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      Surgeon  General's  Office
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SuccessM Ligation of External Iliac Artery liy means of Silver Wire
C.   H.   MASTIN,  M.  !>.,

            OF MOBILE,  ALA.



  (Read before the Mobile Medical Society, July 10, 1866.)
lipjjrtutftt from tjje Srpt. No. of  tf»e N. <©. |Wrt. anl> Surg, journal.

     NEW ORLEANS:
Frinted by L. Graham, 90 Camp street.
            1866.
9
 
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     hrmc-
      VI.

p.fyn yf'if  ]■*+*■< ^ 
INC UJNAL  ANEUiiLSM.
   S~\X the 25th of May, 1866, I was requested by my Mend, Dr. W.
   ^   T. Webb,  of this  city,  to take charge of a case  of Inguinal
   Aneurism, in the person of an old and trusted servant of his family,
   Venter Woods, col'd, 53 years of age.   His  general health  was at
   this time good.   For thirty-two years past he had led an active life
   upon a plantation, and with the  exception  of slight rheumatic at-
   tacks, had never been sick.  These pains have always been located
   in the limb which is now the seat  of diseased artery.
     About the close of  December, 1865, he noticed, for the first time,
   a small pulsating tumor in his left groin,  which gradually increased
  in size, becoming more and more painful, until two months later
   (the 1st of March, 1866)  he was  forced to abandon his work.  Be-
  lieving he was suffering from his old rheumatism, which was proving
  more ungovernable than former attacks,  he sought the  advice of a
  physician residing near, and was advised by him  to come to Mobile
  for an operation,  as his disease "was not rheumatism."  Several
  weeks later, when he was  placed in  my hands, I found a large fusi-
  form aneurism of  the left groin, pulsating violently, with great oede-
  ma of  the thigh,  leg and  foot.  This  tumor,  passing from  under
  Poupart's ligament, had extended downward, until it protruded into
  the saphenous opening,  lifting up the falciform process of the fascia
 lata, the crescentic edge  of which process* stretched across the tumor,
 marked it with a  distinct  sulcus.   The artery,  from  above the epi-
 gastric and circumflex ilii arteries,  to considerably below the point
 from which the profunda leaves the femoral, was the seat of an  aneu-
 rismal tumor.
   A consultation with Drs. Nott* Drodie, and  other medical friends,
 decided that ligation  of the iliac  artery offered the only possible
 chance  for  his recovery, as the very  great oedema of the limb ren-
 dered it unsafe to attempt compression of  the  vessel.  Having fully
 apprised him of  the dangers of th^ operation and the probable fail-
 ure of the same, he determined to  take the chance offered.  Just
previous to the operation, by measurement we found a difference of
six inches in circumference between  the  two thighs, and an increase 
                             L 2J
in temperature of 3° in the region of the tumor, above that of the
sound side; the former being 96°, the latter 93Q.
  June 9th.   This morning, having cleared his bowels by an enema..
and placed him fully under the influence of chloroform, assisted by
my friends, Drs. Brodie, Boss  and Iglehart, and in the presence of
some fifteen medical gentlemen of the city, I proceeded to ligate the
iliac artery, through a  line of incision beginning at a point a little
outside of the upper and outer edge of the external ring,  and ex-
tending to a point in a line drawn from the anterior superior spine of
the ilium to the umbilicus, and two and a half inehes from that pro-
cess.  The incision passed in a plane  parallel  to the  fibres of the
tendon of the external oblique muscle, and was just five inches in.
length.  After having  cut through the integuments,, together with
the three muscles, the fascia transversalis was uncovered.  T did not
cut through  this fascia  at the point where it  was first exposed,
but with my hand gently passed between it and the muscle of the
same name, I reached a point near the brim of the time  pelvis, where
the peritoneum- leaves this fascia, to be reflected backward over the
pelvic viscera.  Here  a  small  space  is found,  filled with  cellular
tissue, and at this point the fascia was opened, without injury to the
peritoneum.  Having reached this subfascial space,, so to speak, by
gently introducing the hand the peritoneum may be lifted upward
from the psoas muscle, and the vessel exposed.
  The greatest difficulty in the operation is the opening of the sheath
of the vessel, which consists more truly of a mass of dense fibro-cel-
lular tissue,  binding the  artery and vein close together, than a true
arterial sheath.  This renders the passage of the aneurismal needle
around the artery both difficult and dangerous.   I however succeed^
ed in opening this, and,  separating the vessels,  passed from within
outward a silver vdre  (No.  32, of the silversmith's gauge)  around
the external iliac, at a point half an inch below the bifurcation of the
iliac proper.  This wire was secured by a double knot;  the ends, cut
close to the knot, were bent down and returned into the  cellular
sheath.   All pulsation ceased  in the tumor immediately  upon the
knot being drawn, previous to which time it had been intensely  vio-
lent.  The wound was  now closed by three sutures of gilded anneal-
ed iron wire, which were  passed deeply through the integuments and
the three muscles, while  the  spase intermediary between these su-
tures was closely united by pin sutures passed through the skin
alone.  The wound was now dressed with cold water, and, after the 
                              ! •'• J
effects of the (chloroform  had passed off, 50 drops Tr. Opii were or-
dered, and the patient was returned to his bed.
  To  my friend, Dr. K. L. Brodie, I am  indebted for the following
notes of the progress  of  the case until it was discharged cured.  It
is an  interesting fact that, with the great oedema and the age of the
patient, there should have been so little  fall of temperature in the
leg, after having had the  full  supply of blood cut off.   On one day
only,  the second after the operation, was there to be observed *a dif-
ference of more than two degrees between the two limbs.
  " 5|, p.  m., five hours since the operation, complains of some nau-
sea, the effects of chloroform.   No pulsation whatever in the tumor,
which has measurably subsided, presenting a  soft, doughy sensation
upon pressure.   Pulse; 6G beats at wrist.  Thermometer in diseased
groin shows a  temperature  of 98°;  in  groin  of sound side,  100°.
Bottles of hot water had been used around the leg since the opera-
tion, but were removed for 15 minutes before the thermometric ob-
servation was made.
  June 10th, 9, a. m.   Slept well during the night.  No pain what-
ever,  with only slight  sensation of numbness in the leg and foot.
Oedema much diminished.   Temperature of room, 86^'; sound groin,
104°; diseased groin, 100°.  Passed a quantity of pale limpid urine
  June 11th, 11|, a. m.  Rested quietly  last  night.  No pain either
in leg or bowels.   Incision  appears to  be glued firmly together;
tumor rather more firm and  much lessened  in  size.  Oedema con-
tinues to subside.  Pulse, 98.   Temperature of room, «S6°; diseased
groin, 96^; sound groin,  98°.
  June I'ith, 10i,.a. m. General condition favorable; although he was
somewhat restless in the  early part of the night, toward morning he
slept  quietly.  His appetite is capricious.  The  wound has,  toward
its upper and outer angle, a slight erysipelatous blush, with  some
tenderness upon pressure. Oedema of limb much reduced. Pulse, 84.
Temperature of room,  86°; groin of operation, 96g; sound side, 98°.
  June 13th, 11, a. in.  Slept well last night.  No pain.  Pulse, 86
Tongue slightly furred; bowels unmoved since operation.   A solu-
tion of citrate of magnesia was ordered,  with instructions to repeat
the same if  necessary.  The  wound  looks  better, the blush having
faded.  No change in the thermometric  condition.
  June 14th, 9, a. m.   His condition appears improved.  Magnet a
operated well, but left him with some slight nausea, which an effer-
vescing draught quieted.   Tongue  cleaning ;  pulse reduced to 80..
.No ajjpreciable difference in thermometric state since the 12th/" 
                            [4]
  June 15th, 9', a. m.  This morning I noticed a point of ulcera-
tion around the gilded sutures, and concluded to remove them.  I
was not a little astonished to see, upon their removal, a tablespoon-
f ul of thick pus pour out from  the space  closed by these sutures.
The pin sutures showed no appearance of ulceration, and the edges
of the wound, at the points through which the pins had passed,
seemed to be thoroughly healed.
  Was it probable that the iron wire, which was gilded, could have
proved more irritating than the ordinary "Carlsbad suture-pin;" or
may it have been possible that  a sort  of galvanic action had been
set up by this wire,  composed  as it is  of two different metals, pro-
ducing a galvanic issue ?   There  was no more strain upon the wire
than upon the pins, as both were passed and confined simply to
close the wound without  pressure.   Whatever  may have been the
cause, one thing is certain — there has been no more suppuration or
ulceration, save around the points through  which have passed these
gilded sutures.   The discharge of pus comes from a little pouch em
tirely subcutaneous, and just where these sutures have passed.  The
muscular wound is  entirely  closed, also the portions of integument
united by the pins.
   A mixture  of chlorate of potash, with a few drops of the muriated
fr. of iron, was ordered every three hours ; also compress over .ab-
 scess, with roller around abdomen.
   ''June 16th, 11, a. m.  Venter has improved very much within the
past twenty-four hours, and every  symptom gives assurance that he
 is decidedly better.   Tongue clean, and discharge of pus much less-
 ened.   No pain.  Pulse, 84.  Ordered the medicine continued at in-
 tervals of four hours, and gave him a bottle of porter.
   " June 19th,  11, a, m.   There  has been no material change in his
 condition for several days, with  the exception  that, from the point
of ulceration, two small sloughs of cellular tissue escaped.  The pin
sutures are removed to-day.  No  ulceration whatever  where they
 were used, and the wound perfectly cicatrized, with the exception of
 the  small  pouch around the point  of wire sutures.  This however
 granulates kindly.  He takes brandy, porter, and good diet.
   " June 23d.  Nothing has occured of interest since  the last note.
 Fourteen days have elapsed since the operation.  The  wound has
 nearly healed.   Got out of bed to-day and walked around his room.
 Has no pain, and very little numbness about his leg or foot.  Tumor
 lessened to almost the size of  a pecan.  Oedema scarcely to be no^- 
[.  "> J
ticed.  Circulation  through  the  collaterals,  from all  appearances,
established."
  July 14th.   Venter is walking  about the city.  His limb has as-
sumed its natural appearance, the tumor has  disappeared, and,  with
the exception of weakness, the result of confinement and the exces-
sively hot spell of weather through which we have recently passed,
we may without hesitation pronounce him well, and radically cured.
  The line of incision adopted in this operation avoided injury to
the epigastric artery, and lessened the chances of ventral hernia, as
was liable in the line proposed  by Sir Astley Cooper.  There was
also less danger of injury to the peritoneum than in the operation of
Abernethy or Mott.   On  the score of haemorrhage, no vessel is in
danger, not even the little artery of Haller which supplies the  skin.
Being below the line of  incision, it was avoided, and scarcely two
spoonsful of blood were  lost.  No ligature was  used,  and the  little
venous blood lost was  apparently the result of congestion of the
dermal tissue.
  It was my intention, when the operation was commenced, to ligate
the common iliac,  as the  size and extent of the aneurism justified
the opinion that the vessel was diseased, at least up to the bifurca-
tion.   I was relieved, however,  to find sound space  upon which I
could secure a ligature, half an inch below the  point  at which the
external leaves the common iliac.  This  offered a small space for a
-clot; but, with the hope of having an encysted ligature, I determin-
ed  to  try the  experiment.   This  line  of incision  afforded ample
space to ligate the common iliac, should it have been found neces-
sary to do so, without extending  it longer, as is  necessary in the op-
eration of Abernethy; or to make an angular cut,  as is requisite,  if
the line  of Sir Astley Cooper is adopted.   The gentlemen around the
table saw clearly the entire  course of the common iliac,  when the
wound was held apart by the curved spatula1, and there was no  more
difficulty in ligating one  than the other.  By incising the fascia at
the place I have suggested, we are absolutely safe, as regards doing
any injury to the peritoneum; and a sort of valvular wound being
made, we lessen the risk of ventral hernia.
  Upon  the point of ligating so large a vessel as the iliac with a me-
tallic thread, and leaving the same  to become encysted around the
artery, I am not aware that it has ever before been successfully per-
formed.   In  1859 Dr. Stone, of New Orleans, tied the common  iliac,
for a case of aneurism of the external iliac, with  a silver thread; but. 
[ « ]
unfortunately, his patient died on the twenty-sixth day after the op-
eration, from some disease of the bowels,  consequently offering no
satisfactory results as to the use of  metallic threads in these opera-
tions.  If it can be established as a safe procedure (and I have no
hesitation in saying that it can be), we have gained much in being
enabled to close the wound by the first intention, thus lessening the
chance of inflammation, suppuration,  hernia, and, not least of all,
secondary haemorrhage.   This usually takes place at the time when
the ligature ulcerates through the  coats of the artery, and the im-
petus of the heart's force impelling the blood against the clot, an
opening is forced in the  weakened tissue of the vessel, and haemor-
rhage is the result.   However,  when the metallic thread has  been
used, and not tied so tight as to rupture the coats of the vessel,
ulceration, if it does occur, is at least retarded, until the clot on the
proximal side has in a measure become organized and the vessel ob-
literated.  There being no clot formed on the distal side of the liga-
ture, even should this ligature be late in coming away, and the prox-
imal side perfectly closed by clot,  or even obliterated, we still have
danger of haemorrhage  at the time the ligature separates, dependent
upon a recurrent circulation through the sack of the aneurism.
   However, should we have been fortunate enough to place upon the
vessel a ligature of some substance  which will be slowT in producing
ulceration, or perhaps not cause it  at  all, but he harmless in the tis-
sues, we  at least lessen the chances of haemorrhage, and convert a
hitherto grave  operation into  one of comparatively  little  danger.
Even with the advantages offered by these ligatures, it must not be
considered that they are entirely free from danger, or that I am dis-
posed, under all circumstances, to advocate their use.  Such are not
 the views which I entertain.  I am satisfied that the trouble most to
 be apprehended in  the use of inorganic  ligatures, where they are
 left to be encysted in the sheath of the vessel, is  subsequent irrita-
 tion, which may be produced in the  associate nerve against which
 they are to lie in contact.  That they will become encysted and re-
 main innocuous, so far as ulceration or subsequent abscess is to  be
 considered, has been fully tested and proved by experiments to which
 I will refer before closing this article.  I am persuaded,  however,
 that the point has not  yet  been settled, and that there is probable
 danger of neuritis being excited, which will necessitate the removal
 of the metallic knot.   We see this state of things to take place when
 a leaden ball has been lying for years  harmless in the flesh : it may 
L  7 J
 change position, and give  trouble from pressure upon a nerve twig.
 In these cases the pain is intolerable, and when the ball is removed,
 we observe the cyst to be dry, offering no appearance of suppurative
 inflammation.  The same thing is observed where other inorganic
 substances have become encysted and remain, without giving trou-
 ble, for years.  I have recently removed  a fragment of glass, about
 the size of a filbert, from under the plantar fascia of a gentleman of
 this city, which had been there for the past twelve years, and, until
 very recently, had caused him no pain.  The glass was perfectly en-
 cysted, showing no  appearance whatever of either  inflammation or
 moisture.  The circumstance of  having  trod upon the  glass years
 before had been forgotten, and was not remembered until he sought
 relief for what he believed to be "a  wen in the bottom oi his foot/'
 It was now causing him trouble  by interfering with his locomotion,
 owing to pressure upon the internal plantar nerve.
   That the pressure of the ligature against a nerve may cause trou-
 ble, at least functional, if  not organic, there can be no doubt.  In
 1849 I remember to have been present at the ligation of the common
 carotid artery for aneurism.  No operation was ever better perform-
 ed.  The sheath was opened without injury to its contents, and  a
 silk thread passed around the vessel.  Almost immediately the most
 intense hiccough set in, caused by the presence of the ligature against
 the pneumogastric nerve, and this continued to such an extent as to
 threaten  the life  of the patient.  By the use of antispasmodics,
 opiates, etc., he was rendered more comfortable until the separation
 of the ligature, which fortunately took place without haemorrhage,
 and the patient was cured.
   In those arteries which have no associate nerve in their sheath,
 these objections do not obtain.  The  iliac offers a most favorable
 example, as the nearest nerve, the anterior crural, is separated in its
 entire course from the vessels by  the psoas muscle,  and with the ex-
 ception of the geiiito-crural nerve, a  small thread lying outside of
 the sheath, there is no nerve upon  which pressure  can be made.
 Hitherto, the liability to secondary haemorrhage after ligation of this
 vessel has been so great, that the operation has offered few hopes of
 success; hence some procedure is requisite, by which this danger
 may be lessened or averted.  I beheve nothing will offer more chances
 of a successful issue, than the use of the metallic thread.
  Just here, upon  the subject of metallic  ligatures, the profession
has been much interested for the past few years, and much has been 
[«J
 written, both in Europe and America.   It appears to my mind, that
 the suture has  been confounded with  the  ligature, and, with this
 view, it has been attributed to Dr. J. Marion Sims, as having been
 its originator.   He certainly deserves the full meed of  praise for his
 application of the silver thread as a suture, in his special operations;
 and the publication of his cases, together  with his remarkable suc-
 cess in an operation hitherto considered almost  as the opprobrium
 of our art, has won for him the high position which he  occupies, and
 has introduced extensively in the various  operations of surgery the
 use of this wire, as a suture,  but not as  a  ligature.   To the late Dr.
 Henry S. Levert, of this city, is due the credit of first having brought
 the attention of  the profession to this most interesting subject.  At
 the suggestion of the late Dr. Physic (who had observed that leaden
 baUs would remain apparently harmless  in the tissues  after becom-
 ing encysted), he was induced to institute a series  of experiments
 upon inferior animals, in which he ligated the various large arteries,
 using both  organic and  inorganic material as  the ligature.  These
 experiments established the fact that leaden, gold,  and  silver  wire
 would become encysted,  and  not  cause ulceration of the arterial
 tunic.  The result of these experiments, some thirty or forty in num-
 ber, constituted his inaugural thesis, and was afterwards published,
 by order of the faculty,  in the " American Journal of Med. Sciences,"
 vol. iv., p. 17, 1829.   The preparations were  deposited  as wet speci-
 mens, together with a history of the same, being a contribution to
 the " Wistar Museum of the University of  Penn."*
   It remained however to be applied to practice, and it is to be re-
 gretted that this justly  honored physician and surgeon,  who after-
 Wards enjoyed a  large and extensive field of observation, should  have
 neglected to introduce the principles he first  established.
   I have been led to make this  statement as  an act of justice to the
 memory of  Dr. Levert, without attempting  to detract anything from
 those who may have applied the principle suggested to more success-
 ful practice.  True it is,  he who, acting upon the suggestions of an-
 other, puts in practice an art, is justly entitled to  the reward of his
 labors; but the mind which first conceived the  idea, should receive
its due proportion.  It is meet,  therefore, that we  "render unto
 Caesar the tilings that are Caesar's."

   *Notb.—During the summer of 1848,1 repeated the experiments of Dr. L. upon the arteries of
 dogs, using principally the leaden wire ; and after having repeated them to a considerable extent
fu almost every instance I attained the ^me results described in the paper above mentioned. ' 
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