Elements of Surgery

by Robert Liston

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.