[From the New Orleans Medical and Surgical Journal, July, 1875.] 
A CASE OF TRAUMATIC ANEURISM OF THE LEFT SUBCL - 
VIAN ARTERY TREATED SUCCESSFULLY BY DISTAL COM- 
PRESSION. 
BY WARREN STONE, M.D., 
Professor of Surgical Anatomy, Charity Hospital Medical College, New Orleans. 
(Read before the New Orleans Medical and Suryioal Association.) [From the New Orleans Medical and Surgical Journal, July, 1875.] 
A CASE OP TRAUMATIC ANEURISM OF THE LEFT SUBCLA- 
VIAN ARTERY TREATED SUCCESSFULLY BY DISTAL COM- 
PRESSION. 
BY WARREN STONE, M.D., 
Professor of Surgical Anatomy, Charity Hospital Medical College, New Orleans. 
(Bead 'before the Mew Orleans Medical and Surgical Association.) 
T. C , aged about 25 years, while in perfect health, was 
wounded on the 22dof April, 1874, by a pistol ball, which entered 
immediately above the left clavicle about \ to f of an inch from 
the sterno-clavicular articulation, and passed downwards and 
backwards, lodging under the skin just at the margin of the pos- 
terion border of the scapula, at a point corresponding to the 
origin of its spine. The wound was received at 8£ a. m. He 
walked about two squares to the office of Dr. Herrick, who first 
examined him, and, while undergoing the examination, he ex- 
pectorated a small quantity of blood. 
I was subsequently sent for, and visited him at his residence 
about 11 o’clock the same morning. I found him in a state of 
collapse, not due to the loss of blood, as the haemorrhage had 
been trifling, but rather to general shock, somewhat increased 
and prolonged by intense pain, extending down the left arm and 
side, in consequence of injury to the brachial plexus, the arm be- 
ing partially paralyzed. Opiates were duly administered, and .n 
proper time reaction ensued. The next day he had some fever, 
with circumscribed pneumonia in the apex of the left lung, which 
soon subsided. The case progressed favorably, presenting noth- 
ing of particular interest, and I ceased visiting him at the end of 
two weeks. 2 
Shortly after this he noticed a slight swelling over the clavicle, 
immediately opposite the cicatrice, to which he paid no attention 
until about the latter part of May, 1874, when its constantly in- 
creasing size, with other uncomfortable symptoms, excited his 
alarm, and he called at my office for advice. 
Examination at once revealed an aneurismal tumor about the 
size of a guinea egg, and very much of its shape. 
Thus, according to his statement, the aneurism manifested 
itself at a period between two and three weeks after the in- 
fliction of the wound. The course taken by the bullet, and 
the consequent bruising of the artery, is easily accounted for 
by taking into consideration the relative positions of the com- 
batants when the shot was fired. The patient’s opponent was 
on a platform a foot or two in height, and he (the patient) stood 
upou the pavement, with his left shoulder depressed to its 
utmost in the act of dodging, thus, to some extent, exposing the 
vessel in its convex portion, as it arched upwards and outwards 
from the aorta. 
The case thus presented being of such magnitude, it required 
some days of careful reflection before absolutely determining 
upon the plan of treatment to be adopted. He was kept per- 
fectly quiet and carefully watched. The tumor steadily increased, 
and it was not long before it became apparent that further delay 
would not answer. I then determined to attempt the occlusion 
of the sac by digital compression exerted on the distal side, where 
I found the artery could be controlled with the thumb pressing 
it against the first rib. 
Dualizing the absolute necessity of having compression made 
with the utmost skill and diligence, as there can be no doubt 
many of the numerous cases of failure by this method are due to 
neglect in this particular, I made every effort to secure a corps 
of assistants upon whose skill and faithful attendance I could 
implicitly rely. The following named gentlemen promptly and 
enthusiastically responded to my request, viz., Drs. Lceber, Czar- 
nowski, Salomon, Dell’Orto, Schmittle, issegle, Mainegra, LeMon- 
nier, Hopkins, Mandeville, Durr, and Messrs. Faget and Dreyfus, 
resident students of the Charity Hospital. To their untiring 
zeal and well directed labor am I truly indebted for the result 
here related. To each and every one I extend my most sincere 
thanks. 
I chose this means of procedure without any data to encourage 3 
a hope of success, although Mr. Eriehsen does mention that, if 
such a case were presented to him, he would first try distal com- 
pression. There was the difficulty of completely controlling the 
artery, as well as that of getting the patient to tolerate the requi- 
site amount of pressure fora sufficient length of time—for, taking 
into view the currents of blood flowing through the vertebral, 
thyroid-axis and internal mammary arteries, all just bordering 
on the tumor, I deemed it necessary for success to thoroughly 
check any direct flow through the sac, hoping thus, in a measure, 
to counteract any adverse influence the circulation in these ves- 
sels might have upon the consolidation of the tumor. Had this 
have been upon the common carotid, I doubt if it would have 
been necessary, there being no branches from its origin to its 
bifurcation. 
However, there being no danger attending the attempt except 
perhaps the very remote one of exciting inflammation in the sac, 
whereas the array offered by the statistics as to the results of the 
application of the ligature resembled grave yard reports, we took 
courage, and determined to give him the full benefit of the doubt. 
My friend, Prof. Lcebei, visiting physician and surgeon to the 
Touro Infirmary, kindly proffered the necessary accommodations 
in that institution, and the work of compression was commenced 
on the 15th day of June, 1874. It was continued without inter- 
ruption for 39 hours, when we were forced to desist, as the soft 
parts beneath had begun to slough, and the patient was so 
exhausted from pain and fatigue as to be unable to bear more. 
After carefully placing him in bed, it was found that the tumor 
had diminished to nearly one half its original size, and that, 
although distinct pulsation was felt, it w as markedly feebler, and 
the density of the sac greatly increased. Perfect quietude was 
enjoined, and the result awaited with feverish impatience. 
The pulsation still continued, but the tumor did not increase 
in size, or in any degree did that hardness, which followed com- 
pression, diminish, nor did the pain with which he had previously 
suffered return. 
The case being of such general surgical interest, as well as in- 
volving so much to the patient, numerous consultations were in- 
vited, and the various operative measures freely discussed and 
advised. 
Still, daunted by the unfavorable history appended to all such 4 
operations, and, feeling satisfied, from the course the case had 
pursued since compression had been made, that a fibrinous 
nucleus had been established, I determined to build a hope upon 
this, and to postpone the consideration of any surgical interfer- 
ence. A strict surveillance was kept over the patient, and it 
was observed that the swelling and pulsation slowly diminished 
from month to month, proportionately increasing iu density. 
About the middle of last March, all pulsation had ceased, and 
has not returned up to date. 
The tumor is as hard as a marble and quite small. 
The pulsation at the left wrist can be felt, but is very leeble— 
he is in good health, suffers no inconvenience whatever, and is 
gradually recovering the use of the left arm, which, until recently 
he has been forbidden to use but to a very limited extent, for 
tear of disturbing the aneurism. 
Now, as to the practical bearing of the case: 
I fully recognize the significance of the old adage that “ one 
swallow does not make a summer,” but I feel justified in saying 
that it could in no wise apply in this instance. I do not believe 
that by giving a full and unqualified share of credit to distal 
compression, I would be guilty of the too frequent error of sub- 
stituting a coincidence for a fact. A reference to the history of 
the case, from the time of the appearance of the aneurism until 
the day compression was inaugurated, shows a rapid increase in 
the size of the tumor with all the accompanying disturbances, 
thus evidencing no tendency to spontaneous cure. And then fol- 
lowing it on further we find the swelling materially diminished, 
its consistence increased, the pulsation much less, and the thrill 
scarcely audible after compression. Therefore, can I not safely 
state that the result obtained was due to pressure sufficiently 
exerted to completely check the direct flow through the vessel, 
until fibrinous layers were amply deposited, so as to present a 
satisfactory basis upon which nature built and finished the work 1 
I have no doubt that we could have secured complete consolida- 
tion at the time if the soft parts could have borne the pressure 
longer, and the patient’s powers of endurance stood the necessary 
tax. Ligature of the artery at the point where compression was 
made, in the third portion of the artery, might have been tried. 
I have only to refer to all well-established authorities on that 5 
subject to create a comparison favorable to distal compression. 
Ligature of the proximal end in the first portion of the artery— 
a proceeding presenting very serious anatomical difficulties, 
and at all times dangerous—necessitating the taking up of the 
vertebral to avoid distal haemorrhage, would have been under 
any circumstances worse than a forlorn hope. But, yet, granting 
that this fearful risk had been taken, and that the same 
success attended it, as did in the case of Dr. Smythe, where the 
innominate, common carotid and vertebral were successively tied 
for aneurism of the right sub clavian of traumatic origin, the 
middle coat of the artery having been ruptured by a sudden 
violent extension of the shoulder, would not the experience re- 
cently gained in that very instance give us another favorable 
comparison'? Dr. Smytlie’s patient lived, it is true, ten years 
after the operation, for which too much credit cannot be given 
the operator, but he died a short time ago of haemorrhage pro- 
ceeding from the original sac, which had become filled with 
blood poured into it by the collateral circulation, which had ex- 
traordinarily enlarged to supply the urgent demands of nature. 
No doubt, the Doctor will give the surgical world a detailed 
account of the termination of this interesting case, which now 
stands prominently on record. Compression successfully applied 
on the distal end is not, I should think, likely to be followed by 
this accident, for the thyroid axis will supply the arm, and there 
being not the same extra demand for blood as in the other 
method, the small collateral branches, which, under the dictates 
of nature, would enlarge in proportion to this demand, remain 
natural and should give no trouble. This seems to me to be a 
fair inference, and, as the patient resides here and can be kept 
under observation, I trust time and opportunity in the future 
will be granted to verify it.