Special Correspondence

1863 BMJ (Clinical Research Edition)  
A SURGICAL operation at the Royal Infirmary, in the early part of last month, is of such unusual interest and importance, that, deviating from my ordinary practice of reporting those cases only which I have witnessed myself, I am induced to relate it from the narration of a friend who was present on the occasion. It was an example of that exceedingly rare kind of aneurism called fusiform, consisting of a dilatation of a considerable portion of the axillary artery. The subject of the disease was
more » ... of the disease was an artisan about forty years of age, who came into the hospital on the evening of the 7th of May, complaining of a large pulsating tumour which filled up the left armpit, distending the pectoral muscles, and lifting up the shoulder towards the ear. The patient had noticed, several months previous to admission, the existence of a swelling of about the size of an orange, which pulsated strongly, but which caused no particular distress or uneasiness until a few days before his admission, when he was seized one night with severe pain in the arm, and discoveredthat the swelling bad suddenly become greatly increased. It was evident that an aneurism existed, which had burst its sac and become diffused. The arm was now o3dematous, and the distension and enlargement were increasing rapidly. The arm was bandaged with flannel, and the patient kept quiet in bed until the next morning, when the tumour was found to be still farther enlarged, so that the shoulder was pushed up towards the ear. There was considerable ecchymosis, with dark livid spots on the skin of the armpit. The pulsation in the tumour had entirely disappeared. Impending external rupture of the tumour, with inevitable fatal hbamorrhage as a consequence, indicated that an immediate operation was imperative. Under these circumstances, as it appeared almost impracticable to reach and tie the subelavian artery in the usual position, Mr. Bickersteth, who had charge of the case, after a consultation with his colleagues, determined to follow a mode of proceeding which bas been adopted by Mr. Syme, and which is, in fact, the original operation for aneurism as practised previous to the improved method introduced by John Hunter-namely, to lay open the sac, empty out its contents, and tie the vessel above and below the opening. Notwithstanding the formidable difficulties which must necessarily attend this plan of procedure, it seemed, under the circumstances, to be the only practicable method of dealing with the case. The steps of the operation were as follows. An incision was made along the outer edge of the sterno-mastoid muscle and through the cervical fascia, enabling an assistant's finger to be placed on the subclavian in the usual position. When the artery was commanded by compression, a free incision was made into the tumour, and the clots cleared out. OwiDg to the admirable and efficient manner in which this somewhat difficult and critical task of commanding the artery was effected by Mr. Fletcher, very little blood was lost. After a careful examination 16 of the interior of the aneurism with a view to ascertain the point at which the artery opened into the sac, the operator discovered what, of course, could not have been previously found out, and wbich materially augmented the difficulties of the case-namely, that the aneurism was fusiform, the dilatation extending from the first rib to the commencement of the brachial artery. In order to obtain access to a sound part of the artery above the dilatation, it was necessary to divide the pectorales major and minor. An aneurism-needle was then passed round the artery about half an inch below the point where it crosses the first rib, after which it was requisite to tie each of the several branches of the artery given off from the sac or dilatation, including the subscapular, the posterior circumflex, and the brachial, all of which bled profusely into the sac until the ligatures were applied. Yet considering the formidable nature of the operation, which occupied from first to last about forty minutes, the amount of heemorrhage was inconsiderable; and, by one of the boldest efforts of surgery, the patient was rescued from a position of imminent peril to one of comparative safety. A short time after the operation, numbness of the band and forearm came on; and in three or four days it was evident that the hand would be sphacelate-a result which might naturally be expected from the fusiform character of the aneurism, which necessitated ligature of all the anastomosing arterial branches upon which the surgeon depends for the reestablishment of the circulation after tying the subelavian. The subsequent progress of the case was as favourable as could be anticipated. All the ligatures came away between the twelfth and fifteenth days; the wound contracted well, and is now nearly healed; and the patient is sufficiently recovered to leave his bed and walk about the ward. The hand and the lower third of the forearm are black and dried up, in the condition analogous to that of senile gangrene. This portion of the limb is, of course, doomed; but for the present, at least, the patient is out of danger, and he lives a striking example of what surgical dexterity and skill is sometimes capable of effecting for suffering humanity towards rescue from the very jaws of death. I am happy to be able to report the satisfactory progress of the Waters Fund. The Liverpool subscription. list has increased from £70, as noticed in my last communication, to about £110; and it is hoped it may ultimately reach from £120 to £150. It is only due to Dr. Stookes, the treasurer, to say that, without at all detracting from the liberality and promptitude with which the profession have responded to this call, the success already achieved is in a great measure owing to the tact and energy with which he has discharged his duty, sparing no pains or trouble in bringing the subject under the notice of our brethren here, and thus affording all who were so disposed an opportunity of contributing. I have heard that at Chester about £100 has been collected from members of the profession, and £300 from the laity (if I may use the expression); at Birkenihead, nearly £20; and at Manchester, about the same sum has been raised; making, at present, a total of about £550 from this district. As it is understood that
doi:10.1136/bmj.2.131.16 fatcat:exxlwa7umbhgpfcwv7jjkyvcwu