THE 4ustrafian Medical 7ournal MARCH 15, 1885. rigirial Articles. LIGATURE OF RIGHT VERTEBRAL ARTERY OF AN EPILEPTIC—RUPTURE OF INTERNAL JUGULAR VEIN—RECOVERY. By ROBERT B. DuNcAN, Surgeon to the Kyneton Hospital. Whether the ligature of the vertebral arteries in cases of confirmed epilepsy will ever become a recognised surgical operation may well be open to doubt. When we take into consideration, however, the large number of hopelessly incurable epileptics, and the powerlessness of medicine to afford them any relief, any aid that surgery may promise should certainly have a fair trial. The cases already recorded, and the results achieved by Dr. Alexander of Liverpool, point to a fair amount of success, and would certainly warrant further operations in the same direction. I had not the advantage of being able to consult his article when the present case came under my care. The literature of the subject is otherwise very scanty, and the method of operating is scarcely alluded to in works on systematic surgery. Erichsen, quoting Smyth of New Orleans, devotes a few lines to the method of procedure in his celebrated case. In Stephen Smith's Principles and Practice of Operative Surgery, a pretty full and accurate account of the method of operating will be found. The mere fact of having ligatured the artery would not really merit any special communication, except for the unlooked for and formidable complication which attended it. As no mention is made, in anything I have read of, the occurrence which happened to myself, it may not be uninteresting to those who contemplate performing the operation to place on record a not improbable complication. Whether the rupture of the internal jugular was due to any weakness in the coats of the vein itself from its frequent distension during the fits, or the result of pre-existing disease, I am quite unable to determine ; it suddenly gave way when being cautiously pulled aside, with the other structures surrounding it, at a certain stage of the operation. VOL. VII. No. 3.—NEW SERIES. 98 Australian Medical Journal. MAR. 15, 1885 The patient, a young, healthy-looking man, aged 30, had been subject to epileptic seizures for fifteen years. As is frequently the case, no cause could be assigned for them, nor had any medical treatment been of the least avail in lessening their severity or mitigating their frequency. He was admitted to the hospital in September last, and kept under observation for a month. During that time he had on an average five fits every night, and generally two daily. The attacks were most severe and prolonged. Such, I was informed, had been about his usual state for ten years at least, and for five years previously, the attacks, however, at that time not being of such intensity. On the 10th of October last, the patient having been put under the influence of chloroform, I proceeded with the operation. The head being inclined a little to the left side, an incision three inches long was made along the posterior border of the sterno-mastoid muscle, terminating a short distance above the clavicle, the external jugular vein being divided and secured. The cellular tissue was divided the whole length of the wound, some lymphatic glands pushed aside, and a depth reached on a level with the internal jugular vein. To reach that part of the vertebral artery lying between the scalenus anticus and longus colli muscles, it became necessary at this stage to displace the vein and other surrounding structures which lie immediately over it. As this was being carefully done by one of my colleagues with a retractor, a gush of venous blood took place, of such magnitude immediately as to reveal its source. Almost instantaneously with its appearance a whistling sound was heard issuing from the bottom of the wound, which only too surely denoted the entrance of a considerable quantity of air. The appearance of the blood and the rush of air being almost coincident, no time was of course afforded to prevent it, but on its occurrence I immediately stuffed the wound with a sponge. The patient's face by, this time had become dusky and the heart's action much embarrassed. Artificial respiration was at once commenced and carried on energetically, the condition soon becoming more favourable. How to remove the sponge and secure the vein without permitting the entrance of any more air was the next question. Although this was attempted with the utmost promptitude, a large influx of air again took place, but I succeeded in introducing my index finger into the proximal end of the rent. The patient was now in a MAR. 15, 1885 Australian Medical Journal. 99 condition of extreme peril, the respiration stertorous, face livid, and fluttering pulse. Artificial respiration was again resorted to, with the result of bringing the patient into a more favourable state. While this was being carried out, I found that the vein had given way a little over an inch distant from its union with the brachio-cephalic. My finger completely filled it, and it was torn almost quite across. As the part of the vein in which I had my finger inserted was under the clavicle and out of sight, great difficulty was found in securing it. This was at last accomplished by passing an aneurism needle round my finger outside the vein, threading and withdrawing it. The vein being out of view, the risk of including other structures was very great, but fortunately this was avoided. It was then carefully tied, and an additional ligature above the rent. An opening was then quickly made in the aponeurosis covering the scalenus anticus and longus colli muscles, an inch below the transverse process of the sixth cervical vertebra, and the muscular structures separated. By good fortune the artery was exposed at once and ligatured, the operation not being unduly prolonged. The wound was irrigated with carbolic acid solution, drained with carbolised kangaroo tendon, and closed with the same material. The patient was removed to bed in a critical state, from which, however, he satisfactorily rallied in the course of a few hours. His temperature never exceeded 100° F., and his recovery was rapid and without the intervention of a single bad symptom. The antiseptic dressings were continued for fourteen days, and at the end of three weeks the wound had completely healed. Although the left vertebral still remains to be liga- tured, it is pleasing to note the gratifying results already obtained. For ten days after the operation he had no fits, then one or two slight ones, and now at the end of four months he will be sometimes four days without one. Their regularity and severity have been completely altered, and viewed as merely a palliative measure, there is much to recommend what has already been done. How . far the case will progress favourably, or a cure be attained when the operation is completed, I hope to be able to state at some future time. I ought to have mentioned that I had the assistance of my friends Drs. Langford, Smith, and Ryan, without whose valuable aid the result might have been very different. G 2 100 Australian Medical Journal. Men. 15, 1885 PRIMARY SCIRRHUS—PLEURO-PNEUMONIC AND RENAL. By W. V. Jakins, L.R.C.P. Ed., Fell. Obst. Soc. Lond. The great rarity of this complaint, and the infrequency of its correct diagnosis, render this case of unusual interest. James G., aged 62, a miner, weight about 12 stone, admitted into the Ballarat Hospital 13th July, 1883, for stricture of the urethra ; treated by gradual dilatation, and discharged cured 7th August. He was re-admitted under my care 17th May, 1884, for pleurisy with effusion on right side. Height about 5 feet 7 inches, weight about 91 stones ; pale, but with a little natural ruddiness over cheek bones ; body seems destitute of fat ; hair brown, turning grey, and scanty. Right chest enlarged, intercostal spaces a little prominent, and action inefficient in respiration ; glands not enlarged. On percussion, anterior dulness below nipple, less above it, laterally and posteriorly dulness not absolute ; vocal fremitus defective ; bronchial breathing all over to extreme base. No pain, cough, or elevated temperature ; eyes prominent, pupils exceedingly contracted, eyeballs hard, vision indistinct. These latter conditions were much relieved by eserine locally. As usual he passed his catheter about once a month, sometimes drawing blood. Urine was examined occasionally for albumen and sugar without finding any. Always grumbling. The treatment was pot. iod. internally, iodine paint externally, and fomentations. He left on 30th August very much better. Dulness but slight, breathing less bronchial, eye affection not troublesome. He had taken daily exercise in the garden, and slept fairly. On 17th September he was again admitted, decidedly thinner and paler than on 17th May, signs and symptoms as at that date, save that his eyes did not trouble him. His temperature never rose above 98°, in the evening it sometimes fell to 97°, yet he gradually wasted till 2nd December, when slight bronchitis with dyspncea set in. This was relieved by lobelia and senega, but he gradually became weaker, and died quietly at 2.45 a.m. on 16th January, 1885. At the autopsy, at 3 p.m. on the 17th, the body was still warm, much emaciated, pale, no enlarged glands to be detected. Costal cartilages required sawing. Anterior right pleura had to be dissected off the sternum, was much thickened, and of leathery 101 MAR. 1, 1885 Australian Medical Journal. consistence. Right lung needed dissection from the parietal pleura as anteriorly. The chest was half full of degenerated clots, from the size of a pigeon's egg to an orange, sienna coloured, shaggy externally, internally containing a pale or burnt sienna, thin fluid, a few amber-coloured irregular clots posteriorly.