Ligature of the innominate artery : with the report of a case / by Herbert L. Burrell.

  • Herbert Leslie Burrell
Date:
1895
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Licence: Public Domain Mark

Credit: Ligature of the innominate artery : with the report of a case / by Herbert L. Burrell. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    [Reprinted, from the Boston Medical and Surgical Journal of August 8, 1895.] LIGATURE OF THE INNOMINATE ARTERY, WITH THE REPORT OF A CASE.1 BY HERBERT L. BURRELL, M.I)., BOSTON, Surgeon, Boston City Hospital; Assistant Professor of Clinical Surgery, Harvard University. fink The ligature of the innominate artery has been so fatal an operation that it had been questioned whether the operation is justifiable or not. This leads me to record this case. Some of the accounts of attempts to ligature the artery describe such difficulties of technique, as, for example, in the article by Mitchell Banks, that any surgeon hesitates before performing this hazardous operation. The literature of the sub- ject is not large, but it is filled with an almost un- broken record of fatal results. The causes of death as the result of the operation have been three: first, shock; second, hemorrhage, usually from the distal end of the artery ; and, third, sepsis. The operation of ligature of the innominate artery has been done twenty-nine times, including my own case. Twenty-six were performed for aneurisms of the subclavian artery, generally involving the junction of the carotid and innominate arteries; and three times it was done for trauma — of these one was for hemorrhage from the subclavian, one for hemorrhage from the axillary artery, and one for secondary hemor- rhage following ligature of the subclavian. Three cases are reported as recoveries; the first was Smyth’s of New Orleans, 1864. The patient lived ten years, but finally died from hemorrhage from the sac of the original aneurism. The second case was Lewtas’, of India, 1889, who reported a recovery at the end of 43 days. The third was Coppinger’s, of Dublin, 1893, who reported the patient well at the end of 42 days. Graefe, of’ Berlin, in 1822, reported a case which died on the 68th day of hemorrhage. The success of an operation must be considered as applied to an individual case. If my own case had been reported at the end of 50 days, it would go on record as a successful case. In the light, however, of Graefe’s case that died from hemorrhage on the 68th day, it is too early to report a recovery on the 42d or 43d day. In my own case the patient lived 104 days. He had been up and about for a number of weeks at- tending to his affairs, and died of hypertrophy and dilatation of the heart and general arterial sclerosis. The innominate artery was closed and the aneurism had shrunken. The patient might have lived for a long time so far as the ligation of the innominate was concerned. The success of this operation may be measured by the question whether the patient lived longer and with more comfort than without operation. I believe (it is unfair to assert) that the patient lived as a result of the operation in more comfort and a longer time than he would have without operation. With the foregoing qualifying statement 1 beg to record the case as one of recovery, with death resulting from other causes on the 104th day. Appended to this article is an epitome of the recorded cases of ligature of the innominate artery. The various materials which have been used for securing the vessel are as follows: silk, hemp, catgut, ox-aorta, kangaroo tendon, and a clamp combined with acupressure. In the majority of instances the method of exposing 1 Read before the American Surgical Association, New York, May, 1895. the vessel has been the obvious one of making an in- cision along the inner border of the lower part of the sterno-cleido-mastoid muscle, combined with a division of at least a part of this muscle. At the time this operation was done I supposed that the removal of a portion of the sternum and the sterno-clavicular articulation was a new procedure, but it has been found that Cooper, of San Francisco, twice used this method of exposing the artery. Bardenheuer has also a number of times resected the manubrium, the sterno-clavicular articulation and portions of the first and second ribs, in order to remove with safety large tumors at the base of the neck. He is convinced that ligature of the innominate artery cannot be done with safety unless a free access to the artery is obtained. It seems clear that the removal of that part of the sternum which overlies the innominate artery must allow the operator accurately to place a ligature in a far more satisfactory manner than if the ligature is slid down in the dark behind the sternum. The medical history of this case was the following: The patient, a male, R. F., was fifty-four years of age, married, a clerk, and was under the care of my colleague, Dr. A. L. Mason. The family history was as follows: The father died of old age; the mother, a brother and one sister died of consumption ; three sisters are alive and well. The present history is as follows : The patient had always been well until two years ago when he noticed a little shortness of breath. He had never had any venereal disease, rheumatism or chorea. He had never worked very hard, nor was he of a nervous temperament. About eighteen mouths ago he noticed a “lump in his throat’’ on the left side, which, on exertion, seemed to throb and to choke him. There was no pain. The lump has increased in size but very little. About a fortnight previous to entrance he had to walk some distance, since which time he has had a good deal of dyspnea and the choking sensation has increased. The patient sleeps well, his appetite is good, his bowels are regular, and there is no palpita- tion of the heart. Physical examination: The patient is well de- veloped and nourished. The tongue is clean. The pulse is regular, of good strength and volume. The heart area is enlarged one finger's breadth to the right of the sternum. The apex is in the fifth interspace, one-half inch to the outer side of nipple. Over the entire precordise is heard a blowing systolic and a sharp diastolic murmur, especially well-marked over the aortic region. This is transmitted upward and outward into the axilla, and is heard also faintly over the back at the level of the sixth dorsal spine. There is a marked pulsation of the vessels of the right side of the neck, where there can be made out a well- marked, expansive thrill and a systolic bruit (Fig. 3, a). Lungs: Good resonance and respiration over all. Liver: Dulness from fifth rib to one inch below the costal border. Spleen : Area not enlarged, edge not felt. Abdomen : Lax, tympanitic, not tender. F tremities: There is a well-marked pulsation in