iJLC4X-*€~
Wfc<
 
 


:>»®®®®®$®e<
OTPM^SFTO* MAAVV1MI
COMMON  ILIAC  ARTERY
BY
VALENTINE MOTT, M. iK^Jgg^l  '
PROFESSOR OF SURGERY, NEW YORK.
 
 
(   3   )
Successful Ligature of the Common Iliac Artery.  By Valentine
         Mott, M. D. Professor of Surgery, New York.


       [Extracted from the American Journal of the Medical Sciences, for Nov. 1827.]


  A detailed account of the first operation ever performed upon the
arteria iliaca communis, for the cure of aneurism, and especially of
the first attempt to  apply the ligature to  so  great  a vessel, without
dividing the  peritoneum,  may prove interesting to the profession ge-
nerally, and must be immediately serviceable to practitioners  of sur-
gery. It is therefore as an act of duty, rather than of choice, that the
following  statement has been  prepared, during such few and brief
intervals of leisure, as could be obtained amid the daily engagements
and solicitudes of business.
  On the 15th of March, 1827, I was  requested to visit a  patient
with  Dr.  Osborn, (of Westfield, New Jersey, about  twenty-five
miles distant from New  York,) whom  we  found labouring under a
large aneurism of the right external iliac artery.
  Israel Crane, aged  thirty-three years, by  occupation  a farmer, of
temperate and regular habits, having  generally enjoyed excellent
health, says about the middle of January he felt some pain about the
lower part of the belly, which he attributed  to a fall received during
the winter.   He is  in the  habit of using great efforts in lifting heavy
logs of wood, as his  employment at this season consists in carrying
wood to market.   It, however, was not until a fortnight since, that
he perceived any tumour about the lower part of the abdomen. Upon
examination, the abdomen on the right side was considerably enlarged
from about the crural arch, as high as the umbilicus. When the hand
was applied to the  parietes of the abdomen,  a pulsation was felt and
rendered visible to some distance.  To the  touch  the  tumour beat
violently, and appeared to contain only fluid blood.  It commenced
a little above Poupart's ligament, and  reached, judging by the touch,
from without, near the navel—inwards, almost to the linea alba—
outwards and backwards filling up all the concavity of the ilium, and
reaching beyond the posterior spinous process of that bone.
   The rapid increase of this aneurismal tumour occasioned, as the
countenance of our patient indicated, the most extreme agony.  His
sufferings at times  were so great that his screams could be heard at a
distance from the  house.   He had  been bled  several  times, taken
light food, and was kept constantly under the eflect of opium.   He
was now informed  of the serious nature of his case, and that  without 
(  4   )
an operation very little chance of his life remainedj with great com-
posure he immediately consented to whatever  would give him the
best prospect of saving his life.
  From the extent and situation of the tumour, he was apprised of
the uncertain nature of the operation, as well as the difficulty of per-
forming it, and indeed that it would  require an artery to be tied,
which never had been before operated  upon for aneurism.  With these
views of his situation, he cheerfully submitted  to be placed  upon a
table of suitable height in a room which was well lighted.
  Then, in the presence of Dr. Osborn, Dr. Liddle, and Dr. Cross,
the following operation was performed:—
  The pubes and groin  of the right side being shaved, an incision
was commenced just above the  external abdominal ring, and carried
in a semicircular direction half an inch above Poupart's ligament, un-
til it terminated a little beyond the anterior spinous process of the
ilium, making it in extent about five inches.  The integuments and
superficial fascia were now divided,  which exposed the tendinous
part of the external oblique muscle, upon cutting which  in the whole
course of  the incision, the  muscular  fibres  of  the internal oblique
were exposed;  the fibres of which were cautiously raised with the
forceps and cut from the upper  edge  of Poupart's ligament.  This
exposed the spermatic cord, the cellular covering of which was now
raised with the forceps, and divided to an extent sufficient to admit the
forefinger  of the left hand  to  pass upon the cord into the internal
abdominal ring.  The finger serving now as a  director, enabled me
to divide the internal oblique and transversalis muscles to the extent
of the external incision, while it protected the  peritoneum.   In the
division of the  last mentioned  muscles outwardly, the circumflexa
ilii artery  was cut through, and it yielded for a few minutes a smart
bleeding.   This, with a smaller artery upon the surface of the inter-
nal  oblique muscle,  between the rings, and one in the  integuments
were all that required ligatures.
  With the tumour beating furiously underneath, I now attempted
to raise the peritoneum from it,  which we found difficult and danger-
ous, as it  was adherent to it in every direction.  By degrees we sepa-
rated it with great caution from  the aneurismal tumour, which had
now bulged up very much into the incision.  But we soon found that
the external incision  did not enable us to arrive to  more  than half
the  extent of the tumour  upwards.  It was therefore extended  up-
wards and backwards about half an  inch within the ilium, to the dis-
tance of three inches, making a wound in  all about eight inches in
length.
  The separation of the peritoneum  was now  continued,  until the 
                            (   »   )
fingers arrived at the upper part of the tumour, which was found  to
terminate at the going off of the internal iliac artery.  The common
iliac was next examined by passing the fingers upon the promontory
of the sacrum, and to the  touch appearing to be sound, we deter-
mined to place our ligature upon it about half way between the aneu-
rism and the aorta, with a  view to allow length of vessel enough on
each side of it to be united by the adhesive process.
  The great current of blood through the aorta made it  necessary to
allow as much of the primitive iliac to remain between it and the li-
gature as possible, and the probable disease of the artery higher than
the aneurism, required that it  should not  be too low  down.   The
depth of this wound, the size of the aneurism, and the pressure of the
intestines downwards by the efforts to bear pain, made it almost impos-
sible to see the  vessel we wished to tie.  By the aid of curved  spatu-
las, such as I used in my operation  upon  the  innominata,  together
with a thin,  smooth piece  of board, about three inches wide, prepared
at the time,  we succeeded in keeping up  the  peritoneal  mass, and
getting a distinct view of the arteria iliaca communis, on the side of
the sacro vertebral promontory.  This required great effort on our
part, and could only be continued for a few seconds.  The difficulty
was greatly augmented by the elevation of the aneurismal tumour,
 and the interception it gave to the admission of light.
   When we elevated  the  pelvis, the  tumour  obstructed our sight;
 when we depressed it, the crowding down of the intestines presented
 another difficulty.   In this part cf the operation I was greatly assist-
 ed by Dr. Osborn and my enterprising pupil, Adrian A. Kissam.
   Introducing my right hand now behind the peritoneum, the  artery
 was denuded with the nail of  the forefinger, and the needle convey-
 ing the ligature was introduced from within outwards, guided by the
 forefinger of the left hand in order to avoid  injuring the vein.  The
 ligature was very readily passed underneath the artery, but  consider-
 able difficulty was experienced in hooking the eye of the needle, from
 the great depth of the wound and the impossibility of seeing it.  The
 distance  of the  artery from the wound was the whole length  of my
 aneurismal needle.
   After drawing the ligature under the artery, we succeeded by the
 aid of our spatulas and board in getting a  fair  view  of  it,  and were
 satisfied  that it was fairly  under the primitive iliac, a little below the
 bifurcation of the aorta.  It was now tied—the knots were readily con-
 veyed up to the artery by the forefingers—all pulsation  in the tumour
instantly ceased. The ligature upon the artery was very little below
 a point opposite the umbilicus. 
(   6   )
   The wound was now dressed with five interrupted sutures, pass-
ing them not only through the integuments, but the fibres of the cut
muscles,  so as to bring their divided edges together at all parts of the
incision, which was muscular. Adhesive plaster to assist the stitches,
lint and  straps to retain it, completed the dressing.  The operation
lasted rather less than one hour. *
   He was removed from the table and put into  bed upon his  back,
with the knee a little elevated upon pillows to relax the limb as much
as possible, and to avoid pressure upon it. It was considerably cooler
than the opposite leg, and flannels were applied all over  it,  and a
bottle of warm water to the foot.   From the  habit he had been in of
taking largely of anodynes, a tea-spoonful of the tinct. opii. was ad-
ministered, with directions to repeat it in an hour if the pain should
be severe.
  In less than one hour from the operation, considerable reaction of
the heart and arteries took place; he felt, as he stated, altogether re-
lieved from the excruciating agony he had suffered  since the  aneu-
rism  commenced.   The  whole limb  had now recovered its natural
temperature.
  March 16th.  The day after the operation,  pulse  eighty—skin
moist—limb warm as the other—complains of some pain at the liga-
ture—ordered a purgative of neutral salts.
   17th.—Pulse eighty, and fuller than yesterday—took  5x. of blood
from his  arm—skin  moist—tongue  brown—considerable uneasiness
in the limb—no pain at the ligature—leg of natural heat—salts had a
good effect.
  18th. Pulse seventy-five—skin moist—tongue white—pain in the
limb considerable—no pain at the  ligature or in the v/ound—limb
warm.
  19th. Bled him to-day to ten ounces,  the  pulse  being  tense  and

  * Dr. Gibson, then professor of surgery in Baltimore, being near the  spot
during the riots in that city, when  a  man was wounded by a musket ball,
"which entered the left side of the abdomen, passed through the  intestines,
opened the iliaca communis artery, and lodged in the  sacrum."  The doctor
states, "thrusting into it, (the wound,) the forefinger of my left hand, I dis-
covered that a very large artery had been torn across, and was pouring out
blood in considerable quantity."  The man died in a few days.  " Upon in-
specting the vessels of the abdomen," says the doctor, "I found that I had
placed two ligatures upon the common iliac aitery of the left side, one about
half an inch below the bifurcation of the aorta, and  the other immediately
above the division of the artery into the external and internal iliacs." See NK:
dical Recorder, Vol. 3, p.  185. 
(   7   )
beating eighty strokes in a minute—repeated the  cathartic—suppu-
ration appearing to have taken place, the dressings were removed.
   20th.  Pulse  seventy and soft—skin  moist—wound looks  well—
pain in the limb continues—leg warm as the other—cathartic operat-
ed well.
   21st. Pulse seventy and soft—wound  looks well—repeated the
laxative—pain in the leg rather less—continues warm.  There has
been at no time tension of the abdomen or any  particular uneasiness
in that part.  The patient thus far has been altogether more comfort-
able than could  have been imagined.  He takes more or less opium
daily,  from the long habit he has been in of taking anodynes.
   26th.  No unpleasant symptom—wound looks well—bled again to
  xij. as there was a  little tumefaction and inflammation about the
wound.
   30th.  Our patient continues to do well—--wound dressed daily.
   April 3d. Not being able to leave the city, I requested Dr. Proud-
foot, my late pupil, and a most promising  young surgeon, to visit the
patient.  He reports that he was free of fever—wound all healed but
where the large ligature was passing.  The ligature appearing to be
detached, the Dr. took hold of it and removed it: this was on the
eighteenth day from the time of its application.  Limb of the natural
temperature—enjoined upon him to keep very quiet and in bed.
   8th.  There are no disagreeable appearances whatever—he appears
to be doing remarkably well—has been  bled once since the last re-
port—takes a purgative every other day, and an opiate every night—
pulse as in health—no pain—says he is entirely comfortable—wound
is dressed with dry lint.
   16th.  Has improved rapidly since the last report.  Two days after
the ligature came away he very imprudently got out  of bed  without
experiencing any difficulty, except  weakness.  Rode out  to-day—
wound perfectly healed.
   April 26th.  He has  been using crutches for  a few  days to favour
the lame leg, which, as yet, feels rather weak.  General health great-
ly improved.
   50th. Is perfectly restored in health—has  a  little stoop in his
walk, which he says is occasioned by the external cicatrix.   Leg is
not yet of its  full size, nor quite so strong as the   other.  From the
period of the operation, to the recovery of our patient, he did not ap-
pear to suffer more pain, or have more  unpleasant symptoms, than
would  ordinarily take place in a flesh wound of equal extent. Much
of this, in my opinion, is to be attributed to the  prompt and judicious
antiphlogistic treatment pursued by Dr. Osborn,  to whom  I am in-
debted for the daily  reports of the case. 
(   »   )
   May 29th.  My patient visited me to day, having come twenty-five
miles; he was so  much improved in health that I did not recognize
him.  Examined the cicatrix and found it perfectly sound—could not
discover any remains of aneurismal tumour—felt the epigastric artery
much enlarged and beating strongly, and  a feeble, though  distinct
pulsation in the  femoral artery  immediately below the crural arch.
The leg has its natural temperature and feeling, and he says it is as
strong as the other.
   Much credit is due the patient for his firmness on the occasion;
although apprised of the great danger attending so formidable  an ex-
periment, and the uncertainty of its result; yet with a fortitude un-
shaken, and a full conviction that it was the only chance of prolong-
ing his life, he cheerfully and resolutely submitted to the operation.
   The gratification his visit afforded me is not to be imagined, save
by those who have been placed under  similar circumstances.   The
perfect success of so important and novel an operation, with the  en-
tire restoration of the  patient's health, was a rich reward for the
anxiety I experienced in the case, and in a measure compensated for
the unexpected failure of my operation on the arteria innominata.

   Xcw York, 25 Park Place, October  15th, 1827. 
 
I
I