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and some of the sutures were removed, the upper half of the wound having healed. The lower half of the wound was unhealed, and there issued from it some sanious pus. The superficial dressing previously used was renewed. In the evening it again became necessary to use the catheter. The pulse was 112 and the temperature 101-25°. On the day following, the pulse was 100 and the temperature 101°. The aneurismal tumor began to show signs of rupture. Its wall, at the lower portion and external border, had become extremely thin and black, and the overlying integument, for a space of two inches by four, was black and gangrenous. During the evening there was some febrile reaction. On the 18th of October, the pulse was 102 and the temperature 101°. The lower three inches of the wound gaped widely, but the aneurismal sac had not yet burst. The catheter was used until the 21st of October, when the patient again urinated spontaneously. On the 22d, dark, tarry blood first began to ooze from the sac through a small opening, and the sac was floating, as it were, in a pool of pus. The gangrenous integument, being loose, was removed by slight traction. The patient began to complain of his chest, or rather of his lungs; but nothing is stated in the notes of the case as to the precise nature of the pulmonary complaint. This respiratory uneasiness may have been due to the existence of purulent foci in the lungs, since other signs of pyæmia had already manifested themselves. Although the patient slept well and spoke of feeling well, he appeared to be daily losing ground, and his pulse and temperature obstinately remained abnormal.
On the 24th of October, the pulse was 100 and the temperature 99.5°. The area of ulceration over the tumor measured five by six inches, extending two inches below the lower extremity of the incision, and the sac began to protrude. On the 26th, the pulse was 120 and the temperature 102°. The patient had been sleeping well but had no appetite. I cut short the slow, spontaneous enucleating process of the aneurismal sac, by introducing a finger and sweeping it around that part of the sac which was out of sight, and at the same time I removed portions of sloughy muscular tissue. No hæmorrhage followed this procedure. After the sac had come away, I could, with the finger still in the cavity, distinctly feel the bladder. The tumor consisted of two sacs;
the real aneurism, which was of the size of a hen's egg, and an outer and larger sac, separated from the inner by a layer of firmly-coagulated blood, two inches in thickness. The cavity thus exposed was then thoroughly cleansed and was filled with picked lint saturated with carbolized oil. The removal of this mass seemed to give him great ease. In the evening, however, there was febrile reaction.
The diet of late had been one quart of milk and three eggs daily, with eight ounces of whisky. The internal medication consisted of quinine and aconite.
On the 27th of October, the patient had a chill which lasted fifteen minutes. He was placed upon a water-bed on account of the appearance of a bed-sore. The pulse was 140 and weak, and the temperature was 103°. The daily quantity of quinine was then increased to thirty grains. At two o'clock in the afternoon, the pulse was 120 and the temperature 102°, and at six o'clock he had a second, and a more severe chill. On the 28th, he had two chills, and his pulse was 128.
On the 29th of October, the pulse was 124. At 10 A. M., he had a chill and began to sink. In the evening, he complained for two hours of intense pain in the heel and foot of the affected side, although ordinary sensation was abolished and the surface was cold. Warm applications to the feet were ordered, and a dose of morphine was given. On the 30th, the pulse was 124. The pain in the foot was more severe but was afterward relieved by opium. A chill occurred at 9 A. M. The face was cadaverous, and he was fast sinking.
On the 31st of October, the right ankle was ecchymosed but not swollen. The pain in the ankle had extended to the leg and was intense. On that day he had several slight chills.
On the 1st of November, the ecchymosis had greatly increased. The patient died on November 2d, at 2 P. M., at the end of the twenty-first day after the operation.
Autopsy. The ligature lay loose in the wound and was removed. The primitive iliac artery was completely obliterated. Nearly the whole of the external iliac had sloughed away with the sac, leaving less than an inch of its lower extremity, which was entirely closed. There was a pelvic abscess which involved the psoas muscle. The femoral and iliac veins were pervious and free
from thrombi. The wound had healed to the surface, except in the track of the ligature.
The relatives of the deceased having objected to a complete autopsy, the examination was consequently confined to the pelvic region.
REMARKS. The fatal result in this case served to strengthen the opinion I had expressed as to the management of the sac after ligature of the artery. It reminded me of the more fortunate case of a soldier who, in 1861, received a sword-thrust in the upper part of the left arm and was brought to me a few hours after with a tumor, at the seat of injury, of the size of a hen's egg. I immediately expressed the belief that the brachial artery was wounded, and that the tumor, consisting of clotted blood, was the beginning of an aneurism which, if left undisturbed, would eventually become diffuse. The injury being a little below the insertion of the pectoralis major muscle, pressure was applied to the subclavian artery, and I made a longitudinal incision directly through the tumor, turned out the clots, exposed the wounded artery, which I tied above and below the wound, then cut away the vessel between the two ligatures, and thus excised an embryo aneurism. It is fair to say that a wound of an artery is an aneurism in embryo. The patient made a complete and rapid recovery. I believe that excision of a portion of a wounded artery is not a modern practice, but a revival, with but slight modifications, of what was long ago recommended and executed.
The particular point in the report of the case of diffuse aneurism, to which I have the honor of asking your special attention, relates to the management of the sac. It seems to me that, in the case in question, if I had carried out my intention of freely opening the sac, the chances of recovery would have been greatly increased; and that this procedure, for which we have such strong warrant, and which is in itself so simple, so philosophical, and therefore so eminently surgical, should be more insisted upon than it has been of late years. The patient was in an excellent condition at the beginning to bear the proposed
operation of incision of the sac. He succumbed from pyæmia, solely because a great bag of dead and decomposing blood was retained in his flank. The necrotic process was so slow that it became necessary to resort to artificial enucleation of the sac, but the decomposing mass had already caused damage that could not be repaired. If, after ligature of the main artery, the sac had been freely opened, the clots extracted, and the cavity filled with lint, I am sure that the risk would have been infinitely small as compared with the expectant plan which was so unfortunately adopted.
If I be wrong in this view of the case, I trust that those who think so will candidly state their reasons. I therefore urge that the following question be fully discussed: Whether free incision of the sac of a diffuse traumatic aneurism, after ligature of the artery or arteries by which it is supplied, is, as a general rule, a proper or an improper practice.
DR. FIFIELD, of Boston.-During the first part of the present century, a great fountain of surgical knowledge was opened in England, and it has continued to flow ever since, almost all modern authors in surgery having derived their inspiration from this source. John Bell was that fountain of knowledge. Time has not taken much from what he has said, and it has not added much to what he pronounced. If we should turn to the famous book in four volumes, "Principles of Surgery," written by John Bell, we might read, even at the present time, his essay upon diffuse aneurisms, with great profit to ourselves. It is very curious to observe how he anticipated the views held by Lister and the modern apostles of antiseptic surgery. In speaking of diffuse traumatic aneurisms, John Bell told this story: When such an aneurism holds at first, perhaps, not more than an ounce, it speedily increases until it contains ten or twelve ounces. The overlying tissues change,
and the skin assumes a different hue and approaches sloughing. The sac itself becomes filled with blood, which forms a clot, perhaps plugging the artery above and below, and also plugging the vessels leading into it. By this crowding and compression, sloughing occurs in the aneurismal sac, and, at the bottom of the sac, in this condition, is a putrescent fluid, which, as soon as the sac opens, will set up pyæmia, or blood-poisoning. John Bell said further that, instead of allowing sloughing to take place in the aneurismal sac, with the subsequent development of pyæmia, it had been proposed to make a crucial incision into the sac. More than that, the same author has stated that, in a diffuse traumatic aneurism, it is useless to make pressure above the sac, and it is useless to throw a ligature around the artery; and that the only way in which it should be treated is to put the knife to the skin, thrust it boldly into the aneurismal sac, and then scoop out the contents with the hand. When a jet of blood appears above the orifice, the vessel is to be compressed by the thumb, and a ligature cast about the upper as well as the lower portion of the artery. The aneurism itself should then be entirely removed. He also said, most significantly, treat it with antiseptics. He used the very word antiseptic. The ancients applied the actual cautery to the sac, and in this way the development of pyæmia may be prevented.
DR. E. M. MOORE, of Monroe County.-We can often accomplish much good by placing on record our mistakes; and I may say that my experience in a case of traumatic aneurism of the brachial artery was almost precisely the same as that of Dr. Gouley. The case terminated fatally. The operation was postponed for several days, in the hope that some benefit might be obtained from pressure; but the injury was situated where pressure could be applied only with great difficulty, and it proved of no avail. The wound was so high up in the axilla that a ligature could not be put upon the artery above it. I determined, therefore, to cut the sac open and to tie both ends of the vessel. I proposed to have an assistant compress the subclavian artery as it passed over the rib, and intended to make a bold cut into the aneurism, which was about four inches in length, seize the clot, and then thrust my finger into the opening of the vessel above. But the gentleman who was securing the subclavian artery by