This  may  sound  simple,  but  in  practice  it  proved
exceedingly  difficult.  Thus,  a  man  was  wounded
by  a  very  minute  fragment  of  a  shell  on  the  right


166  A  CONSULTING  SURGEON  IN  THE  NEAR  EAST

side  of  the  root  of  the  neck.  The  wound  healed
in  five  or  six  days  and  he  was  sent  to  a  convales-
cent hospital.  In  four  days,  a  pulsating  swelling
appeared  above  the  right  clavicle  and  he  was
returned  to  a  general  hospital.  In  two  days  more,
the  swelling  had  extended  as  high  as  the  fifth
cervical  vertebra  and  was  pushing  downwards
into  the  chest.  The  question  of  diagnosis  was
whether  we  were  dealing  with  an  aneurysm  of  the
innominate,  the  first  or  second  part  of  the  sub-
clavian, or  the  vertebral  artery.  We  thought
the  second  part  of  the  subclavian  most  likely.
So  rapidly  did  the  aneurysm  extend,  that  we
decided  to  operate  without  delay.
The  difficulties  encountered  were  great.  All
the  large  nerve  cords  were  stretched  over  the
aneurysm  ;  the  great  veins  were  adherent  to  it ;
and  it  flattened  the  dome  of  the  pleura,  which  was
likewise  attached  to  it.  We  were  able  to  ascertain
that  the  aneurysm  had  originated  in  the  second
part  of  the  subclavian  artery.  We  tied  the
vessel  on  either  side  and  extirpated  the  affected
portion  of  artery.  Unfortunately,  the  shock  and
length  of  the  operation  proved  too  much  for  the
patient  and  he  sank  the  same  afternoon.  At  the
post-mortem  examination  he  was  found  to  have
a  fatty  and  dilated  heart.  On  laying  open  the
second  portion  of  the  subclavian  artery,  after
excision,  it  was  found  that  a  very  minute  piece
of  "  H.E.  "  shell  had  penetrated  the  outer  coat
of  the  artery  and  was  lying  in  the  middle  coat.
