressure of sac, 2 years after recognition. 1 case. Died from dyspnoea and exhaustion from pressure of sac 1^^ year after recognition. 1 case. Died from rupture of sac into lungs Ig^ year after recognition. 1 case. Died from rupture of sac into lungs 81^ months after recognition. 1 case. Died from rupture of sac into tissues, becoming diffused, and causing death by pressure 5^ months after recognition. 1 case. Died from rupture of sac, death by pressure 5 months after recognition. 1 case. Died suddenly (probably from cerebral clot) 1^ year after recognition. 1 case. Died suddenly, cause not stated, not rupture of sac. 2 cases. Died from rupture of popliteal aneurisms. 1 case. Died from typhoid pneumonia 3 years after recognition. Of the 4 cures, 3 remained well ; 1 died about 4 years later from rupture of an aortic aneurism. Of these 18 fatal cases in which no treatment was undertaken, 3 died of other disease than the aneurism. Of the 13 cases in which the duration ot life is noted after the recognition of the aneurism, the sum total is 47 years and 9 months The sum of life in the 13 cases after deligation of the innominate is about 8 months, a difference in favor of non-interference (in an equal number of cases) of about 47 years of life. An examination of the cases on the next page will show that judicious treatment without ligature is a more successful method than either this latter or perfect non-interference. INNOMINATE AND SUBCLAVIAN AltTEI4IK3. 225 SYNOPSIS OF 14 CASES TREATED BY VALSALVA'S METHOD. (More or less modified.) 1 case. M. ; R. Subclavian aneurism. Size, hen's egg. Venesection ; cold and lead lotion locally. Recovered. Two and a half years later was work- ing as a carter in the city. 1 case. M. ; R. Subclavian. Immense size. Venesection. Cold and astringents locally. Tumor reduced in size and firmer; lost sight of while in pro- cess of cure. lease. M. ; R. Subclavian (syphilitic)r Valsalva's method and antisyphilitics. Cure complete. lease. M.; R. ; age 45. Subclavian (syphilitic). Valsalva's method and anti- syphilitics. Cured and seen well 6 years later. 1 case. M. ; age 42. Subclavian. Venesection. Digitalis. Rest. Marked im- provement, so that patient left hospital and was lost sight of. 1 case. M. ; age 50. Subclavian. Was treated for an intercurrent attack of rheu- matism by rest, strict diet, and antiphlogistics. Cured. 1 case. M. ; age 39. Subclavio-axillary (Pancoast's case). Valsalva's method had been tried and considered a failure. Operation determined on. Carried into operating room. Patient fell into collapse and operation was post- poned. Recovered cured. (It is stated that a large dose of aconite had been given by mistake just before the operation was to have taken place.) 1 case. M. ; age 37. Subclavian. Venesection. Valsalva's method and careful and persistent direct compression for 1^ year. Cured. 1 case. M. ; age 51. Subclavio-axillary (by Pelletan). Valsalva's method. Cured. 5 cases treated by this method (in part) were fatal. Venesection was not practised except in one case. Only local and constitutional treatment. All died within 12 months of the recorded recognition of the disease ; 1 from ulceration into trachea, haemoptysis, and exhaustion; 2 from external bursting of sac ; 2 from exhaustion and coma (with pressure on the trachea in one case). Summary. — 14 cases. Cured 7 ; improved, and in process of cure when lost sight of, 2 ; died 5. No venesection in 4 of 5 fatal cases. 1 successful case modified by direct pressure. SYNOPSIS OF 6 CASES TREATED BY DIRECT PRESSURE UPON THE SAC (modifications GIVEN). (All subclavian aneurism.) 1 case. M. ; 46 years ; R. Leather " cup" moulded over tumor and held in place by figure-of-8 straps around shoulders and axilla. Cured in 14 months. Did light work during treatment, and had no other medication. lease. M.; 39 years; L. Enormous size. Treated by cold and pressure "in turns." Small cannon-ball suspended so as to press comfortably. Dis- charged relieved. Some months later violent inflammation (from fall), suppuration, rupture of sac, discharged two quarts of pus and blood. Cured. Debility of arm probably permanent. 15 226 PRIZE ESSAY. 1 case. M. ; 41 years. (13 months' dui'ation.) Kept in bed, on back, ice locally, restricted diet. 3d day air cushion for 12 hours with intermissions amounting to 3 hours. Every half-hour interval of ice. Treatment for 7 days. Tumor began to subside and was cured in 12 months. 1 case. (T. Holmes.) [Lancet, Feb. 12, 1876, p. 237.) Subclavian. Treated by direct pressure from rubber ball. Cured. 1 case. (Dupuytren.) Direct pressure. Eesulted fatally. 1 case. (Porter.) Exposed axillary and passed needle under it. 35 days later exposed innominate and passed the " acupressure needle" under it. Died from hemorrhage from innominate on 10th day. (In 1 case given in preceding table, direct pressure was practised with Valsalva's method.) Summary. — 5 cases of "direct pressure" (without operative pro- cedures). Cured 4 ; died 1. SYNOPSIS OF CASES OF MASSAGE OR KNEADING IN THE TREATMENT OF SUBCLAVIAN ANEURISM. Of this method there are 6 cases. 3 cured ; viz., by Fergusson, Little, and Porter. 3 died ; viz., by Fergusson, Hilton, and Morgan. (See Guy's Hospital Reports, vol. xvi. p. 42 et seq.) In addition, Mr. Bryant, in his "Practice of Surgery," p. 190, gives a case by Dutoit, of Berne, in which a subclavian aneurism was cured by injection of ergotin around the sac under the skin, and digital compression. Poland cured one case by digital pressure on cardiac side. A third case was tried for 46 hours and abandoned on account of pain from pressure. The patient died from exhaustion. Paget tried mechanical pressure in a fourth case, but abandoned it as a hopeless undertaking, A fifth case by Yerneuil was improved, but lost sight of before a cure was effected. Conclusions. 1. That the circumstances justifying ligature of the arteria inno- minata, for the cure of subclavian aneurism, will occur so rarely that practically the operation should be abolished. 2. That nature, unaided, is more successful than surgery which ligatures the innominate. 3. That judicious venesection, prersistent and perfect rest in bed, restricted diet, careful medication, combined with a determination, INNOMINATE AND SUBCLAVIAN ARTERIES. 227 on the part of both patient and surgeon, to succeed, is safer and more certain of success than either nature or the ligature. 4. That direct pressure by means of any substance that will press equally upon the entire surface of the tumor (Holmes's elastic ball seems best adapted), applied gradually, in order to accustom the patient and the tumor to its presence, in connection with the last method above mentioned, is surest of success as compared with all known methods of treatment. 5. That, should all these means fail after a persistent trial, should the sac by ulceration open and threaten instantaneous death, or should the surgeon from the appearances judge that this accident was on the eve of occurring, then I should deem ligature of the innominate artery justifiable and imperative. As insisted upon in the "operative surgery" in connection with this vessel (which see), the artery should be twisted after being tied, the carotid treated in the same manner, and the subclavian tied near the innominate. It is most probable that this last vessel will be so involved in the disease that torsion would scarcely be safe. In all cases the vertebral, the thyroid axis (or its branches), the internal mammary, the intercostal, and the posterior scapular should be tied or twisted. 6. That "kneading, or massage," has an element of danger in the suddenness of its action, and is inferior to the above method. 7. That pressure on the cardiac side is scarcely practicable; while pressure on the distal side is dangerous and useless as compared with other methods. 8. That the introduction of wire, horsehair, acupressure, galvano- puncture, and injections into the cavity of the sac are not to be practised. 9. That in wounds of the innominate it should be tied and twisted (as heretofore given), and the carotid and subclavian treated as before. [In case the carotid were wounded within half an inch of the in- nominate, or the subclavian within the same distance, I would consider it safer to practise ligature of both carotid and subclavian, and then torsion of both "stumps" with the innominate — the distal ends of these two vessels to be treated as above. Especially would I insist upon this in wounds of the subclavian, since ligature of this artery in its first surgical division has invariably proved fatal. (See 19 cases in history.)] 228 PRIZE ESSAY, GENERAL SUMMARY OF CASES OF LIGATURE OF THE SUBCLAVIAN ARTERY. This collection of cases includes 283 instances of ligature of the subclavian artery (all in the third surgical division, excepting 32). The sex is given in 262 cases; of this number 240 were males and 07ily 22 females; an unmistakable indication that exposure and violence are causes of the lesions requiring so grave an operation. As to the side of body, mention is made in 222 cases ; of which 132 are on the right, and 90 on the left side. The ages of the patients were as follows (as far as noted): — 17 years of age 1 43 years of age 3 18 " " " 3 44 " " " 1 19 " " " 4 45 " " " 2 20 " " " 6 46 « u » 1 21 " » " 13 47 " " " 3 22 » " " ■ . 8 48 " " " 3 23 " " " 4 49 « " " 2 24 " " " 2 50 " " " 8 25 " " " 5 51 " " " 3 26 " " " 2 53 " " " . 1 27 " " " 4 54 u u u 4 28 " " " 7 55 " " " . 3 29 " " " 3 56 " " " . 1 30 " " " 11 57 " " " . 1 31 " " " 5 59 " " " . 1 32 " " " 6 60 " " " . 3 33 " " " 8 61 " " " . 2 34 " " " . • - . 5 63 " " " 2 35 " " " 11 65 " " " 1 36 » " " 9 68 " " " 1 37 " " " 6 73 " " " 1 38 " " " 4 Noted as old . 1 39 " " " 4 " child . 1 40 " " " 13 " " young 2 41 " " " . 3 " " middle-aged 15 42 " " " . 3 A resume by decades shows that accidents leading to ligature of the subclavian are more apt to occur in the "active periods" of life. Under 20 years there were only 9 cases. From 20 to 30 years there were 48 " " 30 " 40 " " " 69 " " 40 " 50 " " " 34 " " 50 " 60 " " " 22 " " 60 " 73 " " " 10 " INNOMINATE AND SUBCLAVIAN ARTERIES. 229 7 th day 1 9 " 1 10 " 2 11 " 6 12 " 10 13 " 8 14 " 3 15 " 7 16 " 5 17 " 7 18 " 8 19 " 6 20 " 4 21 " 4 22d day 23 11 24 If 26 a 27 " 29 li 31 a 32 " 34 il 36 « 43 « 47 i( 85 la(k>)- Arnpiit:ition (No. lOl). 7 cases (nothing specially interesting in character of injury;. 9 Total. Of punctured wounds there are 13 cases, with 9 cures; 4 deaths. Ratio of mortality 31 per cent. Ligature of the Subclavian in its Bd Division on account of Surrjical Procedures. Synopsis of fatal cases. Cause and date of death : — 1 case. "Wound of axillary in reduction of shoulder. Died of exhaustion and gangrene, 6th day. 1 case. After amputation. Prostration, 6th day. 1 case. After amputation. Prostration, ? 1 case. After ligature of axillary for shot wound, a few minutes. 1 case. After reduction of shoulder, 2 months. 1 case. After removal of head of humerus. Exhaustion, 25th day. 1 case. After excision of head of humerus. ? ? 1 case. After opening abscess of axilla. Pyaemia, 6th day. 1 case. After dividing cicatricial contractions of axilla. ? 1 case. After removal of sarcoma of axilla. Septicaemia, 20th day. 1 case. After sarcoma (supposed aneurism). Hemorrhage, 2,oth day. lease. After removal of mamma (sarcoma ?). Pleuritis, 3d day. lease. After removal of humerus. Carcinoma. Septicaemia, 5th day. 1 case. After removal of humerus. Carcinoma. Exhaustion, 3d day. 1 case. After removal of tumor in axilla. ? ? 1 case. After fungus, axilla (supposed aneurism). Exhaustion, ? 1 case. After malignant tumor of axilla. Phlebitis, 6th day. 17 Total. The 15 cases of recovery under the above heading are given below. Cases of recovery. Cause of operation, etc.: — 1 case. Amputation for encephaloid of humerus. 1 case. Eemoval of clavicle and scapula for osteo-sarcoma (No. 91). 1 case. Removal of head of humerus and scapula ; cancer. 1 case. Eemoval of sarcoma of axilla. 1 case. Removal of carcinoma of axilla. 1 case. Osteo-sarcoma. Supposed aneurism. Recovered, not cured. 2 cases. After ligature of brachial for aneurism. 2 cases. After opening abscess in axilla. 2 cases. Amputations for railroad crush. 1 case. After resection of humerus for fracture. 1 case. After excision of humerus for fracture. 1 case. Ulceration of amputated stump. 15 Total. 238 PRIZE ESSAY. Out of 32 cases coming under the above caption 17 were fatal, or 53 per ct. (It is worthy of note that of the 15 recoveries, 6 were in connection with malignant diseases.) Resume of Cases of Ligature of the Subclavian in its 2>d Division on account of Hemorrhage. Gunshot wounds .... Lacerated wounds ... Punctured wounds . ? wound Hemorrhage after, or on account of, sur procedures' Total . . . Or a death-rate of 65 per cent. Cases. Died. Recovered . 49 41 8 3 2 1 13 4 9 1 1 irgical 29 15 14 95 62 33 SUMMARY OF CASES OF LIGATURE OF THE SUBCLAVIAIST ARTERY FOR ALL LESIONS EXCEPT ANEURISM AND GUNSHOT WOUNDS IN ITS FIRST, SECOND, AND THIRD SURGICAL DIVISIONS. Under this head there are 52 cases in the table, with 27 recoveries. The conditions are as follows : — ■ Cured with no remaining lesion 20 Cured with amputation of scapula, clavicle, and humerus for osteo- sarcoma . 1 Cured with amputation at shoulder (punctured wound) . . .1 Cured with amputation at upper third (railroad accident) . . 1 Cured with amputation at shoulder ...... 1 Cured with resection of arm 1 Case not cured (tumor still persisting) ...... 1 Reported as recovered, no mention made of condition ... 1 Total 27 Resume. Ligature in the third Division on account of Aneurism. Under this head I have made a summary of the following sub- divisions, viz. : — 1st. Subclavian aneurism.^ 2d. Subclavio-axillary. 3d. Axillary. ' The 3 cases of "supposed aaelTrism" are omitted in this r/sumi. 2 It is very probable that all of these cases were subclavio-axillary, as it would be difficult to tie the artery in its third division for aneurism luvolving this portion alone. INNOMINATE AND SUBCLAVIAN ARTERIES. 239 4tli. Aneurism on distal aide of ligature, situation not given. 5tli. Aneurism on cardiac side of ligature. (Wardrop as sug- gested by Brasdor.) For Subclavian Aneurism. Total 5 cases; recovered, 2. Of tlie 3 fatal cases the cause of death in — 1 was gangrene and exhaustion, on 5tb day. 1 (probably injury of thoracic duct) on ? 1 cause not given. Suhclavio- Axillary Anenrism, Total 29 cases. Died 13, or 45 per centum. The cause and date of death and cause of aneurism as far as given were in — 1 case exhaustion . 1 case exhaustion . 1 case exhaustion . 1 case hemorrhage ] case hemorrhage I case pleuritis, pneumonia, em- physema . 1 case hemorrhage I case hemorrhage 1 case hemorrhage 1 case hemorrhage and pj-aemia 1 case pleuritis 1 case phlebitis and coma 1 case pneumonia . 5tli day, fall from horse. 4th day. ? 7th day. ? 35th day, syphilis. 29th day, carrying weight on shoulder. 15th day. ? 12th day, rheunuitisra. 65th day, rheumatism. ? day, shot wound. 14th day, punctured wound. 3d day. ? 22d day, fall. 22d day. ? 13 Total. Of the 16 recoveries, all were cured but one. In 8 cases no cause of disease is given. In 1 case the cause was " strain while drawing a cork !" In 1 case " barrel fell on shoulder." lu 1 case " struck with rope." In 1 case shot wound (military). In 1 case (No. 147) after amputation. In 1 case " cask fell on shoulder." In 1 case shot wound (civil). In 1 case idiopathic. Axillary Aneurism. The ligature was applied in the third division on account of "axillary aneurism" in 75 cases, with 47 recoveries; the death-rate being 37 per cent. As far as given the following is a synopsis of the causes and dates of death and the cause of the aneurism in the 28 fatal cases. 2-iO PRIZE ESSAY. 1 case. Exhaustion 1 case. Cerebral symptoms . 1 case. Hemorrhage 1 case. Hemorrhage 1 case. Hemorrhage 1 case. Hemorrhage 1 case. Hemorrhage 1 case. Hemorrhage 1 case. Hemorrhage 1 case. Hemorrhage 1 case. Hemorrhage 1 case. Hemorrhage 1 case. Hemorrhage 1 case. Hemorrhage 1 case. Exhaustion and hemorr. 1 case. Exhaustion 1 case. Exhaustion 1 case. Exhaustion 1 case. Exhaustion 1 case. Exhaustion 1 case. Exhaustion and dyspnoea 1 case. Shock 1 case. Cause unknown 1 case. Cause unknown 1 case. Cause unknown 1 case. Cause unknown 1 case. Cause unknown 1 case. Pyaemia . 5th day. ? 8th day, traumatic. 12th day, rheumatism. 6th day, punctured wound. 15th day, punctured wound. 37th day, " sack of beans fell on shoulder." 27th day. ? 46th day, shot wound. ? shot wound. 16 th day. ? 62d day. ? 42d day, " rebound of cannon." 33d day, reduction of shoulder. 14th day, shot wound. 60th day. ? 30th day, fracture of humerus. 46th day, idiopathic (opened for abscess). 30th day. 2d day, shot wound. 12th day, shot wound. 6 hours, shot wound. 4th day. 4th day, traumatic. ? pistol wound (civil). ? traumatic, several days ? ? thrust of pitchfork. 18th day. ? 28 Total. In the 47 recoveries, the causes of the aneurism as given were — 4 cases. Idiopathic. 7 cases. Punctured wounds. 4 cases. Shot wounds (2 civil and 2 military). 2 cases. " Fall." 2 cases. " Strain." 1 case. " Fall, with wound and dislocation of shoulder." 1 case. " Fall and catching by arm." 1 case. " Muscular exertion." 1 case. " Gored by cow." 1 case. " Lifting weight." 1 case. " Thrown from carriage." 1 case. " Traumatic." 26 Total given. In addition to the foregoing there were 12 cases of aneurism be- yond the seat of ligature, the vessel involved in the lesion not being given. The majority (if not all) of these were no doubt aneurisms of the axillary ; 6 died and 6 recovered. INNOMINATE AND S L/ B C L A V I A N A li 'I' E It 1 K S , 241 The cause and date of doatli, and cause of aneurism were- I. Ilc'iiiorrliiigu 1. i l('in()rrliii<,^c 1. JIcinorrlia<;o 1. KxlituiHtion .... ]. ? . . . . 1. Iiifiammatioii of kiic, plciiritis, and pericarditis Causes of aneurism in the 6 cases of recovery 3 cases. Cause not given. 1 case. Punctured wound. 1 case. Pistol-sliot wound (civil). 1 case. Dislocation or reduction of shoulder. 7tii day, sliot wound (civil), ll'itli day, Iranmatic. Hevei'al days, dislocation (subglenoid). 4tli day. V ? ? 7 til day. SYNOPSIS OF CASES OP LIGATURE OF THE SUBCLAVIAN IN ITS uD DIVISION, FOR ANEURISM BETWEEN THE LIGATURE AND THE HEART. (Wardrop's operation, after suggestion of Brasdor.) 1. Ligature of subclavian alone. • 2. Ligature of subclavian and the right common carotid. Ligature of Subclavian alone. 1 case (No. 61. Wardrop). Recovered, temporarily relieved. 1 case (No. 227. Broca). " " " 1 case (No. 237. Bryant). " permanent relief. Total 3 cases. (Wardrop's case died of the disease 2 years later. Broca's of "pulmonary gangrene." Bryant's case was alive and doing well at last account.) The following cases were ligatures of the 3d portion, and of the carotid : — Operations Simu'taiieous. Fatal cases: — No. Operator. 246. Durham. 247. Eliot. 248. Ensor. 257. Holmes. Hodges. Weir. Maunder. Seat of Aneurism. Date of Death. Innominate. 6th day. 25 Aorta and innominate. 65 " Innominate. 57 " 11 " 11 " " Few days. Cause. Shock. Hemorrhage. 260. 279. 283. Recoveries: — 284. Barwell,' aortic, carotid, subclavian and innominate aneurism. cure, 3 months later doing well. 276. Sands, aorta. Died 13 months later from the aneurism. Probable ' Barwell's case died three months after operation. (See foot of page 100.) 16 242 PRIZE ESSAY. 259. Heath, innominate. Died 4 years later from the aneurism. 261. Lane, innominate. No improvement. 270. Little, innominate or aorta. Marked improvement, one year after opera- tion doing well. Cases in which the carotid was tied at a previous operation. Fatal cases: — ■ 242. Bickersteth, innominate and aorta. 21st day, suffocation. Carotid tied 7 weeks previously. 280. Wickham, innominate. Died 3 months. (?) Carotid tied about 3 months previously. 282. Speir, aortic. Died 32d day, hemorrhage. Carotid obliterated by " con striction" 2 days before. Recoveries: — 255. Fearn, innominate. Much improved. Carotid tied 2 years before. 265. A. B. Mott, innominate. Cured. Carotid tied by Doughty, of New York, 1 year previously. Total 17 cases ; 10 deaths ; 7 recoveries. [On a previous page I have given 6 other cases of the double operation (see ISTos. 14 to 19 inclusive), all of which were fatal, making 22 cases, with a mortality of 16, or 73 per cent. Hemor- rhage was the cause of death in 10 of these 16 fatal cases; viz., from the -sac in 5 instances; from the distal end of the subclavian in 3; the carotid in l;-and rupture of the internal jugular in 1 (Hodges). Hemorrhage occurred in one case which recovered temporarily (Prof. Sands).] A GENERAL SUMMARY OF CASES IN WHICH THE SUBCLAVIAN ARTERY WAS TIED IN ITS IST, 2d, AND 3d DIVISIONS ON ACCOUNT OF ANEURISM. Of the 283 cases of ligature of the subclavian given in the accom- panying "History," 167, or 59 per cent., were for the cure of aneu- risms. All of these aneurisms were beyond the ligature excepting 21, which were lesions of the aorta, innominate, or both. As to Sex. Of the 167 cases, the sex is stated in 153 ; of which 140 were males, and only 13 females / We may expect (according to this ratio) to meet with 12 males with aneurisms, suggesting ligature of the subclavian, to 1 female. It is an interesting fact, that, in 13 females, suffering from aneurisms for which the above operation was performed, 6 {or one-half) were for aortic or innominate aneurism, the ratio in males being only 1 in 13 cases. INISrOMIlSrATK AND S IJ IKJ L A VI A N" ARTICRIPJS, 243 Of tlie 21 cases of the distal operation, the sex is given in 17, of which 11 are males and ^females. All of the females recovered hut one^ while of the 11 males only three recovered. It is clear from this that the distal ligature is fuller of promise in females than in the opposite sex. I am of the opinion that this is due to the fact that women are more patient and obedient under treatment, and can be kept quieter than men. As to Side of Body. ^he side is designated in 145 instances: on the r?>//i^ in 89; on the left in 56. According to this aneurism will exist about 1-| times on the right, to 1 on the left side. Of the entire 167 cases of aneurism, 85 recovered, a death-rate of 49 per cent. Of these 85 recoveries the side of body is given in 80, 37 on the right and 43 on the left. Since the artery was tied on the right side in 89 given cases, with only 37 recoveries, we have a death-ratio of 58.5 per centum on this side ; while on the left side, out of 56 given cases there were 43 re- coveries, or a death-ratio of only 23.2 per cent., a difference of about 35 per cent, in favor of the ligature of the left subclavian artery. (This difference is doubtless in great measure due to : 1st, the "Brasdor-Wardrop" operations being on the right side. 2d, the greater length and more favorable position of the left subclavian.) The condition after recovery on the right side is as follows : — Reported permanently and completely cured 24 With amputation at the shoulder, cured 1 With loss of use of hand by ulceration, cured 1 Aortic or innominate aneurism (distal), " improved" ... 2 " " " " improved" (died, 4 years, of aneu- rism) 1 Aortic or innominate aneurism, " improved" (died, 13 months, of aneurism) . 1 Aortic or innominate aneurism, " no better" 1 " " " " improved," died, few months, of pulmonary gangrene 1 Aortic or innominate aneurism, " improved" (died in 3 months of pleuritis I Aortic or innominate aneurism, " temporary relief," died in 2 years of aneurism 1 Contents of sac remained fluid for some time 1 Aneurism persisted 5 years after operation 1 2M PRIZE ESSAY. Of the conditions on the left side, in 43 cases Cured without any injury or lasting deformity " Avith amputation at shoulder (gangrene) (fall) " ' " upper 3d (pistol shot) " partial anchylosis of elbow (punctured wound) " (fall) " " disability of arm (shot wound) . " lost two fingers, gangrene (fall) Small tumor persisted in Noted as recoveries, cure not reported . 32 1 1 1 1 1 1 1 1 3 43 It will be seen that not onlj are the chances for recovery greater after ligature of the left subclavian for aneurism, but that the recovery is more apt to terminate in a complete cure than upon the right side. Conclusions as to Ligature of the Sid'clauian Artery in its third Surgical Division. 1. That in gunshot wounds of the axillary region, the ligature of the subclavian is fraught with danger from secondary hemorrhage after the establishment of the collateral circulation. That ligature in the seat of injury, upon both sides of every bleeding vessel (in this as in all other lesions) without regard to the extent of the in- cisions necessary, should be the practice. That wounds thus made in the track of the original wound should be left freely open for drainage. That in case the tumefaction or any accidental condition of the part injured should render the operation at the seat of lesion impossible, then the subclavian should be tied in its third division, the posterior scapular sought for and tied (if present). Two ligatures should be placed upon the subclavian, the vessel divided between them, and torsion practised with both ends. 2. That in all lesions causing dangerous hemorrhage, while the danger of death does not exist to such an alarming extent as in gunshot wounds, the same operative procedures should be practised as in the foregoing class of cases, subject to the same exceptions. 3. In aneurisms of the axillary region, the ligature (which is fatal in 40+ per cent.) should not be attempted until a persistent trial is made of the various methods recommended under the head of " Aneurisms of the First Surgical Division." Digital or mechanical pressure as the vessel crosses the first rib, in connection with Val- salva's method, rest on the back, gentle pressure directly upon the INNOMINATE AND SUBCLAVIAN AltTKRIES. 245 tumor, if undertaken with a determination on the {)art of both sur- geon and patient to succeed, will ([ believe) fail so rarely that ligature of the subclavian will not be necessary in the great majority of cases. Should however the necessity arise, the same rules are applicable as heretofore given. 4. Simultaneous ligature of the subclavian and carotid arteries for relief of aneurism on c«n/i«c side of these ligatures (Brasdor- Wardrop) is of questionable propriety. I would advise that the conservative methods given (and illustrated in the successful cases) heretofore be courageously and persistently tried. Should these fail and deligation be determined upon, the carotid should be first tied, and, after an interval of some weeks, the subclavian, in its third division (subject to the rules laid down in the operative surgery, which see). The subclavian should not be tied first, since the danger of an embolus being carried into the cranial circulation would be thus increased. Fig. 1. c % fl ,2 H a ^ o to fc tc pS ^ y2 CO ^ "aj 3J c3 * > S t« c3 "S ^ b N.^ to t^ Si Fig. 2. Range of origin of the right and left vertebral and internal mammary arteries (deduced from 52 consecutive dissections). (Figure reduced from life-size drawing.) Fiq. 3. Suprascapular Supr. Intercostal Int. Mammary ' Comes Nervi Phr. - "- Suprascapular Int. Mammary Supr. Intercostal CORONARY- Occasional abnormal positions of the branches of the subclavian arteries. (Reduced from life-size drawing.) Fig. 4. Range of origin of the inferior thyroid, posterior scapular, and superior intercostal branches of the right and left subclavian arteries. De- duced from 52 consecutive dissections. (Reduced from life-size drawings.) Fig. 5. Level with Top of Stovuum ST" OriginofRiirht Subclavian Arch of the Aorta. — Relations of the great vessels when the riglit snbulavian is derived from the descending portion of the arch. (Reduced from a life-size drawing.) THE SURGICAL ANATOMY TIBIO-TARSAL REGION,' WITH SPECIAL REGAED TO AMPUTATIONS AT THE ANKLE-JOINT, AS DEDUCED PKOM EIGHTY-SEVEN CONSECUTIVE DISSECTIONS. DIAGRAM SHOWING THE AKTERIAL SUPPLY TO THE CALCANEAK REGION, ON THE TIBIAL SIDE OF THE FOOT DRAWJf BY THE AUTHOR, FROM THE AVERAGE OF EIGHTY-SEVEN DISSECTIONS. M. — Interual Malleolus. PMCN. — Tibio- tarsal Quadrilateral, tlie Surgical reg-ion of this Articulation. K. — Posterior Tibial Artery. O. — Its point of bifurcation into G. — Internal Plantar and F. — External Plantar Artery. III. — Calcaneau Branches of External Plantar. T. — Articular Branches from Posterior Tibial. H. — Articular Branch from Internal Plantar. Q. — Tendon of Tibialis Posticus Muscle. E. — Tendon of Flexor Longus Digitorum. S. — Tendon of Flexor Longus PoUicis. MC. — The line of incision of Gross. ML, MD, ME, ME.— Lines of incision showing that the nearer the incision approaches the heel, the more danger is incurred of cutting off the principal blood supply to the Calca- nean Flap, in amputation. MN. — Line crossing the. usual point of bifurca- tion of the Posterior Tibial. MA, MB. — Anterior incision. • Reprinted from American Journal of Medical Sciences, April, 1876. This Essay was awarded the Annual Prize of One Hundred Dollars, offered by Prof Jnmes R. Wood, to the Alumni Association of the Bellevue Hospital Medical College, for "The best Essay on any subject connected with Surgical Pathology or Operative Surgery," Febru- ary, 1876. The Committee were Professors W. H. Van Buren, Austin Flint, St., and Alpheus B. Crosby. (247) 2'18 PRIZE ESSAY. In botli the amputations at the tibio-tarsal articulation (Syme's and Pirogoff''s), surgeons agree that the perfect success of the ope- ration depends upon the vitality, i. ?., the non-interference with the blood supply of the inferior or calcanean flap. D(5scriptive and surgical anatomists and operative surgeons agree, with remarkable unanimity, that the integrity of this flap is depend- ent upon its blood supply, partly from the anterior and posterior peroneal arteries^ on the outer side, but principally from the calcanean branches of the posterior tibial on the inner side of the ankle-joint. In reference to this. Gross says: "Care should be taken not to wound the posterior tibial prior to its separation into its plantar branches, otherwise sloughing of the soft parts might ensue from deficient nourishment;" while Yalentine Mott, in his edition of Vel- peau''.5 Surgery {c[uoting from Syme), uses almost the same language: "Both incisions should be continuous, and exactly opposite to each other. Care should be taken not to cut the posterior tibial before it divides into the 2)Ia7itars, as in two instances when this happened (to Mr. Syme) there was partial sloughing of the flap." Erichsen says, "unless care be taken to cut the plantar arteries long, the flap will be insufficiently supplied with blood, and slough- ing, especially of its outer angle, will be likely to occur;" and Ham- ilton, in the same connection, writes, " the operator must not wound the posterior tibial before it has given off' the internal calcanean branches. Division of the posterior tibial at a point loioer than this does not, as has been affirmed, endanger the vitality of the fiap^ as it receives no arterial supyply from a lower source^^ Holmes is of the opinion that "the integrity of the j'^osterior tibial, though desirable, is by no means essential, provided the rest of the subcutaneous tissue has been left uninjured."^ Apropos to the generally accepted idea of the origin of this prin- cipal blood supply, the following quotations are given: — "The m/erna I? calcanean consist of several large branches which arise from the posterior tibial ^ust before its division." — Gray. Quain, while mentioning these vessels in his text only in a gene- • The italics are the writer's, not Prof. Hamilton's. 2 Laying no claim to personal experience, the author cannot understand how it would be possible to dissect out a bone so full of iniientatioiis and rough eminences, so covered with the insertions and origins of ligaments and muscles, and sheaths, through which tendons play, and leave "the subcutaneous tissue uninjured." There are no less than thirteen muscles in relation to this dissection, to say nothing of ligaments. TIBIO-TAKSA T. REfilON. 249 ral wn,y, gives them specially in liis diagrams as branches from the jMsterior tibial^ anastomosing vvitli branches of the 'imsti'Tior peroneal. ^^T\\(d rnlernal calcancxtn hran.rJi.eH, three or four in nurnber, [)ro- ceed {'You\i\\Q posterior tihud artery itninediatiiiy before its division." — Wilson. "Tlie cahanean arteries are two or three branches from the lower part of the posterior tibial.^'' — Leidij. "Under the arch of the calcaneum the pos^er/or ^i'/^itt^ gives origin, 1st, to branches distributed to the periosteum, to the adductor (?) of the great toe, the short flexor of the toes, and to the superficial structures; and, 2d, to other branches of less calibre, which mount the inner border of the foot, to anastomose with descending branches of the internal malleolar branch of the anterior iibial.^^^ Hyrtl mentions the operation of amputation at the ankle joint, but does not consider the surgical anatomy relating to this pro- cedure. I assert, without equivocation, that the arterial supply to the calca- nean region, as given above, is not correct, in the main; and that the operative surgery at the ankle-joint, based upon the idea that the arterial supply to the caleanean flap is derived from the poste- rior tibial, is unsafe. Having failed to find this distribution, as given in the text-books some years ago, I determined to investigate this matter thoroughly, and to that end, made 80 consecutive dissections of this region, with all requisite care, the result of which is given in the table and re- sume appended to this essay. In 72 of 80 cases the posterior tibial bifurcated into its plantar branches on a line between the lower border of the inner malleolus and the middle or centre of the heel's convexity. In four of the remaining cases, the separation occurred one-fourth of an inch, and in the other four cases one-half an inch heloial\i\s line M N {see dia- gram). Any variations^ in the point of division tend, in all cases, toward the line of incision in amputations in this region. In 38 out of 80 dissections {almost one-half)^ there was not a single caleanean artery derived from the posterior tibial (K 0, see diagram). 1 Sous le voute du calcaneum la tibuile posterieure donne naissauce ; 1°, a des ra- iiieaux qui se distribuent au perioste, an muscle adducteur du gros orteil, au court flechisseurcommuudes orteil, et aux teguments ; 2", a d'auties rameaux d'un moindre calibre qui remoutent sur le bord interne du pied pour s'anastomoser avef des ra- meaux descendants de la malleolaire interne, brauclie de la tibiale anterieure. — Sappei], 250 PRIZE ESSAY. So it must follow that any line of incision that approximates the terminal bifurcation of this vessel will, in a great many cases, en- danger the blood supply, and consequently the success of the ope- ration'. I cannot think that the exceptional cases in which good recov- eries have resulted, after division of this vessel, above or at its bifurcation, are arguments of any weight in favor of the incision "well back toward the heel," when compared with the fact that, in such a great proportion of cases, there is no blood supply above this point to the inner side of the flap, and that in some recorded cases where this accident has happened, dangerous sloughing has occurred. From the standpoint of surgical anatomy, the incision recom- mended and practised by Prof. Gross, and represented in the annexed diagram by the line M C, is the most rational, since it is farthest removed from the most constant blood supply to this inferior flap, viz., the calcanea7i branches of the external plantar artery. In 80 cases, 51 calcanean branches were derived above the bifur- cation. In 80 cases, 18 were derived opposite this point. While out of 80 cases the number of calcanean branches derived from the external plantar artery, and distributed to the posterior or calcanean flap, safely within the line of incision of Gross (M C) given above, was 221, or more than three times in number, and carrying, without the least exaggeration, twice the volume of blood of those derived opposite to and above the bifurcation. Erichsen in his text says: "It is of importance that the incision across the heel should be carried well back over its point. Unless this be done, a large cup-shaped cavity will be left, in which blood and pus will accumulate, and retard the cicatrization of the stump. The principal point to be attended to, however, is that the pla^itar arteries be cut long." These two propositions I hold as anatomically incompatible. The arteries will be cut short, dangerously short, if the incision is carried "well back over the point of the heel," while the great danger of re- tardation of healing, on account of retained septic matter, might be obviated, by leaving the wound open for drainage at its most depend- ent part, or cutting a drainage hole in the under surface of this cup-shaped flap, as is recommended by surgeons of experience. In fact, strict attention to cleanliness should render the collection and absorption of septic matter impossible. TIBIO-TARSAL REGION. 251 IlamiUon, agreeing with Eriobsen, pcrliaps a little more emphatic in his method of expressing it, says: "^J'he ]ir)es of this second inci- sion ought not to fall vertically from the malleoli; that is, not at right angles with the sole of the foot, as this would give a redun- dancy of flap; it would also iii-crease the danger of sloughing, etc. It is better to carry the lines of incision from the two mal- leoli a little backwards, so that the knife will cross the bottom of the foot about an inch and a half further back; and, in the case of an unusually long heel, it will be proper to carry the incision back- wards two inches." And in the same connection as quoted before, he adds: "The operator must not wound the 'posterior tibial artery before it has given o?f the internal ccdcctnean branches, which supply the cellulo-adipose tissue and integument composing the posterior flap. Division of the posterior tibial at a point lower than this does not, as has been affirmed, endanger the vitality of the flap, as it receives no arterial supply from a lower source." The language of this eminent surgeon is decisive and emphatic. In 38 of 80 dissections^ there ivas not an artery that I could find, by careful dissection, derived from the posterior tibial and distributed to the calcanean region, ivhile in every case of 80 dissections there ivas one or more branches derived from the external plantar, and distributed directly to this part. Lister, author of the chapter on amputations in Holmes''s Surgery, advises that "the calcanean incision be made either vertical to, or sloping towards the heel, commencing at the tip of the external mal- leolus, and going under the foot to a point considerably below and behind the tip of the inner malleolus Even the integrity of the posterior tibial artery, though desirable, is by no means essen- tial, provided the rest of the subcutaneous tissue has been left uninjured."^ The great unevenness of the os calcis, its peculiar shape, covered with the attachments of muscles, sheaths, and ligaments, renders it anatomically difficult to be dissected out in this operation, without wounding, more or less, the subcutaneous tissue, upon which, Mr, Lister says, the integrity of the flap depends. Moreover, if the "integrity oi the posterior tibial is not essential," why does this gen- tleman recommend so positively an incision that must always save this vessel to the operation? Why not cut an "inch and a half, or, in the case of a long heel," two inches back of the vertical line (as 1 Holmes's Surgery, vol. v. pp. 643, 644. 252 PRIZE ESSAY. Hamilton does), where he would have plenty of flap and an easier dissection ? The language of these two phases of his operation is irrecon- cilable, and the assertion that "the integrity of the posterior tibial artery, though desirable, is not essential," is not strictly in accord- ance with the clinical history of this amputation, and is utterly at variance with the anatomy of the blood supply to the calcanean region. Stephen Smith, in his comprehensive report, says the necessity for re-amputation in this operation is three per cent, greater than in any other. Perhaps the cause of this may arise from the reckless sacrifice of the arterial supply to this region, sanctioned by such eminent sur- geons as I have quoted. The writer of this essay, deeming it unnecessary to introduce any further quotations and comments, since he wishes to be concise, sinjply begs leave to state that he has entrusted his work to no one; that he measured every dissection with accuracy, and noted it on the spot; and that, in differing so widely in his results and conclu- sions with gentlemen of such eminence (whom it seems almost sac- rilege to contradict), he reiterates his assertion that the surgical anatomy of this region has, heretofore, 7iot been correctly described. TIBIO-TAKSAL REGION. 253 T ABLE SIIOWINft ORIGIN OF THK OAI,(!ANKAN BIIANCIIKS Or TIIK I'OSTKKIOIi TIKIAI. AND KXTKRNAI. I'l.ANTAH AUTKUIKS, AH DF.DIH'.KI) PKOM NOTKS ON KiailTY CONSECUTIVK JJIHSKCTIONS. Number. Number of Calcanoan Briuichos derived from tlio Posterior Tibial Artery. NiiiMber of Calcaneal! Briiiiclios derived opposite tlie Termi- nal Uifurcatioii of the PoHtorior Tibial. Number of Calcancaii HranchoH derived from the External 1' la 11 tar Artery witliin l]/^ iucbet of itH orit^in. 1 3 2 1 3 3 3 4 7 5 4 6 2 5 1 1 4 8 1 2 9 1 10^ i 3 11 1 W 1 3 13 1 4 14 4 15 1 3 16 1 3 n 4 18 1 2 19 3 20 1 1 3 21 1 1 2. 22 1 2 23 2 24 3 25 2 26 1 2 2Y 1 1 4 28 1 1 1 29 1 2 30 1 2 31 o o 32 1 1 2 33 1 3 34 2 2 35 1 1 2 36 3 , 37 6 38 1 2 39 I 3 40 1 1 ' This case bifurcated one-half iucb lower than usual. 2 This case bifurcated one-half inch lower than usual. 21 )4 PRIZE ESSAY. Number. Number of Calcanean Branches derived from the Posterior Tibial Artery. Number of Calcanean Branches derived opposite the Termi- nal Bifurcation of the Posterior Tibial. Number of Calcanean Branches derived from the External Plantar Artery within IJ^ inches of its origin. 41^ 2 2 42 1 3 43 1 2 44 3 45 1 2 46 1 4 47 2 48 1 3 49 2 2 50 3 51 3 52^ 1 2 53 2 6 54 1 I 4 55^ 3 56 2 57 1 1 58 1 3 59 2 60* 2 1 61 1 2 62^ 2 2 63 1 3 64« 3 65 1 1 3 66 3 67 2 1 68 3 69 1 4 70 3 71 1 3 72 1 2 73 2 2 74 1 4 75 4 76 3 77 1 3 78 5 79 2 80 Total . . 1 1 51 18 221 This case bifurcated one-fourth inch lower than usual. This case bifurcated one-fourth inch lower than usual. This case bifurcated one-fourth inch lower than usual. This case bifurcated one-half inch lower than itsual. This case bifurcated one-half inch lower than usual. This case bifurcated one-fourth inch lower than usual. T n? I O - T A liS A L R K (i ION. 255 Summary ON the Suiuiical Anatomy of tiik AiiTKiuAi. Shj'I'ly TO THE TiBIO-TaRSAL ItKOION, AS DEDUCED EJiOM 80 DISSEC- TIONS. In 72 of 80 cases the posterior tibial artery bifurcated into the external and internal plantar, on a level with a line drawn i'vom the most dependent portion of the internal malleolus, to tiie middle of the heel's convexity. {See M N, fig. 1.) In 4 of 80 cases, this bifurcation occurred -|- inch below this |)oint. In 4 of 80 cases, it was | inch below this point; any variation from the usual point of division tending, in my experience, mva- riahly (hionivard. Although anatomists give the arterial supply to the calcanean region {internal calcanean arteries) as coming from the |:>o.s^f?-wr tibial artery (as shown in extracts given heretofore), the resume of tabu- lated dissections shows that, out of a total of 80 cases, in 38 there was not a single calcanean branch derived above the termincd bifurcation of the posterior tibial artery^ while in all of these 80 dissections, one or more good-sized ccdcanean arteries were derived from the external plantar^ within one and a quarter inches of its origin. In 80 cases, the number of ccdcanecm arteries derived from the posterior tibial was 51. In 80 cases, 18 branches were derived opposite the point of bifur- cation, and distributed to this region. In 80 cases, the number of calcanean arteries derived from the external plantar was 221, and every one of these was safely inside the line of incision in amputations at the ankle-joint, when that in- cision is not more than one-half inch posterior to the axis of the leg {see M 0, fig. 1), with the foot at right angles to the leg. In all cases, ctrticidar branches are derived either from the posterior tibial or inter7ial plantar, or from both. In some exceptional cases, the internal plantar gave off small branches to the heel. The anterior flap is plentifully supplied in all instances by branches from the anterior tibial, especially the malleolar arteries. The anterior and posterior peroneal dLX&ixihutQ branches to the outer portion of the calcanean flap, those from i\iQ posterior anastomosing with the calcanean, branches of the external plantar, and with those of the posterior tibial, when they are present. I do not think the branches from the peroneal arteries sufficiently large to supply blood enough to maintain the integrity of the calcanean flap, especially when their anastomoses are cut off by section of the posterior tibial, or of its plantar branches, too near their origin. 256 PRIZE ESSAY. The relation of the jjosterior tibial artery is quite constant with the two muscles between which it runs; the flexor longus digitorum in front, and the flexor longus pollicis behind. The most reliable guide-to this vessel is its pulsation; but in the event the tourniquet is applied/the thumb should be placed over tlie middle of a line drawn from the inner malleolus to the centre of the heel's convexity, while the four lesser toes are held still by an assistant, the surgeon moves the great toe, and marks the point at which he feels the ten- don gliding under his thumb. The tendon of the longus digitorum is found in the same manner, and half-way between the two a curved incision, with its concavity towards the malleolus, will be over the artery. The relations of the veins on either side, and of the iwsierior iihial nerve behind, are among the least variable features of the anatomy of this region. In two cases I have seen the artery immediately behind the inner malleolus. When the posterior tibial is small, the peroneal branches undergo compensatory enlargement. P. S. — Since closing these notes, some weeks ago, the writer has made seven additional dissections of this region, with the following result : — In 4 out of 7 cases, calcanean branches originated from the poste- rior tibial artery — 1, one inch ; 1, one-half inch, and 2, one eighth of an inch above the bifurcation. In 7 cases, 2 calcanean branches were derived opposite the bifur- cation. In 7 cases, 19 calcanean branches were derived from the external plantar, within one inch of its origin; 3, within one-sixteenth; 2, within one-eighth; 1, witiiin one-fourth; 4, within one-half; 4, within three-fourths, and 5 within one inch of the bifurcation. Articular branches were, as usual, from posterior tibial and internal plantar. The posterior tibial bifurcated in every case, as usual. {See dia- gram.) N O T E S UPON TIIK SURGICAL ANATOMY OF THE OBTURATOR ARTERY/ THE DIFFERENCE OF ITS RELATIONS IN THE MALE AND FEMALE, "WITH A CONSID- ERATION OP ITS IMPORTANCE IN THE OPERATION FOR RELIEF OF FEMORAL HERNIA — DEDUCED FROM TWENTT-SKVEN CONSECUTIVE DISSECTIONS OF THE ARTERIES IN THE MALE, AND TWENTY-SIX IN THE FEMALE PELVIS. In its distribution the obturator artery is simple find constant; in its origin and relations there is no artery in the human body which presents so many vagaries. In support of this last statement it will suffice to quote from some of the standard text-books the different opinions of different anatomists upon this artery. Quain gives its origin as " usually from the posterior trunk of the internal iliac, not unfrequently from the epigastric." Sappey takes a different view, and says "from the hypogastric (anterior trunk of internal iliac), sometimes from the external iliac, rarely from i\ie femoral.'''' Leidy is of the opinion that it " is a branch of the posterior trunk, and often a branch of the anterior trunk of the internal iliacJ^ Wilson gives it "from the anterior trunk; frequently from the posterior trunk of the internal iliac.'''' Gray agrees with Wilson verbatim, adding that "in 2 of 3 cases the obturator arises from the internal iliac, in 1 of 3J from the epigas- tric, in 1 of 72 by two roots from both vessels." Luschka, " from anterior trunk of internal iliac ; occasionally, from external iliac, epigastric, ov femoralJ'' Velpeau writes: "An examination of several thousand cadavers does not permit me to say that the obturator artery comes from the epigastric in 1 of 3, nor 5, nor 10, but only 1 in 20." (!) Tiedemann says, on the other hand, that "you may expect to find ' New York Medical Record, October, 1877. 17 ( 257 ) 2-38 PRIZE ESSAY. the oUurator from the epigastric in 1 of 3 cases, this variety being more common in the female than in the onale.'^^ In the two following tables I have given the analysis of 58 dis- sections, made in order to contribute something of certainty to the anatom)^ of this artery. Thirteen subjects of each sex were chosen, and both sides noted as they were dissected. FEMALES. MALES. 6 ,Q 0) in R L R L R L R L R L R L R L R L R L R L R L R L R L ll 1i "S ° .2-5 fcuS 'C ^ 1 i "1} I] 11 1 11 H 11 a- 5 s =0 Eemarks. 6 f 27 128 (29 130 ,31 \32 (33 |34 (35 (36 (37 (38 J 39 140 f41 142 (43 (44 J 45 146 f47 148 J 49 150 f51 \52 53 1=^ R L R L R L R L R L R L R L R L R L R L R L R L R L L ll -g o "i "i i 1 22 o .2-S ge al g s 1 '§1 1 ao p g £■" "\} 1 1 4 Remarks. 1? I 8 f 9 )10 ll2 fl3 114 (15 tl6 fl7 118 (19 \20 (21 122 (23 124 f 25 I26 ] 1 L 1} w 1} I] 1 1 i 1 13^ In Nos. 7 and 8 the ob- turator arclied over the crural ring in such a manner, that, had femo-i rat hernia existed, the intestine might have been closely encircled by the artery. One origin (quite small) from posterior trunk ; one, larger, from deep epigastric ; both united in obturator ca- nal, to form a single trunk. 1 The writer is iudebted to Dr. I. Minis Hays for valuable reference iu regard to this artery ; to " Lawrence on Ruptures," one of the most valuable books on this subject published ; and to Dr. W. L. Wardwell for assistance in taking notes of the dissections. 2 The ^^— to the left indicates the dissections to have been made upon both sides of the same subject; that to the right, that the origin was the same on both sides of the same subject. Note. — In 8 other dissections in which the sex was not noted, this artery came from the anterior trunk in 5, from the posterior in 1, from the deep epigastric in two instances. OBTUKA'I'Oli AKTEKV. 259 It will be seen that ]n females, of 26 cases, the ohturalor was from the deep cpiyantric in V6}^ instances; from the posterior trunk of the internal iliac in 1^-; from tiic anterior trunk in 11 i)i,sl,aii(;(;s. In males, of 27 cases, it was from the epigastric in only 5; from \\\Q posterior trunk in 1 ; while from the anterior trunk of the internal iliac it was derived in 22 instances. In these cases it is seen that, in females we may expect to find the obturator to be derived from the deep epigastric in 1 of 2 cases; in males, in I of 4| cases. And, in a total of 61 cases, regardless of sex, the proportion is 20, or 1 in 8. Tiedemann is the only one of these anatomists who notices the difference between the origin of this vessel in males and females. In 160 cases in which Cloquet noted the obturator as coming from the internal iliac, 87 were in males, 73 in females, showing, as in my cases, the greater tendency of this vessel to come from the internal iliac in men. In 56 cases this same author noted from the epigastric, 21 were in males, 35 in females; agreeing, also, with the dissections embodied in this article, that the tendency of the obturator to come from the deep epigastric was much greater in women than in men. So great is this difference, that the estimates made from both sexes should not be considered, in view of the probable contact with this vessel in femoral hernia. An examination of the foregoing tables will show that, in 19 of 26 subjects, this artery was derived from the same point on the two sides, showing, in this respect, a symmetry of arrangement I have not noticed in any other artery of the body. Femoral hernia being comparatively a rare accident in the male, and the obturator artery having a dangerous relation to the femoral ring in the male sex in only a small proportion of cases, the surgi- cal interest of this vessel belongs to the opposite sex. When derived from the epigastric, it usually comes off from this artery from | to f of an inch from the origin of the epigastric from the external iliac. It then turns abruptly down on the outer side of the femoral ring, being in intimate relation with the sheath of the external iliac vein, and thus makes its way to the obturator foramen in such a manner that it would be exceedingly difficult for the in- testine, descending to form a femoral hernia, to insinuate itself between the iliac vein and the obturator artery, so as to loop this latter vessel around the hernia. This danger will be greater as the 260 PRIZE ESSAY. obturator is distant at its origin from the external iliac. However rare this double accident may be (femoral hernia, with the olturator artery looped around it), 3^et, as it can and has occurred in several instances, the surgeon should proceed in every case as if he supposed this accidental arrangement existed. In the American Journal of the Medical Sciences^ July, 1878, p. 269, is a notice of a case in which death resulted from division of the obturator artery in an operation for femoral hernia in a woman. The vessel was from the epigastric, | an inch from its origin. Mr. Barker had collected 12 cases of this accident; in six of these the vessel was secured either by ligature, or with a hook. Of this group 2 died. In 6 nothing was done, and only one died (his own case, which is reported as dying of peritonitis). " At the autopsy, 3 or 4 ounces of Mood were found effused under the peritoneum in the pelvis." This extravasation may have caused peritonitis and death. It is to be regretted that Mr. Barker does not say what proportion of these twelve cases were females. I do not doubt that most of them were of this latter sex. When the stricture is so situated that Gimbernat's ligament re- quires division, the point of the probe pointed bistoury should be kept hard pressed against the surface of the os pubis to which this ligament is attached, and as is advised by one of the most eminent American surgeons, " the ligament should be divided without any sawing motion."^ It is evident that, if the cutting edge of the knife is not pushed beyond the ligament into the pelvis, the artery will not be divided. I have noticed that the obturator vein is in relation to the femoral ring in a much larger proportion of cases than the artery, it being often double, one going to the internal iliac, the other to the exter- nal iliac vein, when the artery was from the anterior trunk of the internal iliac alone. Deductions: 1st. That anatomists giving the origin of the obtu- rator artery from the posterior trunk of the internal iliac are positively wrong, the vessel not originating from this point in more than 10 per cent. 2d. That in females it will be derived from the deep epigastric in on& of tiuo or two and one-half cases. 3d. That in males it will be from the deep epigastric in one oifour or six cases, 1 Hamilton's System of Surgery, p. 743. OBTURATOR ARTKIiY. 201 4th. That the ohlurdlor vein i.s found to empty into tin; exlernal iliac or ejrtijasiric vein in ;i mueh i/reater [)roportion of crises than the artery is found to orignate from the ej^idustric or exli-rnal iliac. 5th. That tlie advice to "feel for the pulsation of this artery be- fore cutting Gimbernat's ligament'" (as is frequently given), seems unnecessary, since the insertion of the finger through the constricted canal, completely filled by the intestine, ihxit has for this reason he- come strangulated, is impossible until after the section is made. 6th. That, although the conditions in which the oltura.tor artery is found to the inner side of a femoral liernia rarely exist, the ope- ration should be niade with every regard to this abnormal arrange- ment. Note. — In one instance I have seen the obturator a bi'auch of the epigfisiric, and this latter a branch of the profunda femoris. This specimen is the property of the Wood Museum of Bellevue Hospital, and is not included in these notes, on account of its being so unusual. ■ Holmes's Surgery, vol. iv. p. 779. 262 PRIZE ESSAY. NOTES ON THE SURGICAL ANATOMY OF THE HIP-JOINT/ The comparatively trifling amount of blood lost in an operation of such magnitude as the excision of the hip-joint, when there is no means of stopping the supply of blood to the part, has doubtless added very much to tlie remarkable success which has attended this operation in the hands of its author. The following synopsis of twenty dissections of the hip-joint made with regard to the arterial distribution to this region, may serve to show the extreme nicety of execution requisite, in order to avoid hemorrhage, that would always be annoying, and in some instances dangerous. The arteries found distributing branches to this region were the gluteal^ sciatic^ ohturator^ external and internal circumflex^ and the superior perforating by anastomoses. None of these approached the line of incision given by Prof. Say re near enough to be divided, before they broke up into branches of distribution too small to give rise to any notice- able hemorrhage, except one of the terminal branches of the internal circumflex, sometimes mentioned as the trochanteric branch, but never described in connection with the surgical anatomy of this ope- ration, to my knowledge. In 20 dissections this artery was present in every case. In 18 of these it came from the internal circumflex^ passed between thequadratus femoris behind, and the obturator ex- ternus in front, and turning toward the digital fossa, broke up into its terminal branches within from one-eighth to one-fourth of an inch of the insertion of the tendon of the obturator externus into that fossa, anastomosing with the sciatic^ gluteal^ and external circumflex arteries. In 2 cases in which it failed to come from the internal circumfitx^ it was derived from the sciatic, and ran in the depression between the quadratus femoris and obturator externus muscles, near the digital fossa. This vessel varied in size from a crow's-quill, down, oftener small than large, but in all cases of sufl&cient size, at the distance from the fossa above given, to interfere with the success of the operation, if carelessly divided. As it is only at this point that the knife is used in the deeper structures (in cutting the tendon of the obturator ex- ternus out of this fossa), it behooves the surgeon to guard against this danger by keeping the point of the knife "well against the bone," as advised in the operation, and never to attempt to divide this tendon out of the fossa. (The obturator externus muscle was occasionally observed to be inserted into the great trochanter, and not into the digital fossa.) 1 From Orthopedic Surgery and Diseases of tlie Joints. By Prof. Lewis A. Sayke. COLUMBIA UNIVFRSITY LIBRARIES (hsi.stx) RD14W97C.1 Essays in surgical anatomy ant) surgery 2002097583 l^P/4 IVdl Wyeih — St^Tgica-l '■k^:.:":,.^.wa:^'.j:.ha^^.'