LIGATION OF RIGHT-EXTERNAL ILIAC ARTERY FOR TRAUMATIC ANEURISM OF FEMORAL ARTERY. E. BURKE HAYWOOD, A M, M D„ RALEIGH, N. C. Published by Order of the Raleigh Academy of Medicine, -AND - The North Carolina Medical Society. RALEIGH: NICHOLS & GORMAN, BOOK AND JOB PRINTERS, • 1870. LIGATION OF RIGHT-EXTERNAL ILIAC ARTERY FOR TRAUMATIC ANEURISM OF FEMORAL ARTERY. BY E. BURKE HAYWOOD, A M., M. D„ BALEIGH, N . C. Published by Order of the Raleigh Academy of Medicine, -AND- The North Carolina Medical Society. RALEIGH: NICHOLS & GORMAN, BOOK AND JOB PRINTERS, 1870. LIGATION OF MMfflllllMBIFMBIMmilSII OF FEMORAL ARTERY. By E. Burke Haywood, A. M., M. 1). In December, 1869, I was requested by Acting Assistan Surgeon White and Major Worth, U. S. A., to visit the post hospital at Raleigh, N. C., for the purpose of seeing and consulting about the case of Sergeant Johnson, Company B, 8th Reg. U. S. A., who was wounded October 23d, 1869, by a pistol ball in the outer-upper third of the right thight The ball ranged upwards and inwards, and wounded the fe- moral artery. December loth, 1869, I again visited, by request, the post hospital. I invited Drs. Little and F. J. Haywood, Jr., to accompany me. We found Sergeant Johnson in a debilitated condition, caused, principally, by his long confinement to bed, in a constrained position, his right limb having been flexed since the reception of the wound. The right knee joint was anchylosed. At the upper third of the right thigh there was a very large aneurismal tumor, extending from the middle of the anterior and inner aspect of the thigh to Poupart's ligament. This tumor had made its appearance 4 soon after the reception of the wound, and had been slowly increasing in size. Digital and instrumental compression had been used for weeks, but with no beneficial result. The whole limb was now oedematous from venous congestion, and very painful. The aneurismal tumor was pulsating violently, showing on one side a dark reddish spot, indicating inflammation, ulcera- tion, and most probably immediate death. Near Poupart's ligament, there was a small ulceration, caused by the use of an arterial compressor. On consultation, we advised an immediate operation, and proposed the following one : To control the circulation in the femoral artery by pressure on it, where it passes over the os pubis, to open the aneurismal tumor by a longitudinal incision, then turn out the clots and tie the artery above and below the point where it was wounded. This operation being regarded as too hazardous by Dr. White, he requested time for reflection until the next day. December 16th, 1869. The proposed operation having been declined by Dr. White, as too dangerous, 1 then pro- posed to ligate the external iliac artery, and offered to do the operation, or assist Dr. White in performing it. Dr. White kindly offered the favor of the operation to me. We at once gave the patient an ounce of brandy, and had him put on the operating table. Ether was administered by Major Ernest from a cone. I proceeded to operate in the manner advised by Abernethy, and modified by Gross. 1 found but little difficulty in ligating the external iliac artery near its middle. I applied the ligature tightly, using the reef knot. After waiting several minutes, upon examination, I thought I detected pulsation in the external iliac artery below the ligature. I called the attention to it of the other 5 medical gentlemen present, who were of the same opinion. To make assurance doubly sure, I applied a second ligature immediately below the first. I then closed the wound by interrupted sutures, uniting the deep seated muscular tissues first, and then the integuments, by separate sutures, to pre- vent hernial protusion. The patient lost but little blood from the necessarily cut branches of the superficial epigastric and circumflex iliac arteries. I was so fortunate as not to injure the peritoneum or external iliac vein, by the aneurismal needle or ligature. The patient sustained the operation remarkably well. Soon after, his right limb became cold. We had him put to bed, the limb enveloped in warm flannel, and bottles of hot water applied to it. Twenty-four hours after the operation, I discovered, by means of a Camman's stethoscope, slight pulsation in the tumor and also in the femoral artery, where it emerges from Poupart's ligament, which I attributed to the establishment of the collateral circulation. The anasto- mosing branches, in this case, must have been much en- larged by the frequent and long-continued interruption of the current of blood in the femoral artery, by the digital and instrumental compression previously used. The pulsation in the external iliac artery, felt soon after the operation be- low the first ligature, might have been caused by the im- pulse of the current of blood in such a large artery, against the ligature, being communicated to the artery below by continuity of tissue. The wound being deep, I was fearful that the ligature had not been tied sufficiently tight to cut the middle and inner coats of the external iliac artery, and that its canal was still pervious, and that secondary hem- orrhage would follow the detachment of the ligature. "We know now that it is not necessary, as Jones taught, 6 that the internal and middle coats of an artery should be cut through by the ligature. All that is requisite being to bring the internal coat into central contact under the liga- ture."-[Prof. Pancoast's letter.'] The pulsation in the femoral artery and aneurismal tumor continued for several days, becoming fainter until it disappeared entirely. The fibrinous stratification of blood in the sac gradually ob- literating the cavity of the aneurism. The ligature came away on the 27th of December, eleven days after the opera- tion. There was no hemorrhage. In this operation I was ably assisted by Drs. White, W. Little, and J. J. Haywood, Jr. Under the care of Acting Assistant Surgeon White, Ser- geant Johnson continued to improve in health and strength. The tumor diminished slowly in size and became hard, with not the slightest pulsation perceptible in it. February Ifith, 1870. I saw Sergeant Johnson to-day He is now walking about the hospital grounds, aided by a stick. There is stiffness of the right knee joint, caused by his long confinement to bed, the injured limb having been kept in a flexed position most of the time since he was wounded. The anchylosis will yield to passive motion and friction. The measurements to-day, (February Ifith, 1870,) are: circumference over largest part of right limb and tumor, eighteen (18) inches, over the same part of sound limb, six- teen (10) inches. This is the first successful ligation of the external iliac artery in North Carolina, that I am aware of. 7 A WARNING TO LOVERS. Not long since I saw a young lady suffering from buccal chancre, caused by a kiss given her on the lips by her en- gaged lover, who was at that time suffering from secon- dary syphilis. The contagion was communicated by the secretion from a mucous patch on the upper lip of her lover. He was ignorant of the danger of contaminating his lady love by this manifestation of his affection. He had been under treatment, several weeks before for primary syphilis, and thought that he was cured. When first seen by me, the young lady had a well marked chancre on her upper lip. It had existed for more than ten days, and was thought by her to have been caused by a chapped lip. There was a great deal of induration of the upper lip, and the parotid and submaxillary glands, were much enlarged and very painful. This induration Continued for several weeks, and was followed by well marked secon- dary symptoms. E. BURKE HAYWOOD, A. M., M. D. Raleigh, N. C., May 23, 1870.