of the bloodless nictJwd. If, however, the trunks of the veins are entirely
empty and have collapsed, it may be difficult to distinguish them from the
THE TREATMENT OF WOUNDS
249
\
layers of cellular tissue. For this purpose it is advisable to form a blood
reservoir below the wound by placing, for instance, before the elastic. bandag-
ing of the injured arm, _ _
a constrictor band around
the wrist. If this con-
strictor is subsequently
removed, and if the arm
is raised, the blood which
had remained confined
in the hand fills the
veins, and, in case one
of the veins is injured,
gushes from the vein
wound.
When the injured
place of the artery or the
vein has been found, and
has been exposed so far
that the whole extent of
the injury can be sur-
veyed or inspected, the
vessel must be isolated
and firmly and securely
ligated in the healthy
part above and below the
injury with catgut or silk
("reef knot"). Next,
if the continuity of the
vessel is not already in-
terrupted by the injury,
it is divided in the mid-
dle between the two liga-
tures, and the operator
convinces himself that
no principal branches of
the vessel are interposed between the two Hgatures. If such branches
are found they must also be well isolated, ligated, and separated from
the trunk of the vessel. In order to proceed with absolute safety the
injured portion of the vessel lying between the two ligatures can be excised.
Fig. 447. Arteries of the Thigh
250
SURGICAL TECHXIC
Next, the constrictor band is removed, and all the vessels from which
blood is still oozing are carefully ligated, while the limb is raised in order to
limit the parenchymatous hemorrhage.
1.^
Fig. 44S
Arteries of Arm
Fig. 449 Fig. 450
Arteries of Leg. a, posterior side; h, anterior side
THE TREAT-MEXT OF WOUNDS 25 1
LIGATION OF ARTERIES AT THE PLACE OF SELECTION
(hunter's indirect ligation;
The ligation of an artery above the wound is hardly ever resorted to at
the present 'ixm.o. for arrestmg hemorrhages ; but it is much to be recom-
mended for practising the technique and for testing the knowledge of topo-
graphical anatomy. Ligation of arteries, however, is often made to prevent
permanently the flow of blood to certain parts of the body in important and
bloody operations, or to heal diseased conditions. Thus the carotid artery
is ligated in resection of the upper jaw; the lingual, in operations on the
tongue; the thyroid arteries, in struma vasculosa (vascular goitre); the sub-
clavian, in the disarticulation of the shoulder joint; the common iliac, in
disarticulation of the thigh ; the hypogastric, in tumors of the pelvis and
hypertrophy of the prostata. (Preliminary ligation of large arteries in
performing the operations mentioned above is seldom performed at the
present time, since the surgeon has been placed in possession of local
hemostatic resources which, if properly applied, make him master of the
situation in arresting the hemorrhage.)
The following rules should be observed in finding and ligating the trunks
of the principal arteries : —
1. The surgeon should recall very exactly and vividly to his memory the
anatomical relations of the place of ligation before commencing the oper-
ation. The direction and length of the skin incision is made accordingly.
It is of advantage to indicate the incisions by a line drawn upon the surface
of the skin.
(This advice may be of some benefit to the novice in surgery, but no
experienced surgeon would think for a moment of adopting it. )
2. The portion of the body is placed in the most advantageous position
for the operation, and in the best light.
3. If the operation is to be performed on one of the extremities, it is
advantageous to constrict the same previously, and to citt off the flow of
blood with the modification mentioned above in direct ligation. As soon
as it is of importance to feel the pulsation of the artery, the upper con-
strictor is removed.
4. The external incision is made either free hand, while the fingers of
the left hand stretch well the surrounding integument and the knife pene-
trates everywhere the whole thickness of the skin (Fig. 335), or when the
artery or other important parts are lying directly under the skin, by raising
2 C2
SURGICAL TECHXIC
a transvci'se ciUaneous fold, which is divided with one sweep of the knife
(Fig. 338).
5. In penetrating deeply, with care, the operator and his assistant grasp
with two good forceps the uppermost layer of cellular tissue on both sides
of the axis of incision, and at the same time raise the
cellular tissue so that the air can enter into its meshes
(emphysema). One sweep with the knife divides the
raised cellular tissue (Fig. 451).
Immediately both forceps release their hold and
grasp, now above and now below, the slit thereby
made ; again the layer of cellular tissue is lifted up
toward the knife, which divides the fibres until the layer
is divided from one angle of the wound to the other.
This procedure is repeated in dividing the remaining
layers until the sheath of the artery is reached. Any veins, small arteries,
nerves, and muscles which are met are drawn aside wdth blunt retractors.
6. As soon as the sheath of the artery has been exposed, the forceps
grasp the middle of the sheath of the artery, lift it upward, and raise it in the
form of a cone ; the handle of the knife is lowered laterally and so far in an
exterior direction that the lateral surface of the blade is turned against the
artery, while the point of the knife enters at a right angle to the point of
the forceps, and under it into the grasped cone (Fig. 452).
Fig. 451. Division of
Cellular Tissue be-
â– nvEEN Two Forceps
Fig. 452. Opening Sheath oi hil Akilry
A small incision opens the sheath, and while the forceps lift up the tri-
angular segment formed thereby, the point of the knife carefully separates
the sheath of the artery from the arterial wall.
(In ligating large vessels, their sheaths should be incised freely, as it
facilitates their isolation from adjacent important structures, and does in
THE TREATMENT OF WOUNDS
253
453. Introducing
Curved Probe
Fig. 454. Introducing Aneu-
rism Needle
no way interfere with the nutrition of the ligated ends. By applying the
ligature through a small slit in the sheath, important structures are often
included in the ligature.)
7. In the case of large arteries, this procedure is con
tinned as follows : while the surgeon still holds the divided
cone, he introduces with his right hand another pair of closed for-
ceps into the opening at the base of the cone between the artery and
the cellular sheath ; here he grasps the inner wall of the cellular
sheath and draws it forward. By this means, the artery is gently
rolled around its axis, and the cellular tissue fibres, which fasten
the sheath to the lateral and posterior wall of the artery, appear to
view ; they are detached in the same careful manner and only as
far as the opening first made. If the sheath of the artery is
detached too far, the artery can become necrotic, and then sec-
ondary hemorrhage occurs at the place of ligation.
(In his experiments on the lower animals, the editor isolated
arteries the size of the common carotid to the extent of 2 inches
or more, and after double ligation never observed necrosis or sec-
ondary hemorrhage.)
In case of the largest arteries, the procedure must also be
repeated on the other side after one-half of the circumference has
been liberated.
8. As soon as
the artery has been
freed on all sides,
a curved p7'obe (or
a strabismus hook)
is carefully intro-
duced, and always
carried around the
v&ssqY from the side
on which the principal vein lies, while with a forceps the margin of
the incision of the sheath is held taut (Fig. 453).
9. With a probe, the artery is lifted up so far that a small
Coopers or Syme s aneurism needle (Fig. 455) with an eye at its
point can be passed around the same in an opposite direction
(Fig. 454). Fig. 455
10. Next, the probe is removed, a strong cats^nt or silk thread is ^^"^^^'^
1 Aneurism
passed through the eye of the needle, and the needle is with- needle
254 SURGICAL TECHNIC
drawn ; the middle portion of the ligature remains in position under the
artery.
II. The ligature is tied around the artery and tied in a "reef knot" —
see Fig. 365 (not with a '^ gt-amiy knot'' — see Fig. 366) and ivithoiit dis-
placing the artery ; the knots must be tied in the depth of the wound with
the points of the two index fingers (Fig. 456).
Fig, 456. Tying Ligature
12. It is advisable to ligate the artery doubly and to divide the vessel-
between the two ligatures so that the two ends can retract into the sheath
of cellular tissue.
(Dovible ligation of an artery in its continuity without division of the ves-
sel, if the operation is performed under the necessary aseptic precautions,
furnishes absolute protection against secondary hemorrhage.)
LIGATION OF THE PRINCIPAL TRUNKS OF THE ARTERIES
CAROTID ARTERY
The common carotid takes its course from the sternoclavicular articula-
tion behind the sternocleidomastoid perpendicularly upward, and is crossed
opposite the lower margin of the cricoid cartilage by the omohyoid muscle
on a level with the sixth cervical vertebra (tuberculum caroticum — Chas-
saigiiac). Below the omohyoid muscle it lies behind jDlatysma, fascia, sterno-
mastoid muscle, sternohyoid, sternothyroid, and the anterior jugular vein ;
in front of it lies the inferior thyroid artery and the recurrent laryngeal
nerve. Above the omohyoid muscle, the artery lies only behind the pla-
tysma, cervical fascia, and the internal margin of the sternocleidomastoid.
The strong sheath of the artcjy contains, toward the median line, the caro-
tid, laterally the internal jugular vein, and in a posterior direction between
the two the nervus vagus (pneumogastric); the descendant branch of the
THE TREATMENT OF WOUNDS
255
hypoglossal nerve passes over it, and closely behind it the sympathetic
nerve (Fig. 457). At the height of the third
cervical vertebra opposite the superior mar-
gin of the thyroid cartilage, the common
carotid divides into the external and the
internal carotid.
The external carotid is covered at its ori-
gin from the common carotid at the height
of the superior margin of the thyroid carti-
lage, only by skin, platysma, cervical fascia,
sternocleidomastoid, and the facial vein, as-
cends in a gentle curve to the height of the
neck of the lower jaw (collum mandibulae), Fig. 45
and is crossed in its course at the height of
the hyoid bone by the biventer muscle, the
hypoglossal nerve, and further up by the
stylohyoid muscle. Upon its external mar-
gin, the descending ramus of the hypoglossal nerve takes its course. At its
Situation of the Carotid
Artery (Cervical Section), i, carotid;
2, jugular vein; 3, pneumogastric
nerve; 4, hypoglossal nerve; 5, brach-
ial plexus; 6, sympathetic nerve;
7, vertebral artery
A. iemporalis^
A. maxUlaris int.-
A. auricularis post.-
3^
IV'
A. pliaryngea asc.
A. hngualis
I A. maxilla} is externa
I I AT. hiienfer
1^1 I '^^ mylohyoideus
II AM - h
M. stylohyoideus—
^M. hiventei -
A. cccipiialis-
Carotis iiiterna -
Carotis externa -
Carolis communis -
M. oniohyoideus -
M. sternothyreoideus .
Fig. 458. Branches of the External Carotid Artery
posterior surface it is crossed by the superior laryngeal nerve, a branch of
the lingual artery, and the glossopharyngeal nerve above the biventer
256
SURGICAL TECHXIC
muscle. It can be ligated most easily between the branches given off as
the superior thyroid artery and the lingual artery.
The internal carotid ascends from the bifurcation of the common carotid
as its continuation to the carotid canal in the petrous portion of the tem-
poral bone, and lies somewhat posteriorly and externally from the external
carotid (Fig. 458).
LIGATION OF THE COMMON CAROTID
(rt) On a level with the cricothyroid ligament (Fig. 459, Plate I. i).
I. After a pillozv has been placed under the shoulders, the head {â– s, well
extended.
Fig. 459. Ligation of the Common
Carotid Artery
Fig. 460. Ligation of the Common Carotid
Artery between the Two Heads of
the Sternocleidomastoid
2. External incision 6 centimeters in length, along the inner margin of
the sternocleidomastoid, commencing on a level with the superior margin of
tJie thyroid cartilage {YX^Xq. Li).
3. Division of tJie platysma and the cellular tissue (avoiding the super-
ficial veins).
4. The sternocleidomastoid (st) is drawn outxvard ; the omohyoid {0),
downward (Fig. 459).
5. The descending branch of the hypoglossal nerve {Ji), which passes
over the artery in a downward direction, is drawn outivard.
6. Opening of the common sheath over the middle portion of the artery.
The same (^) lies iniuardly ; the internal jugular vein {J), externally and a
PLATE I
External Incisions for ligating the arteries, i, 2, Common Carotid. 3, Lin-
gual. 4, Masseteric. 5, Temporal. 6, Occipital. 7, Subclavian.
v^^^X'
'^'
Ligation on a level with the crico-
thyroid ligament.
Ligation between the two heads of
the sterno-cleido mastoid muscle.
Ligation of the Common Carotid Artery
THE TREATMENT OF WOUNDS
257
little more superficially ; t)i& p7ieitmogastric nerve (r'), deeply between the two.
The sympathetic nerve courses behind the carotid
(Fig. 457).
7. The artery needle with a silk thread must be
carried around itfroiii the oiLtside. Great care should
be taken not to injure the pneumogastric nerve.
{b) Between the two (Plate I. 2) heads of the ster-
nocleidomastoid muscle (Fig. 460 j.
1. External incision, 6 centimeters in length ;
between the two heads of the sternocleidomastoid
downward to the clavicle, 2 centimeters outward from
the sternal articulation (Plate I. 2).
2. Division of the platysma. The slit between
the sternal and the clavicular portion of the sterno-
cleidomastoid is enlarged with tJie fingers until the
internal jugular vein appears to view (Fig. 460,7").
3. The vein, with the clavicular portion {cl), is
drawn carefully oiitivard by the finger of the assist-
ant ; the stei'nal portion {st), with the sternohyoid
and the sternothyroid muscles, is drawn imvard.
4. At the inner side of the vein appears the pnen-
viogastric nerve (v) ; a little more inwardly and deeply lies the artery (e).
On account of the deep position of the artery this place is selected for liga-
tion only in exceptional cases.
Fig. 461. Ligation of the
External Carotid Ar-
tery. //, skin; nk, h>-po-
glossal nerve; o/i, hyoid
bone (greater cornu) ; zf,
facial vein; sm, sterno-
cleidomastoid
LIGATION OF THE EXTERNAL CAROTID
(Plate II. I)
1. Position as described above.
2. External incision 6 to y centimeters in length, along the inner margin
of the sternocleidomastoid, from the level of the thyroid cartilage toward
the angle of the lower jaw.
3. Division of Xh^ platysma and the sipeificial fascia.
4. The digastric muscle and the hypoglossal nerve in the superior angle
of the wound are drawn Jipward ; the superior thyroid vein and the facial
vein in the lower angle are drawn downward ; the intertial carotid and the
jugular vein are drawn outward.
5. After the artery has been exposed, the artery needle is carried around
it from without inwardly, guarding against any injury to the superior laryn-
geal nerve.
258 SURGICAL TECHNIC
LIGATION OF THE INTERNAL CAROTID
1. External incision 6 centimeters in length, parallel to the anterior
margin of the sternocleidomastoid, a little more outward than the preceding
incision.
2. After division of these several layers of tissue, the external carotid is
exposed and drawn inward ; the digastric muscle is drawn upward.
3. Opening of the sheath covering the internal carotid, which is now
exposed. The artery needle is carried around it carefully from without in-
ward, since the internal jugular vein, the pneumogastric nerve, the sympa-
thetic, and the ascending pharyngeal artery are lying close to the vessel.
Kocher exposes the bifurcation of the carotids and the branches of the
external carotid by means of a transverse incision (Plate II. a, i ), as follows: —
1. External incision, a finger's breadth below and behind the angle of
the jaw in a line extending from the anterior extremity of the mastoid pro-
cess to the middle of the hyoid bone.
2. After division of the platisma the external jugular vein and the great
auricular nerve coursing behind it are drawn backward.
3. By division of the fascia, the anterior margin of the sternocleido-
mastoid is exposed and drawn backward, whereby the common facial vein
appears to view as far as its place of anastomosis with the common jugular
vein. It is drawn downward and outward.
4. The external carotid is now exposed, distinguishable by the superior
thyroid artery branching off directly above its origin ; at its side and
behind it lies the internal carotid (without branches).
5. In exposing the external carotid care must be taken not to injure the
descendant ramus of the hypoglossus (anteriorly upon the artery), and
the superior laryngeal nerve (coursing obliquely behind the artery). At the
point of exit of the external maxillary artery the hypoglossal nerve sur-
rounds the external carotid from behind and exteriorly.
From this incision also the trunk of the Hngual artery, the external
maxillary artery, and the occipital artery can be ligated (Fig. 457).
The external maxillary artery (facial) is found at the lower margin of the
inferior maxillary bone, near the anterior niargin of the masscter under the
skin (Plate I. 4).
The temporal artery is exposed by a vertical incision 2 centimeters in
length upon the zygomatic arch between the tragus and the condyle of the
lower jaw (Plate I. 5).
PLATE II
Ligation of the External Carotid Artery
â– ^
Ligation of the Lingual Artery
THE TREATMENT OF WOUNDS
259
The occipital artery is found in the line between the posterior margin of
the mastoid process and the external occipital protuberance (Plate I. 6).
LINGUAL ARTERY
The ling2ial artery, as the second branch from the external carotid (2 cen-
timeters above its bifurcation) arising on a level with the greater cornu
of the hyoid bone (Fig. 458), ascends a short distance, is crossed by the
digastric and the sternohyoid muscles, passes transversely upon the my-
lohyoid muscle beneath the posterior margin of the hyoglossus muscle,
behind which it takes its course along the upper border of the greater
cornu of the hyoid bone, parallel to the hypoglossal nerve, passing over it
and upon the hyoglossus muscle, thence upward to ramify at the under
surface of the tongue (ranine artery).
LIGATION OF THE LINGUAL ARTERY
(Plate II)
1. External ijicision 4 centimeters along the upper margin of the greater
cornu of the hyoid bone.
2. Division of the platysma ; the posterior facial vein is drawn out-
ward.
3. The external belly of the digastric mnscle is nozv exposed (Fig. 462, d),
behi7id and beneath which the hypoglossal
nerve {hp) appears. The submaxillary
gland {gl) is drawn tipzuard.
4. The hypoglossal nerve passes in
front of the hyoglossus muscle {hg) accom-
panied by the lingual vein ; beneath the
nerve, the lingual artery {a) lies behind
the hyoglossus muscle.
5. Between- the hypoglossal nej-ve and
the greater cornu of the hyoid bone (oh\ the fibres of the hyoglossus muscle
are carefully divided ; directly behind it lies the lijigual artery, accompanied
by a vein.
Also, in the trigonum linguale (lingual triangle) between the external
belly of the digastric and the lateral margin of the mylohyoid muscle
{mil), the artery can be ligated after division of the hyoglossus muscle
(^Htceter).
Fig. 462. Ligation of Lingual Artery
26o
SURGICAL TECHNIC
SUBCLAVIAN ARTERY
The subclavian artery takes its origin on the left from the arch of the
aorta, on the right from the innominate artery, courses in a shght curve be-
hind the clavicle between the scalenus anticus and medius muscles, thence
crossing obliquely over the surface of the first rib to the axilla. The scalenus
medius and posticus muscles lie behind and across the artery. Beneath
and in front of the scalenus anticus muscle will be found the subclavian
vein.
LIGATION OF THE SUBCLAVIAN ARTERY
(fl) In the supraclavicular fossa (Plate III. i).
1. The arm is drawn downward ; the head, toward the healthy side ; a
pillow is placed under the back.
2. External incision 6 to 8 centimeters in length in the form of a curve
from the external margin of the sternocleidomastoid to the external third por-
tion of the clavicle, obliquely across the supraclavicular fossa.
3. ThQ platysma is divided ; the margin of the sternocleidomastoid (st) is
exposed ; the external jugular vein (_;') must not be injured ! (Fig. 463.)
4. Division of the superficial layer of the fascia of the neck and of the
adipose cellular tissue in the supra-
clavicular fossa.
5. The omohyoid (0) is sepa-
rated and drawn upward.
6. Incision through the adipose
and cellular tissue (with veins!)
to the scalenus muscle {^sc\ the
tendon of which can be felt at
the side of the tubercle of the
first rib.
7. The internal margin of the
brachial plexus {pi) appears to view
and is drawn upward and out-
ward.
8. Between the scalenus mus-
cle and the brachial plexus, but a little deeper than the latter, lies the artery ;
it becomes visible after division of the deep layer of the deep fascia of
the neck.
Fig. 463. Ligation of Subclavian Artery in
THK Supraclavicular Fossa
PLATE III
1, Above the Clavicle
2, Below the Clavicle
I, Above the Clavicle in the
Supra-Clavicular Fossa
2, Below the Clavicle in the
Infra- Clavicular Fossa
Ligation of the Sub-Clavian Artery
THE TREATMENT OF WOUNDS
261
9. The subclavian vein {vs) lies in front and beneath the tendon of the
scalenus muscle and closely beJmid the clavicle.
Injury to the external jugular vein (along the external margin of the
sternocleidomastoid), to the suprascapular artery (near the clavicle), to the
transverse cervical artery (upon the brachial plexus), to the phrenic nerve
(/) (which descends upon the scalenus), must be avoided.
{b) In the infraclavicular (Plate III. 2) fossa.
1. The shoulder is forced upward.
2. An external incision 6 to 8 centimeters in length, beginning at the
coracoid process parallel to the external half of the clavicle, exposes the
triangular depression between the deltoid and the pectoralis major muscles
(trigonum Mohrenheimii, Moh-
renheim's fossa), in which the
cephalic veiii joins the subclavian
vein.
3. The cephalic vein {ce^ is
drawn externally with the mar-
gin of the deltoid imcscle{d), the
margin of the pectoralis major
muscle {pmj ) (which in case of
necessity is freed to some extent
from the clavicle) is drawn in-
ward (Fig. 464).
4. After division of the adipose cellular tissue, the coracoclavictdar fascia
appears in the depth of the opening ; this is carefully divided. In most
cases, the external thoracic artery must be ligated.
5. The pectoralis minor muscle (^pmi) can be seen ; its internal (upper)
margin forms with the subclavius muscle an angle opening inward. The
artery lies deeply in this angle between the brachial plexus {pi) and the
subclavian vein (vs), the vein lying inward, the nerve outward.
In case of necessity, the pectoralis minor muscle may be detached from
the coracoid process, and the artery ligated nearer the axilla. Temporary
resection of the clavicle and drawing apart the bone, after it has been
sawed through, may also facilitate the operation in difficult cases, and
enlarge the field of operation {von Langenbeck). This is especially of
great advantage in punctured wounds of the artery behind the clavicle
{Rotter).
Fig. 464. Ligation of Subclavian Artery in the
Infraclavicular Fossa
262 SURGICAL TECHNIC
VERTEBRAL ARTERY
The vertebral artery takes its origin from the superior and posterior cir-
cumference of the subclavian opposite the external mammary artery, passes
close to the inner edge between the internal margin of the scalenus anticus
muscle and the longus colli muscle in an upward direction, in order to enter
the opening of the intertransversary canal in the transverse process of the
sixth cervical vertebra ; immediately behind its entrance into the canal lie