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from gunshot wounds of the stomach, it is seen that the recorded cases of recovery are exceedingly rare, and that possibly there is but one.
The subject of this paper, at the time of writing, November 1, 1884, is reported as being in perfect health, which is a matter of considerable surgical importance, in view of the almost hopeless prognosis, given in these cases, by Professor Kocher, of Berne, who is reported in the “ American Journal of the Medical Sciences” for October, 1884, p. 574, as saying that, “considering the impossibility of recovery in cases of gunshot wound of the stomach when active measures are not taken, it is the duty of the surgeon to perform laparotomy whenever an injury of that kind is suspected.”
REPORT OF A CASE OF LIGATURE OF THE RIGHT PRIMITIVE ILIAC ARTERY FOR DIFFUSE ANEURISM OF THE EXTERNAL ILIAC; DEATH FROM PYÆMIA ON THE
By John W. S. GOULEY, M. D., of New York County.
Read November 20, 1884.
M. MCM., twenty-two years of age, a laborer, was admitted to Bellevue Hospital on the 8th of October, 1871, suffering from a painful, hard, and elastic pulsating tumor in the right inguinal and iliac regions, extending six inches above and two inches and a half below Poupart's ligament, and two inches and a half to the left of the median line, clearly marked in outline and evidently intra-abdominal.
The history of his case, given by the patient, was as follows: About two years before his admission to the hospital, a barrel of lime had rolled against him, inflicting a contusion in the neighborhood of the right inguinal region. Soon after this injury, he contracted urethritis with a chancre, followed by an enlarged inguinal gland which soon subsided without suppuration. No constitutional symptoms ensued so far as he knew, and none were apparent when he applied for treatment on the 8th of October, 1871. Nine months before his entrance into the hospital, he noticed a tumor in the right inguinal region, above Poupart's ligament. Three months after it was first noticed, the tumor had attained the size of a hen's egg, and he then observed for the first time that it pulsated. After another period of three months, it had very
greatly increased in size, and, two months before his admission to the hospital, it had nearly attained the dimensions noted on the 8th of October, 1871. The man continued his work of handling and sometimes even lifting barrels of lime, until the tumor had become very painful ; and not until then did he apply for treatment at the hospital. The pain was seated partly in the region of the tumor-and there it was of a burning character—but chiefly in the course of the anterior crural nerve, as far down as the knee, and it was here due to compression of the nerve by the tumor.
In the physical examination of the case, various tests were employed, among them that of placing at the summit of the tumor a square bit of white paper with one of its corners turned up. By this simple and well-known expedient, an excellent device for demonstration in a large amphitheatre, the pulsations were rendered very distinct and could be seen at a considerable distance. By palpation and compression, the heaving of the whole tumor and its pulsation were made still more certain, while auscultation revealed the existence of a well-marked bellows murmur. The integument overlying the tumor was dark-colored and ædematous. The discoloration was believed to be due to rupture of the aneurismal sac, the foregoing facts having led me to the diagnosis of traumatic aneurism, and now of diffuse traumatic aneurism of the external iliac artery. There was slight pulsation of the anterior tibial, but none of the posterior tibial or femoral arteries, The patient was somewhat emaciated but had no apparent lesion of the thoracic or abdominal viscera. On the 12th of October, it was noticed, even by the patient, that the tumor had markedly increased in size since the 8th of October, and he said that his pain was much worse, although he had taken a free dose of morphine. In addition, the local heat was greater than it had been for the three days past, and the rapid unfavorable progress of the patient compelled immediate surgical interference. At a consultation with my colleagues, I proposed, as the only chance for the patient's life, ligature of the primitive iliac artery, and, if necessary, of the common femoral, to be immediately followed by free incision of the aneurismal sac, in order that the blood-clots might be removed and the whole cavity of the aneurism cleansed. The gentlemen all agreed with me as to the necessity of ligature of the primitive iliac but would not consent to any form of disturb
ance of the aneurismal sac. I yielded to their objection, without, however, changing my opinion with reference to the propriety of incision of the sac, so warmly advocated by one of the best and wisest authorities of the early part of this century, and so successfully executed by Professor Syme in our own time.
Operation.-On the same day, October 12, 1871, ether was administered to the patient in the usual way. The size and configuration of the tumor rendered the operation more than ordinarily difficult, and, for the sake of safety, it was thought necessary to adapt the course of the incision to the requirements of both. Before, however, I proceeded to cut, a trusty assistant was notified to be in readiness to compress the abdominal aorta manually in case the sac should suddenly burst when exposed. This provision having been made, I began my incision at the lower border of the tenth rib, in a line drawn from the center of the axilla to a point on the level of the anterior-superior spinous process of the iliurn, and one inch nearer the median line of the body than this bony process. This was the general course of the slightly curvilinear incision, which was nine inches in length, except the lower two inches, which formed an arc of a much smaller circle and took an upward and inward direction in the discolored portion of the integument. The object of this deviation in the line of incision was to permit retraction of the skin and underlying tissues, and thus afford sufficient space to expose and reach the main artery. A few superficial bleeding vessels were secured, and the incision was then extended through the oblique and transversalis muscles and through the fascia transversalis, bringing into view the subperitoneal connective tissue. After separating with the fingers the peritonæum from the transversalis fascia, retraction of the wound and protection of the tumor and the peritoneal contents were effected, partly by one hand of an assistant, and partly by means of a steel spatula about three inches broad—the same spatula that had been used for a similar purpose by the late Dr. Valentine Mott, and was skillfully employed on this occasion by his son, Dr. A. B. Mott. By this large wound and very efficient retraction, the artery was brought into view for one inch of its length. Nevertheless, it was somewhat difficult to pass beneath the vessel, from within outward, the Mott artery-needle, which was armed with a stout silk ligature ; but this step of the operation was successfully
accomplished. Before knotting the silk, I made a careful examination, to be sure that neither the ureter nor the iliac vein was included in the ligature, which was then securely tied. From that moment, the pulsation of the tumor ceased. The wound was then cleansed, its edges were stitched, and the dressing was completed by the application of strips of adhesive plaster, layers of cotton, and a retentive bandage. The whole limb was swathed in cotton, and bottles of hot water were placed on either side. The operation was concluded within thirty-two minutes. A hypodermic injection of ten minims of morphine-solution was administered before the patient had recovered from the anæsthesia, and, when he did recover, stimulants were given him in small and frequentlyrepeated doses.
On the 13th of October, in the morning, the pulse was 128 and full. A dose of aconite was given. In the afternoon, the tumor had already softened and the crural neuralgia had disappeared. The temperature of the affected limb was higher than that of the limb on the sound side.
On the 14th, the pulse was 130 and full. There was little if any pain. The patient slept well but had no inclination to eat. The tumor was softer and was decreasing in size. The discoloration of the skin at the seat of the operation had lessened. From the first day, evacuating catheterism of the urinary bladder had been necessary, but on the third day he urinated spontaneously. He had, during the night of October 14th, a sudden attack of diarrhea, which was, however, quickly checked by a dose of morphine.
Early on the morning of the 15th, his pulse was 130 and he was sweating profusely. Eight hours later, he was much better ; pulse 108; body-temperature 102° Fahr. In the course of another hour, the pulse rose to 120, and the bowels became tympanitic, although he was generally better and in good spirits, eating well and with relish. There was some discharge of pus from the lower end of the wound, but none from the upper half, which appeared to be healing. The parts were washed and covered with sheetlint soaked in carbolized glycerin and water,
On the 16th of October, the pulse was 112 and the temperature 102.75o. He had slept well all night, had no pain, and urinated normally. The adhesive strips were for the first time changed