VERTEBRAL ARTERIAL LIGATION IN VERTEBRAL ANEURISM*

THE diagnosis of vertebral aneurism is obscure, in the great majority of cases; that is, it is often very difficult to decide whether the pulsatory swelling in the lateral region of the neck is due to an injury of the vertebral artery, on the one hand, or of the common carotid or one of its branches, on the other. The only means of determining whether an aneurism in this region is supplied by the carotid system or the vertebral artery is, as is well known, alternate, isolated compression of the vertebral and common carotid arteries.

The vertebral artery may be compressed against the cervical vertebræ below the carotid tubercle, but in this place pressure is likely to occlude both the common carotid and the vertebral arteries.

Above the carotid tubercle, that is, above the place where the vertebral artery enters the canal, it is possible, by pressure, to occlude the common carotid alone. While in the majority of cases this will be conclusive, it is not always reliable, since the vertebral artery may enter the canal at the fourth or fifth instead of the sixth cervical vertebra. It is, hence, not only always difficult, but it may be impossible, to locate the vessel supplying the aneurism.

If the vertebral artery has been found to be the vessel supplying the aneurism, three procedures suggest themselves: First, external compression; second, vertebral artery ligation below the carotid tubercle; third, the radical operation, that is, the opening of the sac, removal of the clots, and stoppage of the hemorrhage by ligation or compression.

The first two methods are unreliable, but still direct pressure has succeeded in stopping the pulsation and the patient has recovered. The majority of patients cannot endure pressure sufficient to cure the aneurism, on account of the excessive pain, but this procedure should, of course, be tried before resorting to more radical measures, since cases may occur in which either the arterial wound is so small or the local conditions so favorable that absolute immobility of the parts may cure the aneurism.†

The central end of the vertebral artery below the carotid tubercle has not been ligated in any hitherto reported successful cases, although it has been tied here for other purposes.

The radical operation has finally to be resorted to when pressure fails to cure the aneurism. In the course of the artery through the canal of

* Med. Standard, 1887, vol. i, p. 33.

† See, for case, Holmes' System of Surgery, vol. ii, p. 415.

the transverse processes of the cervical vertebræ, it has been found so far impossible to apply a ligature, and consequently the hemorrhage in the exposed cavity of the traumatic aneurism can be checked only by plugging the cavity with tampons so as to occlude the arterial opening. This treatment was successful in Kocher's case, in which pulsation and hemorrhage resulted after a punctured wound in the region of the fifth and sixth cervical vertebræ. When he had laid open the cavity, he could see both ends of the divided vertebral artery, but was unable to seize and ligate them. The cavity was plugged with tampons soaked in iron perchlorid, and, despite an attack of erysipelas, the patient recovered.

Dr. J. Mason Warren,* of Boston, reports the case of an eleven-yearold boy who received a gunshot wound of the vertebral artery, followed by violent hemorrhage. The next morning Dr. Warren resected a portion of the transverse process of the second or third cervical vertebra. The hemorrhage now recurred; systematic plugging with bits of sponge was followed by recovery of the patient.

As shown in the following successful case, the artery can be ligated between the occiput and the axis, and is preferable to plugging, since it is as safe as the latter is unsafe. As Vischer † has said, ligation at this point is difficult, since that "part of the artery between the occiput and the transverse process of the first and second cervical vertebræ is not accessible for direct ligation, even when part of the sternocleidomastoid muscle has been removed."

As will be seen from the history of the case, my patient came near dying on the table, and lost so much blood that immediate transfusion was imperative. It is, however, possible that ligation at this point might be facilitated by previously cutting down upon and securing the central end of the vertebral artery below the carotid by a loop, to be used for compression during the operation.

G. C., aged nineteen, cook, robust and well nourished, had always enjoyed good health up to January 6, 1881, when, while intoxicated, he was shot in the neck with a 32-caliber revolver. A large stream of blood spouted from the wound, and in fifteen minutes his face around his lower jaw became so swollen that he was unable to open his jaws more than1⁄2 inch. On admittance to the Cook County Hospital an external bullet wound was found to exist 1 inch external to, and to the left of, the posterior nuchal median line, on a line with, and 2 inches behind, the mastoid. Considerable swelling existed in the left parotid region, extending forward upon the masseter and around the left eye, where it was evident, from the bluish color of the skin, that the tissues were infiltrated with blood. The mouth could be opened only 1⁄2 inch. In the left half of the floor of the mouth was a bluish-red swelling. There was constant severe pain in the region of the swelling, especially around and behind the left angle of the lower jaw. The bullet was not found. Five days later the patient, while straining at stool, felt something give way behind the angle of the jaw. This was followed by intensely agonizing pain, accompanied by decided pulsation of the left subauricular region. Four days later a decided aneurismal bruit was detected over this. As there could be no doubt of the existence of a traumatic aneur

ism at this point, Dr. E. W. Lee ligated the left common carotid artery. Two weeks later the bullet wound had entirely, and the operation wound had nearly, healed. The patient felt well, with the exception of a slight headache and slight sensation of pulsation below the left mastoid process. No aneurismal bruit was detectable on stethoscopic examination. Three days subsequently, while undergoing cross-examination in court, the sensation of pulsation increased, and, on return to the hospital, a decided thrill but no bruit could be detected behind and below the left mastoid process. By February 9th the pain and pulsations had markedly increased. As it was obvious that a traumatic aneurism had recurred and was endangering life, I decided to make the radical operation, and began by securing the external carotid. An incision was made, 3 inches in length, along the entire upper half of the sternocleidomastoid, the tissues were carefully separated, a careful watch kept for the pulsating vessels around the border of the pulsating tumor, with a view to ligating them before opening the aneurismal sac. When pulsation on pressure in various places had been apparently felt, and the aneurismal pulsations seemed to cease, an aneurismal needle, armed with heavy aseptic silk, was passed successively around the area of the tissues involved, and ligature made en masse, but in vain.

I then determined to lay open the sac and catch up the supplying artery in loco. A transverse incision, 21⁄2 inches in length, was made, extending from the upper end of the former incision backward from the mastoid process through the skin and insertion of the sternocleidomastoid, in order to secure the posterior occipital artery, possibly the source of the aneurism. On removal of the sternocleidomastoid the pulsations were more markedly felt. After a thin layer of the deep nuchal muscles had been cut through, the aneurismal sac was opened and found filled with dark clots, on removal of which arterial blood spurted out. This hemorrhage could be controlled only by pressure on the bottom of the cavity at its deepest part. The squama ossis occipitis was found to be denuded, and in the internal wall, formed by the atlas and axis, some splinters of bone were felt. The tissues were cut through downward along the transverse processes of three or four cervical vertebræ and the whole sac laid open, which necessitated the removal of the upper fourth of the sternocleidomastoid muscle. Artificial respiration and injections of whisky were required at this stage, as respiration had ceased. When the respirations again began, search was made for the vertebral artery, which was finally taken up, at its curvature around the axis, and ligated. The bleeding stopped. The vertebral artery was nearly as large as the internal carotid. During ligation the respirations had stopped, and the patient was pulseless and seemed dead. After dressing the wounds, 8 ounces of defibrinated blood were transfused. The patient rallied rapidly, and left the hospital April 7th. Five years later he was treated by Dr. Kiernan for some dyspeptic difficulty, who found that, despite a very dissipated career, the patient had enjoyed good health.

The case is the first in which vertebral artery ligation has been successfully performed between the occiput and axis, and the fifth in which vertebral artery ligation for a wound involving a traumatic aneurism of the vertebral artery has resulted in recovery.

REMARKS ON DERMOID CYSTS OF THE OVARY, WITH ILLUSTRATIONS FROM SPECIMENS *

IN entering upon the question of the dermoid cysts of the ovary, I wish to call attention to the two theories of their origin. According to Heschl, dermoid cysts in general owe their origin to isolated islands of the epiblast, displaced during embryonal development and located somewhere in the territory of the mesoblast. This theory of fetal inclusion did not explain the origin of the dermoid cysts in the testicle and ovaries. It was not until His had shown that the internal genital organs are developed from a part of the embryo, the so-called “Axenstrang," in which all the germinal layers are included, that we were able to understand the presence of dermoid cysts in those genital glands.

The second theory of the origin of dermoid cysts in the ovary is the view of the older authors, recently adopted by Waldeyer. Epithelial cells of the ovary, capable of transformation into the ovum with all its formative possibilities, may enter into an irregular formative activity and produce a dermoid cyst-a process almost analogous to a parthenogenetic development, as Olshausen states it. This second theory would only explain the origin of dermoid cysts in the ovary, and would not enable us to understand their presence in all other parts of the body. Consequently, it seems more natural to accept the Heschl-His theory, as this gives a satisfactory explanation of the origin of dermoid cysts in general, and is in conformity with Cohnheim's theory of the origin of all other new formations, from an isolated group of embryonal cells, dormant until the unknown cause of the new formation calls them into formative activity.

A dermoid cyst is always a monocyst, and if, as is seldom the case, we find more than one in the same ovary (Olshausen in one case found three), we may expect to have had more than one embryonal matrix, from each of which a cyst has developed, the one independent of the other. It often appears as if a dermoid cyst of the ovary were a multiple one, but closer examination will prove that we have before us a combination of a dermoid cyst and a proliferating cystoma, or, more rarely, a dermoid cyst with multiple local colloid degeneration of the stroma of the wall. Cystic transformation of the sweat-glands—extensive cysts to the size of a fist-was seen in one case by Friedländer.

I shall not go any further into the subject of the dermoid cysts here, but only present to the Society 3 specimens removed by laparotomy * Chicago Med. Jour. and Examiner, 1887, vol. liv, p. 381.