the dreadful consequences of the disease above described; it is
quite intractable in its later stages. Confinement to the recumbent
posture, and strict rest of the affected parts must be enjoined;
and blood is to be abstracted locally, once and again, according to
circumstances; afterwards counter-irritation is to be employed, and
repetition of moxas or of caustic issues is the most efficacious. When
the painful feelings have subsided, and some impression has been made
on the disease, the patient appearing to convalesce, the head must be
supported by a proper machine for a long time. He will thus be enabled
to use his limbs, to move about, and repair his general health, the
weight of the head being taken from the weakened column.
[Illustration]
_The External Jugular_ vein may require to be opened for the
abstraction of blood in affections of the head; or when venesection
cannot be readily performed at the bend of the arm, from the small and
indistinct condition of the veins in children, or in people loaded with
fat. The vein is made to rise by pressure with the finger or thumb, as
seen in the accompanying cut, above the clavicle. The lancet is passed
though the integuments and platysma myoides into the vessel, midway
between the jaw and clavicle. After a sufficient quantity of blood has
been withdrawn, the pressure below is removed, and the edges of the
wound are put together with a bit of court plaster, or by means of a
compress and bandage lightly applied.[41]
_Ligature of the common Carotid_ may be required for the cure of
aneurism at the angle of the jaw; or on account of hemorrhage from deep
wounds in the same situation, when, from any circumstances, the divided
extremities of the vessels cannot be secured. A deep incision of the
angle of the jaw, towards the base of the cranium, not only divides
important branches of the carotid, but may also wound the vertebral
arteries where they project in a tortuous fashion, betwixt the dentata
and atlas, or betwixt the latter bone and the occiput.
Ligature of the common carotid has been had recourse to, in order to
stop bleeding from the mouth, nostrils, and other parts connected
with the face,—for the cure of large or deep-seated aneurism by
anastomosis,—and as a preliminary step to the removal of large
and firmly attached morbid growths of the face or neck. This last
proceeding, as already remarked, does not in any way enhance the
patient’s safety, whilst it adds much to his suffering.
The carotid has also been tied for the cure of aneurism at the root
of the neck, when it was impossible to place a ligature betwixt the
tumour and the heart. My opinion regarding this practice I have given
formerly, when treating of aneurism in general.
For aneurism at the angle of the jaw, the point of deligation must in
a great measure depend on the size of the tumour. The artery is most
conveniently reached where it is crossed by the omo-hyoideus; and, when
deligation at this point is both practicable and eligible, the vessel
is exposed at the upper edge of the muscle. But circumstances may
require the ligature to be placed much lower.
The patient is placed, either sitting or lying, with the head thrown
back, and turned slightly to the side opposite the tumour. An incision
is made in the upper triangular space of the neck, and in the course
of the vessel, midway betwixt the sterno-mastoid muscle and the
muscles covering the forepart of the larynx. Its extent depends on
the thickness of the neck—on the muscular development and quantity of
fatty matter, whether the neck be long or short. From two to three
inches will in general afford sufficient space. The first sweep of the
scalpel penetrates the skin, platysma-myoides, and cellular tissue. The
cervical fascia is then divided carefully, with the hand unsupported.
During the incision, the parts should be a little relaxed by attention
to the position of the head. The sheath of the vessels is exposed by
cautious division of the cellular tissue which occupies the space
betwixt it and the cervical fascia. Thin copper spatulæ, bent to suit
the purpose, are used to keep the edges of the wound apart. In general
there is very little bleeding; but, that the operator may be sure of
what he cuts, it is necessary frequently to clear the cavity with a
bit of soft sponge. Each step of the operation should be slowly and
surely accomplished; the least hurry is culpable. When the slight
oozing has ceased, the common sheath,—which is distinctly seen, with
the descendens noni lying on its forepart,—is to be opened to a slight
extent with the point of the knife—the hand steady and unsupported,
and no director used. The descendens noni is left to the inner side.
The internal jugular vein, swelling up on account of the struggles
and hurried respiration of the patient, has in some cases been found
troublesome at this period of the operation, rendering the opening of
the sheath and the use of the needle difficult. I have not met with any
such obstacle in the cases in which I have been concerned. The aneurism
needle should be slightly curved, with a perforation near the point;
and the point should neither be bulbous, nor at all sharp, but all of
the same thickness, and well blunted at the extremity and edges. It
is introduced, carrying a firm round ligature of flax or silk, well
waxed through the opening in the sheath, betwixt the par vagum and the
artery, and from the outer side. The point is moved very slightly from
side to side, and carried under the artery; no force being used, as it
is unnecessary, and apt to be injurious. The instrument is thus gently
insinuated, not thrust, through the cellular tissue, and made to appear
on the opposite side of the vessel, with its point towards the trachea.
It ought to be passed close to the arterial coats, and care must be
taken to avoid including within its track part of the common sheath, or
the descending branch of the ninth. Unless the surgeon be indeed very
rash, there is little risk of the vein or par vagum being injured; to
include them along with the artery would argue no small degree of most
deplorable ignorance. The loop of the ligature is laid hold of either
with the fingers, with forceps, or with a small blunt hook, and drawn
towards the surface of the wound. It is then divided, and one-half
retained, whilst the other is withdrawn along with the needle. The
vessel must not be raised up from its situation, or detached from its
cellular and vascular connexions, more than is merely sufficient for
transmission of the needle. A single knot is cast upon the remaining
half of the ligature, passed down, and tied firmly on the vessel, by
the forefingers of the operator. This is secured by the finger of an
assistant, whilst the ends are again passed through, so as to complete
the reef-knot, and run down tight as before, the assistant slowly
withdrawing his finger to make way for the ligature. A third knot
may be made to insure security; but is seldom, if ever, necessary.
As already observed, everything must be done with deliberation and
caution, and the operation may be thus safely concluded in a very
few minutes. One end of the ligature may be cut away close to the
knot, or both brought out of the wound. The edges of the wound are
put together, after all oozing has ceased, by one or two stitches,
and the intermediate application of isinglass plaster; bandaging is
unnecessary, and might be hurtful. The patient is placed in bed, with
the head elevated considerably, so as to relax the neck. The wound
will probably heal by the first intention, excepting in the immediate
neighbourhood of the ligature; and the separation of this may be looked
for from the tenth to the twentieth day. Then all risk of danger may be
considered as past.
_Ligature of the Arteria Innominata_ has been practised in very few
cases. It may possibly be required for aneurism of the subclavian, or
of the root of the carotid; or for large axillary aneurism, greatly
raising the shoulder, and involving the parts at the root of the neck.
The patient should be placed recumbent, with the head well thrown
back. An incision from two inches and a half to three inches in
extent is made in the course of the carotid, terminating over the
sterno-clavicular articulation. If the incision is made more towards
the inner border of the left mastoid muscle, greater space is gained.
From that point, another is carried along the upper margin of the
clavicle, to the extent of an inch and a half. The sternal attachment
of the sterno-mastoid muscle is separated, the cervical fascia divided,
the cellular tissue betwixt the sterno-hyoid muscles separated, and the
vessel exposed. During the dissection, the internal jugular vein, the
par vagum, and the recurrent branch, the inferior thyroid artery, and
the arterial distributions from the thyroid axis, must be carefully
avoided. The operator should, by free external incisions, make a
dissection sufficiently spacious to admit of his seeing the bottom
of the wound distinctly as he proceeds. It is necessary that he not
only feel but see what he is about to cut; groping in this situation,
and amongst such important parts, is unsafe, to say the least of it.
Caution in passing the needle is here required equally as in ligature
of the carotid. In such deep wounds the aneurism needles of Weiss,
Bremner, Mott, or Gibson, may perhaps be found useful; but in general
the common one is sufficient, and has always answered my purpose
perfectly. During the dissection, it must be borne in mind that the
pleura is not far from the edge of the knife. In one case of aneurism
above the clavicle, and close to the outer border of the sterno-cleido
mastoid muscle, and of the anterior scalenus, I exposed the arteria
innominata by a cautious dissection; but, instead of surrounding that
vessel, applied ligatures to the root of the subclavian and of the
carotid. This latter was closed with the view of insuring the formation
of a clot in the arteria anonyma. The patient suffered under abscess
of the mediastinum, inflammation of the heart and pericardium, and
ultimately he had repeated hemorrhage from the wound. The arteria
innominata and the root of the two vessels were obstructed by firm
coagulum. The blood had come from the distal end of the subclavian, and
had been furnished by the regurgitation through the vertebral, thyroid,
mammary, &c.
_Ligature of the Subclavian Artery_ is required for the cure of
axillary aneurism. That portion of the vessel within the scalenus and
outside of the pneumogastric nerve is unfavourable for operation, in
consequence of many branches being given off in an exceedingly short
space. Besides, important veins and nerves are in the immediate
vicinity. And though these were avoided, and the vessel reached and
tied, still there would be no likelihood of a favourable result;
obliteration of the vessel would not be expected to take place at the
deligated point, one or more collateral branches arising close to the
ligature. On the outside of the scalenus there is no such objection.
But the vessel is deep, even in the healthy state, and much more so
when aneurism has appeared in the axilla, and has attained but even
a small size. But again, when the tumour is large, the shoulder is
much elevated, and firmly fixed in its exalted level, so as greatly to
increase the depth of the vessel.
The shoulder is to be depressed as much as possible, and the head
thrown to the opposite side. An incision is made along the upper margin
of the clavicle, and a second perpendicular to the first. These must
be proportionate to the size of the patient, and the supposed depth
of the vessel. It is better to err in making the external incisions
too large than too small; neither the pain nor the duration of the
cure is much increased thereby. But, by an opposite course, both
the difficulties and the dangers of the operation are rendered far
greater. The external jugular vein must be avoided if possible by
the knife; it should be detached slightly, and pulled inwards. The
supra-scapular artery, running in a line with the clavicle, ought also
to be saved; it acts a principal part in performing the anastomosing
circulation after ligature of the trunk; and, although the arm would
receive a sufficiency of blood from other branches, it is well to
keep this entire—not to mention the trouble which wound of it would
occasion the operator, by constantly filling his incisions with blood,
and the delay caused by the application of ligatures to the bleeding
extremities. Its division can easily be guarded against, and should
be avoided. The subclavian vein is not in the way; it is lower down
under the clavicle than where the surgeon requires to introduce his
instruments. The fascia and cellular tissue are divided carefully,
until the cervical plexus of nerves appears, and then the artery is
to be looked for on the same level with the plexus, and towards its
sternal margin. But, in cutting for this or any other vessel, it
must be recollected that pulsation is a very uncertain guide. It is
communicated to the neighbouring parts, and often is scarcely to be
felt at all, or is at least very indistinct. In any situation pulsation
is very perceptible before division of the integuments, and other
superimposed parts; but after resistance has been removed by exposure
of the vessel, it ceases almost entirely. The sense of touch is the
principal guide, and, to experienced fingers, the feel of nerves is
different from those of arteries. The ligature has been passed round
one of the cervical plexus, as happened in one of my own cases; the
mistake was, however, not without its use, for, on discovering that it
was a nerve, I retained the ligature, no knot having been cast, and by
it pulled the nerve out of the way, so as to allow of the artery being
more readily secured. The artery is felt as it crosses over the first
rib, and by pressure there, pulsation in the arm is stopt; sometimes it
may be even seen. The knife, guided by the finger, is then used very
cautiously to prepare the vessel for ligature. The vessel may be found
unsound, and dilated to a further extent than had been expected; and
then it may be necessary to trace it towards the heart, and even to
divide the scalenus anticus in part, the phrenic nerve being kept free
from injury, in order to expose a sound portion for the application
of the ligature. This was found necessary in one of my own cases,
and also in one operated on by the Baron Dupuytren. A blunt-pointed
needle is passed, either plain or with a separable point, and the knots
made as was formerly described. A piece of strong wire doubled, and
either notched or perforated at the extremities, affords assistance in
securing the knots in so deep and contracted a space. Various kinds
of serre-nœuds and needles have been recommended; but the simpler the
instruments employed are, and the less a surgeon depends on them, the
more likely is he to succeed in his undertaking.[42]
During the time that this sheet was passing through the press, a case
of aneurism above the right clavicle came under treatment in the
hospital, on which it was proposed to perform the operation of tying
the trunks of the subclavian and carotid as they pass off from the
innominata. The necessary incisions were made, but the innominata was
found wanting. After some troublesome dissection, the subclavian
artery, which appeared to have come off irregularly, was discovered
crossing from the left to the right side, to take its place betwixt
the scaleni, rather more than half an inch behind the carotid, and
close upon the forepart of the vertebræ. The ligature was placed on the
mesial side of the pneumogastric nerve, and close to it. Up to this,
the twenty-second day, the case is going on most favourably.
_The axillary portion of the brachial artery_ cannot require to be
tied for true aneurism. Were the aneurism seated at the border of the
axilla, and the upper portion of the vessel beneath the clavicle free,
the best, wisest, and safest proceeding is to tie the subclavian. Then,
the shoulder not being raised, the vessel is not so deep as when the
aneurism involves the whole axilla. The incisions are not so deep nor
so extensive, and do not implicate so important neighbouring parts as
those for ligature of the axillary artery; and besides, the vessel is
tied farther from the diseased part.
The axillary artery may be tied on account of wounds, either
immediately upon the infliction of the injury, or some time afterwards.
The dissection is difficult, the vein being much in the way, and the
vessels surrounded by nerves, and intimately connected with them by
dense cellular tissue. The artery is more involved at the middle
portion of the axilla than at the superior and inferior; at that point,
too, the cephalic vein, as well as the axillary, impedes the operator.
To reach the upper portion of the artery, much muscular substance must
be divided. An extensive incision, in the course of the vessel, is
made through the integuments. The pectoralis major is got through by
separation and division of the fibres, the incision in it being made
with as little cross-cutting as possible. Part of the pectoralis minor,
probably the superior half of the muscle, must also be cut. The parts
are then exposed, the vein to the inner side of the artery, and the
nerves interlaced. The vessel is carefully isolated at one point, and
there secured.
It is almost impracticable to reach the middle portion of the
axillary—supposing the vessel to be divided into three equal
portions—without injurious interference with the nerves. If operating
with the view of tying the extremities of the vessels wounded at this
point, the probability is that the nerves have been divided along with
the artery, and then the proceedings are more simple. The incisions are
made in the direction of the bleeding point; this is reached, and each
extremity of the vessel securely tied.
The lower third of the artery is less involved with the vein and
nerves, and can be reached without division of muscular fibres. The
arm is abducted and elevated as much as possible. The axilla is thus
exposed. A free incision is made in the course of the vessel, which, by
cautious dissection, is brought into view; it can then be dealt with as
may be required.
Spontaneous aneurism is of rare occurrence, lower in the brachial
artery than its axillary portion. However, it is sometimes met with
at the bend of the arm. But the aneurismal tumour in this situation
is more frequently the consequence of wound of the vessel, inflicted
whilst opening a superimposed vein. The mode of proceeding in
venesection, the precautions to be employed, and the evils that
sometimes follow this little operation, will be treated of by and by.
Wounding of the artery is not so common an accident now as formerly.
Venesection is not so universally and unnecessarily resorted to as
formerly, and is performed by better instructed practitioners.
Puncture of the brachial artery, at the bend of the arm, is not
uniformly followed by extravasation of blood, or by the formation of
aneurism. That it is wounded is known by the impetuous and saltatory
flow of florid blood, accompanied with a wheezing noise. In such
circumstances, the thumb is placed firmly over the wound; the fingers
separately, the hand and the forearm of the patient are all supported
by uniform bandaging; and a graduated compress, supplying the place
of the thumb, is firmly applied, and must be retained for many days.
Thus extravasation is effectually prevented. But the measures must be
adopted instantly, before the edges of the opening are rounded, and any
quantity of blood has escaped into the cellular tissue; the apparatus
must be well applied and retained. When pressure is required on any
point, it is absolutely necessary to give support to the lower part
of the limb, as was formerly insisted on; and the proceeding is, if
possible, more necessary in this case, the requisite pressure being
very great. If ordinary compression only, sufficient to prevent the
flow of blood through the opening in the integuments, is applied,
blood is extravasated into the cellular tissue, breaking it up, and
causing condensation beyond; fluid blood accumulates in the space thus
formed; the surrounding cellular tissue is more and more condensed, at
length constituting a firm sac, confining the fluid, and communicating
with the opening in the artery; in fact, a pulsating and gradually
increasing aneurism is established.
Or a sac is formed, into which blood is propelled from the artery, and
which also communicates with the opening in the vein. This state of
parts is denominated varicose aneurism; it is very rare.
Or, again, no extravasation takes place, and the artery and vein unite
by lymph effused around the openings, the wounds remaining unclosed,
and forming a permanent communication between the vessels. Thus, a
portion of the arterial contents is constantly being injected into the
vein, producing a thrilling sensation, but little or no tumour. The
passage of the blood through the narrow aperture is also accompanied by
a peculiar noise, closely resembling that caused by the motion of the
fly-wheel in a musical box. This disease is termed aneurismal varix,
and is not so rare as the preceding. For this treatment is seldom
requisite.
In recent cases of false aneurism, the sac may be cut into, the vessel
exposed, and tied above and below the opening. This is recommended
from its being found that the tumour is sometimes slow of disappearing
after ligature of the vessel at a distance above. But when the tumour
is of considerable duration and size, containing coagula, and the
surrounding parts are separated and altered in structure, there is
no doubt as to the propriety of tying the humeral near its middle—as
also, in the case of spontaneous aneurism. The vessel is not deep, but
much entangled with nerves and veins. A free incision is made over its
course, dividing the skin, cellular tissue, and fascia; the sheath is
opened, and a ligature passed round the exposed artery. But it must be
recollected that high division of the humeral is not uncommon, and,
before casting the knots, pressure should be made on the vessel with
the finger against the loop of the ligature, and the effects on the
tumour watched; if pulsation cease, and the tumour become flaccid,
the ligature should be secured; but, if no effect is produced on the
swelling, high division is demonstrated, and the other branch must
be looked for. Pulsation is certain to return in the tumour, after a
few days, and if slow in again disappearing, gentle pressure should
be employed—the arm, hand, and fingers being previously bandaged, to
prevent infiltration of the limb.[43]
Wounds of the radial and ulnar arteries may require their being
exposed and tied at various points and at various periods—shortly
after the accident, or after the lapse of many weeks—on the occurrence
of secondary bleedings, or after the formation of false aneurism.
This is accomplished by incision in the course of the wounded vessel,
sacrificing as few muscular fibres as possible. Nevertheless, the
incision must always be free, to enable the surgeon to effect his
purpose readily.