The vague plans of Surgical operation, at present practised, are too
generally known, and too sincerely deplored, by every man of science and
of feeling, to demand much of comment on the present occasion.
How often, in the attempt to take up an artery, does the ignorant and
timid operator make an incision so limited that he is afterwards forced
cruelly to extend it! How often, having extended his incision, does he
find no artery beneath it, and dig or mine for it in a new direction, by
cutting up the flesh of the patient! How often, having reached the place
he sought for, does he mistake another artery, a nerve, or even a vein,
for that which ought to be the subject of operation! How often, having
found the artery, is he at a loss to recognize it! What trepidation and
alarms does not this operator, more miserable than the patient himself,
endure!
I know no situation more wretched or more pitiable than this. Here,
even at the best, the most exquisite torture is inflicted: the poor
trembling patient, abstracted from every other earthly object, and with
the most exquisite feelings concentrated on the present, awaits, in awful
suspence, the impending stroke which is to divide the skin, that seat of
accumulated sensibility, and deliver him from wretchedness; but the hope
is vain, his torments are again and again renewed; he perceives that his
life is the sport of a fool; he writhes in agony, or sinks in deliquium;
and the issue is, as might be expected, too generally, even at the best,
unsuccessful.
When all this is not the case, how often does the operator, on the
contrary ignorant and rash, plunge his knife into some vital organ of the
patient, and at once terminate his life and his diseases?
That this picture is not too highly coloured, I solemnly appeal to the
conscience and the feelings even of the best operators, who are too
candid to deny that melancholy reflection has often oppressed them from
the fate of patients—martyrs to their want of precision.
* * * * *
To obviate this train of miseries; to give ease and satisfaction to the
operator, by conferring precision and success upon his operation, and
to rescue from death, or rather from torture and agony, innumerable
sufferers, are the results which I confidently expect from the adoption
of the following method. Nor can I say more in proof of its importance.
I doubt not, that it will, ultimately, constitute the basis and direct
the genius of surgery.
* * * * *
There exists no other method of effecting this, than by the enunciation
of the following principle; namely, that there is, especially in such
parts as are not liable to be deranged by voluntary motion, an invariable
relation between the arrangements of internal and the situation of
external parts, which may justly be considered as accurate signs of them;
in consequence of which, by adopting, on each side of the nerve, artery
or other subject of operation, a fixed point, or one rendered fixed by
particular positions of the body; and by dividing, according to a line
or rule, the space between these fixed points into a given number of
proportional parts, _i. s._ parts, not equally large in all subjects,
but uniformly of the same size, with relation to the whole which they
compose, and generally differing in the male and female—by these means, I
say, the situation of any given subject of operation, in any given part
of the body, may be most accurately indicated, as being undeviatingly a
certain number of proportional parts distant from the one, and a certain
number from the other of these points.
Thus does anatomy, by what I term precise or real proportional
measurements between fixed points, afford an obvious and simple, though
hitherto unobserved, general means of rendering the operations of surgery
perfectly precise and easy.
Indeed, such wonderful precision and ease do these real proportional
measurements confer, that, by means of them, the finest instrument may be
passed from the surface of the body through any great nerve or vessel
that is liable to be the subject of surgical operation.
Having stated this principle, I may merely observe, that, proceeding
with all the ease and security, such accuracy must infallibly confer,
it is, in all operations the first duty of the operator to ascertain
by feeling, as nearly as possible, the thickness of cellular substance
situate immediately under the skin of the patient, and then, with a bold
and steady hand, to make an incision, deep in proportion to the thickness
of that substance, and long in proportion to its depth, as well as to the
additional depth and extent of the part to be operated upon.
These general principles excepted, other subordinate rules are chiefly
applicable to particular operations.
* * * * *
In order to illustrate this general principle, I cannot adduce a fairer
or a better example than that which, according to it, is necessary to
direct the taking up of the subclavian artery above the clavicle.
The patient must, in this operation, rest on the fundament, his body
slightly inclining backward, so as to form an obtuse angle with the
thighs, and his neck and head inclined backward so as to form with the
trunk an angle similar to that formed by it with the thighs; the inferior
of these angles being concave, the superior convex. This last may indeed
be more properly called an irregular segment of a circle, formed in
consequence of the vertebrae of the neck bending in that direction. In
this position, therefore, the neck is, in general, in the same parallel
with the thighs. The head of the patient is to be turned to the opposite
side from that in which the operation is to be performed, where also the
operator must stand. The light must fall directly downward from the head
of the patient.
In this case then, the bringing of the shoulder forward and downward,
which I deem indispensible, however necessary to the ease of the
operator, is not very material to the correctness of the measurement.
It is however of some consequence; for, as the subsequent measurement
is dependent on the clavicle, and as that bone describes a portion of
a circle in having its lateral end brought forward, every single point
of it would, in that position, have a different relation to the vessels
beneath from that which each would have had, if kept in its usual
position.
Here then, the shoulder being in this position, and the arm held by the
side, the measurement commences, and the fixed point chosen on each side
of the immediate subject operation are the two ends of the clavicle; as
nearly between these as can be done, consistently with keeping quite
clear of the bone, a line must be drawn superior and internal to it,
and the given number of proportional parts, into which this line must
be divided, are seven in number both in the male and female; and now
the situation of the artery may be most accurately indicated as being
undeviatingly three of these proportional parts distant from the inner,
and four from the outer end of the clavicle; in consequence of which, if
a fine instrument, held at right angles to the clavicle, were directed
downward and inward, it would at 1 and ¼ of the above mentioned parts
from the surface of the clavicle, reach the artery, and being pushed
farther, would pass through it.
This is an absolute demonstration of the precision and ease attending the
principle I have announced, and of its applicability even to the most
difficult of all operations.
In order, however, to perform the operation throughout, the point which I
have indicated must be the center of an incision through the integuments
made in the line above mentioned, and must extend at least two parts
inward and two outward from the central point. Over the Trapezius
outward, and over the clavicular attachment of the Sterno-cleido-mastoid
muscle inward, it is not adviseable to cut deeper than the integuments,
which sufficiently relieves the hand of the operator, without the present
execrable practice of dividing the last mentioned muscle, which is not
only unnecessary, but highly faulty, as this attachment serves as one
of those particular points, above alluded to, incidental to certain
operations, which, by means of its edge, kept lax during the operation,
very nearly directs the knife to a small protuberance on the superior
anterior surface of the first rib to which the scalenus primus is
attached, and immediately external to which the artery itself lies.
Above all, the incision ought to be cautiously continued on the inner
side, in order to avoid the large veins situate there; various branches
of these veins may come in the way, and the more considerable may be
easily avoided, but if not, they may be tyed.
In continuing the incision inward and downward, an ascending branch
of the vein is in the way, which, when it is considerable, may also,
previous to the continuance of the incision, be tyed. The incision
itself, as you pass inward, must be very limited indeed, as the jugular
vein is internal to it; and external to it there is a twig of the
brachial nerve, both of which are much exposed to injury.
When the incision has been made one and a fourth of these proportional
parts inward from the outside of the clavicle, you have reached the
artery. It lays external to that protuberance of the first rib into
which, as already observed, the scalenus primus is inserted, and
consequently to the insertion of the muscle itself. The twig of the
nerve actually crosses the artery immediately below the point where the
latter ought to be tyed. The course of the artery is, in descending,
obliquely outward, and the precise space in which it lays resembles
an isosceles triangle formed by the clavicle, clavicular portion of
the sterno-cleido-mastoideus and the omo hyodeus; its base being the
clavicular portion of the sterno-cleido-mastoideus. The nerve is external
and anterior to the artery, particularly its branch. Both the twig and
trunk of the nerve ought to be seen by the operator before he attempt to
take up the artery.
These directions are so precise, that, were the operator blind and the
artery destitute of pulsation, he need not scruple to take up that which
presents itself in the above mentioned situation.
By similar measurements, may every great artery in the body, liable to
be the subject of surgical operation, be discovered with similar ease
and precision, nor does there exist any other method of effecting this
purpose.
I shall now then state the objections which may be urged against this
principle.
* * * * *
It may be objected to the adoption of this fundamental principle of all
surgical operation.
_1st_, That the accidental and probable fracture of the bone affording
the fixed points, would, by deranging these points, render all such
measurement inapplicable.
_2d_, That varieties in the distribution of arteries, and those
deviations which are often produced by disease, would have the same
effect.
I know not of any other objection that can be urged against it, and these
I shall immediately answer.
* * * * *
_1st_, To the objection that the accidental and probable fracture of
the bone affording the fixed points would, by deranging these points,
render all such measurements inapplicable, I answer, that, to chuse as
an example the operation I formerly described, it is, in such a case,
only necessary to transfer the measurement to the sound clavicle,
and to convert the three inner or four outer proportional parts into
absolute inches, quantities similar to which may then be measured from
the corresponding ends of the fractured one, and thereby indicate the
situation of the vessel or nerve with as great precision as if no
fracture were involved.
_2d_, To the objection that varieties in the distribution of arteries,
and those deviations which are often produced by disease, would have the
same effect, I answer, that variety of distribution does not at all take
place in some of those parts in which the most important operations have
to be performed; namely, high in the groin, above and below the clavicle,
&c. and that, wherever great deviation is caused by disease, it will
generally be attended by external signs, according to which the operator
may modify his measurements. I also further answer, that wherever
deviation, from either of these causes, occurs, he who, by means of these
measurements, knows the precise situation, according to the most usual
and regular structure, will have the most decided advantage over him
who is ignorant of it: the former will possess data, from which he can
calculate probable deviations, the latter none; the former, even at the
worst, will have to _calculate_, the latter will be unable to do more
than _guess_.
Thus I have answered the only objections that it is possible to urge
against the principle proposed.
I have already said, that private objections by persons who dare not
publicly make one, and who themselves cannot, by one or two incisions,
approach within several inches of any artery, I shall uniformly despise,
and shall only ask them to perform the operation with my youngest pupil.