Extracted from the American Journal of the Medical Sciences for April, 1882. 
TRUE ANEURISM OF THE BRACHIAL ARTERY AT 
ITS UPPER THIRD. 
CURED BY COMPRESSION MAINTAINED FOR TEN HOURS BY 
MEANS OF A CONICAL PAD, 
WITH A RESUME OF THE LITERATURE OF THE SUBJECT. 
BY 
L. EMMETT HOLT, A. M., M. D., 
OF NEW YORK, 
Late House Surgeon to Bellevue Hospital. [Extracted from the American Journal of the Medical Sciences for April, 1882.] 
TRUE ANEURISM OF THE BRACHIAL ARTERY AT ITS 
UPPER THIRD 
CURED BY COMPRESSION MAINTAINED FOR TEN HOURS BY MEANS 
OF A CONICAL PAD, 
WITH A RESUME OF THE LITERATURE OF THE SUBJECT. 
By L. EMMETT HOLT, A.M., M.D., of New York, 
LATE HOUSE SURGEON TO BELLEVUE HOSPITAL. 
In consulting the literature of brachial aneurism, arising from other 
causes than traumatism, one is struck at the outset with the extreme 
rarity of recorded cases. John Hunter does not mention it at all. Astley 
Cooper1 says: “ I do not recollect to have seen a case of aneurism from 
disease of the brachial.” Hodgson says :2 “ those morbid alterations in 
the coats of arteries which predispose to the formation of aneurism are 
rarely met with in the brachial or its branches I have never 
seen an aneurism of the arm which was not produced by accidental vio- 
lence.” Crisp3 tabulates five hundred and fifty-one cases of aneurism of 
all varieties, in which there does not appear,a single case of spontaneous 
brachial aneurism. Alluding to it he says it is extremely rare. 
Scarpa4 reports a case of his own (Case V.) and refers to one by Fla- 
jani (Case XIII.). Birkett, who reports Case VII., says he had searched 
the records and inquired among his professional friends, but was unable 
to learn of another case. Sir Benjamin Brodie, who saw this with him, 
had never seen one. 
Broca5 in his tables mentions twelve aneurisms of the brachial, but 
they were all of traumatic origin. 
Liston6 says: “ disease of the coats of the arteries of the upper extremity 
to a great extent is not known, and very few cases of true aneurism below 
the axilla are mentioned. I have treated but one such case” (Case XI.). 
Coming down to more recent authorities we find that it is barely alluded 
to by Holmes, Hamilton, and Bryant. 
1 Surgery, p. 78. 
3 Diseases of the Bloodvessels, Lond., 1847. 
’ Anevrysmes et leur Traitement, Paris, 1856. 
3 Diseases of Arteries, p. 338. 
4 Sur l'Anevrysme, Paris, 1809. 
6 Surgery, p. 144, ed. of i838. 2 
Erichsen1 says : “ spontaneous aneurism rarely occurs below the axilla, 
but may be met with at any part of the upper extremity.” He alludes to 
four published cases, but does not mention any of his own. 
Gross2 says: “ spontaneous aneurism of the brachial is extremely un- 
common. I do not believe it has ever been noticed in this country.” 
Ashhurst does not mention a case. Agnew relates Case IX. as his 
only experience upon the subject. 
The first case related below came under my own observation last sum- 
mer. After a very careful search through the literature of the subject, 
I have been able to get together from all sources thirteen other cases ot 
brachial aneurism which seemed to be of spontaneous origin, i. e., not 
directly traceable to a wound or injury of the vessel. In some of these 
cases, slight exciting causes are stated to have been present, but that fact 
does not seem to me to be sufficient to exclude them from the number. 
There are very few surgical diseases which the patient does not attribute 
to some antecedent strain or fall. A shadow of doubt is thrown upon one 
or two of the cases on account of the brevity of the histories given. It is 
noteworthy that only three of the thirteen cases, Nos. II., III., and IX., 
were observed in this country. 
Case I Jas. Corcoran, a;t. 36, labourer, was admitted to Ward 11, 
Bellevue Hospital, May 31, 1881, for an aneurism of the right brachial 
artery which he had discovered only four weeks before. lie states that 
his father died by accident at the age of eighty, and that his mother is 
still living in good health at eighty-two. He has a sister suffering from 
a malignant growth of the face, probably cancerous. When a child the 
patient had an articular osteitis of the right knee, which resulted in an 
anchylosis of the joint at almost a right angle, and which has necessitated 
the use of a crutch upon that side up to the present time. No distinct his- 
tory of syphilis ; admits the use of tobacco to excess ; drinks ‘‘moderately.” 
About four weeks ago, after he had been at work shaking some carpets, 
he felt severe pains in his right wrist, and noticed it was a little swollen. 
The pains continued ; and, under the impression that they were rheumatic, 
lie applied to a druggist, who, strange to say, advised him to consult a 
physician, which he did. The doctor discovered a pulsating tumour, which 
lie told the patient was a brachial aneurism, and attempted to treat by 
compression by means of a tourniquet. The pain from this became in a 
short time so intolerable that the patient was obliged to have it removed. 
He has had no other attempt at treatment, and the pains have continued 
with increasing severity up to the present time. The tumour has also 
grown steadily in size, but quite rapidly during the past week. 
On examination there is found, about two and one-half inches below the 
border of the pectoralis major on the right side, a tumour the size of a 
hen’s egg, pulsating strongly. Its pulsation is forcible, expansile, but is 
easily controlled by pressure upon the axillary or the subclavian artery. 
There is a distinct thrill and a loud bruit which can be heard in the 
brachial below, and also in the radial at the wrist. The radial pulse 
seems to be slightly delayed upon this side. The whole extremity is swol- 
len so that it measures from half an inch to an inch larger than the left, 
1 Surgery, vol. ii. 140, ed. of 1878. * System of Surgery, ed. 1872, vol. i. 778. 3 
and it is the seat of some venous congestion. The patient now complains 
more of numbness and tingling in the hand than of pain, but there is very 
little if any anaesthesia. A careful examination of the heart was made 
without detecting any organic disease. Dr. Frank H. Hamilton, who 
was on duty at the time, very kindly turned the case over to me for treat- 
ment, advising that I use compression without an anaesthetic. Digital 
pressure was first thought of, but was given up and the following contri- 
vance resorted to : A piece of splint board was cut about a foot and a half 
long, and three inches wide at one end tapering to a half inch at the 
other. This latter was padded so that it made a hard ball about three- 
fourths of an inch in diameter. The patient was placed at the edge of the 
bed, and his arm, stretched out at a right angle with the body, rested 
upon a table. Seating myself in front of the patient, I rested the broad 
end of the splint-board against the front of my shoulder, and placed the 
padded end upon the artery in the axilla. With one hand this was 
steadied and kept in position. The other hand was kept upon the tumour 
to make sure that its pulsation was completely controlled. We were thus 
enabled to make very constant and even pressure with comparative ease. 
June 1 at 10.40 A. M. After having used digital pressure at intervals 
for about half an hour previous, the above was applied with the purpose 
of controlling entirely the pulsation of the tumour. 
11.15 A. M. Patient complains of numbness and anaesthesia in the hand 
and arm, and of considerable pain. 
11.45 A. M. Pain has increased so that Magendie rrpviij are admin- 
istered hypodermically. 
12.50 P. M. It is found that by a little care the pad can be so placed as 
not to include any of the nerve trunks between it and the bone, and that 
when this is done he complains of no pain. A very slight deviation from 
this position is immediately announced by darting pains down the arm, 
which is a signal for a readjustment of the pad. As a little soreness 
begins to be felt, the pad is removed entirely and digital pressure used 
for twenty minutes. 
1.50 P. M. There has been no pain of any consequence for the past two 
hours. The patient is in fact so comfortable that he has been dozing for 
ten minutes. The hand is warm but the arm and forearm are quite cold, 
and there is some venous congestion. 
3.45 P. M. A radial pulse is detected, even when there is no pulsa- 
tion in the aneurism. On making pressure higher up in the axilla above 
the usual point, this is completely arrested. For the last half hour there 
has been considerable pain in spite of all effort not to press upon the nerve 
trunks, and Magendie npvj is given. 
6 P. M. During the day, the assistants, who were the internes of the 
Hospital, relieved each other at intervals of from half an hour to an hour. 
During the change of hands, occasionally the aneurism would pulsate three 
or four times before the pad could be adjusted. Sometimes, also, it would 
slip a little in avoiding nerves, so that there has not been more than fif- 
teen or twenty minutes at a time when there was no pulsation whatever of 
the tumour. Since 5 P. M., it has been noticed that much less pressure 
was required to control the pulsation, and also that none took place during 
a change of hands. The whole limb is now warm and of neaidy normal 
colour. 
9 P. M. No pulsation in the sac has occurred since five o’clock. The 
radial pulse has steadily improved. There has been no numbness since 
early in the afternoon. The only pain the patient has experienced for 4 
the last few hours has been in his back, from his constrained position. No 
bruit can be detected. Pulsation of the artery immediately above the tu- 
mour is very feeble, and even high in the axilla is much less forcible than 
normal. The tumour is hard and firm. A hard pad was now placed in 
the axilla and the arm bandaged to the side. The patient was given a 
light supper and Magendie npviij, and in a short time he fell asleep. 
4th. There has been no further pain, and no return of pulsation ; the 
patient has been kept quiet in bed. The axillary pad is now removed ; 
the tumour is found much smaller and very firm. 
20th. There has been no sign of relapse. A careful examination estab- 
lishes this fact, which before has been doubtful, viz., pulsation in the bra- 
chial below the aneurism and throughout its course. This is very feeble. 
The principal means by which the circulation of the arm is carried is by a 
vessel which approaches in size the brachial, situated on the outer side of 
the belly of the biceps. This can be followed down to the elbow, where it 
is lost. The case has been examined by Drs. Hamilton and McBurney, 
and several other gentlemen, all of whom agree that the cure is a radical 
one. The patient is discharged from the Hospital at this date in good gene- 
ral condition, with instructions to use his crutch with the left arm. 
Aug. 1. He returned for observation, having had no symptom of re- 
lapse since his discharge. The tumour can only be found by cai'eful 
search. 
Jan. 9, 1882. I examined the patient to-day, and was unable to satisfy 
myself that I could find the tumour at all. The circulation is still car- 
ried on chiefly through the large collateral branch above mentioned, the 
pulsation in the brachial throughout being quite feeble. The radial pulse 
is about as strong as that upon the opposite side. He complains of the 
hand often becoming cold. In spite of injunctions, he was found to be 
using the crutch with the right arm again. He has no pain or other in- 
convenience than the coldness mentioned. 
Case II. Aneurism of Left Brachial at its Middle; Ligature of the Bra- 
chial at Upper Third; Secondary Hemorrhage; Ligature of the Axillary; 
Cure. (Reported by L. D. Waterman, of Indianapolis. Western Jour, of 
Medicine, 18G7, p. 584.)—A butcher, aged thirty-two years, seen in May, 1857, 
with a tumour, size of small hen’s egg, at middle of the left brachial artery. It 
was steadily increasing. The patient had valvular disease and great cardiac 
hypertrophy. The brachial was tied in its upper third. The aneurism shrunk 
to a small hard lump without pulsation. The ligature did not come away, and 
on the sixteenth day, with the thread still hanging, the patient butchered a 
calf. A few days afterwards he called attention to a rapidly forming tumour just 
above the ligature. Ligation of the axillary was advised, but refused. Two 
weeks later the surgeon was called for hemorrhage, the false aneurism having 
burst. The axillary was then tied in its lower third : the ligature came away 
properly, and the artery between the ligatures as well as the aneurism was com- 
pletely obliterated. The patient died six months later of dropsy. 
Case III. Aneurism of Right Brachial at its Upper Third; Ligature of the 
Axillary in its Lower Third / Secondary Hemorrhage; Ligatures of the Axil? 
lary in its Upper Third; Cure. (Reported by C. B. Kibler, Corry, Pa. Buf- 
falo Med. and Surg. Journal, 1870-71, p. 225.)—Male, aged twenty-nine 
years. The physician was called August 17, 1870, on account of intense pain 
in the right arm, forearm, and hand. In the upper third of the brachial artery 
was a pulsating tumour the size of an orange, which had been noticed six weeks 
before. It was attributed to swinging on a horizontal bar. August 25, the axil- 
lary artery was tied in its lower third. On the eighth day, secondary hemor- 
rhage took place; it was temporarily controlled by pressure upon the subclavian, 
and finally by ligature of the axillary in its upper third. This ligature came 
away in five weeks, and the wound was healed. When last seen, a few months 5 
after the operation, he had but limited use of the hand and forearm, and no 
radial pulsation. 
Case IV. Aneurism at the junction of the Upper with the Middle Third, of the 
Brachial; Instrumental Compression; Cure. (Reported by M. Denuce. 
Gazette des Hopitaux, 1860, p. 170.)—A vinedresser, aged fifty-two years; no 
history of eontusion or injury of any kind ; tumour first noticed three and one- 
half years before, and had grown steadily since that time. He had suffered 
meanwhile from neuralgic pains, numbness, and stiffness of the fingers. He was 
first seen July 20; the tumour was then of the size of a large walnut. It hud 
expansile pulsation, thrill, bruit, and, in fact, all the marked signs of aneurism. 
On July 21, compression of the axillary was begun by means of Broca’s instru- 
ment for compressing the femoral. In fifteen minutes the pulsation ceased, but 
the patient was suffering greatly. After an hour and a quarter, he declared he 
would bear it no longer, and loosened the apparatus. He would not allow it to 
be reapplied for any consideration. Two hours later examination showed that 
the pulsation had diminished very much in intensity ; the pulse was feeble, and 
the whole arm red, and a little cedematous. The next morning the pulsation 
was found to have ceased entirely; it returned again in the evening, but was 
feeble ; patient would not allow anything to be applied. On July 23, and daily 
thereafter, until August 8, the tourniquet of Petit was applied, or at least the 
attempt was made to apply it. Once he allowed it to remain fifteen minutes, but 
usually loosened it immediately, on account of pain. At no time during this 
period was suspension of the pulsation obtained. He left the hospital at this 
time. He was seen August 24, and reported that there had been no pulsation for 
eight days, his pain and numbness were all gone, and he considered himself 
cured. Pulsation was then absent, as was also the bruit, pulsation of the artery 
below the tumour felt with difficulty, feeble radial pulse. On October 2, there 
had been no relapse ; the radial pulse was a little stronger, but still weak. Still 
feeble pulsation in the brachial below the tumour, i. e., the tumour had been ob- 
literated, but the artery not completely. The entire compression was estimated 
at two and one-half hours. . 
Case V. Aneurisms of the Brachial, Radial, and Vascular Tumour of the 
Thumb, all in the Left Arm; Unsuccessful Compression. (Reported by W. D. 
Spanton. London Med. Times and Gazette, 1865, p. 517.)—Female, aged 
twenty-three years, came under observation in Sheffield General Infirmary, Novem- 
ber 5, 1863, for a swelling of the left thumb. She had bronchocele, but reports 
she had always been in good health. Examination revealed a swelling of the 
thumb which looked as though it were going to suppurate; also between the 
heads of the first and second metacarpal bones, an aneurism of the radial the 
size of a small marble, which had been noticed by a sister three years before. It 
had never caused pain, and had grown very slowly. On the following day an 
aneurism of the brachial was discovered three inches above the bend of the elbow, 
of the existence of which the patient was ignorant. It was the size of a 
pigeon’s egg, pulsated strongly, and had a loud bruit. A systolic murmur was 
heard at the base of the heart. She was kept quiet, and a tourniquet applied 
on the upper third of the brachial for a few hours at a time. A little consolida- 
tion of the sac seemed at first to take place, but the surgeons having decided 
against the use of the ligature, she left the infirmary in about the same condition 
as on admission. 
Case VI. Aneurism at Upper Third of the Left Brachial; Treatment Palli- 
ative; Death from Rupture. (Reported by Scarpa. Sur l’Anevrysme, Paris, 
1809.)—T. C., a soldier, perceived, at the beginning of the year 1759, a tumour 
situated just below the left axilla, for which he knew no cause; no history 
of traumatism of any sort. Fordyce, who saw the patient, recognized an aneurism, 
but did not dare to undertake its cure. It steadily increased in size until the 
patient was brought to St. George’s Hospital. The tumour then extended along 
the course of the brachial artery, and presented marked pulsations. The physi- 
cians and surgeons of the hospital were of the opinion that no operation should 
be undertaken, because the tumour was situated so high up. They contented 
themselves with palliative measures, i. e., cataplasms and anodynes. At the 
beginning of December, the aneurism ruptured and the patient died of hemor- 
rhage. On the autopsy, the artery was found corroded and ruptured in the 6 
neighbourhood of the axilla. At first sight it appeared that the sac was formed 
of the arterial coats ; but it was not so. The cavity of the artery was only a 
little dilated where it opened into the aneurismal sac and half a finger’s breadth 
above it was closed. 
Case VII. Aneurism of the Brachial at the bend of the Elbow; Failure of 
Compression; Ligature at Middle 'Third; Cure. (Reported by Jules Boeckel. 
Gazette Hebdom. de M6d. et de Chirurg., 1877, p. 344.)—Mechanic, aged 25 
years, entered the hospital at Strasburg November 19, 1876, for a tumour of 
the right elbow of five weeks’ standing. It is reported to have been of “ sponta- 
neous’’ origin but came quite suddenly and with marked pains down the forearm 
and hand. These obliged him to stop work. A physician treated him two 
weeks before ; a small pulsating tumour in the fold of the elbow was discovered to 
be the cause. It increased in size until it became as large as a small apple [pomme 
d’api\. Compression by a tourniquet was applied, but the patient became so un- 
manageable and the pains produced by it so severe it was discontinued. On ad- 
mission to the hospital, characteristic pulsation, thrill, and bruit were obtained, 
and the radial pulse was feeblet on this side. Compression was not again attempted, 
but the artery was tied with catgut at the junction of the middle and the lower 
thirds followed by cessation of the radial pulse. On the third day the radial 
pulse became again perceptible, and on the following day the stitches having been 
removed, the patient left the hospital. December 7, tumour was one-half the 
original size and there had been no return of the pulsation. In January it was 
observed that both the ulnar and radial recurrent arteries were notably dilated, 
and could be felt pulsating. The patient was last seen on March 5, he had then 
been working a month without any relapse. Nothing had been seen of the liga- 
ture. 
Case VIII. Aneurism of the Brachial at the Bend of the Elbow; Partial 
compression for four months ; Cure. (Reported by Mr. Birkett. Guy’s Hosp. 
Reports, 1862, p. 311.)—A young surgeon, aged 29 years, noticed January 23, 
1862, an aneurism at the bend of the left elbow the size of a hazel-nut. It had 
caused no symptoms, and was only discovered by accident. No blow or injury of 
any kind was known, and he had never been bled. He had had repeated attacks 
of rheumatism during the past five years. When first observed by Birkett, Jan. 
24, it presented all the diagnostic signs of aneurism. Compression by an elastic 
armlet extending six inches above and below the tumour was advised, and a pad 
placed under the upper part so as to make moderate pressure upon the artery. 
During three weeks before this could be made, the aneurism had doubled in size. 
After two weeks’ trial it was discontinued on account of the swelling of the hand 
and the great pain produced. Flexion was then used for a few nights, but also 
caused great pain and swelling. After this until May 7, irregular compression 
was made chiefly by a pad and bandage sometimes combiningflexion. The tumour 
was then about the size of a walnut, and its walls felt much thicker. The pro- 
priety of ligating the artery was now discussed but decided against, and under the 
advice of Sir Benjamin Brodie, the continuance of the compression was deter- 
mined upon. A steel tourniquet with two pads was now tried and worn by the 
patient under his coat, the arm being carried in a sling most of the time. This 
was worn until July 11, when all pulsation ceased, it having been very feeble for 
some days before. After four or five days all pressure was left off. On exami- 
nation September 12, it was found to have diminished in size to a hazel nut. 
There was no pulsation. Considerable wasting in the muscles of the arm took 
place. 
Case IX. Reported by Dr. D. Hayes Agnew (Agnew’s Surgery, i. 605, 
ed. 1878), who says: “In only a single instance have I witnessed a sponta- 
neous aneurism of the brachial artery. The patient was about 60, and the tumour 
was situated two inches above the bend of the arm. The artery was tied two 
inches above the tumour with entire success.” 
Case X. Aneurism of the Brachial at Middle Third; Unsuccessful Com- 
pression; Ligature of the Axillary ; Subsequent Opening of the Sac and finally 
Excision of the greater part of it; Cure. (Reported by Kade. St. Petershurgh 
Med. Zeitschrift, 1866, p. 202.)—Boatman, aged 46. Came under observation 
January 4, 1865, with a tumour commencing three fingers’ breadth below the 
right axilla, and extending to within the same distance of the fold of the elbow. 7 
It was of irregular size, and occupied the internal and anterior surfaces of the arm. 
It measured 19 cm. in length, 17 in width, and the circumference of the arm was 
38 cm. against 23 of the opposite side. In one place it was hard, at another elas- 
tic and soft, and at another there was fluctuation. It was covered by healthy, 
but in places, very thin skin. Expansile pulsation, bruit and thrill all marked; 
pulse in radial and ulnar arteries scarcely perceptible. 
He stated that when he was about 20 or 25 years of age, a heavy board fell on 
his right arm, and that ever since there had been a small nodular swelling at the 
middle of his arm. It did not pulsate, and remained unchanged until six months 
ago, when it began to increase in size and grew steadily until it attained its pre- 
sent dimensions. 
Intermittent compression was tried for six days, being employed for two or 
three hours four or five times a day. It seemed to diminish in size, and the 
bi’uit was sensibly weaker, but at the end of another week it was larger than ever; 
the skin was hot and very thin, and ligation of the axillary was decided upon. 
This was done January 19, and an ice-bag placed upon the arm after the 
tion. January 25, an exploratory incision was made in the sac for pus, and about 
a teaspoonful of blood evacuated. February 4, the sac was opened by a free in- 
cision, and the clots turned out; there was now some pus. The greater part of 
the sac was removed a few days later ; the wound filled in by granulations; and 
by the middle of March was entirely healed. The patient was discharged April 8, 
complaining only of a little weakness in his arm and hand ; the arm then measured 
only 2 cm. more than the opposite one. 
Kade’s interpretation of the history in this case is ingenious and quite 
plausible. Fie concludes that the immediate consequence of the injury 
was an extravasation of blood either between the arterial coats or into the 
sheath of the vessel; that this was gradually changed to a firm fibrous 
tumour adhering closely to the artery ; that the continued pressure and 
irritation of this upon the vessel together with the disturbances from the 
original injury done to the artery were the starting point of an endarteri- 
tis deformans chronica ; and that as a result of the atheromatous changes 
which followed this, the aneurism had developed within the last six months. 
Case XI. Aneurism at Bend of Elbow; Unsuccessful Compression; Cure 
by Ligation. (Reported by Sidney Jones. Brit. Med. Journ., 1872, p. 210.) 
—A woman, aged 80 years, four months before she was admitted to St. Thomas’s 
Hospital, ‘ ‘ violently sprained her left elbow.” There was much pain at the time, 
and only two months later was noticed a pulsating swelling. On admission it was 
the size of a walnut, and situated at the bifurcation of the brachial. Pressure and 
flexion were tried for two weeks without success. The brachial was then ligated 
two inches above the tumour. The ligature came away on the twenty-first day ; 
there was now no pulsation at the wrist or elbow. She left the hospital three 
weeks later, quite well. 
Case XU. (Reported by Liston. Liston’s Surgery, p. 181.)—“An old ship 
carpenter, while at work as usual, felt something snap in his arm, and a pulsating 
tumour was soon after noticed, and before I was asked to see him by Mr Cheyne, 
of Lieth, it had attained during four months the size of a hen’s egg, and was evi- 
dently made up in part of solid matter. The brachial was tied and everything 
went on favourably.” 
Case XIII. Aneurism at the Bend of the Elbow ; Digital Compression for 
ten hours; Cure. (Reported by Viennois. Gazette M6dicale de Lyon, 1866, 
p. 492.)—Male, 17, entered l’HStel Dieu, July 26, 1866, fora pulsating tumour 
of one year’s standing. He had been devoting himself to exercising with a ham- 
mer for two months when he felt a tumour at the bend of the elbow. When he 
entered the hospital it was the size of a pigeon’s egg, situated apparently at 
the bifurcation of the brachial. He had had from time to time numbness in the 
fingers, and the arm was weaker than the other. The tumour was sacciform, 
and situated in front of the artery. It presented forcible pulsation, thrill, and 
loud bruit. On extending the arm completely all these signs disappeared. 8 
Digital compression was begun over the middle of the brachial at eleven o’clock 
in the morning. After three hours the tumour became hard, and neither pulsation 
nor bruit could be detected. In order to insure a cure the pressure was main- 
tained seven hours longer, until nine o’clock in the evening. Patient left the 
hospital August 8, completely cured. He was heard from September 13 : there 
had been no sign of relapse, the tumour was about one-fourth its original size, 
and the arm had regained its function. 
Case XIV. Aneurism at bend of Elbow ; Failure of Compression; Ligature 
applied above and below the Sac; Cure. (Reported by Flajani, Collezzione d'os 
Serv, et riffles di Chirurg., t. ii. 22.)—A plethoric young man, after making 
the muscles of his right arm tense in lifting a weight, could not use it at all for 
several days because of the pain. A lividity of the skin came on the next day ; 
pain and discoloration disappeared in a short time, and he resumed his work. Used 
his arm freely for six months when he began to feel pain, which, at last, obliged 
him to stop work on account of its severity. Although he had seen, for some 
months, a small tumour at the fold of the elbow, he did not think of this as the 
cause. When he came under observation the tumour was the size of a large wal- 
nut, situated about three fingers’ breadth above the internal condyle. The usual 
signs of aneurism were present. After bleeding the patient, as a preparatory 
measure, compression was begun by means of a bandage extending from the axilla 
to the condyles of the humerus. It produced considerable engorgement of the 
arm, though only moderately tight, and not arresting the radial pulse. This was 
removed on the fourth day, having been applied in all thirty-two hours, and the 
only change produced in the tumour was a little flattening ; the hand and forearm 
were greatly congested and oedematous. Believing the aneurism would not war- 
rant any further continuance of this treatment, the ligature was applied the next 
day above and below the sac. On the fifth day afterwards the radial pulse was 
detected, and suppuration established in the sac. The ligatures came away on the 
eleventh and twelfth days, and on the forty-first day he left the hospital cured. 
Abstracts of the three following cases by Paletta, Pellatan, and Richet, 
are introduced here, because they have been so often referred to, especially 
the first two, by other writers upon this subject, as instances of true bra- 
chial aneurism. It does not seem to me that they ought to be included 
under this head. 
Paletta’s case (Giornale di Venezia, Marzo, 1796) was in a nun, a scorbut10 
subject, who heard one day, in her left arm, “a noise as if she had broken a 
nerve.” Immediately afterward a pulsating tumour appeared a little above the 
internal condyle. An attempt was made to treat it by compression, but had t° 
be abandoned on account of a fracture of the forearm of the same side, which was 
received soon after. The aneurism extended to the lower extremity of the arm? 
and the increased pulsation of this, together with frequent attacks of hemorrhage? 
are said to have hastened the death of the patient, which appears from the history 
to have been two or three months from the appearance of the aneurism. No 
autopsy was made, but the author had no doubt that it was produced by corrosion 
and rupture of the brachial artery. 
Pellatan’s case (Clinique Chirurg., t. ii. 4) occurred in a man of fifty-four, 
who was first seen June 21, 1779. He was in wretched general condition, and 
had had for about three months a very bad cough, during which he rested mostly 
with his head upon his right hand. About three weeks before admission to the 
hospital he had noticed a swelling in the fold of the arm, which had increased in 
size with all the signs of inflammation, finally rupturing and discharging a large 
amount of pus. It appeared like an ordinary phlegmon, the skin over it had a 
gangrenous look ; the sinus was still present, but, on careful examination, strong 
pulsation was detected at the bottom of it. “ Everything indicated an effusion of 
arterial blood,” says the author, who then proceeded at once to apply a ligature 
above and below the tumour. Secondary hemorrhage came on the tenth day, 
and the patient lost so much blood that he died on the fourteenth. On autopsy 
the brachial was found ossified at its lower extremity to its bifurcation ; along this 
track a large rent was found, which he thought had been produced by extension 
of the prolonged flexion. 9 
llichet’s (Bulletin de la Soci6t6 Anatomique, 1873, p. 697) case is a more 
recent one. The patient was a man of sixty-five, who, when seen, had a large 
tumour extending from a little above the left elbow to the middle of the forearm, 
and was of eight days’ standing. It came suddenly after a blow received upon 
some barrel-staves which he was carrying in this arm, and with an acute pain. 
There was then neither expansion nor bruit. But a week later the tumour had 
become circumscribed and the size of an orange, and gave all the signs of aneu- 
rism. Flexion and compression by sand-bags failing to produce any change in 
the tumour ; digital compression was practised for ten consecutive hours. This 
arrested permanently the pulsation of the tumour. The bruit could be heard for 
a week and then disappeared completely. The radial and ulnar pulse continued 
imperceptible. The patient died comatose one month after the compression. 
Arteries of the brain were found atheromatous, and extensive cerebral softening, 
but no hemorrhage or embolus discovered. The aneurismal sac was very thin, 
and in the anterior part of this a portion much thicker was found, which Avas 
interpreted to be another smaller aneurism, by the rupture of which the secondary 
traumatic aneurism had been produced. This was supposed to have existed a 
much longer time, but unobserved by the patient. A rupture of the artery was 
found to correspond to the opening into the sac. 
The accompanying Table is a summary of the main points in the pre- 
ceding cases :— 
No. 
Authority. 
Age. 
Sex 
Side. 
Site. 
Supposed 
cause. 
Treatment. 
Result. 
1 
Holt 
36 
M. 
Right 
Upper 
third 
Shaking 
carpets 
Instrumental compres- 
sion for ten hours. 
Cure 
2 
Waterman 
32 
Left 
Middle 
third 
None 
stated 
Ligation of brachial ; 
ligation of axillary 
for secondary hemor- 
rhage. 
3 
ibler 
29 
Right 
Upper 
third 
Swinging 
on horizon- 
tal bar 
Ligation of axillary, 
lower part; ligation 
of upper part for 
hemorrhage. 
4 
Denuce 
52 
Junction 
of upper 
mid. third 
None 
known 
Intermittent instru- 
mental compression. 
5 
Spanton 
23 
F. 
Left 
Lower 
third 
Compression by tourni- 
quet. 
Left hospi- 
tal unim- 
proved. 
6 
Scarpa 
M. 
U 
Upper 
third 
* 
Palliative. 
Death 
7 
Boeckel 
25 
Right 
Bend of 
elbow. 
Spontane- 
ous 
Failure of compression 
by a tourniquet; li- 
gation of brachial. 
Cure 
8 
Birkett, 
29 
“ 
Left 
U «i 
None 
known 
Intermittent compres- 
sion and flexion. 
9 
Agnew 
60 
•• 
Lower 
third 
Ligation of brachial. 
** 
10 
Kade 
46 
M. 
Right 
Middle 
third 
Blow 25 
r’rs before 
Failure of compression; 
ligation of axillary. 
“ 
11 
Jones 
30 
F. 
Left 
Bend of 
elbow. 
Sprain 
Failure of compression 
and flexion ; ligation 
of brachial. 
12 
Liston 
“ an 
old 
man” 
M. 
Strain 
Ligation of brachial. 
13 
Viennois 
17 
Exercise 
with 
hammer 
Digital compression 
ten hours 
14 
Flaj ani 
“ a 
young 
man” 
Strain 
Failure of compression; 
ligation above and be- 
low the sac. 
“ 
From the foregoing cases the following conclusions may be drawn re- 
garding :— 
1. Age By the best authorities on the subject of aneurism between 
thirty and forty years is given as the time of life in which the disease is the 10 
most frequent. Seven of the above cases, eight, if we include Case XIV., 
which is said to have been in a “ young man,” occurred under thirty-two 
years. 
2. Sex The predominance of the male sex is borne out by our statis- 
tics, as well as by those of all observers on the subject. Only two of the 
cases (V. and XI.) occurred in females. In one the sex is not men- 
tioned. 
3. Site of the Disease—The aneurism affected the left side five times, 
the right four times, and in five the side is not mentioned. In six of the 
cases, nearly one half of the whole number, the tumour was at the bend of 
the elbow, presumptively at the bifurcation of the artery. In two cases 
(V. and IX.) it was situated at the lower third. Of the remaining six 
cases, two (II. and X.) were at the middle third ; one (IV.) at the junc- 
tion of the middle and upper thirds, and three at the upper third (I., III., 
and VI.). 
4. Exciting Cause In five of the cases it is distinctly stated that no 
assignable cause was known. In one (VII.) it is stated to have been 
“spontaneous.” In Waterman’s case (II.) no reference whatever is made 
to etiology. It may be thought that it is not quite fair to accept this nega- 
tive evidence as proof that the aneurism was not from an injury. But 
the additional evidence afforded by the fact mentioned of coexisting vah 
vular disease of the heart, together with the occurrence of secondary 
hemorrhage following a ligature placed close above the sac, and the death 
of the patient six months later from dropsy, make it more than probable 
that the aneurism depended upon disease of the arterial coats. 
In Kibler’s case (III.) the history states that it was attributed to exer- 
cise upon a horizontal bar. Arterial disease seems pretty clearly demon- 
strated in this case also, by the occurrence of secondary hemorrhage on the 
eighth day after ligation of the artery just above the sac. 
In Case X., that of Kade, the aneurism is believed to have been due to 
an injury by a falling board received twenty-five years before symptoms 
developed. Ilis argument, though very interesting, does not appear to 
me to furnish sufficient grounds for excluding this case from the category 
of true aneurisms. 
In Cases X., XII., XIII., and XIV., the tumour could be pretty dis- 
tinctly traced to a strong muscular effort or a blow as an exciting cause. 
In two instances it is stated in the history that the tumour was first noticed 
some months after the occurrence of the injury. In the other two cases 
there is no evidence in the histories that a rupture of the artery had been 
produced. In my own case, the patient, on being questioned, could re- 
member no other possible exciting cause than the carpet-shaking, but it was 
some little time after this before the tumour was discovered. Whether the 
use of the crutch under that arm for thirty years had anything to do with 
the production of the aneurism, is an interesting question, and one upon 11 
which there was quite a diversity of opinion among those who saw the 
case. I am myself not quite prepared to admit it as the cause of the 
arterial degeneration. My reasons for this are twofold: In the first place, 
the pressure of the crutch came two or three inches above the point at 
which the tumour developed ; secondly, notwithstanding the frequency 
with which crutches are used at all ages, and in all conditions, and that 
we see almost daily the effects of pressure upon the nerves in the shape 
of “ crutch paralysis,” this, I believe, is the only instance on record, if 
indeed this be one, in which the use of a crutch has been followed by 
aneurism. 
5. Treatment Palliative treatment only, was used in one case 
(Scarpa’s), it being decided that it was unfit for operation, and the patient 
was left to die. 
In eight cases the ligature was used, with ultimate success in every in- 
stance. In four of these the vessel was tied pretty close to the sac, i. e., 
within two or three inches. Secondary hemorrhage followed in two in- 
stances, II. and III. The Hunterian operation was done twice, in Cases 
VII. and X., in one of which it was followed by suppuration in the sac, 
and the excision of the greater portion of it. In Liston’s case it is not 
stated at what point the ligature was applied. In Flajani’s case (XIV.) 
the old operation of cutting down upon the sac and placing a ligature on 
the vessel above and below was performed. 
Compression was tried in nine cases ; it was successful in four, and 
failed in five. Of the unsuccessful cases, four (VII., X., XI., and XIV.) 
were afterwards cured by the ligature, and one (V.) left the hospital 
unimproved, the ligature being decided against. In Case VII., the 
compression was made by a tourniquet, but it had to be removed on 
account of the intense pain produced. In Case X., intermittent com- 
pression, which appears to have been digital, was tried for six days, being 
kept up for two or three consecutive hours four or five times a day. No 
lasting improvement seemed to follow, and it was then given up. In Case 
XI., it is simply stated that compression and flexion were unsuccessfully 
tried for two weeks. In Case XIV., compression was made by means of a 
bandage extending from the Axilla down to the tumour at the bend of the 
elbow. So much oedema and congestion were produced that it was re- 
moved in thirty-two hours, and no change having taken place in the 
tumour, the bandage was thrown aside. In Case V. the tourniquet was 
used for a while and then given up, as no special improvement had taken 
place. 
Of the successful cases of compression, digital alone was used in one 
case (XIII.). It was kept up ten hours, but consolidation of the tumour 
took place in three hours, as neither bruit nor pulsation could be detected 
after that time. In three cases some form of instrumental compression 
was used. In Case VIII. it was made first by an elastic armlet and a 12 
pad, but this had to be discontinued on account of intense pain and swell- 
ing. A steel tourniquet making partial compression was then worn for 
two months before pulsation ceased. In Case IV. instrumental compres- 
sion was kept up for an hour and a quarter, when the pain became intoler- 
able, the instrument had to be removed, and the patient would not allow 
it to be reapplied. For a week afterward a tourniquet was endured for 
a few minutes each day, and then the patient left the hospital disgusted. 
Pulsation ceased spontaneously eight days later. 
My own patient (Case I.) had had a tourniquet tried before I saw him, 
but was unable to stand the pain. By means of the conical pad he was 
kept free from pain the greater part of the ten hours during which com- 
pression was kept up. Only twice was morphia required: once early in 
the day before we had discovered that it was possible to avoid entirely 
the nerve trunks. Prompt and complete relief was afforded in both in- 
stances. The thickening of the integument in the axilla, consequent 
upon the long use of the crutch, was undoubtedly of a good deal of ad- 
vantage in enabling the.patient to tolerate the pressure for so long a time. 
Six hours were required for the consolidation of the tumour; in Case XIII. 
it was accomplished in three hours. The existence of a good radial pulse 
at end of five hours, through the collateral circulation, seems to be worthy 
of more than a passing notice. The condition of the radial pulse is only 
referred to in three cases. In Case IV. the patient was not seen until 
eight days after pulsation of the tumour had ceased, and then the radial 
pulse is said to-have been feeble. In Case VI. the radial pulse was not 
noted until the third day after the application of the ligature; and in 
Case XIII. not until the fifth day. 
May this not be explained in my case, by the supposition that the pres- 
sure of the crutch upon the artery had already produced a considerable 
dilatation of the collateral branches ? 
The cure of the aneurism without the obliteration of the artery was 
noted in Denuce’s case (IV.), as well as in mine. 
From the foregoing it will be noticed that those aneurisms, situated at 
the bend of the elbow or just above it, have been quite easily managed by 
pressure when persisted in, or by the ligature. The real difficulties in the 
treatment of these cases meet us in those in which the aneurism is situ- 
ated in the middle or upper third of the artery. Broca (op. cit., p. 884) 
says that aneurisms of the upper third of the brachial still call for the 
ligature of the axillary, and that pressure is not applicable on account ot 
the proximity of the large nerve trunks. Below the insertion of the 
coraco-brachialis the indications change; here he advises alternating com- 
pression by means of two pads, as even here continuous compression at 
one point is out of the question. 
Ashhurst (Principles and Practice of Surgery, p. 558) condemns in 
toto the ligature of the axillary for aneurism of the upper third of the 13 
arm. He says these “may be treated by direct compression or by flexion, 
and if these fail by the old operation or amputation, either of which is 
preferable to ligature of the axillary.” 
Of the six cases above narrated, situated above the middle of the arm, 
the use of the ligature was followed in two (II. and III.) by secondary 
hemorrhage ; in one (Case X.), by suppuration and excision of the sac. 
Scarpa’s case was left to die, being decided unfit for operation. Denuce’s 
case left the hospital because of the great pain to which he was subjected 
by compression, and nature completed the cure. With this showing, the 
simple contrivance of the conical pad, which we will not dignify by the 
name of an apparatus, but which fulfilled so well the indications in the 
case in which it was used, seems to deserve a further trial in similar cases. 
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