A Manual of the Operations of Surgery Part 4

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 ma.s.s 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 sc.r.a.ped 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 pa.s.sed 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 haemorrhage, 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 a.s.sisted 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, pa.s.sed 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 haemorrhage 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 pa.s.sed 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 circ.u.mscribed or diffuse.

If circ.u.mscribed, 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 circ.u.mscribed, 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 a.s.sistant, prevents all fear of haemorrhage, 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 haemorrhage 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 haemorrhage 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 venae 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 p.r.o.nator 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 s.p.a.ce 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 volae, and the radial again in the triangular s.p.a.ce, 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 ill.u.s.trating 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] _Cyclopaedia 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 Encyclopaedia 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.