E-text prepared by Michael Ciesielski, Pilar Somoza Fernández, and the
Project Gutenberg Online Distributed Proofreading Team
(https://www.pgdp.net)
Note: Project Gutenberg also has an HTML version of this
file which includes the original illustrations.
See 24564-h.htm or 24564-h.zip:
(https://www.gutenberg.org/dirs/2/4/5/6/24564/24564-h/24564-h.htm)
or
(https://www.gutenberg.org/dirs/2/4/5/6/24564/24564-h.zip)
Transcriber's note:
Spelling mistakes have been left in the text to match the original,
except for obvious typographical errors.
A MANUAL OF THE OPERATIONS OF SURGERY
For the Use of Senior Students, House Surgeons, and
Junior Practitioners.
Illustrated.
by
JOSEPH BELL, F.R.C.S. EDIN.
Lecturer on Clinical Surgery, Surgeon to the Royal Infirmary and to
the Eye Infirmary, and Late Demonstrator of Anatomy
in the University of Edinburgh.
FIFTH EDITION, REVISED AND ENLARGED.
Edinburgh: Maclachlan & Stewart,
Booksellers to the University.
London: Simpkin, Marshall, & Co.
1883.
TO THE MEMORY OF
JAMES SYME, ESQ., F.R.C.S. AND F.R.S.E.
SURGEON TO THE QUEEN IN SCOTLAND
PROFESSOR OF CLINICAL SURGERY
IN THE UNIVERSITY OF EDINBURGH
ETC. ETC.
THIS BOOK IS DEDICATED
BY HIS OLD HOUSE-SURGEON AND ASSISTANT
THE AUTHOR.
PREFACE TO FIFTH EDITION.
To retain the small size of the work and to keep it up to date have been
the Author's aim in the Fifth Edition.
20 MELVILLE STREET, EDINBURGH,
_August 1883._
PREFACE TO THE FIRST EDITION.
Having been asked, year after year, by the members of my Class for
Operative Surgery, to recommend to them some Manual of Surgical
Operations which might at once guide them in their choice of operations,
and give minute details as to the mode of performance, I have been
gradually led to undertake the production of this little work.
My aim has been to describe as simply as possible those operations which
are most likely to prove useful, and especially those which, from their
nature, admit of being practised on the dead body.
In accordance with this plan, neither historical completeness of detail,
nor much variety in the methods of performing any given operation, is to
be expected. Hence, also, many omissions which would be unpardonable in
the briefest system of Surgery are unavoidable. For example, excision of
tumours and operations for necrosis are hardly mentioned, because for
these no special instructions can well be given; for, while general
principles may guide us to _what_ should be done, the special
circumstances of each case must dictate _how_ it is to be done.
In such a work as this, to attempt originality would be undesirable and
intrusive; a judicious selection, a faithful compilation, are all that
can be expected.
That the selection of operations may sometimes show "Northern
Proclivities" is possible; and this is perhaps not unnatural to a
scholar and teacher in the Edinburgh School.
An earnest endeavour has been used to make the references correct and
copious: for any mistakes or omissions the author would crave
indulgence.
The four plates which precede the letterpress were drawn on wood (from
original photographs) by Mr. D.W. Williamson, Melbourne Place, and the
lines of incision for the various operations were added by the author.
The rough woodcuts scattered through the work were drawn on wood by the
author, and for their roughness he, not his engraver, is responsible. He
also hopes that the references in the letterpress will be accepted as
sufficient acknowledgment of the true ownership, in those few instances
in which the idea of the diagram has been borrowed.
It has been thought unnecessary to introduce woodcuts of surgical
instruments, as the illustrated catalogues lately published by Weiss,
Maw, and others, are sufficiently accurate.
In excuse of the frequent baldness and brevity of the style, the author
must point to the size and price of the work. Its composition would have
been easier had its dimensions been greater.
Though intended chiefly to guide the studies, on the dead subject, of
students and junior practitioners, the author ventures to hope that the
Manual may be useful to those who, in the public services, in the
colonies, or in lonely country districts, find themselves constrained to
attempt the performance of operations which, in the towns, usually fall
to the lot of a few Hospital Surgeons.
JOSEPH BELL.
5 CASTLE TERRACE, EDINBURGH,
_July 1866._
CONTENTS.
CHAPTER I.
LIGATURE OF ARTERIES.
PAGE
Ligature of Arteries--General Maxims--Ligature of
Aorta--Iliacs--Gluteal--Femoral--Popliteal--Innominate--Carotids--
Lingual--Subclavian--Brachial, etc., 1-45
CHAPTER II.
AMPUTATIONS.
Eras of Amputation--Flap and Circular compared--Special Amputation of
Arm and Leg, 46-107
CHAPTER III.
EXCISION OF JOINTS.
Brief Historical Sketch--Comparison of Excisions with
Amputations--Special Excisions of the six larger Joints--Excisions of
smaller Joints and Bones, 108-146
CHAPTER IV.
OPERATIONS ON CRANIUM AND SCALP.
Trephining--Excision of Wens, 147-150
CHAPTER V.
OPERATIONS ON THE EYE AND ITS APPENDAGES.
Entropium and Ectropium--Trichiasis--Tarsal Tumours--On Lachrymal
Organs--Mr. Bowman's Operation--Pterygium--Strabismus, convergent
and divergent--Paracentesis of the Anterior Chamber--Operations
for Cataract by Displacement, Solution, and Extraction--Various
methods of Extraction--Operations for Artificial
Pupil--Iridesis--Corelysis--Iridectomy--Excision of Staphyloma--Excision
of Eyeball, 151-174
CHAPTER VI.
OPERATIONS ON THE NOSE AND LIPS.
Rhinoplastic Operations from Cheek, Forehead, and elsewhere--Removal of
Nasal Polypi--Excision of Cancers of Lips--Cheiloplastic
Operations--Operations for Harelip, 175-187
CHAPTER VII.
OPERATIONS ON THE JAWS.
Excision of Upper Jaw--Of Lower Jaw, 188-195
CHAPTER VIII.
OPERATIONS ON MOUTH AND THROAT.
For Salivary Fistula--Excision of Tongue, complete and partial--Fissures
of the Palate, soft and hard--Excision of Tonsils, 196-205
CHAPTER IX.
OPERATIONS ON AIR PASSAGES.
Larynx and
Trachea--Tracheotomy--Tubes--Laryngotomy--OEsophagotomy--[see
Addendum, p. 302], 206-217
CHAPTER X.
OPERATIONS ON THORAX.
PAGE
Excision of Mamma--Paracentesis Thoracis, 218-221
CHAPTER XI.
OPERATIONS ON ABDOMEN.
Paracentesis Abdominis--Gastrotomy--Ovariotomy--Operation for
Strangulated Hernia--Inguinal--Femoral--Umbilical--Operations for the
Radical Cure of Hernia, 222-255
CHAPTER XII.
OPERATIONS ON PELVIS.
Lithotomy--Varieties--Lithotrity--Operations for Stricture--Puncture of
the Bladder--Phymosis--Amputation of
Penis--Hydrocele--Hæmatocele--Castration--Operation for
Fistula--Fissure--Polypi of Rectum--Piles, 256-295
CHAPTER XIII.
TENOTOMY.
On Tenotomy for Wry Neck and Club Foot, 296-298
CHAPTER XIV.
OPERATIONS ON NERVES.
Nerve-stretching--Nerve-cutting--Nerve suture, 299-301
ADDENDUM to Chapter IX., 302
INDEX, 303-311
LIST OF ILLUSTRATIONS.
FIG. PAGE
I. Amputations of Fingers, 50
II. Diagram of Finger showing Articulations, 50
III. Dubrueil's Amputation at Wrist (front view), 57
IV. " " (dorsal view), 57
V. Amputations of Toes, 69
VI. Excision of Wrist-joint--Lister's, 126
VII. Operations for Ectropium and Entropium, 151
VIII. Operation for Trichiasis--Streatfeild's, 151
IX. Operation for Epiphora--Bowman's, 155
X. Greenslade's Instrument for above, 156
XI. Operations for Squint, 157
XII. Linear Extraction of Cataract, 162
XIII. Flap Extraction of Cataract, 162
XIV. Operation of Corelysis--Streatfeild's, 171
XV. Operation for Staphyloma--Critchett's, 172
XVI. Result of above, 172
XVII. Rhinoplastic Operation from Cheek, 176
XVIII. " " Forehead, 177
XIX. Operation on Lip, V-shaped incision, 181
XX. Operation on Lip, by scissors, 181
XXI. Operation for a new Lip, incisions, 182
XXII. Operation for New Lip sewed up, 182
XXIII. Diagram of Partial Fissure (Harelip), 184
XXIV. Nelaton's Operation for ditto, 184
XXV. Operation for Double Harelip, 185
XXVI. Diagram of Double Harelip, 186
XXVII. Excision of Upper and Lower Jaws, 189
XXVIII. Operation for Salivary Fistula, 196
XXIX. Operation for Fissure in Soft Palate, 201
XXX. Operation for Fissure in Hard Palate, 203
XXXI. Diagram illustrating Operations on Air Passages, 207
XXXII. Diagram illustrating Operations for Hernia, 241
XXXIII. Diagram of an Artificial Anus, 253
XXXIV. Diagram of Section of Prostate, 257
XXXV. Diagram of Membranous portion of Urethra, 259
XXXVI. Diagram illustrating Puncture of Bladder, 284
XXXVII. Diagram of Operation for Phymosis, 286
XXXVIII. Diagram of Amputation of Penis, 287
[Illustration]
PLATE I.
1. Ligature of Aorta--Sir A. Cooper's incision.
2. Ligature of Aorta--South and Murray's incision.
3. Ligature of Common Iliac.
4. Ligature of External Iliac--Sir A. Cooper's.
5. Ligature of Femoral in Scarpa's triangle.
6. Ligature of Femoral below Sartorius.[1]
7. Ligature of Innominate.
8. Ligature of third part of Left Subclavian.
9. Ligature of Axillary in its first part.
10. Ligature of Axillary in its third part.
11. Ligature of Brachial.
12. Amputation of Arm by double flaps.
13. Amputation at Shoulder-joint (1st method), showing portion of skin
left uncut till the conclusion of the disarticulation.
14. Amputation at Ankle-joint by internal flap--Mackenzie's.
15-16. Amputation of Leg just above the Ankle-joint.
17-18. Amputation below Knee--modified circular.
19. Amputation through Condyles of Femur--Syme, and Pl. III. 5.
20. Amputation at lower third of Thigh--Syme, and Pl. III. 6.
A. Excision of Head of Humerus.
B. Excision of Knee-joint; semilunar incision.
FOOTNOTES:
[1] This line is placed too low down; it should be in the middle third
of the thigh.
[Illustration]
PLATE II.
1. Amputation at lower third of Fore-arm--Teale's.
2-2. Amputation at Shoulder-joint by large postero-external flap--2d
method.
3-3. Amputation at Shoulder-joint by triangular flap from deltoid--3d
method.
4-5. Amputation through Tarsus--Chopart's.
6-7. Amputation at Knee-joint.
8. Amputation by Single Flap--Carden's, and Pl. IV. 16.
9-10. Amputation of Thigh--Teale's.
A. Excision of Hip-joint.
B-B. Excision of Ankle-joint--Hancock's incisions.
[Illustration]
PLATE III.
1. Ligature of Popliteal.
2. Amputation at Elbow-joint--posterior flap.
3. Amputation at Shoulder-joint--posterior incision of first method, and
Pl. I. 13.
4. Amputation at Ankle-joint--Mackenzie's, and Pl. I. 14.
5. Amputation through Condyles of Femur--Syme, and Pl. I. 19.
6. Amputation at lower third of Thigh--Syme, and Pl. I. 20.
7. Amputation at Knee--posterior incision.
8. Amputation of Thigh--Spence's, and at Pl. IV. 18.
9. Amputation at Hip-joint, and Pl. IV. 20.
A. Excision of Shoulder-joint--deltoid flap.
B. Excision of Shoulder-joint by posterior incision.
C. Excision of Elbow-joint--H-shaped incision.
D. Excision of Elbow-joint--linear incision.
E. Excision of Hip-joint--Gross's.
F. Excision of Os Calcis.
G. Excision of Scapula.
[Illustration]
PLATE IV.
1. Ligature of Carotid.
2. Ligature of Subclavian (3d stage)--Skey's incision.
3. Amputation at Wrist-joint--dorsal incision.
4. Amputation at Wrist-joint--palmar incision.
5. Amputation at Fore-arm--dorsal incision.
6. Amputation at Fore-arm--palmar incision.
7. Amputation at Elbow-joint--Anterior flap, and Pl. III. 3.
8. Amputation at Arm--Teale's method.
9. Amputation at Shoulder-joint--1st method, and Pl. III. 3.
10-11. Amputation of Metatarsus--Hey's.
12-13. Amputation at Ankle--Syme's.
14-15. Amputation of Leg--posterior flap--Lee's.
16. Amputation at Knee-joint--Carden's, and Pl. II. 8.
17. Amputation of Thigh--B. Bell's.
18. Amputation of Thigh--Spence's, and Pl. III. 8.
19. Amputation of Thigh in middle third.
20-20. Amputation at Hip-joint, and Pl. III. 9.
A. Excision of Wrist--radial incision.
B. Excision of Wrist--ulnar incision.
CHAPTER I.
LIGATURE OF ARTERIES.
LIGATURE OF ARTERIES.--In a work of this nature there is no room for any
discussion of the principles which should guide us in the selection of
cases, or of the pathology of aneurism, or the local effects of the
ligature on the vessels. One or two fundamental axioms may be given in a
few words:--
1. In selecting the spot for the application of the ligature, avoid as
far as possible bifurcations, or the neighbourhood of large collateral
branches.
2. A free incision should be made through the skin and subjacent
textures, till the sheath of the artery is reached and fairly exposed.
3. The sheath must be opened and the artery cleaned with a sharp knife
till the white external coat is clearly seen. The portion cleaned
should, however, be as small as possible, consistent with thorough
exposure, so that the ligature may be passed round the vessel without
force.
4. As the artery should never be raised from its bed, it is generally
advisable to pass the needle only so far as just to permit the eye to be
seen past the vessel. The ligature should then be seized by a pair of
forceps and gently pulled through, the needle being cautiously
withdrawn. When catgut is used, it is better to pass the unarmed needle
till the eye is visible, then thread and withdraw it, thus pulling the
catgut through.
5. As a rule, the needle should be passed from the side of the vessel at
which the chief dangers exist. This will generally be in the side at
which the vein is.
6. The ligature should be single, and consist of strong well-waxed silk,
and should always be drawn as tight as possible, so as to divide the
internal and middle coats of the vessel. In cases where the wound is to
be treated with antiseptic precautions and an attempt at immediate union
made, the ligature may be of strong catgut properly prepared, and both
ends of it may be cut off.
7. Before the ligature is tightened, it is well to feel that pressure
between the ligature and the finger arrests the pulsation of the tumour.
LIGATURE OF THE AORTA.--It has been found necessary in a few rare cases
to place a ligature on the abdominal aorta; no case has as yet survived
the operation beyond a very few days, but they have in their progress
sufficiently proved that the circulation can be carried on, and gangrene
does not necessarily result even after such a decided interference with
vascular supply.
_Operation._--The ligature may be applied in one of two ways, the choice
being influenced by the nature of the disease for which it is done.
1. A straight incision (Plate I. fig. 1) in the linea alba, just
avoiding the umbilicus by a curve, and dividing the peritoneum, allows
the intestines to be pushed aside, and the aorta exposed still covered
by the peritoneum, as it lies in front of the lumbar vertebræ. The
peritoneum must again be divided very cautiously at the point selected,
and the aortic plexus of nerves carefully dissected off, in order that
they may not be interfered with by the ligature. The ligature should
then be passed round, tied, cut short, and the wound accurately sewed
up.
2. Without wounding the peritoneum.
A curved incision (Plate I. fig. 2), with its convexity backwards, from
the projecting end of the tenth rib to a point a little in front of the
anterior superior spinous process of the ilium. At first through the
skin and fascia only, this incision must be continued through the
muscles of the abdominal wall, one by one, till the transversalis fascia
is exposed, which must then be scraped through very cautiously, so as
not to injure the peritoneum, which is to be detached from the fascia
covering the psoas and iliacus muscles, and must be held inwards and out
of the way by bent copper spatulæ. The common iliac will then be felt
pulsating, and on it the finger may easily be guided up until the aorta
is reached.
The really difficult part of the operation now begins: to isolate the
vessel from the spine behind, the inferior cava on the right side, and
the plexus of nerves in the cellular tissue all round. The cleaning of
the vessel must be done in great measure by the finger-nail, and much
dexterity will be required to pass the ligature without unnecessarily
raising the vessel from its bed, especially as the vessel itself may
very possibly be diseased, and the aneurism of the iliac trunk for which
the operation is required will displace and confuse the parts, and may
have set up adhesive inflammation.
_Results._--Operation has been performed at least ten times. By the
first method by Sir Astley Cooper and Mr. James; by the second by Drs.
Murray and Monteiro, M'Guire, Heron Watson, and Stokes, and Mr. South,
and Czerny of Heidelberg. All the cases proved fatal; Dr. Monteiro's
survived for ten days, and eventually perished from hæmorrhage; the rest
all died at shorter intervals.
LIGATURE OF COMMON ILIAC.--_Anatomical Note._--This short thick trunk
varies slightly in its relations on the two sides of the body. As the
aorta bifurcates on the left side of the body of the fourth lumbar
vertebra, the common iliac of the right side would have a longer course
to pursue than that on the left, if both ended at corresponding points.
However, this is not always the case, as has been pointed out by Mr.
Adams of Dublin, as the right common iliac often bifurcates sooner than
the left does. With this slight difference, the position of the two
vessels is precisely similar, each extending along the brim of the
pelvis from the bifurcation of the aorta towards the sacro-iliac
synchondrosis for about two inches. Sometimes the division takes place a
little higher, even at the junction of the last lumbar vertebra and the
sacrum. This variation depends chiefly on the length of the artery,
which, as Quain has shown, varies from one inch and a half to more than
three inches.
The anterior surface of both arteries is covered by the peritoneum, and
each is crossed by the ureter just as it bifurcates into its branches.
The artery of the right side is in close contact behind with its
corresponding vein, which at its upper part projects to the outside, and
below to the inner side. The artery of the left side is less involved
with its vein, which lies below it, and to the inside. The right is in
contact with a coil of ileum, the left with the colon. The inferior
mesenteric artery crosses the left one, while to the outside of both,
and behind them, lie the sympathetic and obdurator nerves.
There are no named branches from the common iliac.
_Operation._--The chief difficulties to be encountered are--1. The close
proximity of the peritoneum, and specially the risk there is that it has
become adherent to the sac of the aneurism; 2. The depth of the parts,
and tendency of the intestines to roll into the wound; 3. Specially on
the right side, the proximity of the great veins. With these exceptions
the passing of the ligature is not so difficult as in some situations,
the lax cellular tissue in which the vessel lies generally yielding much
more easily than the tough sheath which elsewhere, as in the femoral,
requires accurate dissection.
_Incision._--(Plate I. fig. 3.)--From a point about half an inch above
the centre of Poupart's ligament, a crescentic incision should be made,
at first extending upwards and outwards, so as to pass about one inch
inside of the anterior superior spine of the ilium, and then prolonged
upwards and inwards, as far as may be rendered necessary by the size of
the aneurism or the depth of parts. It must extend through skin and
superficial fascia, exposing the tendon of the external oblique, which
must then be slit up to the full extent visible. The spermatic cord may
then be easily exposed under the edge of the internal oblique, and the
forefinger of the left hand inserted on the cord, and thus beneath the
internal oblique and transversalis muscles, the peritoneum being quite
safe below.
On the finger these muscles may be safely divided to the full extent of
the external incision. The deep circumflex iliac artery if possible
should not be divided, but may bleed smartly and require a ligature.
The peritoneum must then be very cautiously raised from the tumour, and
supported, along with the intestines, by copper spatulæ. The surgeon
will rarely succeed in obtaining anything like a satisfactory view of
the vessel, but can expose it for the ligature by the aid of his
finger-nail. An ordinary aneurism-needle will generally suffice for the
conveyance of the ligature.
The difficulties may occasionally be much increased by special
circumstances, such as great stoutness of the patient, and consequent
thickness of the abdominal wall; or large size of the aneurism, which
may cause alterations in the relation of parts and adhesion of the
peritoneum. The ureter generally gives no trouble, as in pressing back
the peritoneum it is adherent to it, and is removed along with it
towards the middle line.
_Results._--Are not by any means satisfactory.
Out of twenty-two cases in which the common iliac has been tied for
aneurism, eight recovered and fourteen died; while out of thirteen cases
where it required ligature for hæmorrhage after amputation, rupture of
aneurism, etc., only one recovered.
LIGATURE OF INTERNAL ILIAC.--Little need be added to the account just
given of the operation for ligature of the common iliac, as precisely
the same incisions are required. The operator having reached the
bifurcation of the vessel, must, instead of tracing it upwards,
endeavour to trace it downwards, and the same time inwards, into the
basin of the pelvis. To do this his finger must cross the external iliac
artery, which will pulsate under the joint of the ungual phalanx, while
the pulp of the finger is touching the internal iliac,--the external
iliac vein, which occupies the angle formed by the bifurcation of the
artery, lying between these two points. The ligature should be applied
within three-quarters of an inch from the bifurcation.
_Anatomical Note._--This short thick trunk extends backwards and inwards
(Ellis); downwards and backwards (Harrison), in front of the sacro-iliac
synchondrosis, as far as the upper extremity of the great sacro-sciatic
notch, a distance varying in the adult from one and a half to two inches
in length. It forms a curve with its concavity forwards, and at its
termination divides into, rather than gives off, its two or three
principal branches. Its corresponding vein is in close contact behind,
as also the lumbo-sacral nerve, the obdurator nerve to its outer side.
The peritoneum covers it anteriorly, and it is crossed just at its
commencement by the ureter. On the left side it is covered anteriorly by
the rectum. Of its anatomical relations, that of the external iliac vein
is perhaps the most important, as it is apt to interfere with the
passing of the needle.
_Results._--This vessel has been tied for aneurism of one or other of
its branches, or for wound, about seventeen times.[2] Of these seven
recovered; in ten the operation proved fatal, in most of them from
secondary hæmorrhage. In one case the hæmorrhage occurred within twelve
hours after the operation. The circulation of the parts supplied after
the ligature is carried on mainly by the lumbar and lateral sacral
branches, which become much developed even before the operation, in
cases of aneurism.
LIGATURE OF EXTERNAL ILIAC.--_Anatomical Note._--This artery extends
from the bifurcation of the common iliac to the centre of Poupart's
ligament, where it leaves the abdomen, passing under the ligament, and
becomes the common femoral. Its upper extremity is thus not always
constant, varying in position from the sacro-lumbar fibro-cartilage to
the upper end of the sacro-iliac synchondrosis, or even a little lower
down. Thus, though the position of the lower end is at a fixed point,
the artery varies in length. In an adult male of moderate stature it is
from three and a half to four inches in length. On the surface of the
abdomen the position of this vessel would be indicated by a line drawn
from about an inch on either side of the umbilicus to the middle of the
space between the symphysis pubis and the crest of the ilium. Its
relations to neighbouring parts are as follows:--The peritoneum lies _in
front_ of it, separated from it only by a subperitoneal layer of loose
fascia, in which the artery and vein lie, which varies much in
consistence and amount, and which occasionally gives a good deal of
trouble in the operation of ligature. Near its origin it is sometimes
crossed by the ureter, and near its termination the genito-crural nerve
lies on it. The spermatic vessels cross it, and occasionally a quantity
of subperitoneal fat marks its course. _Externally._--The fascia-iliaca
and some fibres of the psoas muscle separate it from the anterior
crural nerve, which lies outside of the vessel, and at a somewhat deeper
level, hidden amid the fibres of psoas and iliacus. _Internally._--The
external iliac vein lies on the same plane, and to the inner side of the
artery, at Poupart's ligament, on both sides of the body. As we trace it
upwards we find that on the left side it lies internal to the artery in
its whole course, while on the right side it becomes posterior to the
artery as it approaches the bifurcation of the common iliac. Lastly,
just before the vessel reaches Poupart, the circumflex iliac vein
crosses it from within outwards.
_Branches._--The two large branches to the wall of the abdomen, the
epigastric and the circumflex iliac, rise a few lines above Poupart's
ligament. Their position is unfortunately apt to vary upwards, to the
extent of an inch and a half or even two inches, and they are important,
as, besides being liable to be cut during the operation, their position
very materially modifies the prognosis, as, if too high up, they
interfere with the proper formation of the coagulum.
_Operation._--Various plans of incision through the skin have been
recommended by various operators, the chief difference being with regard
to the part of the artery aimed at; the plan known as that of Mr.
Abernethy, with various modifications, being intended to expose the
artery pretty high up, and enable the surgeon to reach it from above;
while the method going by the name of Sir Astley Cooper's exposes the
lower part of the artery, and enables the surgeon to reach it from
below. Though the latter is in some respects easier, the former method
is generally to be preferred, being further from the seat of disease,
and especially more out of the way of the epigastric and circumflex
arteries.
The higher operation (ABERNETHY'S modified).--An incision must be made
through the skin about four inches in length, but longer in proportion
to the amount of subcutaneous fat, and the depth of the pelvis,
extending from a point one inch to the inside of the anterior superior
spine of the ilium, to a point half an inch above the middle line of
Poupart's ligament. It must be slightly curved, with its convexity
looking outwards and downwards.[3]
The subcutaneous cellular tissue and the tendon of the external oblique
may then be divided freely in the same line. Then at some one point or
other (generally easiest below), the internal oblique and transversalis
muscles must be cautiously scraped through with the aid of the forceps,
till the transversalis fascia is reached; they may then be freely
divided by a probe-pointed bistoury (guarded by the finger pushed up
below the muscles) to the required extent. The muscles being held aside
by flat copper spatulæ, the fascia transversalis must be carefully
scratched through near the crest of the ilium, and thus the operator
will be enabled to push the peritoneum inwards, and by the forefinger
will easily recognise the pulsation of the artery lying on the soft brim
of the pelvis.
A branch of the circumflex iliac artery will very likely be cut in
dissecting through the muscles, and must be secured, as also any
branches of the epigastric which may be divided in the incisions through
the abdominal wall (_ut supra_, p. 5).
The operator should then, by pressing the peritoneum and its contents
gently inwards, endeavour to see the vessel; if, from the depth of the
pelvis, this cannot be done, the sense of touch will be in most cases
sufficient to enable him to isolate the artery by the point of his
finger-nail, or by the blunt aneurism-needle, from the vein. The
ligature should be passed from the inner side to avoid including the
vein, and thus there will be less chance of wounding the peritoneum
from the convexity of the needle being applied to it. If possible, the
genito-crural nerve should not be included in the ligature, but probably
such an accident would do no great harm.
It is of much more consequence to avoid injuring the peritoneum. This is
sometimes very difficult, from the adhesions which are set up between
the peritoneum, the artery, and especially the aneurism, as the result
of pressure and inflammation. The accident of wounding the peritoneum
has happened to Keate, Tait, Post, and others, and in some cases with
perfect impunity. However, the peritoneum should be displaced as little
as possible from its cellular connections, as such displacement
increases the risk of diffuse inflammation of that membrane; and the
vessel itself should be raised and disturbed as little as possible, lest
destruction of the vasa vasorum cause ulceration of the weak coats and
secondary hæmorrhage.
The operation from below (Plate I. fig. 4), SIR ASTLEY COOPER'S, is thus
described by Mr. Hodgson:[4]--"A semilunar incision is made through the
integuments in the direction of the fibres of the aponeurosis of the
external oblique muscle. One extremity of the incision will be situated
near the spine of the ilium; the other will terminate a little above the
inner margin of the abdominal ring. The aponeurosis of the external
oblique muscles will be exposed, and is to be divided throughout the
extent, and in the direction of the external wound. The flap which is
thus formed being raised, the spermatic cord will be seen passing under
the margin of the internal oblique and transverse muscles. The opening
in the fascia which lines the transverse muscle through which the
spermatic cord passes, is situated in the mid space between the anterior
superior spine of the ilium and the symphysis pubis. The epigastric
artery runs precisely along the inner margin of this opening, beneath
which the external iliac artery is situated. If the finger therefore be
passed under the spermatic cord through this opening in the fascia, it
will come in immediate contact with the artery which lies on the outside
of the external iliac vein. The artery and vein are connected by dense
cellular tissue, which must be separated to allow of the ligature being
passed round the former."
In comparing the two methods of operating, we find that while the latter
is in some respects easier, and the vessel in it lies more superficial,
it has certain disadvantages which more than counterbalance its
advantages. Thus, first, the epigastric artery is very likely to be
wounded. It may be said, Well, if so, the ends can be tied; but this
tying is sometimes very difficult; and, as shown in Dupuytren's case of
this accident, involves considerable interference with the peritoneum,
and a possibly fatal peritonitis. Besides this, by cutting the
epigastric you destroy an important agent which would have carried on
the anastomosing circulation, and thus greatly increase the risk of
gangrene. By this method, also, the artery is exposed too near to the
seat of disease; and if found to be enlarged and involved in the
aneurism, considerable difficulty may be experienced in reaching the
upper part of the vessel. Again, ligature of the lower third or half of
the vessel, which this method implies, is dangerous from the occasional
high origin of the circumflex or epigastric, or both, rendering the
formation of a clot much more difficult, and secondary hæmorrhage much
more likely.
The circumflex iliac vein must also be remembered, as it crosses the
artery from within outwards in the lower end of it, just before it goes
under Poupart's ligament.
However, the method may occasionally vary with the individual case. In
every case of ligature of the great vessels of the abdomen, the bowels
should be carefully evacuated before the operation, and the bladder
emptied. A properly managed position, with the shoulders raised and the
knees semiflexed, will greatly facilitate the gaining access to the
vessel.
In sewing up the wounds in the abdominal walls, advantage will be gained
by putting in a certain number of stitches so deeply as to include the
whole thickness of the muscles, and in the intervals between these deep
ones to insert others less deeply, so as accurately to approximate the
edges of the skin. This will both facilitate union and also render the
occurrence of hernia less probable. This latter accident did occur in a
case, otherwise successful, in which Mr. Kirby tied the external iliac.
Both external iliacs have been tied in the same patient with success, on
at least two occasions, once by Arendt, with an interval of only eight
days between the operations; and a second time by Tait, at an interval
of rather more than eleven months.
This operation is in the great majority of cases performed for femoral
aneurism, and naturally secondary hæmorrhage is a too frequent result.
Wounds of these great vessels generally result in so rapid death from
hæmorrhage as to give no time for surgical interference. One case,
however, is recorded,[5] in which the external iliac was cut in a lad of
seventeen by an accidental stab, and in which Drs. Layraud and Durand,
who were almost instantly on the spot, succeeded in stopping the
bleeding by compresses, till Velpeau arrived, who tied the vessel above
with perfect success.
Of the first twenty-two cases collected by Hodgson, fifteen recovered--a
mortality of 31.81 per cent.; and of 153 in Norris's collection,
including Cutter's cases, forty-seven died--a mortality of only 32.5 per
cent.,--a very satisfactory result, considering the size of the vessel
and the importance of its relations.
LIGATURE OF GLUTEAL.--This vessel, though one of the branches of the
internal iliac, approaches the surface so nearly as to be occasionally
wounded. It is also, though very rarely, the subject of spontaneous
aneurism. The principle of treatment and the operation to be selected in
any given case, depends upon its origin, whether traumatic or
spontaneous. For if traumatic, the wound must almost necessarily be
accessible from the outside; the neighbouring part of the artery is
probably healthy, and hence the case can be treated by the old
operation, slitting up the tumour, and tying the vessel above and below
the wound. When the aneurism is spontaneous, there is no guide to tell
us where the aneurism may have first originated; it may be that it is
high up in the pelvis, and that the visible tumour is only its expansion
in the direction of least resistance, or the coats of the vessel may be
extensively diseased. The only chance is ligature of the internal iliac.
1. The old operation, or ligature of the gluteal artery in the hip.
_Anatomical Note._--The gluteal is the largest branch of the internal
iliac, and leaves the pelvis by the great sacro-sciatic notch just at
the upper edge of the pyriformis muscle. After a very short course, it
divides into superficial and deep branches opposite the posterior margin
of the glutens minimus, between it and the pyriformis muscles.
Very precise rules have been given to enable the operator to hit on the
exact spot where the artery leaves the pelvis. These, though perhaps
interesting anatomically, are quite useless in a surgical point of view,
for the only reasons which could possibly induce a surgeon to cut down
upon the gluteal in the living body, are the existence either of a wound
of the vessel or an aneurism. In the first the flow of blood, in the
second the tumour, would give sufficient guidance.
In cases of traumatic aneurism the operation should be something like
the following:--A free incision should be made into the tumour, dividing
it in its long direction; the contents should be rapidly scooped out,
and a finger placed on the bleeding point, just at the upper corner of
the sciatic notch. This will at once stop the hæmorrhage till the vessel
can be secured. This sounds easy enough, and has been done several times
with success. Thus, John Bell, by an incision two feet long, as he tells
us in his hyperbolical language, was enabled to tie the vessel in the
case of the leech-gatherer who had punctured the artery by a pair of
long scissors. Carmichael of Dublin used a smaller incision, removed one
or two pounds of clots, and tied the vessel, in a case of wound by a
penknife.[6]
Now, though both of these cases were eventually successful, both
patients lost during the operation a very large quantity of blood; John
Bell's especially could not be removed from the operating-table for a
considerable time after the operation. The period at which the great
loss of blood took place was the interval after the incision was made,
and before the artery was exposed to view, _i.e._ the interval in which
the surgeon was busy dislodging the clots from the cellular membrane,
the sac of the false aneurism. The procedure devised by Mr. Syme to
obviate this difficulty, and which was put in practice by him in several
very trying cases, is best given in his own terse description of an
operation in a case of traumatic gluteal aneurism:--
"The patient having been rendered unconscious, and placed on his right
side, I thrust a bistoury into the tumour, over the situation of the
gluteal artery, and introduced my finger so as to prevent the blood from
flowing, except by occasional gushes, which showed what would have been
the effect of neglecting this precaution, while I searched for the
vessel. Finding it impossible to accomplish the object in this way, I
enlarged the wound by degrees sufficiently for the introduction of my
fingers in succession, until the whole hand was admitted into the
cavity, of which the orifice was still so small as to embrace the wrist
with a tightness that prevented any continuous hæmorrhage. Being now
able to explore the state of matters satisfactorily, I found that there
was a large mass of dense fibrinous coagulum firmly impacted into the
sciatic notch; and, not without using considerable force, succeeded in
disengaging the whole of this obstacle to reaching the artery, which
would have proved very serious if it had been allowed to exist after the
sac was laid open. The compact mass, which was afterwards found to be
not less than a pound in weight, having been thus detached, so that it
moved freely in the fluid contents of the sac, and the gentleman who
assisted me being prepared for the next step of the process, I ran my
knife rapidly through the whole extent of the tumour, turned out all
that was within it, and had the bleeding orifice instantly under
subjection by the pressure of a finger. Nothing then remained but to
pass a double thread under the vessel, and tie it on both sides of the
aperture."
The bleeding in this case was thus rendered comparatively trifling, and
the patient made a speedy and complete recovery. He returned home within
six weeks after the operation.[7]
2. In one case, at least, the gluteal artery has been tied with success
(for traumatic aneurism) just where it leaves the pelvis, without the
tumour being opened. This was in the practice of Professor Campbell of
Montreal. The operation was a very difficult one, and while possible
only in cases seen very early, and where the tumour is very small, does
not appear to have any advantage over the old method.
Cases of spontaneous aneurism of the gluteal artery should be treated by
ligature of the internal iliac. Steven's and Syme's cases of ligature
of the internal iliac were of this nature.
Manuals of operative surgery occasionally devote pages to the
description of special operations for the ligature of such arteries as
the sciatic, epigastric, circumflex ilii, and pudic. They do not require
ligature, except in cases of wound either of the vessels themselves or
their branches; and, according to the modern principles of surgery in
such cases, the ligature should be applied to the bleeding point, rather
than to the vessel at a distance above it.
LIGATURE OF FEMORAL.--Under this head we practically mean cases of
ligature of the superficial femoral, for the common femoral, or (as
called by some anatomists) the femoral, before the profunda is given
off, very rarely requires to be tied. If it is wounded, of course the
bleeding point must be sought, and the artery tied above and below it,
but if an aneurism on the superficial femoral renders ligature of that
trunk impossible, experience teaches that ligature of the external iliac
gives better results than ligature of the common femoral. Erichsen
asserts that out of twelve cases in which the common femoral has been
tied, only three have succeeded, the others dying from secondary
hæmorrhage. The experience of the Dublin surgeons, Porter, Smyly, and
Macnamara, has been more satisfactory, as in eight cases of this
operation six were successful.[8] A ninth case was unsuccessful. Reasons
to explain the danger are not far to seek, for the numerous small
muscular branches, along with the superficial epigastric, circumflex,
and pudic trunks, reduce the chances of a good coagulum in the common
femoral to a minimum, even without taking into consideration the
shortness of the trunk before the great profunda femoris is given off.
For the common femoral artery is only from one to two inches in length,
and if there are some rare cases in which it is a little later in its
bifurcation, there are others in which it divides nearer to Poupart's
ligament.
The superficial femoral is the name given to the main trunk between the
origin of the profunda, and the point at which, passing through the
tendon of the adductor magnus, it receives the name of popliteal. During
this long course it gives off no branch large enough or regular enough
to receive a name, except one, the anastomotica magna, which rises in
Hunter's canal, close to the end of the vessel, so in that respect it is
peculiarly suitable for the application of a ligature. Again, in the
upper part of its course, it is superficial, being covered only by skin
and fascia. A short notice of its most important anatomical relations is
necessary.
For the first two inches or two inches and a half of its separate
existence, the superficial femoral lies in Scarpa's triangle, covered,
as we said, only by skin and fascia. This triangle is formed by the
sartorius and adductor longus muscles which meet at its apex, and by
Poupart's ligament, which defines its base. The artery lies almost
exactly in the centre of the space, and at the apex is covered by the
sartorius muscle. The spot where it goes under the sartorius is the one
selected for the application of the ligature. The femoral vein lies to
the inner side of the femoral artery in this triangle, but their mutual
relations vary with the portion of the limb; for, on the level of
Poupart's ligament, the artery and vein lie side by side on the same
plane, but in different compartments of their sheath; as the artery
dives below the sartorius, the vein is still on the inside, but on a
plane slightly posterior; while, by the time they reach Hunter's canal,
the vein has got completely behind the artery. The separate compartments
of the sheath in which the vessels lie are much less marked as the
vessels go down the limb, the septum between the artery and the vein
being in most cases very ill marked, even at the level where the
ligature is applied. The anterior crural nerve, which on the level of
Poupart's ligament lay outside of the artery and on a plane somewhat
posterior, has divided into numerous branches before it reaches the
point of ligature. One of its branches requires to be mentioned, and may
sometimes be noticed and avoided during the operation, namely the
internal saphenous nerve, which, first lying external to the artery,
crosses it in front, reaching its inner side just before it enters
Hunter's canal, where it leaves the vessel accompanying the anastomotica
magna branch.
OPERATION OF LIGATURE OF THE FEMORAL--SCARPA'S SPACE.--The patient being
placed on his back, and being brought very thoroughly under chloroform,
the knee of the affected limb should be bent at an angle of about 120°,
and supported on a pillow. Having previously ascertained the angle of
junction of the sartorius and adductor, the surgeon should make an
incision (Plate I. fig. 5) just over the pulsations of the vessel, in
the middle line of the space, having its lower end quite over the
sartorius muscle, and its upper one, at a distance from two and a half
to three and a half inches, varying according to the amount of fat and
muscle. The saphena vein can generally be recognised, and is almost
always safe out of the way of this incision at its inner side.
The first incision should divide the skin, superficial fascia, and fat,
quite down to the fascia lata. The edges of the wound being held apart,
the fascia should be carefully divided, and the sartorius exposed; its
fibres can generally be easily enough recognised by their oblique
direction; once recognised, the fascia should be dissected from it till
its inner edge be gained, the corner of which should then be turned so
that it may be held outwards by an assistant with a blunt hook. The
sheath of the vessels is now exposed, and after having thoroughly
satisfied himself of the position of the artery by the pulsation, the
surgeon should carefully raise a portion of the sheath with the
dissecting forceps, and open it freely enough to allow the coats of the
artery to be distinctly seen. If the parts are deep, as in a fat or
muscular patient, great advantage will be gained by seizing one edge of
the sheath by a pair of spring forceps, and committing it to the care of
an assistant, while the operator holds the other in his dissecting
forceps; there is thus no fear of losing the orifice of the sheath,
which without this precaution may easily happen, from the parts being
confused with blood, or the position altered by movements of the
patient. Now comes the stage of the operation on which, more than on
anything else, success or failure depends. A _small_ portion of the
vessel must be cleaned for the reception of the ligature, and it must be
_thoroughly_ cleaned, so that the needle may be passed round it without
bruising of the coats, or rupture of an unnecessary number of the vasa
vasorum by rough attempts to force a passage for it. Hence all
compromises, such as blunted instruments, silver knives, and the like,
are dangerous, for in trying to avoid the Scylla of wounding the artery,
they fall into the Charybdis, on the one hand, of isolating too much of
the vessel and causing gangrene from want of vascular supply, or, on the
other, expose the vein to the danger of injury by the aneurism-needle in
their attempts to force it round an uncleaned vessel.
The needle should in most cases be passed from the inner side, care
being taken to avoid including the vein which is on the inner side and
behind the vessel; the internal saphenous nerve, if seen, should be
avoided. The needle must not be passed quite round the vessel raising it
up, still less must the vessel be held up on the needle, as used to be
done, as if the surgeon was surprised at his own success, but the needle
should be passed just far enough to expose the end of the ligature,
which must be seized by forceps and cautiously drawn through. It must
then be tied very firmly and secured with a reef knot.
The edges of the wound must be brought into accurate apposition, and
secured by one or two stitches. If antiseptics are used, drainage should
be provided for.
From the very fact that ligature of the superficial femoral is a
remarkably successful operation in causing consolidation of the aneurism
and a rapid cure, there is also a corresponding danger that the limb be
not sufficiently supplied with blood at first. The limb may very
possibly become cold, and remain so for some hours at least after the
operation. To avoid this as far as possible, it should be wrapped in
cotton wadding, and very great care should be taken that it be not
over-stimulated by hot applications, friction, or the like, any of which
measures might very likely excite reaction, which would result in
gangrene.
Complete rest of the limb and of the whole body must be enjoined; the
food must be nourishing and in moderate quantity. The chief danger is
from gangrene of the limb, which is especially apt to result when the
vein is wounded, or even too much handled during the operation.
When properly performed, and in suitable cases, the operation is very
successful. Mr. Syme tied this artery for aneurism thirty-seven times,
and of these every one recovered. The statistics of Norris and Porta,
who collected all the cases in which ligature of the femoral had been
employed for _any_ cause, show a mortality of somewhat less than one in
four. Rabe's table up to 1869 with the additional cases collected by Mr.
Barwell to 1880 gives 297 cases with 53 deaths.[9] Mr. Hutchinson's
table, again, of fifty cases collected from the records of Metropolitan
Hospitals, shows the very startling result of sixteen deaths out of the
fifty cases, or a mortality, in round numbers, of one-third.
Certain anomalies have been observed in the distribution of the femoral
vessels, of some importance as affecting the possibility of applying,
and the result of, ligature; such as--1. A high division of the branches
which afterwards become posterior tibial and peroneal. 2. A double
superficial femoral, both branches of which may unite and form the
popliteal, as in Sir Charles Bell's well-known case. 3. Absence of the
artery altogether, as in Manec's case, where the popliteal was a
continuation of an immensely enlarged sciatic.
In such a case the absence of pulsation in front, and the presence of
increased pulsation behind the limb, ought to prevent any fruitless
attempt at search.
LIGATURE OF THE SUPERFICIAL FEMORAL BELOW THE SARTORIUS MUSCLE.--This
operation, though once common in France, and though the one recommended
by Hunter himself, is now comparatively little used in this country; and
rightly so; for while it has no advantage over the upper position, it is
at once nearer the seat of disease, and the vessel is more deeply buried
under muscles, and has a more distinct fibrous sheath, which requires
division.
It is, however, by no means a difficult operation, and is thus
performed:--
The limb being laid as before on the outside, and slightly bent, the
skin shaved and the pulsation of the artery detected, an incision (Plate
I. fig. 6) must be made from the lower edge of the sartorius muscle just
as it crosses the vessel, along the course of the vessel, avoiding if
possible the internal saphena vein.
The sartorius when exposed must be drawn inwards. The fibrous canal
filling the interspace between the abductor magnus and vastus internus
is then recognised, and must be fairly opened; the artery is now seen
lying in it, and over the vein which is posterior to it, but projects
slightly on its outer side; the internal saphenous nerve is lying on the
artery. The needle is best passed from without inwards so as to avoid
the vein. The anastomotica magna is sometimes a large trunk, and has
been mistaken for the femoral in this situation, and tied instead of it.
LIGATURE OF THE POPLITEAL.--This operation is now hardly ever performed
for aneurism, ligature of the superficial femoral having quite
superseded it, and it is very rarely required for wounds, from the
manner in which the vessel is protected by its position.
Before the invention of the Hunterian principle of ligature at a
distance, the old operation for popliteal aneurism consisted in cutting
into the space, clearing out the contents of the aneurismal sac, and
tying both ends of the vessel; from the depth of parts and the close
connection of the popliteal vein, this operation was very rarely
successful, and is now quite given up. If the vessel is wounded the
bleeding point is the object to be aimed at, and is generally sufficient
guide.
In cases of hæmorrhage for suppuration of an aneurismal sac, it might
possibly be advisable, and there are certain cases of rupture of the
artery, without the existence of an external wound, in which attempts
have been made to save the limb by tying the vessel.[10] From the
complexity of the parts, the numerous tendons, veins, and nerves crowded
together in a narrow hollow, and chiefly from the great depth at which
the artery lies, any attempt at ligature is very difficult. It is least
so at the lower angle of the space, where, between the heads of the
gastrocnemius, the vessel comes more to the surface, but is still
overlapped by muscle.
_Operation._--The patient lying on his face, a straight incision (Plate
III. fig. 1), at least four inches in length, should be made over the
artery, and thus nearer the inner than the outer hamstring; a strong
fibrous aponeurosis will require division after the skin and superficial
fascia are cut through, the limb is then to be flexed, and the tendons
drawn aside with strong retractors; fat and lymphatic glands must next
be dissected through, and then the vein and artery, lying on a sort of
sheath of condensed cellular tissue, are seen, the vein lying above the
artery and obscuring it. The vein must be drawn to the outside, and the
thread passed round the artery, which lies close to the bone, on the
ligamentum posticum of Winslowe.
It is a very difficult subject to decide what operations should be
described in a work of this character, on the vessels of the leg and
foot. A very large number of distinct methods of operations on the
various parts of the three chief arteries of the leg have been described
by surgeons and anatomists, but specially by the latter.
The fact is, however, that these complicated procedures are rarely
required, for aneurisms of the arteries of the leg and foot are almost
unknown, while in cases of wound of the vessel, or rupture resulting in
traumatic aneurism, the proper treatment is not to tie the vessel higher
up, but by dilating the wound and clearing out the clots, if required,
to secure the bleeding point, and tie the vessel above and below.
Again, a wound of the sole of the foot often gives rise to very severe
and persistent hæmorrhage, while the fasciæ and complicated tendons
render ligature of the vessel at the spot very difficult; yet ligature
of either the anterior or posterior tibial would probably be
insufficient; and to tie both these vessels, with possibly the peroneal
and interosseous as well, would be a much more severe and dangerous
procedure than ligature of the superficial femoral; while probably
careful plugging of the wound, combined with flexion of the knee, will
be found to stop the hæmorrhage sooner than either of the more
formidable methods.
A competent knowledge of the anatomy of the part, and of the ordinary
methods of checking hæmorrhage, such as ligatures, graduated compresses,
and styptics, aided by position, specially flexion of the knee after Mr.
Ernest Hart's method, will suffice to enable the surgeon to check any
hæmorrhage of the foot or leg, without it being necessary to burden the
memory with the three positions in which to tie the peroneal, or the
various methods, more or less bloody and tedious, by which the posterior
tibial in its upper third may be secured.
NOTE.--While, as a matter of surgical principle to guide our
practice on the living, I still hold very strongly the opinions
here expressed against special operations for ligature of the
arteries of the leg, and allow the sentences to stand as in the
first edition of this work, I insert in a note a brief description
of the more important ones, in deference to the advice of friends
and the urgent request of pupils, as these operations are used by
Examining Boards as tests of the operative dexterity of
candidates:--
1. ANTERIOR TIBIAL ARTERY IN LOWER HALF OF LEG.--_Anatomical
Note._--This vessel is related on its tibial side to the tibialis
anticus, and on its fibular, to the extensor longus digitorum
above, and the extensor pollicis below. The anterior tibial nerve
lies first on its outer side, then crosses the artery, and
eventually reaches its inner side near the foot. _Operation._--An
incision, at least three inches long, parallel with the outer edge
of the tibia, and about three-quarters of an inch from it, exposes
the deep fascia. This being divided, the outer edge of the tibialis
anticus must be found, and will be the guide to the artery, which,
surrounded by its venæ comites, lies very deeply between the
muscles.
2. Posterior Tibial.--_A._ In middle third of leg. Here the artery
is separated from the inner border of the tibia, by the flexor
longus digitorum, and is covered by the soleus. _Operation._--An
incision at least four inches long, along the inner margin of the
tibia, exposes the edge of the gastroenemius; then divide the
tendinous attachment, then expose the soleus, and divide its
attachment also; the deep fascia will then be seen; slit it up, and
the vessel will be found about an inch internal to the edge of the
bone. The nerve is there just crossing it.
Guthrie's, or the direct operation, has the very high authority of
the late Professor Spence in its favour. An incision through skin
and fascia in the middle of the back of the leg allows the two
heads of the gastrocnemius to be separated to the same extent. The
soleus is then to be scraped through in same direction, and its
deep aponeurotic surface carefully slit up. The artery and vein are
then easily seen.
B. In lower third of leg.--This is an easier and more scientific
operation, as it does not involve the division of great tendons. An
incision midway between the internal malleolus and the tendo
Achillis, parallel with both, will expose the very deep and strong
fascia in which the tendons lie. The artery, with its venæ comites,
occupies a central position, having the tendons of the tibialis
posticus and flexor communis in front between it and the internal
malleolus, and the posterior tibial nerve behind it, while the
flexor longus pollicis lies still nearer the tendo Achillis.
TABLE illustrating anastomotic circulation after ligature of
arteries of lower limb.
1. AORTA.--Epigastric and mammary of both sides. Hæmorrhoidal and
spermatic, with branches of pudic both deep and superficial.
2. COMMON ILIAC.--Internal iliac and branches, with those of the
other side, along with the following:--
3. EXTERNAL ILIAC.--Internal mammary and deep epigastric.
Iliolumbar and lumbar branches of aorta, with deep circumflex ilii.
Pudic from internal iliac, with superficial pudic of common
femoral.
Gluteal, sciatic, and obturator, with the circumflex and
perforating branches or deep femoral.
4. FEMORAL.--External circumflex, with external articular of
popliteal.
Perforating, with branches of gluteal and sciatic.
Profunda branches with anastomotica and articular branches.
Obturator and internal circumflex with anastomotica and superior
internal articular.
NOTE.--The importance of the articular branches of the popliteal
explain the danger of gangrene after a sudden rupture or increase
in size of a popliteal aneurism.
LIGATURE OF THE INNOMINATE.--The performance of this extremely
dangerous, in fact almost hopeless operation, is by no means so
difficult as might be expected.
The patient lying down with the shoulders raised and head thrown well
back, the sternal attachment of the right sterno-mastoid must be very
freely exposed. This may be done by an incision (Plate I. fig. 7) along
its anterior edge from the upper edge of the sternum, as far as may be
necessary; another about the same length along the upper edge of the
clavicle, will meet the former at an acute angle, and will include a
triangular flap of skin, which must be carefully dissected up. The
sternal, and probably a portion of the clavicular attachment of the
right sterno-mastoid, must then be cautiously divided. This being done,
the sterno-hyoid and sterno-thyroid muscles require division immediately
above their sternal attachments.
A dense process of cervical fascia (just becoming thoracic) now covers
the vessel, binding it on the right side to the right innominate vein,
and on the left maintaining the relation of the innominate artery to the
trachea. The inferior thyroid veins lie on this fascia, and must be
drawn aside, not cut. The fascia is then to be scraped through very
cautiously, exposing the root of the right carotid, which, being traced
downwards, will lead to the innominate. The following parts lie in close
relation to the vessel at the point of ligature, and must be
avoided:--1. The left innominate vein crosses the artery in front from
left to right, and must be drawn down. 2. The right innominate vein and
right pneumogastric are in close contact with the artery on the right
side; to avoid them the aneurism-needle must be entered on the outside
(right of the vessel). 3. The apex of the right pleura and the trachea
are in close contact behind, requiring the point of the needle to be
kept close to the artery in bringing the thread round.
It might have been expected that the sudden arrest of so large a
proportion of the vascular supply of the body, so very near the heart,
would cause serious, or even fatal symptoms; this, however, is not the
case, no serious inconvenience of this sort being experienced; yet
hitherto every case has proved fatal, either from secondary hæmorrhage
or inflammation of lungs and pleura.
In fifteen well-authenticated, and in three more doubtful cases, the
ligature has been applied; all of these died at periods varying from
twelve hours (as in Hutin's case), to forty-two days as in Thomson's,
and sixty-seven days (Graefe's).[11]
A successful case of ligature of the innominate along with the right
carotid and (after secondary hæmorrhage) the right vertebral, in a
mulatto aged thirty-two, for a subclavian aneurism, has been put on
record by Dr. Smyth of New Orleans, in the _American Journal of Medical
Science_ for July 1866.
And here we may also note that Mr. Heath has lately treated a case of
innominate aneurism by simultaneous ligature of the third part of the
subclavian and the carotid. Both ligatures separated on the eighteenth
day, and the tumour was much smaller some months afterwards.[12]
Mr. R. Barwell has reported several most interesting cases in which
simultaneous ligature of carotid and subclavian have proved of marked
benefit in aortic as well as in innominate aneurisms.[13]
In four cases the operation was attempted, but the operators had to
desist before the application of the ligature, in consequence of the
diseased state of the arterial coats. Of these, three died, and one
(Professor Porter's of Dublin) case recovered, the patient leaving the
hospital with the aneurism nearly consolidated.
Dr. Peixotto of Portugal applied a precautionary ligature to the
innominate in a case where secondary hæmorrhage occurred from the
carotid. The ligature was not tightened beyond what was necessary merely
to cause flattening of the vessel. The patient made a good recovery.
Professor George Porter of Dublin records an interesting case of
subclavian aneurism, in which, after failing to close the axillary
artery by acupressure, he applied L'Estrange's compressor to the
innominate itself for three days, with temporary benefit. The patient
eventually died of hæmorrhage.[14]
For a very full and interesting account of ligatures of vessels in root
of neck we may refer to vol. iii. of the 1883 edition of _Holmes'
Surgery_, pp. 119-122.
LIGATURE OF COMMON CAROTID.--Though the anatomical relations of the
right and left carotid are different at their origin, they so precisely
resemble each other in the whole of that part of their course which is
at all amenable to surgical treatment, that one description will suffice
for both, and the necessary anatomy will be brought out quite
sufficiently in the description of each operation.
From its giving off no collateral branches, the common carotid artery
may be tied at any part of its course.
It has been tied successfully at the distance of only three-quarters,
or, in one case by Porter, hardly to be imitated, one-eighth of an inch
from the innominate, and up to an equal distance from its bifurcation.
In choosing the part of the vessel for operation, the operator must be
guided by the position of the aneurism, if on the vessel itself, but if
the aneurism be distant, as in scalp or orbit, he need have regard to
position simply as facilitating the operation.
The easiest position in which to apply the ligature is just above the
omohyoid muscle, the vessel being there superficial.
LIGATURE ABOVE OMOHYOID.--Using the anterior border of the
sterno-mastoid as a guide, but leaving it gradually above to a little
nearer the mesial line, an incision (Plate IV. fig. 1), varying in
length according to the depth of fat and cellular tissue in the neck,
but with its central point opposite the upper border of the cricoid
cartilage, must be made through skin, platysma, and superficial fascia.
While making the incision the head should be held back, and the face
slightly turned to the opposite side; the parts being now relaxed by
position, the edges of the wound must be held apart by blunt hooks or
copper spatulæ, and the deep fascia carefully divided over the vessel,
which will be recognised by the pulsation. It may be noted here that
even in thin subjects the sterno-mastoid edge _invariably_ overlaps the
vessel, though in many anatomical diagrams it would appear to be in part
subcutaneous.
The descendens noni may possibly be seen, but this is by no means
invariably the case, crossing the sheath of the vessel very gradually
from without inwards in its progress down the neck. It must be carefully
displaced outwards.
The sheath of the vessel is then to be cautiously opened to the extent
of about half an inch. The internal jugular vein, possibly much
distended, may overlap the artery on its outer side, and will require to
be pressed, emptied, and held out of the way. A small portion of the
artery being thoroughly separated from the sheath, the aneurism-needle
must be passed from without inwards to avoid the vein, and keep as close
to the artery as possible to avoid the vagus.
The tendon of the omohyoid muscle, or, in muscular subjects, a portion
of its anterior fleshy belly, may be seen crossing the vessel from
above downwards and outwards at the lower angle of the wound.
An enlarged lymphatic gland has occasionally given much trouble, by
being mistaken for the vessel and cleaned, while the ligature has even
been placed on a carefully isolated fasciculus of muscular fibres.
LIGATURE OF CAROTID BELOW THE OMOHYOID.--An incision in precisely the
same direction as the former, but at a slightly lower level, is
required, but the dissection is rather more difficult. The edge of the
sterno-mastoid when exposed must be drawn outwards; the sterno-hyoid and
thyroid inwards; the omohyoid upwards; the sheath opened, and the
descendens noni or its branches drawn to the tracheal side. The jugular
vein and vagus are both at the outer side, and must be avoided, while
the inferior thyroid artery and sympathetic nerve both lie behind the
vessel, and may be included in the ligature if care be not taken.
VARIETIES.--_Sedillot's Operation._--To secure the artery still
lower in the neck: An incision two and a half inches long, from the
inner end of the clavicle obliquely upwards and outwards in the
interval between the sternal and clavicular attachments of the
sterno-mastoid; this divides the superficial textures; the two
portions of muscle must then be drawn apart. The internal jugular
vein lies in the interval, and must be drawn to the outside before
the artery can be seen at all, and it is this that makes this
operation very difficult and dangerous, especially on the left
side, where the vein is close to the artery, and probably even
crossing it from left to right. The thoracic duct is behind.
_Malgaigne's modification of the above_ is an improvement: to
expose the external attachment of the muscle, to cut it through and
turn it to the outside, as in the operation for ligature of the
innominate, then to divide or pull inwards sterno-hyoid and
sterno-thyroid, thus exposing the sheath. The needle must be passed
from without inwards.
_Results._--Pilz has collected 600 cases, of which 43.16 per cent. died.
The united tables of Norris and Wood give 188 cases, with a mortality of
sixty, or nearly one in three. These tables include cases in which the
vessel was tied for wounds, and as a preparatory step in the operation
of removal of tumours of the jaw, etc. Later statistics give a very much
lessened mortality, due chiefly to the use of animal ligatures.
Of thirty-one cases in which it was tied for pulsating tumours of the
orbit, only two died from the operation.[15] Rivington's statistics to a
later date give forty-six cases on forty-four patients with six deaths.
Both carotids have been tied in the same patient twenty-five times, at
intervals of less than a year; and it is a very remarkable fact that
only five of these fifty ligatures proved fatal,--two in which both were
tied on the same day, and three in which the operation was performed to
arrest hæmorrhage from malignant disease of the face and jaws--from
gunshot wound,--and from syphilitic ulceration.
The external carotid, and also most of its principal branches, have been
tied for aneurisms, wounds, goitres, enlargement of the tongue, vascular
tumours on occiput and other lesions; also as a first stage in the
operation of extirpation of the upper jaw, for the purpose of preventing
hæmorrhage. However, such operations are rare, and will probably become
rarer still, and it is hardly necessary to describe the operations on
each _seriatim_.
Aneurism of the external carotid or branches are rare; if idiopathic,
ligature of the common carotid will be found at once easier, not more
dangerous, and more effectual than ligature of the branch; if traumatic,
the aneurism itself should be attacked, and the bleeding point secured
by a double ligature. Wounds are common enough, but if accessible at
all, the injured vessel should be tied at the bleeding point; if
inaccessible (and under this head we may include wounds of the internal
carotid), the common carotid must be tied.
No one would think of trying the superior thyroids for goitre, unless
they were so manifestly enlarged, tortuous, and pulsating, as to render
the operation so simple (from their superficial position) as to require
no special directions; besides this, the cases in which it has been
already done have given very little encouragement to repeat it.
As cases may occur in which any diminution of the cerebral supply is
contra-indicated, and thus the more difficult ligature of the external
carotid may be preferred to the more simple operation on the common
trunk, and as the lingual may require ligature near its root, in
consequence of obstinate hæmorrhage from the tongue, short directions
are given for the performance of both these operations.
1. LIGATURE OF EXTERNAL CAROTID.--Head in same position as for the
common carotid. A straight incision parallel with the anterior edge of
sterno-mastoid, but about half an inch in front of it, must begin almost
at angle of jaw, and extend downwards nearly to the level of the thyroid
cartilage. Cautiously divide skin, platysma, and fascia; the lower end
of the parotid must be pulled upwards, and the veins, which are
numerous, cautiously separated. The anterior border of the
sterno-mastoid must be pulled backwards, and the digastric and
stylo-hyoid forwards and inwards. The superior laryngeal nerve which
lies behind the vessel must be avoided.
2. LIGATURE OF LINGUAL.--To secure this vessel either before it becomes
concealed by the hyo-glossus, or after it is under the muscle, a curved
incision is necessary, following the line of the hyoid bone, and
especially of its greater cornu, but a line or two above its upper
border. After the skin and platysma are divided, the posterior belly of
the digastric must be recognised, which again will guide to the
posterior edge of the hyo-glossus. The edge of the sub-maxillary gland
may very probably require to be raised out of the way. The artery can
then be secured, either before it dips under the hyo-glossus muscle, or
after it has done so, by the division of a few of its fibres on a
director. Care is needed to avoid injury of the hypo-glossal nerve,
which lies above the muscle.
The internal carotid artery occasionally, but very rarely, is the
subject of aneurism. It may, like any other artery, be wounded,
especially from the fauces. The treatment of either of these lesions is
ligature of the common carotid itself, in preference to ligature of the
internal carotid. Guthrie's operation for securing the bleeding internal
carotid at the injured spot, by dividing and turning up the ramus of the
lower jaw, has never been performed in the living body, and is so
difficult, dangerous, and unnecessary, as not to merit description.
LIGATURE OF SUBCLAVIAN.--_Note._--In consequence of the difference in
the origin, and variety in the anatomical relations of the right and
left subclavian arteries, in so far at least as their first stage is
concerned, it is necessary to give a very brief separate account of
each.
_Right Subclavian._--The innominate artery divides into the right
subclavian and right carotid exactly behind the sterno-clavicular
articulation. The right subclavian extends from this point in an arched
form across the neck, between the scalene muscles, over the apex of the
pleura, till, passing under cover of the clavicle, it changes its name
to axillary at the lower end of the first rib. For convenience of
description, the artery is divided into three parts, which have very
various anatomical relations, and differ from each other much in their
amenability to surgical treatment by ligature. The anterior scalenus
muscle defines the three parts, the first extending to the inner border
of the muscle, the second being concealed by the muscle, and the third
reaching from its outer border to the lower border of the first rib.
_Branches of the Subclavian._--While the deep relations of pleura,
veins, and nerves can be noticed under the head of each operation in
detail, one anatomical point must never be forgotten as influencing very
much the success of all surgical interference with the subclavian
arteries--_i.e._ the branches given off. To give any chance of success
in the application of a ligature to such a large vessel, so near the
heart, a large portion of artery free from branches is required, that
the clot may be long, firm, and undisturbed. The first part of the
subclavian gives off the vertebral, thyroid axis, and internal mammary;
the second, the superior intercostal; while the third part has in most
cases no branch whatever. In these anatomical differences we find the
reason for the almost invariable fatality resulting on any interference
with the first and second parts, and the comparative safety of ligature
of the third part, without requiring to account for the difference on
other grounds, such as depth of part, importance of nervous relations,
or nearer proximity to the heart.
The second and third parts of both arteries are so similar to each
other, that a separate account is not required for the two sides.
LIGATURE OF RIGHT SUBCLAVIAN.--_First Part._--_Operation._--An incision
just at upper edge of sternum and right clavicle, extending from inner
edge of _left_ sterno-mastoid transversely to outer border of right
sterno-mastoid through skin, platysma, and exposing sterno-mastoid, to
be joined at an angle by a second incision, which, two, three, or even
four inches long, must extend along inner border of right
sterno-mastoid. Flap to be raised upwards and outwards. The sternal
attachment of the sterno-mastoid must then be cautiously divided, as
also part or the whole of its clavicular attachment, according as room
is required. The sterno-hyoid and thyroid muscles will then require
similar division. The internal jugular will then be seen very
prominent,[16] and will require to be drawn inwards or outwards,
according to circumstances. The carotid and right subclavian arteries
will then be felt lying close together crossed by the pneumogastric and
recurrent nerves, the latter turning behind the subclavian. The nerves
must be drawn inwards; the cardiac filaments of the sympathetic will
then be observed, and drawn outwards. The subclavian vein lies below,
concealed by the clavicle, and will probably not be seen during the
operation. The needle should be passed round the artery from below
upwards, care being taken not to injure the pleura, which lies beneath
and behind the artery.
_Results._--Twelve cases, all of which died; ten of hæmorrhage, one of
pleurisy and pericarditis, and one from pyæmia. Attempted in one case by
Mr. Butcher, but the artery was too much diseased to bear a ligature.
The patient died on the fourth day.
LIGATURE OF LEFT SUBCLAVIAN.--_First Part._--This operation, which has
been described by some as impossible, has, I believe, been only once
performed on the living body. _Operation._--Incisions as for the
preceding operation, except being on the opposite side. After the skin,
platysma, and muscles have been divided, as already described, the deep
cervical fascia requires division close to the inner edge of the
scalenus anticus. The artery lies excessively deep, and great difficulty
is experienced in avoiding injury to the pleura and the thoracic duct.
_Results._--Once performed by Dr. Rodgers of New York; death from
hæmorrhage on fifteenth day.
_Anatomical Note._--The course of the left subclavian in its first stage
is much straighter, as its origin is much deeper, than on the right
side. The pneumogastric, phrenic, and cardiac nerves lie parallel to its
course; the oesophagus and thoracic duct lie behind it, and to its inner
side.
LIGATURE OF SUBCLAVIAN.--_Second Part._--This very rare operation hardly
requires a separate description, as the incisions necessary for ligature
of the artery in its third part will, with very slight modifications, be
sufficient for the purpose.
It has, however, special elements of danger in it, involved in the
unavoidable division, of part at least, or probably the whole, of the
scalenus anticus. The phrenic nerve, from its position on that muscle,
requires special care to avoid dividing it, and in most cases the
internal jugular vein is also in the way. The branches of the thyroid
axis, which cross the neck, are quite in the line of the incision. The
lowest cord of the brachial plexus lies immediately behind the artery,
between it and the middle scalenus. The pleura lies just below it. The
subclavian vein is generally quite safe, running in front of the
scalenus anticus, and at a lower level.
The presence of the superior intercostal branch adds greatly to the
danger of ligature of the vessel in this position, from its interfering
with a proper clot.
_Results._--Dupuytren[17] performed it successfully for a traumatic
axillary aneurism. Auchincloss[18] did it for a large true aneurism, but
the patient died sixty-eight and a half hours after the operation.
Liston cut through the outer portion of the scalenus with success for an
idiopathic aneurism. Thirteen have been collected by Wyeth with four
recoveries and nine deaths.
LIGATURE OF SUBCLAVIAN.--_Third Part._--For this comparatively common
operation, various methods of procedure have been suggested and
employed.
In the dead body, where the axilla is free from swelling, and in thin
patients, the artery in this third stage is tolerably superficial, and
can be secured with ease. But in very muscular men, with short necks and
well curved clavicles, and specially when the axilla is filled up with
an aneurism, and the shoulder cannot be depressed, the operation becomes
very difficult.
_Operation of Ramsden, Liston, and Syme._--_Position._--The patient
lying on his back with his shoulders supported by pillows, and his head
lying back, and drawn to the opposite side; the shoulder of the affected
side must be depressed as much as possible.
_Incisions._--(Plate I. fig. 8.)--One through skin, superficial fascia,
and platysma, along the upper edge of the clavicle, for at least three
inches from the anterior edge of the trapezius to the posterior border
of the sterno-mastoid, and in muscular subjects freely overlapping the
edges of both muscles. Another two inches in length along posterior
border of sterno-mastoid meets the first at an angle. On reflecting the
chief flap thus made upwards and backwards, the external jugular will be
seen, and, if possible, must be drawn to a side; if not, it must be
divided, and both ends tied. The lower edge of the posterior belly of
the omohyoid must then be sought; this leads at once to the posterior or
outer margin of the scalenus anticus. The connection of the deep fascia
to that muscle must then be very carefully scraped through, and by
tracing the muscle to its insertion to the first rib, the artery is at
once reached, lying behind the insertion. The pulsation of the vessel
between the forefinger and the first rib will prove a great assistance;
yet care is required, lest one of the branches of the brachial plexus be
secured instead of the artery. The lowest cord lies very close to the
vessel. The subclavian vein is not likely to give much trouble, from
its being on a lower level, and (unless very much dilated) nearly
concealed by the clavicle. The suprascapular artery is also hidden, but
the transverse cervical crosses the very line of incision, and may give
trouble, being occasionally much enlarged, so much so as even for a time
to have been mistaken for the subclavian itself. If possible, both these
branches should be saved, as being important means of carrying on the
anastomosis for the future support of the limb.
An absorbent gland is occasionally in the way, and has even been
mistaken for the vessel and carefully cleaned. Such may be removed
without scruple.
Care must be taken not to injure the pleura, which lies immediately
behind and below the vessel at the seat of ligature. Various
instrumental devices have been invented for passing the ligature. The
simplest seems still to be best, a common aneurism-needle with a
considerable curve.
_Other methods of operating._--A single curved incision above the
clavicle, with its concavity upwards, of about three or four inches
long, with its inner end rather higher than the outer (Green,
Fergusson).
A linear transverse incision in the same situation (Velpeau).
A single linear incision perpendicular to the clavicle (Roux).
An arched incision (Plate IV. fig. 2) with its convexity outwards,
and its base on the posterior edge of the sterno-mastoid, from
three inches above the clavicle to the clavicular attachment of the
muscle (Skey).
_Results._--Dr. Wyeth's Tables in 1877 give 251 cases with 134 or 53 per
cent. of deaths.
The late Mr. Furner of Brighton reported a most interesting case,
in which he tied both subclavian arteries at an interval of two
years in the same patient, for axillary aneurisms, with success.
LIGATURE OF AXILLARY.--_Anatomical Note._--This vessel, the next stage
in the continuation of the subclavian downwards, may be defined
surgically as extending from the clavicle to the lower border of the
teres major. From the depth of the vessel at its upper part, the
numerous nerves, and the close proximity of the vein, the surgeon has
carefully to study the anatomical relations. It, like the subclavian, is
commonly divided into three stages, and, also like the subclavian, these
stages are defined by the relations of the artery to a muscle, the
pectoralis minor. Surgically we may draw a very close parallel between
the two vessels, for we find that in the axillary, as in the subclavian,
the first stage is very deep, and very rarely amenable to ligature; the
second, still deeper and more rarely attempted, as in both the operation
involves division of a deep muscle; while the third stage in each is the
one most frequently chosen by the surgeon.
_First Stage._--Between the lower edge of the first rib and upper border
of the pectoralis minor the vessel is deeply seated, contained in that
process of deep fascia called the costo-coracoid membrane, and covered
above by skin, platysma, and the clavicular portion of the pectoralis
major. It lies on the first intercostal muscle and the upper digitation
of the serratus magnus, while the cords of the brachial plexus are on
its acromial side, and the axillary vein in close contact with it on its
thoracic side, and frequently overlapping the artery.
_Operation._--The great desideratum is free access. An incision (Plate
I. fig. 9), semilunar in shape, with its convexity downwards, must
extend from half an inch outside of the sterno-clavicular articulation
to very near the coracoid process, stopping just before it arrives at
the edge of the deltoid, in order to avoid injury of the cephalic vein.
It must include skin, fascia, and platysma, and the flap must be thrown
upwards. The clavicular portion of the pectoralis major must then be
divided right across its fibres, which will retract. The arm must then
be brought close to the side to relax the pectoralis minor, which must
be drawn aside. The artery will then be felt pulsating, but hidden by
the costo-coracoid membrane, which acts as its sheath. This must be
carefully scratched through, the nerves pulled outwards, the vein
avoided and pulled downwards and inwards, and the thread passed round
from within outwards. (Manec, Hodgson, and, with slight modification in
the incision through the skin, Chamberlaine.)
Ligature has been performed in this position by separating the
pectoralis and deltoid muscles, without dividing the muscular
fibres (Roux, Desault).
To attempt to gain access between the clavicular and sternal
portions of pectoralis major, as has been proposed by some, is
almost impracticable in the living body, from the position of the
vein, to which, rather than to the artery, this incision leads.
LIGATURE OF AXILLARY, _in its second stage_, is not an advisable
operation, when it is merely intended to throw a ligature round the
artery for an aneurism lower down.
It has been performed at least twice by Delpech, but it is a rude
procedure; in his cases, after the muscle was cut, a dive with the
finger was made to collect the whole mass of vessels and nerves, and
bring them to the surface near the collar-bone; in this position it is
said the artery was easily isolated and tied.
In Mr. Syme's operation of cutting into large axillary aneurisms, and
tying both ends of the vessel, the pectoralis minor may, indeed
generally has, to be divided, and must take its chance without any
special notice or precaution, in the sweeping, free incisions required.
LIGATURE OF AXILLARY _in its third stage_.--This is an operation very
much more common, more easy of accomplishment, and safer in its results
than either of the preceding; the artery in this stage being more
superficial, in fact almost subcutaneous.
_Operation._--The arm being extended and supinated, an incision (Plate
I. fig. 10) two and a half or three inches long, must be made in the
base of the axilla over the artery, involving at first skin and
superficial fascia only; the deep fascia is then exposed and must be
carefully scraped through, avoiding injury of the basilic vein, if (as
sometimes occurs) it has not yet dipped through the fascia. The vessel
can now be felt; the median nerve which lies over the artery, or
slightly to its outer side, must be drawn outwards, and the axillary
vein, which lies at the thoracic side, but often overlaps the vessel,
must be carefully drawn inwards. The ligature must then be passed from
within outwards.
When the patient is very fat or muscular, the coraco-brachialis muscle
may be required as a guide to the vessel; but in general its superficial
position renders any guide quite unnecessary, even in the dead body.
_Anatomical Note._--While in each stage the axillary artery gives off
branches, those arising from the third stage are by far the most
important, especially the subscapular, which leaves it at the edge of
the muscle of the same name. To avoid these the ligature should be
applied as low down on the vessel as possible, and, in point of fact,
the operation called ligature of the third stage of the axillary is,
anatomically speaking, really ligature of the brachial high up, and
where there is room at all, there will be the less chance of secondary
hæmorrhage, the greater the distance is between the ligature and the
great subscapular branch.
_Mr. Syme's Operation for Axillary Aneurism._--Description of the
operation in his own words:--
"Chloroform being administered, I made an incision along the outer edge
of the sterno-mastoid muscle, through the platysma myoides and fascia of
the neck, so as to allow a finger to be pushed down to the situation
where the subclavian artery issues from under the scalenus anticus and
lies upon the first rib. I then opened the tumour, when a tremendous
gush of blood showed that the artery was not effectually compressed;
but while I plugged the aperture with my hand, Mr. Lister, who assisted
me, by a slight movement of his finger, which had been thrust deeply
under the upper edge of the tumour, and through the clots contained in
it, at length succeeded in getting command of the vessel. I then laid
the cavity freely open, and with both hands scooped out nearly seven
pounds of coagulated blood, as was ascertained by measurement. The
axillary artery appeared to have been torn across, and as the lower
orifice still bled freely, I tied it in the first instance. I next cut
through the lessor pectoral muscle close up to the clavicle, and holding
the upper end of the vessel between my finger and thumb, passed an
aneurism-needle, so as to apply a ligature about half an inch above the
orifice."[19]
In a similar operation lately performed by the author for traumatic
aneurism, the result of a stab, very little blood was lost, though no
incision was made above the clavicle. The patient made a good
recovery.[20]
LIGATURE OF BRACHIAL.--To arrest hæmorrhage from a wound of the artery
itself, no special directions are required, except to enlarge the wound,
and secure the vessel above and below the bleeding point. There are,
however, rare cases in which for bleeding in the palm (after all other
means have failed), or for aneurism lower down the arm, a ligature may
be necessary.
_Operation._--The biceps muscle, at its inner edge, is the best guide to
the position of the incision, or if it be obscured by fat or oedema, a
line extending from the axilla, just over the head of the humerus to the
middle of the bend of the elbow will define its course. An incision
(Plate I., fig. 11) three inches in length, about the middle of the arm
(when you have the choice of position), through skin and superficial
fascia, will expose the deep fascia, and probably the basilic vein.
Drawing the latter aside, cautiously divide the deep fascia. The artery
is then exposed, but in close relation to various nerves; of these the
ones most likely to come in the way are--1. The median, which lies in
front of, but a little to the outside of the artery, though in some rare
cases it lies behind it; 2. The internal cutaneous; 3. The ulnar, both
of which ought to be rather to the inside of the artery. Two brachial
veins accompany and wind round the vessel, occasionally interlacing.
Pulsation will, in the living body, usually suffice to distinguish the
artery from the other textures, and the ligature may be passed from
whichever side is most convenient.
_Note._--The relation of the median nerve to the vessel varies
according to the part of the arm--thus, as low as the insertion of
the coraco-brachialis it is to the outer side, as has been
described, it then crosses the vessel obliquely, and two inches
above the elbow it is on the inner side of the artery. Again, the
operator must never forget the possibility of there being a high
division of the artery. This occurs, Mr. Quain has shown, perhaps
once in every ten or eleven cases, and may necessitate ligature of
both trunks.
In those cases (once much more frequent than at present) where an
aneurism has formed after a wound of the brachial at the bend of the arm
in venesection, the aneurism may be either circumscribed or diffuse.
If circumscribed, it is advised by some surgeons, specially by the late
Professor Colles of Dublin, that the brachial should be tied immediately
above the tumour. In most cases of circumscribed, and in all such cases
of diffuse aneurism, the preferable operation is boldly to lay open the
tumour, turn out all the clots, seek for the wound in the artery, and
tie the vessel above and below. A tourniquet above, or, better still, a
trustworthy assistant, prevents all fear of hæmorrhage, and such a
radical operation exposes the limb to far less chance of gangrene than
do any attempts at removing or lessening the tumour by pressure (as
recommended by Cusack, Tyrrell, Harrison), and is much more certain
than a mere ligature above.[21]
LIGATURE OF VESSELS IN FORE-ARM.--Here, as also we found is the case in
the leg, it is almost useless to go on giving exact directions as to the
method of throwing a ligature round the vessels in all possible
situations.
For below the elbow spontaneous aneurism is almost unknown, and even
traumatic aneurisms are extremely rare. It is therefore for hæmorrhage
only that the vessels are likely to require ligature, and it is a rule
in surgery that to enlarge the wound and to apply a ligature above and
below the bleeding point is better practice than to apply a ligature at
a distance.
In the case of wounds of the palmar arch, it is extremely difficult, and
very apt to injure the future usefulness of the hand, thus to seek for
the bleeding point under the palmar fascia, and for _these_, ligatures
of radial and ulnar have occasionally been practised. However, as even
this has proved ineffectual, and the interosseous has proved sufficient
to continue the bleeding, ligature of the brachial at once is preferable
to ligature of so many branches in the fore-arm.
The use of graduated compresses, carefully applied, combined with
flexion of the elbow over a bandage, will generally prove sufficient to
check such hæmorrhage from the palm, without having recourse to either
of the above more severe measures.
_Note._--As in the lower limb at page 24, and for the same reasons,
I here insert a brief account of the methods of tying the ulnar and
radial arteries.
1. LIGATURE OF ULNAR.--Only admissible in the lower half of its
course. _Operation._--Use the tendon of the flexor carpi ulnaris as
a guide, and make an incision along its radial edge, at least two
inches in length; expose the deep fascia of the arm and then
cautiously divide it; then bending the hand, the flexor carpi
ulnaris is relaxed, and the artery is found lying pretty deeply
between it and the flexor sublimis digitorum. The ulnar nerve lies
at its ulnar side, and the venæ comites accompany the artery. In a
tolerably muscular arm, the incision will have to be about an inch
inside of the ulnar border of the limb.
2. RADIAL.--This artery lies more superficial than the preceding,
and may be tied at any part of its course.
_A._ Operation in upper part of fore-arm. Here the artery lies in
the interval between the supinator longus and the pronator radii
teres. In a muscular arm, the edge of the former muscle is the best
guide; in a fat one, the incision may be made in a line extending
from the centre of the bend of the arm to the inner edge of the
styloid process of the radius. The deep fascia must be exposed and
opened, and the muscles relaxed and held aside. The radial nerve
lies on the radial side of the vessel.
_B._ Operation in lower half of arm. Here the vessel is more
superficial, lying in the groove between the flexor carpi radialis
and supinator longus. An incision two inches in length, and
parallel with these tendons, easily exposes the artery. The nerve
is still on its radial side.
_C._ Operation at first metacarpal. The artery may be tied easily
enough in the triangular space bounded by the extensors of the
thumb, on the dorsum of the proximal end of the first metacarpal
bone. Skey[22] recommends a transverse,--Stephen Smith[23] and
others, a longitudinal incision. The author had lately to secure
the radial in its lower third, the superficialis volæ, and the
radial again in the triangular space, in a case where division of
the artery by a transverse cut had caused a large aneurism to form
close above the annular ligament.
TABLE illustrating anastomotic circulation after ligature of
arteries of neck and upper limb.
1. Common carotid.
(_a_) Across middle line: thyroids, linguals, facials, occipitals;
also terminal branches of external carotids; also internal carotids
by circle of Willis.
(_b_) Of same side: occipital with vertebral; superior thyroid with
inferior thyroid, etc.
2. Subclavian, 3d part.
Suprascapular with dorsal branches of subscapular; posterior
scapular with costal and muscular branches of subscapular. Thoracic
anastomosis between internal mammary and intercostals, with
branches of axillary.
3. Axillary and brachial. Anastomosis varies with the position of
the ligature, but is very free between the various muscular
branches of these vessels.
FOOTNOTES:
[2] Erichsen, _Surgery_. Sixth edition, vol. ii. p. 121.
[3] The line 3 in Plate I. shows the direction required. It
will not be necessary to carry the incision so far up for the external
as for the common iliac.
[4] _On the Arteries and Veins_, p. 421.
[5] _Cyclopædia of Practical Surgery_, vol. i. p. 277.
[6] John Bell's _Prin. of Surg._, vol. i. 421; _Dublin Jour._,
vol. iv. 321.
[7] _Observations in Clinical Surgery_, Syme, pp. 171-3.
[8] _Brit. Med. Jour._ 1867, Oct. 5.
[9] _International Encyclopædia of Surgery_, vol. iii. p. 466.
[10] Poland, _Guy's Hosp. Report_, ser. iii. vol. vi.
[11] Mr. W. Thomson's most interesting paper on this subject is
full of information down to the latest date.
[12] _Lancet_, Jan. 5, 1867.
[13] _Lancet_, May 1879.
[14] _Dublin Quarterly Journal_, Nov. 1867.
[15] W. Zehender--Monatsbl. für Augenheilkunde. 1868.
[16] Butcher, _Op. and Cons. Surgery_, p. 861.
[17] _Leçons Orales_, iv. 530.
[18] _Ed. Med. and Surg. Journ._ vol. xlv.
[19] _Observations in Clinical Surgery_, pp. 148, 149.
[20] _Edin. Med. Journal_, March 1879.
[21] See case of recurrence, Fergusson's _Practical Surgery_
1st ed. p. 222.
[22] _Operative Surgery_, p. 279.
[23] _Surgical Operations_, p. 50.