A case of aneurysm involving the innominate, the right subclavian, and the right common carotid arteries : treatment by proximal ligature ... aneurysm to the middle cerebral artery / by Charles A. Ballance.

  • Ballance, Charles Alfred, Sir, 1856-1936.
Date:
1902
Catalogue details

Licence: In copyright

Credit: A case of aneurysm involving the innominate, the right subclavian, and the right common carotid arteries : treatment by proximal ligature ... aneurysm to the middle cerebral artery / by Charles A. Ballance. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

    10/16 (page 8)
    Choice of the knot.—The knot adopted was “ the stay-knot.” It would appear from certain published writings that the method of applying this knot is not clearly understood. The principle upon which the stay-knot depends is that the mutual support which the ligatures afford one another by friction and interlocking prevents the first hitches of the knot slipping when the ends are relaxed, as they must be to complete the reef-knot. The essential part of the stay-knot is therefore the method of applying the first hitches. The best way of tying the stay-knot with two ligatures is to make on each separately, and in the same way, the first hitch of a reef-knot and to tighten each separately so that the loop lies in contact with the vessel without constricting it; then, taking the two ends on one side together in one hand and the two ends on the other side in the other hand, to constrict the vessel sufficiently to occlude it, and finally to complete tiie reef-knot. The simplest method of completing the knot is to treat the two ends in each hand as a single thread and to tie as if completing a single reef-knot (see Figs. 8 and 9). Three or four ligatures can be employed in this manner; by pulling the ends of the ligatures simultaneously they will lie evenly side by side and constrict a greater length of vessel than if they were tied separately and were lying, as they then might, one on the top of the other in a deep groove in the artery. The cause of death.—Death was due to extension of thrombosis from the aneurysm to the middle cerebral artery, and the question arises, Is this an inevitable consequence of ligature of the innominate ? The case supports in a remarkable way some experiments of Spencer and Horsley on the arrest of haemorrhage from the middle cerebral artery and its branches. They showed that compression or ligature of the common carotid artery arrested haemorrhage from the middle cerebral artery and caused anaemia of the brain within its area of distribution. Their experiments led them to suggest the ligature of the common carotid in certain cases of ingravescent apoplexy. Now, it is a remarkable fact that both in Curtis’s case and in my own the common carotid was distended, where exposed for ligature, with clot at the time of the operation, but in my case for some reason or other clotting extended upwards while in Curtis’s case this extension did not take place. When the common carotid is tied though anaemia of the area supplied by the middle cerebral artery of the same side occurs this condition is a temporary one and we do not anticipate coagulation of the blood in the middle cerebral artery; in fact, coagulation on the distal side of a common carotid ligature is not usually extensive. I have no hesitation whatever in saying that the clotting which caused the death of my patient was not due to a local but to a general condition cause. He was ill-nourished, and in order to attempt the cure of the aneurysm without operation the Valsalvan treatment was adopted, combined with the administration of considerable doses of iodide of potassium. The result was not to produce any effect on the aneurysm, but to bring about a condition of low nutrition and the fatal thrombus was really marantic thrombosis and not a necessary sequel of the operation. Such thrombi are not seldom found in the venous sinuses of children who have died from diseases associated with malnutrition. The treatment therefore previously to operation should not have been starvation but a full and generous diet. Under modern conditions the adoption of the Aralsalvan treatment in an operable case of aneurysm is, in my judgment, an error.