A case of aneurysm involving the innominate, the right subclavian, and the right common carotid arteries : treatment by proximal ligature ... aneurysm to the middle cerebral artery / by Charles A. Ballance.

  • Ballance, Charles Alfred, Sir, 1856-1936.
Date:
1902
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Licence: In copyright

Credit: A case of aneurysm involving the innominate, the right subclavian, and the right common carotid arteries : treatment by proximal ligature ... aneurysm to the middle cerebral artery / by Charles A. Ballance. 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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    1501° in the Museum of Guy’s Hospital shows a large thoracic aneurysm which had ■completely obliterated the orifices of the innominate and left carotid arteries ; the patient lived for a year in fair health without a carotid or a right radial pulse.1 A case is related in the Revue de Midecine of a man, aged 46 years, who had been under observation for about 12 months suffering from attacks of angina pectoris. The innominate artery and the left common carotid were found at the necropsy firmly occluded, not as in the above quoted case from the effects of pressure from without, but as the result of endarteritis obliterans.2 At the meeting of the Pathological Society of London on Oct. 21st, 1902, Dr. Thursfield showed a very similar specimen of occlusion of the innominate and left carotid arteries. These cases appear to show that if only the coats of the arteries are not ruptured the great vessels at the root of the neck may be successfully ligated. A\re need not, therefore, be deterred from attempting to bring about surgical occlusion of the innominate for the cure of innominate aneurysm. Proximal ligature is the only sure means of effecting this obliteration; all other methods are uncertain and less effective. Published cases.—From the cases cited by Erichsen,3 H. L. Burrell,4 and Jacobson5 it appears that the innominate artery has been tied in 32 instances, five of them being for haemorrhage. Five only of the 32 cases recovered; in one of these the aneurysm returned 10 years later and then proved fatal, and in another the arrest of pulsation in the aneurysm was only temporary and on the sixty-seventh day the patient died after the first part of the subclavian had been tied as a last resource. The author expresses doubt as to whether he really made a satisfactory ligature of the innominate at the first operation. In the other three cases of recovery the aneurysms are spoken of as “cured,” but the record does not extend over two years. In one it is said that 16 months after the operation the aneurysm was a small moveable and hard tumour. All the cases of recovery are described as subclavian aneurysm and one was of traumatic origin. Subsequently to the publication of these lists I have only found the successful case of Farquhar Curtis previously alluded to. In France and in Germany the operation of ligature of the innominate does not seem to be regarded with much favour, for in the Duplay-Beclus “ Treatise on Surgery ” the question is dismissed in a few lines with the observation : “ That in three cases mentioned by Le Fort in which the operation was attempted it had to be given up as the aneurysm reached too close to the aorta.”(i Bergmann and Mikulicz say: “ In aneurysm of the terminal portion of the innominate the commencement of the artery is not sufficiently accessible for proximal ligature on account of the presence of the sac, and in aneurysms of the subclavian or of the carotid ligature of the innominate is contra-indicated because of the danger of grave circulatory disturbances.” 7 Konig writes : “ Ligation (of the innominate) cannot absolutely be struck 1 See “ Ligation in Continuity,” p. 91. “Revue de Medecine,” tome viii, 3, p. 201 (1888). Article by Dejerine and Huet. 3 “ Science and Art of Surgery.” tenth edition. 4 “ Boston Medical and Surgical Journal,” August 8th, 1895. 5 Jacobson and Steward, “The Operations of Surgery,” fourth edition. 6 Duplay and Reclus, “Traite de Chirurgie,” vol. v, p. 750. : “ Handbuch der Praktischen Chirurgie,” vol. ii, p. 43.