CASE OE CAEOTID ANEURISM, AND SOME REMARKS ON TUB DIAGNOSIS OF THAT DISEASE, PUBLISHED IN THE SOUTHERN MEDICAL AND SURGICAL JOURNAL, WITH DR. PAUL F. EVE’S COMMENTS THEREON, AND A REPLY JAMES M. GREEN, M. D. ill a c a 11: PRINTED BY B. F. GRIFFIN. 184 S. PREFACE. The following publication should properly have taken place several months since; but several untoward events not necessary to mention here, hive prevented its issue until the present period. As, however, the published statements of both parties concerned are given at full length, the professional reader will have an opportunity of forming an impartial opinion of the merits or demerits of the controversy. Macon, January 15ih 1849. CASE OE CAROTID ANEURISM. From the Southern Med. and Sur. Jour. !or June 1848. In the Medico-Chirurgical Review for 1842, Mr. Brans- by Cooper, of London, published a case of ligature of the common carotid, accompanied by some observations in which he advocated an improved method of performing this capital operation in surgery. Mr. Cooper recommends that the surgeon should not make his external incision so near the edge of the stcr- no-cleido mastoid muscle as is directed by authors, and that he should cut directly down upon the trunk of the artery, and not upon the internal jugular, or the line of di- vision between these two vessels. Operating surgeons, in their reports, dwell upon the in- convenience and danger produced by the swelling and turgidity of the internal jugular, during the operation for carotid aneurism ; and it is well known that this import- ant vessel has been punctured in more than one instance —adding a grave complication to a dangerous operation. By cutting down more to the inner side of the jugulo- carotid sheath than has been directed by the surgical au- thorities, these difficulties are avoided,—a considerable mass of undisturbed cellular substance is left, which binds down the internal jugular in its proper place, and prevents it from swelling up and overlaying the artery, thus seri- ously interfering with the success and safety of the ope- ration. 6 Believing that Mr. Cooper’s method is a real improve- ment in the manual of the operation, I am induced to com- municate the particulars of a case in which a somewhat similar plan was pursued by myself,'in the year 1841. If valuable in no other way, it may be in a statistical point of view. In November, 1841,1 was requested, by Dr. Thomas F. Green, then physician to the Georgia Penitentiary, to ope- rate on James Deas, ajconvict in that institution, for an- eurism of the right carotid artery. Deas gave the follow- ing history of the tumor. About eighteen months previously, he first observed a small swelling on the upper part of the right side of the neck, immediately after a severe strain while planing some hard wood. This was at first supposed to be an enlarged gland. It increased in size very slowly until the month of May, ’4l, since which it had rapidly augmented to the size of a hen’s egg; pulsating violently; very sensitive, and pro- ducing much pain ; confusion,; fullness, &c., in the right side of his head. When I first saw him it was a good deal larger than a common sized hen’s egg—pulsated very strongly, and was quite red, and tender to the touch. It was situated just below the ramus and posterior part of the right lower jaw. The peculiar whizzing noise, said by the surgical writers to be so peculiar to aneurismal tu- mors, was very indistinct—almost imperceptible; nor could we hear the fluid rushing into the sac again, after obliterating the caliber of the artery, by pressing it firm- ly against the vertebras. Neither could the sac be entire- ly emptied by stopping the flow of blood into it:—it still retained about a third of its volume, but this we at- tributed to a little surrounding osdema and a few enlarged glands, and perhaps some coagula in the aneurism itself. Always after handling the tumor, the pain, fullness, and 7 confusion in the right side of his head was very much in- creased. For two weeks preceding the application of the liga- ture, Deas was subjected to a very rigid diet, and took blue pill and saline cathartics several times, which treat- ment produced some diminution in the size of the swell- ing, and a marked abatement in its redness and sensitive- ness, as well as the unpleasant feelings in the head. As this improvement, however, was not so great as to suggest a hope of cure by the method of Valsalva, it was deter- mined to apply the ligature. December 14th. Proceeded to perform the operation, as- sisted by Dr. Benj. A. White and Dr. Tho, F. Green. After placing the patient in a recumbent posture, and inclining his head to the left, as usual, the operation was commenc- ed, by making an incision two inches in length through the skin and cellular substance, in the sulcus, between the edg- es of the sterno-mastoid and sterno-hyoid muscles. The dissection was then continued through the superficial and deep-seated fascia, down to the left side of the sheath, di- rectly upon the artery. Finding some inconvenience from the smallness of the external wound and the profundity of the artery, it became necessary to increase the length of the external incision about three fourths of an inch up- wards. Making now a small opening in the sheath, just over the center of the artery, at the lower edge of the omo-hyoid muscle, with the point of the scalpel, the liga- ture was without much difficulty passed under the Artery, by means of Gibson’s aneurism canula, which was care- fully insinuated through the opening in the sheath, and then round the artery from without inwards. We now compressed the artery between the finger and the canula, to observe its effect on the aneurism, and then carefully excluding the pneumo-gastric nerve, the ligature (a Strong silk one) was drawn tight, and secured by three knots. 8 Not more than three ounces of blood|was lost, and no ves- sel but the carotid required a] patient was allowed to rest a few minutes, the edges of the wound were drawn together by two points of suture, and covered with lint, which the attendants were directed to keep constantly moistened with fresh cold water. During, and for some time after the operation, the pa- tient complained of intense toothe-ache in two of his right lower molars, which might have had some connec- tion with an accidental pinch that the dcsrendens noni re- ceived from the dissecting forceps. (?—Edt.) In consequence of making a very small opening, and that on the inner side of the sheath, no trouble was expe- rienced from the bulging and turgidity of the internal jug- ular—indeed it was not seen or perceived during the ope- ration. Subsequently to the application of the ligature, a very obscure pulsation was observed in the tumor; whether from the impulse communicated by the impetuous beating of the artery below the ligature, or from the recurrent cir- culation, we were unable to decide. At our evening visit we found that Deas had a good deal of head-ache, and complained of considerable pain in swallowing; the tooth-ache was gone. Closed the wound with strips of adhesive plaster. 15th. At our morning visit, Deas had a good deal of head-ache ; he said he had vomited freely during the night. His head, face, and neck, flushed ; had slight nausea, fur- red tongue, and some epigastric tenderness. The tempo- ral and other arteries on the left the face and head were very much developed, and the conjunctival vsssels of the right eye a good deal congested. The artery below the ligature was still pulsating strongly. Pulse 70, not much excited. Directed a dose of sulph. magnes., and cloths dipped in cold water to his forehead. In the eve- 9 ning he was better in all respects—the medicine had moved him three times. Ordered aldose of blue pill at bed time. 36th. Found Deas quite comfortable—his head-ache, flushed face, s*c., have passed off, and he has some appe- tite. The pulsation in the tumor and neck had disap- peared, and his medicine had acted twice. The wound united in its whole length, and the sutures were consequently removed. From this time forward Deas went on to recover, without any unpleasant symp- tom ; the tumor rapidly diminished to a small hard lump ; the head-ache, cerebral confusion, &c. soonTdisappeared ; the ligature separated on the 18th day. He presented himself to me some months afterwards, in Macon, well in all respects, save a small lump in the posi- tion of the original tumor, though without pulsation or other inconvenience. [We cannot but express a doubt if an aneurism existed in this case.—Edt.] De. P. F. Eve. OBSERVATIONS ONJTIIE DIAGNOSIS OF ANEURISM. From the Southern Med. and Sur. Jour, for Sept. 1848. “ A tumor progressively on the increase, -;at first compressible, di- minishing under pressure, pulsating violently, and throughout its whole extent, at the margins as well as in the ceniei, the pulsation ceasing and the swelling subsiding in whole, or in part, according to the" size, dura- tion and quantity of solid matter.—the layers of lymph and coagulum it contains, when pressure is made on its proximal side, is undoubtedly aneurismal. ”—(Liston’s Pract. Surgery.) In the Southern Medical and Surgical Journal, for June last, I communicated the narrative of a case of Aneurism, 10 in which it became necessary to apply a ligature to the primitive Carotid. The respected Editor of this Journal having cast a doubt upon the correctness of the diagnosis, and consequently upon the propriety of the practice pursued, it is perhaps due to the other gentlemen who were connected with the case, as well as to myself, that I should present some ob- servations upon aneurismal tumors, going to prove that our diagnosis was correct, and the operation necessary and proper. In doing this,—not very difficult task it is hoped, —1 shall invoke as far as possible the authority of Sir Astley Cooper, Samuel Cooper, Hodgson, Mott, McClellan, Liston, Porter, and Dupuytren, and shall be content, if it can be shewn that I have been right, or have erred, in company with these and other illustrious names in Sur- gery. It must be either a very right thing, or a very wrong thing, to apply a ligature to the primitive carotid ; a very right thing to do so for a progressive aneurism ; a very wrong thing to delligate this great arterial trunk for an abscess, an enlarged gland, or an encysted tumor. There is little that is new to be said on this subject, and in taking a short review of the prominent features of an- eurismal diagnosis, I shall whenever it can be appropriate- ly done, use the exact language of any of the distinguish- ed authorities above named. The diversities in the origin, progress and termination of aneurismal tumors are so infinitely various that no one will contend for an exact parallelism in their general histo- ry, or in the symptoms at any period of their growth. So also, with the sympathetic disturbances excited by them. This must necessarily be the case from the variety which exists in their origin and in the causes—(solid bodies, fas- ciae, &c.)—which favor or resist their development in dif- ferent directions and positions. The mode in which they' 11 originate from the artery, whether by a narrow neck, or from the whole caliber of the vessel, must exercise a ma-. terial influence on their development. The general health, and the vigor or debility of the heart, are also important elements in the rate of progress, of aneurismal tumors. There is perhaps as great a variety in their duration as in any thing connected with them, some requiring only a few weeks for their greatest development, while others extend over a period of several years, and one instance is on re- cord, of an aneurism which lasted for thirty years- It is also well known that they are often stationary for long periods, and then taking a new point of departure, progress rapidly to their termination. Another circumstance which must have a marked bearing upon the diagnosis and histo- ry of aneurisms, is the more or less rapid deposition of lam- inated coagula upon the sides of the sac; the force and vigor of the pulsations ; the aneurismal thrill and whizz are doubtless greatly influenced by the same cause. This must also affect the duration of the pulsation and the ex- tent of the subsidence when the tumor is compressed or the artery obliterated. We learn from Mr. Hodgson, that, u one of the circum- stances which in the most early stage, generally attends the formation of aneurism, is the establishment of that pro- cess which is the basis of its future cure. ” Again : “The opinion that these layers of coagula are not met with in small dilatations of arteries, but are found in large expan- sions of them, is (he says) contradicted by numerous care- ful observations. ”—[Cooper"l s Surg. Diet.) In some instances, however, this process seems to go on very slowly, as must have been in the very interesting case reported by Mr. Kerr, where the softness and pulsa- tion, to a considerable extent, continued for thirty years. A few rare cases have also been recorded of large aneu- risms that were entirely free from lamellated coagula, pro- bably from a constitutional absence of| coagulating power in the blood. It follows then from what has preceded, that an aneu- rism could not be expected to lose all its volume upon ob- literating the arterial canal leading to it, except at its very commencement. Diagnosis. Perhaps the two great features of the diag- nosis of aneurismal tumors, are, pulsation, and change of volume, from compressing the artery upon the proximal or distal side of the swelling. Ist. Pulsation.—This indication, when well developed, is relied upon by surgical authorities as one of the most unmistakable features of aneurism. It is of course syn- chronous with the arterial pulsation, and has a marked and peculiar character. i£ They (the pulsations) are eccentric —the tumor not being raised en masse, but dilated at ev- ery systole of the heart. ” (Cycl. Pract. Med. and Surg.) Dr. Mott considers the sioell and general growth of the pulsation as the chief diagnostic mark of aneurism.— (Motfs Velpeau.) The expansion of an aneurismal sac is equal in every part and every direction, and the pulsa- tion can be felt as correctly at the base or at the side, as at the summit.—(Porter on Aneur.) “Pressure upon the proximal side of the tumor, weakens or destroys the pul- sation according to its degree, the swelling becoming more soft and flaccid, but pressure on the vessel beyond the tu- mor, renders the aneurism more tense and augments its pulsations. ”—(Boyer, quoted in Cyc. Porter, in Cyc. of Anat. and Phys.) In regard to the changes that time produces in this indication, Mr. Porter remarks, that “ the pulsation is said to become more faint in proportion to the growth of the tumor, and this, though generally true, is not so universally, for this symptom will presently be found to be influenced by a number of circumstances, such as the blood within the sac being fluid or coagulated, the situation and depth of the tumor and the coverings of fasciss it may possess.55 It is well also to recollect, in this connection, that occasionally medullary or other tu- mors of a fungous nature, exhibit a pulsatile character. 3d. Change of volume, from pressure upon the artery from which the aneurism originates. This from the na- ture of things, must be the most certain and unfailing of all the symptoms of this affection, for it may be very safe- ly asserted, from all that is known of the subject, that none other but an aneurisraal tumor can exhibit a real difference in size from this cause. Although it is well established by the investigations of Hodgson and others, in regard to the deposition of lami- nated coagula, &c., that an aneurism even when of moder- ate size cannot be entirely removed by pressure upon its proximal side, yet that they do become remarkably dimin- ished, (and in some rare cases where the blood is fluid, en- tisely disappear,) is a fact universally admitted. Pressure upon the distal side of the tumor, where it can be applied, of course increases its volume, tenseness and throbbing. Although the diagnosis of external aneurism, when within a certain size, is generally an easy matter, yet, on some occasions it has been difficult to distinguish them from other tumors situated over the tracks of large having a pulsating motion synchronous with the action of the heart. “ They can however be usually distinguished from aneurisms by their hardness, mobility, and cessation of pulsation when pushed to one side or elevated. ” “If also pressure be made upon the artery above or below the tumor, no alteration occurs in the appearance of the swelling unless it be aneurismal. Moreover aneurisms can usually be diminished by regular compression of the tumor and artery, but regain their dimensions immediately upon its removal. This diminution may be effected to some extent even in old aneurisms—but not in the case 14 of ordinary tumors. ”—(Cyc. of Prac. Med. and Surg.) Mr. Porter draws the following distinction between an abscess seated over a large vessel and a true aneurisraal tu- mor : “An abscess receives only an undulatory thrill from an artery, perceptible in the line of the vessel, but fading away and becoming indistinct in the remoter parts of the tumor. ” Having now taken a very brief glance at some of the main features of the subject, I shall reserve the considera- tion of some others until we come to the discussion of the specific objections advanced by the editor of the Journal, to the diagnosis. A remark may here be made upon the comparative size of carotid aneurisms. One of these tumors as large as a hen’s egg, situated on the side of the neck, constitutes a swelling of no inconsiderable size, and would occupy at least hi If the length of an ordinary neck, supposing its top to be on a level with the os hyoides. Were it twice as long as this, it would extend nearly to the clavicle and render necessary the ligature of the carotid near to its ori- gin, or the innominata itself, if it were considered desirable to ligate a healthy portion of the artery. Of this any one can convince himself who will take the trouble to apply an egg to this region and imagine it to be placed under the skin. I will now proceed to consider the subject with more particular reference to the case at issue. It must be evident, from all that has preceded, that an aneurism in the carotid region could only have been mis- taken for one or other of the following tumors :—Ab- scess, Enlarged Glands, Encysted Tumor, Sarcomatous Tumor, Medullary Tumor. To this list might be added Maunoir’s Hydrcele sur cou., which not infrequently occurs in this region, and which from its generally ellip- tical, rounded and distinct outline and its elasticity, might 15 well be confounded with aneurism by a careless observer. I have met with most of these tumors again and but never found any very great difficulty in distinguishing them from aneurism. There is, it is believed, nothing in the records of surge- ry to justify the assertion that either of the above men- tioned tumors will instantly lose two-thirds of its volume upon obliterating the caliber of a large arterial trunk—by pressure or the ligature—running over, under, or near it.— No one, it is presumed, will advance such an opinion. It follows, then, as a matter of inevitable necessity, that as no other one could have presented this indication the tumor in question could have been nothing else but an aneurism. And thus we arrive at the diagnosis by exclu- sion. Having been, at my own request, politely favored by Dr. Eve with his reasons for doubting the correctness of the diagnosis, and liberally invited to discuss them in the pages of the Journal, I shall proceed to do so seriatim.— The first objection is as follows : 11 The cause of the aneurism {a severe strain while‘plan- ing some hard, wood) is not sufficient to produce the dis- ease. ”—Dr. Eve’s letter.) In answer to this it may be observed that it was the patient’s own statement, and al- together unworthy of confidence. Probably the most au- thoritative opinion on this point is, that all aneurisms except those produced by external violence—traumatic le- sions, &c., arise from disease of the coats of the artery itself. It is true that llicherand and Pelletan maintained that popliteal aneurisms were caused by violent exten- sions of the leg, and the former brought forward some ex- periments upon the dead body in support of this opinion. But this explanation was conclusively refuted by the ar- guments and experimental researches of Samuel Cooper, Hunter, Home, Hodgson and Scarpa.—(Cooper’s /Surg, 16 Hunter, Home, Hodgson and Scarpa.—(Cooper's Surg. I net.) Dr. Hodge, in an able resume of all the knowl- edge on the subject, remarks that 11 spontaneous aneurisms depend on an original diseased condition of the artery. ” “ There is always a morbid condition of the arterial tu- nics as an essential predisposing cause, the dilatation often occurring without any external influence. ” “ Under an- other division, it will be shown that no tumour forms un- less prior disease existed in the artery. ” “ Aneurisms never form in healthy arteries. ” The general conclusion drawn from the facts detailed that aneurisms by dilatation of one or all the arterial tissues, never occur in healthy ar- teries, is confirmed by dissection, showing, in perhaps ev- ery instance of dilatation, a preternatural softness or brit- tleness of the internal coats at least. ”—(Cyc. of Pract. Med. and Surg.) This predisposing cause of aneurism was believed, by Hodgson, Guthrie, Begin and Breschet, to be chronic inflammation. “ It often happens that a patient complains of the crook- ening of the fingers, or the numbness of the foot, unmind- ful of the tumor under the clavicle or in the popliteal space. ” “ These considerations lead us to the belief, that previous to the occurrence of spontaneous aneurism, the artery has undergone some change predisposing to it. ” (Porter, in Cyc. of Anat, and Phys.) This change is believed by Mr. Porter to be unhealthy inflammation. 2d. 11 Aneurism of the carotid is very rare in this State —enlarged glands, tumors of the neck, sfc., very common. You say there were a few enlarged glands, thus shelving a disease cf that system—the glandular—and it was at first supposed to he an enlarged gland. ”—{Dr. Eve’s let- ter.) In regard to the rarity of aneurism in this State, there is no doubt of it. It is so every where. Velpeau, in the last edition of his “Operative Surgery, ” was only able to 17 collect forty-three instances in which the carotid was tied for aneurism.—(.MotVs Velpeau.) Dr. Mott, in his immense practice, extending over a pe- riod of forty years, has applied a ligature to the primitive carotid only twenty-three times, and but a small proportion of these operations were for aneurism.—{MotVs Vel- peau.) Mr. Liston observes that, “Spontaneous aneurism at the angle of the jaw, is not an every day occurrence, and few cases are recorded/’—{Pract. Surg.) They are met with, however, occasionally, in Georgia; I have re- corded one, and a medical friend in Milledgeville informs me that he has seen two cases. Had I time or opportu- nity to consult the profession more extensively, other in- stances, there is little doubt, might be discovered. Aortic aneurisms are not at all unfrequent. The “few enlarged glands” above alluded to, were ab- sorbents, swelled and inflamed from the irritation of the tumor, and it is highly probable that no aneurism can ex- ist in a glandular region like the neck, groin or ham, with- out producing some irritation and enlargement of the sur- rounding absorbents. It was the patient—not either of his physicians—who at first supposed it was an enlarged gland, or “kernel.”— ( Vide the case in the June No.) 3d. The symptoms are not satisfactory. The 'peculiar thrill or whizzing sound ought to have been heard in a case of only eighteen months standing. ”—{Dr. Eve’s let- ter.) The expression used in the narrative was “very indis- tinct—almost imperceptible,” conveying the idea that the bruit or whizzing sound was not entirely absent, though it is not pretended to correct the diagnosis in this respect at this late date. As well as is now recollected, the steth- oscope was not used, but the naked ear applied. The ab- 18 sence, however, of this sound cannot be allowed to vitiate the diagnosis, as it is not insisted upon as a necessary ele- ment in the diagnosis of aneurism by any of the great masters in Surgery, It is only said to be generally pres- ent, This indication, from a variety of causes—thickness of laminated coagula, density of surrounding tissue, and different conditions of the arterial orifice, &c,, must be ve- ry variable. It is also often heard in tumors, not aneuris- mal. “The whizzing sound (bruit de soufflet) generally heard in aneurisms is not pathognomonic, for the fungoid or other tumor situated over an artery may produce it, and it may be created by artificial pressure,”—{Porter.) Vel- peau and Mott place little dependence upon stethescopic indications in this disease. 4th. “ The tumor, if aneurismal, should have been ob- literated by pressure to the proximal side of the tumor—es- pecially as it was only of the size of a hell’s egg.—(Dr. Eve’s letter.) If the observations of Hodgson, Samuel Cooper and Porter, previously quoted and referred to, respecting the early deposition of laminated coagula, are true, it follows that the tumor could not be obliterated completely by pressure on its proximal side, and consequently deprives this objection of all force. The following extract from an article by Dr. Hodge, it is believed, embodies the au- thoritative and almost universally received opinion upon this point. “ In the very early stages, the blood is sometimes, though rarely, entirely fluid, especially where it passes readily into and from the artery, and where the circulation has been active. In such cases pressure can obliterate the swelling. In a short time, however, the blood will be found partially coagulated—at first in soft clots, but very soon in laminae on the circumference of the swelling, while 19 fluid blood occupies the center. Pressure now diminishes, but does not obliterate the tumor. ”—(Cyc. of Pract. Med. and Surg.) A remark in regard to the size of the tumor has been made. The aneurism was stated to be “ a good deal lar- ger than a hen’s egg.” sth. “ But I rest my doubt as to the existence of an an- eurism in this cause, especially upon the fact, that the oper- ation did not remove the tumor. An aneurism of the car- otid, size of a hen’s egg, most certainly would have been obliterated by ligature to the artery. No lump ought to have existed some months afterwards in the position of the original tumor.—[Dr. Eve’s letter.) On the contrary, it can be shown that the usual process of cure is a more or less gradual subsidence of the aneu- rismal swelling after the operation. In some instances this subsidence occupies long periods. In proof of which I quote some cases from that well known work, “Cooper’s Surgical Dictionary.” “In June? 1805, Sir Astley Cooper operated, in Guy’s Hospital, oira man aged 50, who had a carotid aneurism, attended with pain on one side of the head, throbbing in the brain, hoarseness, giddiness, &c.” “ The tumor was at last quite absorbed, though a pulsation existed in it until the begin- ning of September.” “The swelling at the time of the op* eration, was as large as a pullet’s egg, and situated on the left side, about the acute angle made by the bifurcation of the common carotid, just under the angle of the jaw. The patient was cured and returned to his occupation.” Here is a case, from the highest authority, resembling in its symptoms very much the one I have reported, in which the pulsation continued for over three months after the op- eration, and the tumor itself probably much longer. In a case by Mr. Vincent, pulsation continued two days? and the tumor was diminishing until the eighteenth day.— After this inflammation and abscess took place, and the pa- tient died. The case is valuable, however, as showing the gradual and not sudden diminution of aneurism after op- eration.—(Cooper's Surg. Diet. Art. Aneur.) I quote the following from Mr. Porter:—“A man was op- erated on by Mr. Colles, for popliteal aneurism, on the 22d January, 1831. The ligature came away on the seven- teenth day ; the tumor diminished ; in short, every thing went on well, and the patient left the hospital perfectly cured.” He remained healthy until his death from fever in March, 1835, and such an opportunity for pathological investigation was not neglected. The tumor, which had been originally of the size of a turkey’s egg, was found to have diminished to little more than the size of a walnut j externally it felt hard and as if completely solidified. On being cut into, however, neither artery nor sac was oblit- erated.” In this instance the tumor was not obliterated in over four years after the operation. To these cases, I will add one from the lectures of that most brilliant genius and admirable surgeon, George Mc- Clellan, now unfortunately no more. This surgeon tied the carotid of an elderly gentleman, one morning, for an aneurism of the size of a walnut under the angle of the jaw : although pulsation stopped, the tumor became much harder, and (Dr McC. supposed) pressed with such force upon the internal jugular that apoplexy took place, and the patient died about four o’clock in the evening. This case is of value as showing that even small aneurisms do not always subside immediately after the application of the ligature. Dupuytren has reported an instance of axillary aneu- rism, where the inspissated contents of the sac were dis. charged by suppuration three years after the deligation of the subclavian. 21 1 might go on and quote other cases, but enough has been said, to show that it is neither new nor unusual for an aneurism “a good deal larger than a hen’s egg,” not be instantly dispersed by the application of the ligature, and leave no vestige behind some months afterwards. Having previously reached the diagnosis by exclusion, I will now endeavor to arrive at it by the positive method, and will give my reasons for still believing Deas’ disease was an aneurismal tumor. Ist. Because, t.] 28 As our differences here are more in terms than in and not important to the question, I shall say little in re- ply to this comment, though it would be easy to show that my expression was not very inaccurate. Nor do I wish to dispute the important announcement, that one of Dr. Eve’s operations has actually been published in Mott’s Velpeau. [Dr. Green (hen has been more fortunate than most surgeons in this respect. He is not only right with the illustrious authorities he quotes, but does not err in the diagnosis of tumors of the neck like some ofthem have—he“has met with most ofthese tumors again and again, but never found any very great difficulty in distinguish- ing them.” In 1831, Dupuytren made an exploratory puncture in a tumor of the neck, the character of which he could not deter- mine. He took it for an abscess, but it proved to be aneurism of the left carotid artery, in Mott’s Velpeau’s Surgery are recorded two cases of ligature to the carotid, when the aneurisms were sub- sequently found after death to have existed in the aorta. Mr. Benj. Phillips, of London, says, “I know at least eighteen cases where an aneurism has been mistaken for an abscess, and in several cases treated accordingly.” Of thirty-eight eases operated upon for sup- posed carotid aneurism, collected and published last year by Dr. Norris of Philadelphia, in four the tumors were found out subse- quently not to be such. In seven of the thirty-eight cases, errors of diagnosis were made. In one (occurring to the celebrated Lisfranc) the tumor on dissection proved to be a fungus hsemato* des ; in another, it was carcinomatous ; in a third, the tumor sur- rounded the artery; in a fourth, the patient looked upon as cured, the disease was found to be a glandular swelling; in a fifth, an ab- scess was incised, and the patient ciiad from hemorrhage, notwith- standing the ligature to the carotid ; "in a sixth, Mr. Liston opened a scrofulous abscess, aneurism followed, then ligation of artery, but unfortunately this patient died too; and in the seventh, the aneu- rism was situated in the vertebra! artery. A case is reported in the Dictionnaire des Sciences Medicle, where a tumor in the neck, submitted to the diagnosis of celebrated surgeons in America, Par- is and London, was pronounced to be aneurism of the carotid arte- ry. “It was afterwards ascertained by M. Boyer, that no such disease existed—but simply, an extensive enlargement of the glands of the neck.” Dupuytren mentions a case of aneurism of the aorta forming a tumor behind the sternum, which being mistaken for an abscess, was punctured and the patient died. Mr. Porter Cokmest, No. 5. 29 states the fact in one of his lectures, that in an urgent case he punc- tured the trachea with a trocar for what he thought was spasms of the glottis. His patient died three days afterwards of an aneurism of the aorta. He says the idea of an aneurism never crossed his mind. Sam’l Cooper remarks, “there is no part of the body where the diagnosis of aneurisms is more liable to mistake than in the neck. There the disease is particularly apt to be confounded with tumors of another nature. We have already cited examples in which aneurisms of the arch of the aorta so resembled those of the carotid as to have deceived the surgeon who was consulted. The swelling of the lymphatic glands, or of the cellular substance which surrounds the carotid, the enlargement of the thyroid gland, and especially abscesses, may resemble an aneurism by the pulsa- tionsxommunicated to them by the neighboring artery.” In Lis- ton’s Lectures, by Dr. Mutter, we read, “you must be quite sure that the disease you are treating is an aneurism. You must not mistake a solid tumor, or, indeed, a tumor of any kind pressing on a vessel, for an aneurismal tumor.” From these facts, in connection, be it remarked, with aneurisms of the carotid artery alone, and hastily collected, we would suppose that error in diagnosis of cer- vical tumors was not an impossible event.—Edt,] The Editor, here gently rebukes me for presunpfion, in stating that I have not found any great difficulty in distin- guishing the tumors of the neck met with by me from an- eurism. It is certainly not presumptuous to say, that the medullary tumors, enlarged glands, hydroceles sur con, ab- scesses &c., I have met with in this region were so well pronounced as not to be readily mistaken for aneurism, and this is what was meant. The rest of this comment is en- tirely irrelevant, for although many cases of tumor of the neck, have occurred and must occur, where an accurate di- agnosis is impossible, yet the editor will not contend that either of the able surgeons alluded to, would have made a mistake where pressure could be applied on the proximal side of the tumor and it responded to the test by rapidly, suddenly, quickly, instantly decreasing in volume two- thirds. I do not think that even the Augusta Professor could have mistaken a swelling of this character for an enlarged gland or encysted tumor. 30 ...—The following comment is in answer to my observation, “ There is. it is believed, nothing in the re- cords of surgery to justify the assertion,” that any but an aneurismal tumor would lose two-thirds of its size on ob- literating an artery near it, (See page 532 of the “Jour- nal” and page 15 of this pamphlet.) [lt is not stated in Dr. G.’s case, that the tumor lost instantly two-thirds of its volume upon obliterating the artery.— Edt.] Comment, No. 6. It was stated however, that after stopping the flow of blood into it, “it still retained about a third of its vol- ume.” If words have any meaning, this means, that the swelling diminished in volume two-thirds, after the flow of blood into the aneurism was stopped by compressing the artery on its proximal side. lam confident that every body who read the case, but the Editor, understood the ex- pression in this way. Of course it is impossible to tell how many seconds it took to do this, hut rapidly enough to be correctly stated as instantly or very quickly. This is one of the most remarkable specimens of criticism in existence, and as the subject has evidently been a real difficulty to his mind, I have after a careful study of the subject, and consulting the most reliable authors con. structed the following formula for its elucidation. Suppose a certain quantity has been taken from a body, say an apple, an orange, or an aneurism and one-third re- mains. How much has been taken from the whole ? An- swer, two-thirds, or reverse the proposition and the tumor would “still retain about a third of its volume. (Vide Dilworth and other learned authors.) Having thus re- duced the matter to its simplest terras, I hope it is now clear, and have no doubt the Editor is ready to exclaim with Hudibras, “ ’Tis strange there should such difference be Twixt tweedledum and tweedlcdec. ” Comment, No. 7. [Did Dr. Green never see or feel a tumor in the neck recode hy pressure or diminish by treatment of two weeks duration ?—Ei>t.] —See page 53d Journal, and page 15 of this pamphlet. I will reply to this question with another. Did Dr, Eve ever see an enlarged gland or encysted tumor sudden- ly diminish in volume two-thirds upon compressing a large arterial trunk near it ? [Then why mention it—no other cause was assigned by the au- thor.—Eot.]—Sec page 533 Journal, and page 15 of this pam- phlet. Comment, No. 8. I refer the Editor to my reply to No. 2. Comment, No. 9. [Where is the proof that this cause was operating in the case un- der consideration I—Edt.l-,-See page 538 Journal, and page 10 of Pamphlet. The Editor in reply to some quotations from Hodgson and Porter proving that chronic or unhealthy inflammation, as a general rule, precedes spontaneous aneurism, inquire? “ Where is the proof that this cause was operating in the case under consideration? ” I answer that the spontane- ous aneurism itself is the best proof of it, and would be so considered by Hodgson, Guthrie, Begin, Breschet, and Porter. Comment, No. 10. [Dr. Green is here certainly mistaken. Aneurism of the aorta a e not common in Geoigia. Can he point to a single case veri- fied by post-mortem appearances ? We are aware that aortic an- eurisms are sometimes suspected to exist, but the history of them in this region of country is yet to be written. Still less frequent are carotid aneurisms in this State. Wo have the candor to admit, one of our colleagues thinks there is a case in this city. But Dr. Green’s medical friend in Milledgeville, has mot with just as many cases as did Dr, Hodgson, the celebrated pathologist of Londonv and one upon whom our author justly places a high estimate.— During his indefatigable researches on diseases of the arteries and veins, carried on too for years in one of the most important hospitals in the world, and in the city of London, the very center of civiliza- tion, he could only enumerate two cases of aneurism of the carotid artery out of 63 he had collected. In the table by List'ranc of 179 cases of aneurisms in general, only 17 were aneurisms of the car- otid. Indeed, so rare is this disease of the arteries in our country, that Dr. Green can boast of performing a cure never attempted by our own great Dr. Physick. In the satislics already referred to by Dr. Norris, one of the Surgeons of the Pennsylvania Hospital, we learn the carotid has been tied 149 times—in 24 the operation was for true aneurism. The full particulars of only two cases occurring in America are given, one by Dr. Post, of New-York. the other by Dr. Warren, of Boston. Dr. Green's may be the third in the United Stales, so far as we know. Of course, we allude to the application of the ligature for spontaneous, true or mixed aneu- rism of the carotid—the artery itself has been twice ligatured at Augusta.—Edt.] I do not think I am mistaken in regard to the frequency of aortic aneurism. I have known several instances of sudden death with vomiting or purging of blood, or both, which there was every reason to believe proceeded from ruptured aortic aneurism. In one of them, there was a pulsating tumor in the epigastrium, and Jaundice, caused as- - supposed by the pressure upon the gall ducts. It gives me pleasure to inform Dr. Eve that I have ver- ified one of these cases by a post mortem examination and now have the preparation before me. It is a sacculated dilatation of the arch of the aorta involving the roots of the innominata, left carotid and subclavion- It is appa- rently large enough to contain a pint of fluid, and burst at the lower part of the arch into one of the bronchia, the patient dying instantly. The Editor argues, that because Mr. Hodgson only met with two carotid aneurisms during his lengthened re- searches, it is therefore very doubtful whether my medical friend in Milledgeville has met with as many. Now this 33 may be good logic in Augusta, but will not be accepted in the more benighted regions of the state. One of the in- stances referred to occurred upon a negro woman of Dr. Tomlinson Port’s, and was by him (assisted by Dr. B. A. White,) operated on and cured. The other on the person of a negro woman in Jones Co., and came under the ob- servation of Dr. B. A. White, who wished to operate, but she positively refused, and afterwards died suddenly as Dr. W,, subsequently heard. Is it contended that these were not cases of aneurism, and that these distinguished practitioners, in common with every other in the State, (out of Augusta) are incapable of making an accurate di- agnosis of this disease under any circumstances whatever? I hope and believe the medical profession of Georgia, are prepared to treat these ridiculous pretensions with the con- tempt they deserve. Where is the impossibility or impro- bability of two cases of aneurism occurring near Milledge" ville in the last twenty-five years ? The reader’s attention is called to the following curious line of argument expres- sed and implied : 1. Mr. Hodgson only met with two cases of Carotid An- eurism. 2. Dr. Physick never cured a case by operation ? 3. Only two instances are fully ? recorded ? in America. 4. We never had a case in Augusta, though we have tied the artery twice. 5. Ergo, Dr. G.’s case is very doubtful. Comment, No. 11. [This is not so stated in the narrative of the case ; nor can we agree with the author, in the opinion, “it is highly probable that no aneurism can exist in a glandular region like the neck, &c., with- out producing some irritation and enlargement of the surrounding absorbents.” We have consulted the authorities he refers to, and find not one agreeing with him on the subject. Dr. Hodge, on the contrary, entirely differs from him. He speaks of the condi- tion of the tissues or organs connected with or dependent on the 34 diseased artery, and notices the muscles, ligaments, hones, joints, nerves, cellular membrane and skin, fasciae and blood-vessels, and says of the absorbents, they are in many instances, like the arte- ries and veins, closed by the pressure, or more frequently complete- ly obliterated. It is denied that li enlarged glands, absorbents swelled and inflamed, ” result from the irritation of aneurismal tu- mors.—Edt.] The Editor here repeats his offensive contradiction, “ Not so stated in the narrative. ” I take issue with him upon the point of fact. On recurring to the original re- port of the case, Gth paragraph, it will be readily seen, that it was in Deas’ short statement, previous to my own, which commenced at “When I first saw him,” the expression oc- curred. I will proceed to show presently, that Deas had good professional authority for his mistake. The Editor then passes on to a remark of mine, that it is highly probable no aneurism can exist in a glandular re- gion like the neck &c., without producing some irritation and enlargement of the surrounding absorbents. The au- thorities referred to do not differ with me on this subject. They are silent, except Dr. Hodge, who is rather in my fa- vor. But if aneurisms, are capable of exciting so much irri- tation in the surrouning tissues—such varied injury to the muscles, ligaments, nerves, arteries and veins—such in- flammation, suppuration, ulceration and destruction of bones and joints—such pressure, irritation and obliteration of the absorbents—such inflammation in the cellular substance as frequently to cause abscess, why might they not occasion- ally produce some irritation and enlargement in the absor- bents near them ? and why should not a tumor of this sort be red, sensitive, and have its pain increased on hand- ling. I wish to press this upon Dr. Eve’s attention as a point in surgical pathology. And would beg leave to draw his attention to one of Mr. Abernethy’s dis- sections of aneurism in which he states, that around the diseased artery “For nearly two inches above the parl which was tied, the lymphatic glands covering the artery were considerably enlarged, having no doubt became addi- tionally swollen from the irritation excited by the liga- ture.” (From Mr. A’s. works Ist. vol. p. 156, 6th London Edtn.) In Key’s case of ligature of the common iliac> “The aneurism had suddenly appeared in the beginning of November, and had increased in the course of two or three days from what seemed to be a cluster of enlarged, hard glands, to such considerable size, slating that although I had supposed he understood the matter perfectly, if he still thought his letter was of so private a nature that it could not be used in this way, and would furnish me with his objections, as he wished them arranged, and with my manuscript, I would remodel it to suit him in this respect. He did not do so, and his com- plaint is consequently utterly unfounded, not to use a harsher expression. Let us examine the Editor’s own con- duct in this respect. The modesty with which this accu- sation is made may be properly estimated when it is recol- lected that the whole preceding Editorial note is found- ed on a violation of a private communication. He ad- mits that I withdrew my reply. Very well. When I did so it became ray own private property, and Dr. Eve had no more right to know its contents, editorially, than he had to know the contents of a sealed lerter addressed to me. What right had the Editor to attempt to forestall a communication which had been withdrawn from him ? What right had he to misuse my article, by writing to a person alluded to in it, for the purpose of picking out a discrepancy between him and myself? Such conduct must be condemned by the editorial corps, and indeed by all right minded men. Defend us from such editorial jus- tice, fair dealing, charity and generosity. APPENDIX. No, 1. Sir Astley Cooper’s case, with the material fact “omit- ted” by Dr. Eve. Cooper’s Surgical Dictionary, p. 139. 1. In June, 1808. Sir Astley Cooper operated, in Guy’s Hos- pital, on a man aged 50, who had a carotid aneurism, attended with pain on one side of the head, throbbing in the brain, hoarse- ness, cough, slight difficulty of breathing, nausea, giddiness, &c. The patient got quite well, and resumed his occupation as a porter. There \vas afterward no perceptible pulsation in the facial and temporal arte ies of the ancurismal side of the face. 2. On tin* opposite side the temporal artery became unusually large. The tumor was at last quite absorbed, THOUGH A PUL- SATION EXISTED IN IT TILL THE BEGINNING OF SEP- TEMBER. The man’s intellects remained perfect; his nervous system was unaffected; and the severe pain, which before the op- eration used to affect the aneurismal side of the head never return- ed. 3. The swelling, at the time of the operation, was about as large as a pullet’s egg, and situated on the left side, about the acute an- gle made by the bifurcation of the common carotid, just under the angle of the jaw. 4. Sir Astley Cooper began the incision opposite the middle of the thyroid cartilage, at the base of the tumor, and extended the wound to within an inch of the clavicle, on the inner side of the sterno-cleido-mastoideus muscle. On raising the margin of this muscle, the omo-hyoideus could be distinctly seen crossing the sheath of the vessels, and the nervus descendens noni was also brought into view. The sterno-cleido-mastoideus was now sepa- rated from the omo-byoides, when the jugular vein was seen. 'Phis vessel became so distended at every expiration as to cover the arte- ry. When the vein was drawn to one side, the par vagum was manifest, lying between that vessel and the carotid artery, but a lit- tle to the outer side of the artery. The nerve was easily avoided. 5. A double ligature was then conveyed under the artery, with a blunt iron probe. The lower ligature was immediately tied, and the upper one was also drawn tight, as soon as about an inch of the artery had been separated from the surrounding parts above the first ligature, so as to allow the second to be tied at this hight. A needle and thread were passed through the vessel below one Jig. ature, and above the other. The artery was then divided. In a little more than nine weeks, the wound was quite healed, and the patient entirely recovered. [See Med. Chir. Trans, vol. I.] No, 2. Case from Mr. Porter’s article in Cyclopedia of Anato- my and Physiology. Page 236, vol. 1. A man was operated on by Mr. Collis, in the Meath hospital, for popliteal aneurism, on the 22nd January, 1831. The ligature came away on the seventeenth day; the tumor diminished; in short, every thing went on well, and the patient left the hospital, perfectly cured. So far as the aneurism was concerned, he re- rnained healthy and free from inconvenience until his death, which happened in March 1835, from fever, and such an opportunity for pathological inquiry was not neglected. The tumor, which had been originally of the size of a turkey’s egg, was found to have diminished to little more than that of a walnut: externally it felt hard, and as if completely solidified. On being cut into, however, neither artery nor sac was obliterated, the latter being occupied by a coagnlum of a deep red color, through the centerof which was a canal of a sufficient size to allow the blood from the portion of the artery above the tumor to flow freely into that below it. it seemed as if the current of blood through the sac had never been interrup- ted, the only effect of the firmer ligature having been the removal of the impulse of the heart from it. No. 3 Sir B. C. Brodie’s case, from the British and Foreign Medical Review for Oct. 1847. In May 1839, Sir B. Brodie tied the external iliac for an aneu- rism in the groin. The patient, after recovering from a severe attack of peritonitis, was discharged cured. In the latter end of November, slight pulsation returned, but was removed by local pressure, applied during two months. In November 1841, there was a slight recurrence of the pulsation, but no increase in the size of the tumor. In January, 1843, the tumor was larger, but had no pulsation. From this period it gradually but steadily in- creased in size for the ensuing twelve months, during which time it grew to the size of the egg of an ostrich ; its surface was some- what irregular, and softer in some parts than in others, although the tumor itself was perfectly solid. During the whole of the time neither pulsation nor sound of any kind could be detected. In Jan- uary 1543, the tumor became stationary, and some time afterwards it began to diminish ; the decrease was continued until July of the same year, when the patient died of phthisis. On examination after death, the tumor was found lying upon the superficial femoral artery, at about a quarter of an inch below the point where this vessel comes off from the common femoral. It was as large as the head of a full-grown foetus, slightly irregular on its surface, but perfectly solid. Upon being cut into, it presented the characteristic layers of coagulated blood observed in aneurisms which have been cured. These coagula, which had, for the great- er part, lost their coloring matter, were disposed in very thin lay- ers, closely packed together, and completely filling up the aneuris- mal sac, which was formed by the outer coat of the vessel, and re- markably thin towards its anterior part. The collateral vessels were much enlarged, but there was no abnormal distribution ; the return of pulsation, therefore, must be explained by the situation of the tumor, which became affected by the large current of blood brought into its immediate neighborhood. No. 4. Mr. Hodgson’s case of twenty years duration. From Hodge’s article in Cyclopedia of Prac. Med. and Surg. page 51L In this case, an uneurismal tumor of the femoral artery, about four inches below Poupart’s ligament, was treated by compresses, and by a bandage extending from the foot to the groin, for some months, when suddenly the whole limb became extremely cold and benumbed,and the tumor and thigh livid. The next morning the pul- sation of the tumor ceased : soon the warmth returned,and the tumor diminished in size. For twelve years the patient remained well, the upper part of the thigh being larger than natural. The tumor again increased, but very slowly, for eight or ten years, without any signs of aneurism. The apex eventually sloughed, and brown sordes, with larncllated coagula, were evacuated. There was no hemor- rhage, but death ensued from the irritation and fever. On dissec- tion the artery was found obliterated for the space of three inches, the surface of the sac was in a sloughing condition, but no large blood-vessel communicated with its cavity. No. 5, Mr. Porter’s case of Aneurism that “ was gone ” the next morning after the operation. Medico Chirurgical Review, Oct. IS4I, p. 399, and Porter’s Observations on the Surgical Pathology and Treatment of Aneurism, page 100. Some years since, a man suffering from aneurism, was admitted into the Meath Hospital. The tumor was situated low down in the popliteal space, and was large, being fully (he size of a tur- key's egg. The limb was semiilexed, and could not be extended ; pain very considerable, together with a sensation of numbness and singling in the foot ; tumor not compressible, at least pressure in- flue need its size but slightly; it was hard, and did not diminish in bulk when the femoral artery was compressed, which, however, stopped the pulsation. With a view to humor the patient, until he could he persuaded to submit to an operation which I conceived to be absolutely necessary, I rolled a bandage round the entire limb, from the toes upwards. This, as the idea of treating the disease by compression had never been contemplated, was very loose; nor had I the least notion that the tumor could have been influenced by it, one way or the other. But. on my visit the next day, the aneurism was gone. Within an hour after the applica- tion of the bandage the patient experienced some pain in the tumor, which soon became excruciating, and continued the entire night. IN THE MORNING THE TUMOR NO LONGER PULSATED —IT HAD BECOME SOLID AND FIRM, and eventually the disease was cured.