Fig. 487. Ligation of the Anterior
Tibial Artery above the Middle
of the Leg
(Plate IX)
ia) Above the middle of the leg (Plate IX.
I)-
1. External incision 6 to 8 centimeters in
length, 3 centimeters outward from the crest
of the tibia (in the middle between the tibia
^^S and the fibula).
2. Division of the fascia in the direction
of the tendinous white line, which indicates
the space betzveen the tibialis antic?is (^tdy
and the extensor hallucis longus innscles
{eh). This intermuscular space is sought
for and enlarged with the point of the iji-
dex finger, until the deep fascia is reached
(Fig. 487).
3. After a careful division of the deep
2/6
SURGICAL TECHNIC
fascia, the artery is exposed between the two accompanying veins ; on its
outer side lies the anterior tibial nerve (;/).
{b). In the lower third of the leg (Plate IX. 2).
1. External incision 5 to 6 centimeters in length, vertical, a finger's
breadth outward from the crest of the tibia.
2. Division of the fascia. In the space between the tibialis anticns (ta)
and the extensor hallncis longns {eh), the index finger is inserted, and by
upward and downward strokes separates the
bellies of the muscles as far as the interosse-
ous membrane (2 to 3 centimeters deep) (Fig.
488).
3. On this lies the artery between two
veins, accompanied in front and on the inside
by the deep branch of the anterior tibial
nerve (//).
{c) On the dorsum of the foot (Dorsal
artery of the foot; (Plate IX. 3).
1. External ificision 4 centimeters long
closely at the outer border of the tendon of
the extensor longus hallucis from the sca-
phoid bone downward.
2. The musculo-cutaneous ner\'e is drawn
outward. Division of the fascia and the cru-
ciate ligament ; the tendon of the extensor
Jiallucis is drawn inward ; the artery appears between two veins, in an
inward direction and upon it the anterior tibial nerve.
Fig. 488. Ligation of the Ante-
rior Tibial Artery in the
Lower Third of the Leg
LIGATION OF THE POSTERIOR TIBIAL ARTERY
(Plate X)
a. Above the middle of the leg (Plate X. i).
1. External incision 8 to 10 centimeters in length, i centimeter to the
inner side of the internal border of the tibia.
2. After division of the fascia, the border of the gastj-ocneviiiis{g) is drawn
backward ; the salens is separated from the flexor longus digitoruvi, and the
space between these muscles is enlarged with the point of the finger until
the deep aponeurosis is reached, which consists of the tendinous fibres of the
soleus and the deep fascia of the leg.
PLATE X
Above the middle
of the leg
Behind the Internal
Malleolus
Ligation of the Posterior Tibial Artery
THE TREATxMENT OF WOUNDS
277
3. After divisioji of this apo7teicrosis, the artery appears between two
veins ; under it lies the tibial
nerve (n).
b. Behind the internal malle-
olus (Plate X. 2).
I. External incision 3 to 4 cen-
timeters in length in the middle
between the interjial malleolus and
the tendon of
Achilles.
2. Division
of the sural fas-
cia { f),&\iQ,ngth.-
ened by the
fibres of the li-
gatnentimt laci-
niatu^n (Fig.
490, 1).
3. Directly
beneath lies the
artery between
the two accompanying veins, behind it the tibial nerve (;/).
The sheatJis of the tendons of the tibialis posticus, of the flexor longus digi-
torum, and '^o. flexor longus hallucis must not be opened.
Fig. 490. Ligation of
THE Posterior Tib-
ial Artery behind
the Internal Mal-
leolus
Fig. 489. Ligation of the Posterior Tiblai.
Artery above the Middle of the Leg
TRANSFUSION AND INFUSION
After a sudden great loss of blood from injuries or from long-continued
bloody operations, especially in weak patients, the arterial blood pressure,
on account of the defective filling of the blood vessels, soon sinks to such a
degree that the heart is no longer able to propel the contents of the vascular
system.
It acts like an empty pump, without producing any effect, and hence
death ensues from excessive hemorrhage at a time when there still remains
in the vessels a sufficient quantity of blood for the preservation of life.
It is, therefore, of importance to fill the vascular system sufficiently to
enable the heart to perform its function effectually.
The direct transfusion of blood from the artery of a healthy human being
into the vein of a person who is bleeding to death fills the arteries again, and
278 SURGICAL TECHNIC
thus saves life. Unfortunately, however, in doing this it is not possible, in
the conducting canula, to prevent absolutely the formation of coagula, which
seriously obstruct the vessels of the patient receiving the blood. Moreover,
the surgeon succeeds only in rare cases in obtaining a willing, healthy person
to furnish the blood supply for the purpose of saving the life of another.
The direct transfusion of blood from an animal into the veins of a human
being is absolutely to be rejected, because by mixing various kinds of blood
a poison is formed, which rapidly dissolves the red and the white corpuscles,
and causes not only coagulation, but also hemoglobinaemia and hemoglo-
binuria, which, in most cases, are fatal.
Moreover, according to more recent investigations {Kohle}' and others),
the tj'ansfiision of defibrinated blood even from human beings is just as
dangerous, because during the beating of the blood, the fibrin ferment,
having been set free, produces coagula in the circulation and dissolves the
blood corpuscles (ferment intoxication, KoJilcr). Hence, according to modern
views, transfusion of blood whole and defibrinated is to be rejected.
On the other hand, the intravenous infusion of an alkaline solution of
sodium chloride is sufficient in increasing the blood pressure in the blood
vessels to such a degree that the heart can again projoel the blood column
and convey nutrient material to the organs {Kronecker). The sodium chloride
solution is prepared as follows : Dissolve 7 grams of pure salt in one liter
of sterilized water ; add three drops of a solution of soda or one gram of
sodium carbonate. Landerer {Lndwig) adds to this 3 % to 5 % of sugar,
which best preserves the blood corpuscles, and serves as a nutrient material ;
the blood pressure is rapidly raised by an active endosmosis.
In performing the operation, a subcutaneous vein (for example, the
median basilic vein at the bend of the elbow, or the great saphenous vein
in front of the internal malleolus) is exposed by incising a fold of skin,
and isolating it to such an extent that tivo catgut ligatures can be passed
under it.
With one ligature, the peripheral side of the portion of the vein is ligated ;
the other ligature is pushed under the central part.
The exposed vein is opened ; the upper wall is lifted with fine tenaculum
forceps, and an oblique incision is made with the scissors, so that a small
flap wound results (Fig. 491).
By raising the flap, the vein is made to gape, and into the central end
of the vein a canula, rounded at its point (of glass, hardened caoutchouc, or
silver), is introduced and securely tied with the second catgut ligature.
The canula and the rubber tube fastened to it, together with the hard
THE TREATMENT OF WOUNDS
279
rubber tip, are completely filled with the sodium chloride solution, and closed
by means of a stopcock.
For pouring in the sodium solution, either a glass funnel or a graduated
glass cylinder (Fig. 492), of the capacity of 300 to 400 fluid grams, is used,
terminating below in a perforated olive-shaped
point, over which a rubber tube 30 centime-
ters long is drawn. To the lower end of the
latter a small perforated attachment of hard-
ened caoutchouc or glass is fastened, which
fits exactly into the connecting piece.
Fig. 491. Intravenous Infusion
INTRODUCING THE CaNULA
Fig. 492. Infusion with a Graduated
Glass Cylinder
After the vessel has been most carefully cleansed and sterilized, it is filled
with the chloride of sodium solution heated to 40° C. ; the end of the tube
is lowered until the fluid escapes, and securely inserted into the canula.
280 SURGICAL TECHNIC
After all air bubbles have been removed from the tube by pressing and
stroking it upward, the operator raises the glass cylinder with one hand
about half a meter high (corresponding to the blood pressure in the veins),
and with the other hand opens the stopcock to such an extent that the
column of water is seen to enter the vein very slozvly (at the rate of lO
cubic centimeters a second).
The stopcock can also be removed entirely, and the rapidity of the
injection can be regulated by raising and lowering the glass cylinder.
For preventing the fluid from coohng during the injection, the hand
which holds the glass cylinder can hold against it a rubber bag filled with
hot water (Fig. 492).
As soon as the cylinder is nearly empty, the tube is closed by the pressure
of the finger, and detached from the canula.
Next, the canula is withdrawn from the vein, the central end is ligated,
the wound is carefully cleansed and disinfected, and an antiseptic dressing
applied.
The use of a syringe for infusion is not to be recommended ; first : it
might cause too much pressure ; second : by its piston the fluid is easily
contaminated (rancid oil, dry fluid collections from using it previously,
etc.); third: there is greater danger of the entrance of air into the vein.
During transfusion sometimes cyanosis, dyspnoea, and syncope occur, so
that the operation must be interrupted. In most cases, fever, chills, pains
in the lumbar region, moreover, blood and albumen in the urine, occur after
its conclusion.
The subcutaneous infusion of the sodium chloride solution can be made in
a simpler manner. Connect the tube of the glass vessel, containing the
sodium chloride solution (for instance, syringes. Figs. 493, 494, in which,
under a stopper of loose cotton, the infusion fluid is kept sterile ; it must be
warmed when used), with an aspiration needle or a fine trocar ; insert the
instrument by raising a cutaneous fold on any portion of the body (for ex-
ample, the breast), and by elevating the vessel, allow the fluid very slowly to
infiltrate the loose cellular tissue ; it is further distributed by pressure and
kneeding (effleurage). Generally a liter is sufficient, still even three to four
liters have been infused {Sa/ili). Cantani has used this method success-
fully as a hypodermoclysma in the inspissation of blood causing desiccation
in the algid stage of cholera ; likewise it has proved successful in exten-
sive burns, carbonic oxide poisoning (after previous venesection), also after
prolonged laparotomies ; but the intravenous infusion produces a better
effect even in this case.
THE TREAT-MENT OF WOUNDS
281
If the hemorrhage has not been so great that life is in immediate dan-
ger, but if only great weakness and syncope exist, an attempt is made to
Fig. 493 Fig. 494
Syringe Bottles for Subcutaneous Infusion, a, Sahli's apparatus with hollow
needle and thermometer; b, Fiirbringer's apparatus with trocar
revive the patient by placing him in the dorsal recumbent position with the
head low to prevent anaemia of the brain, and by means of administering
stimulants (smelling salts, camphor, ether, alcoholic stimulants) to rouse the
Fig. 495. AUTOTRANSFUSIUN
cardiac function ; the external applications of dry heat (hot bottles, blankets)
to counteract the lowering of the body temperature should never be neg-
282
SURGICAL TECHNIC
lected, and large quantities of liquid nourishment, which is very rapidly
absorbed, will prove valuable in increasing the contents of the vascular
system. The latter is also effected by autotransfusion, by raising one or
more limbs, or by rendering them temporarily bloodless by elastic constric-
tion in the. manner described before. The blood still present in the limbs is
thereby forced into the other parts of the vascular system, and the blood
pressure is raised to such a degree that the heart is capable of performing
its function (autotransfusion, Fig. 495).
By this procedure, transfusion can sometimes be dispensed with ; some-
times, at least, the ebbing life can be sustained until transfusion can be
made.
BLEEDING
was resorted to in former times very frequently in the treatment of the
most various diseases, especially in combating inflammation and in subduing
congestion in different parts of the
body. For this purpose, aside from
puncturing, scarifications, leeches,
and cupping, there was employed
venesection {phlebotomy), which is
now but rarely (oedema pulmonum
pneumonia) performed.
The operation is made exclu-
sively on the arm and on that vein
which is most distinctly prominent
under the skin. This is mostly the
median basilic vein. Since, how-
ever, the latter, as a rule, is crossed
by the brachial artery, and is divided
from it only by the thin aponeurosis
of the biceps muscle, it is advisable
to feel for the pulsation of the artery
before the operation, and to make
venesection either above or below
the point of crossing.
1. The patient lies on his back with the arm in a hanging position in
order that the veins may become distended with blood.
2. A bandage (or a folded cloth) is placed around the middle of the arm
with sufficient firmness so that the return flow of the venous blood becomes
Fio. 496. Bleeding with the Phlebotome
(Phlebotomy)
THE TREATMENT OF WOUNDS
283
Fig. 497. Bleeding \\ith the Lancet
arrested, but not the afferent flow of the arterial blood (the radial pulse
must not disappear) ; the knot of the bandage must be arranged in such a
manner that it can be loosened by making traction on the end which hangs
down (Fig. 496). The surgeon fixes the
arm by forcing his hand between it and
the breast ; the vein is fixed by pressure of
his thumb below the place of puncture.
3. With a lancet (Fig. 497), or better
with Lorinsers phlebotome (Fig. 496), an
incision is made through the skin into the
vein, and the first cut is enlarged sufficiently
by raising the point of the phlebotome to divide the anterior wall of the vein
about 5 centimeters in an oblique direction.
4. The blood must flow in a free jet.
If the flow intermits because the wound,
having been made too small, has become
obstructed or was displaced under the
skin (diffuse haematoma), it can be in-
creased by alternate opening and closing
of the hand,
5. When a sufficient quantity of
blood has been abstracted, the constric-
tion bandage is removed, the skin wound
is somewhat displaced above the vein
with the thumb ; a small antiseptic com-
press is applied, and fastened by a figure-
of-8 bandage, with the forearm slightly
flexed (Fig. 498).
Fig, 498, Dressing after Bleeding
OPERATION FOR ANEURISMS
Fusiform or saclike dilatations of the wall of an artery occur in conse-
quence of injuries or disease of the arteries. In a few rare cases they may
heal of their own accord without surgical interference. In this case lami-
nated coagula are deposited in the interior of the pouch, which are finally
changed into a firm swelling, which gradually contracts. This condition
is aimed at by all methods which endeavor to effect artificially coagulation
of the blood in the aneurism.
284
SURGICAL TECHNIC
I. By a temporary lessening of the arterial current : —
{a) By digital compression upon the proximal side of the artery involved
(see p. 235).
(d) By tourniquets, which have been mentioned especially for this pur-
pose (see also p. 239).
Since the continuous compression with the finger, whereby several per-
sons have to alternate at fixed intervals, day and night, is very tedious and
troublesome for the patient, and since the tourniquets in most cases are not
well tolerated, compression is replaced, especially on the femoral artery, in
popliteal aneurism occurring so frequently, by the more practical —
ic) Pole pressure {iwn Esinare/i).
A long pole, crutch, or broomhandle, propped against the ceiling or a
bedpost (Fig. 499), is applied, with its lower end carefully wrapped with
Fig. 499, Pole Pressure for compressing the P^emoral Artery
IN Popliteal Aneurism
some soft material, upon the trunk of the artery of the leg, which is wrapped
with a bandage, and rotated outward. If the pressure is not well tolerated
in one place it is changed to another. In most cases the patient himself
learns in a short time to regulate the pressure correctly, especially when the
points of pressure are marked by India ink.
By this simple method a considerable number of even large popliteal
aneurisms have been healed.
THE TREATMENT OF WOUNDS
285
2. By arresting the circulation {Reid).
The limb is encircled with an elastic bandage close to the swelling ; the
same is left free, and the bandaging is continued above the swelling.
Simpler still is the treatment by elastic constriction above the aneurism.
The constrictor should be applied as often as possible in the daytime ; it can
remain in position almost an hour uninterruptedly. Before the constrictor
is removed the limb, according to recent methods, must be again bandaged
loosely with an elastic bandage to prevent subsequent hyperaemia after the
constriction has been removed {Billrot/i).
3. Ligation of the artery in modern times is the safest procedure and
the one most frequently employed.
Antyllus
Fig. 500
Fig. 501
Fig. 502
Ligation of the Artery in Aneurisms
(a) According to Antyllus (Fig. 500). He exposed the aneurism in its
whole extent by a longitudinal incision, ligated the artery closely above and
below the aneurism, divided the sac, cleaned out its contents, and tamponed
the wound. His contemporary, PhilagidiLs, went still farther by excising
the aneurism after double ligation.
(b) According to Anel and Hnnter (Fig. 501).
The afferent central end of the artery is ligated either closely above the
sac {Ajiel) or more distant from it at some easily accessible place {at the
place of selection — Hitnter\ owing to the fear that the ligature would cut its
286 SURGICAL TECHNIC
way through the diseased wall of the artery near the aneurism, and thereby
incur the risk of secondary hemorrhage. Since, however, with the more
elastic catgut — the material now usually employed — this danger is no
longer to be apprehended, the ligature, as closely above the sac as possible,
is preferable on account of the greater probability that the circulation in the
aneurism is not restored by collateral vessels. Moreover, some time after
ligation of the afferent artery, when the aneurism has been decreased only
moderately, the longitudinal division of the sac can be made. In that case
remove all coagula and apply a compressive bandage for several weeks
{Mikulicz).
If it is not possible to ligate the central part, for instance, in aneurisms
of the aorta, innominate, subclavian, etc., then —
(r) Kzzox^v!\gX.o Brasdor and Waidrop {Y\g. 502), the efferent periph-
eral portion of the artery can be ligated. Brasdor tried to ligate the
efferent portion as closely to the aneurism as possible. Wardrop contented
himself with ligating the main trunk at an easily accessible place at a greater
distance, thereby effecting a diminution in the force of the arterial current.
Fearn ligated successively all efferent branches below the aneurism (Fig. 503).
A large experience, however, has proved that healing by ligation is ob-
tained with certainty only after all afferent and efferent branches have
been ligated. Otherwise the aneurism nearly always remains permeable
through the collateral circulation which is established in a short time.
Hence, the only procedure that can be recommended is the very old method
of Antylhis, performed under aseptic precautions with the aid of the
bloodless method, and the extirpation of the sac, on account of the certainty
of the result and the ease with which it can be performed.
If the wall of the sac is too firmly agglutinated with its neighborhood,
partial resection is sufficient (especially in the neighborhood of a vein) after
double ligation ; this is made with catgut, because silk thread cuts through
the thin vascular wall ; the wound is tamponed to prevent secondary hemor-
rhages. Sometimes grangrene of the peripheral section of the limb occurs
if a sufficient collateral circulation has not been developed. To prepare this,
so to say, it is advisable in all cases, where the operation (on account of in-
flammation, perforation, and others) is not urgent, to use for a few days pre-
viously the compression method (finger or pole pressure).
In aneurism of the leg, pole pressure should be first tried, and, if it fails,
extirpation should be made.
The numerous methods formerly employed to effect direct coagulation in
the aneurism (injection of ferric chloride, fibrin ferment, ergotin, alcohol.
THE TREATMENT OF WOUNDS 28/
tannin, solution of subacetate of lead, wax, moreover filipuncture, introduc-
tion of needles, watchsprings, magnesium wire, silkworm, gut, horse hair,
catgut threads) are dangerous to life, and should justly be abandoned.
Acupuncture and electropuncture, however, are praised by several as having
proved successful. Having arrested the circulation by appl3dng the elastic
band, Macewen inserted an acupuncture needle into the aneurism, and
moved it to and fro, whereby gradual coagulation of the contents of the sac
occurred. If the needle is connected with an electric battery of 20-30
amperes (anode in the aneurism, cathode plate on the chest), the contents of
the sac, by the galvanic current, coagulate after several applications.
Lanccrcaiix and other Frenchmen report a very good success with the injec-
tion of a gelatine solution (2 grams gelatine : 100 grams physiological sodium
chloride solution). This solution increases the coagulability of the blood.
It is injected into the sac or its immediate neighborhood {Laborde), but can
also be infused sjibciitaneously (250 grams of a 2^ solution at the highest,
every 10 to 14 days, into the vascular region). Still, even wdth this method
fatal cases have occurred {HucJiard).
OPERATION FOR VARICES
Extensive dilatations of the wails of the veins (varices), which involve
especially the veins of the leg in the course of the long saphenous vein,
cause great inconvenience to the patient (muscular spasms, eczema, phlebitis,
ulcers) ; and, by a sudden rupture of their wall, which is often very thin,
cause violent hemorrhages.
In milder cases, some improvement of the condition, or at least some
alleviation, is effected by bandaging the leg with a flannel or elastic bandage
(elastic stocking). (Bandages of pure rubber are harmful, as they frequently
produce maceration of the epidermis and eczema by retention of the secre-
tions of the skin. The ideal bandage for such cases is the rubber webbing
bandage, which is much cheaper and more effective than the elastic silk
stocking.) Likewise, the varix bandage of Landcrer, a pad or compress,
which is fastened over the inside of the leg upon the vein below the knee
joint, forms, so to say, an artificial valve of the vein and sometimes renders
good service.
In the more aggravated forms of varices, and in those cases where press-
ure upon the trunk of the saphenous vein, after the veins have been made
bloodless by elevation of the limb, prevents the blood from again filHng
the varices immediately, the best method of treatment is —
288
SURGICAL TECHNIC
LIGATION OF THE LONG SAPHENOUS VEIN {Trendelenburg)
I. External incision 3 centimeters in length over the inner side of the
thigh about the junction of the middle with the lower third ; the vein at this
point is almost subcutaneous (see also Fig. 504).
2. With the handle of the knife or a blunt
hook, the vein is isolated to the extent of about 2
centimeters, and a double catgut ligature is car-
ried around it with an aneurism needle.
3. The leg is then raised vertically to empty
the vein ; the ligatures are then tied and the vein
divided between them.
4. The little skin wound is sutured throughout.
After the ligation, the whole peripheral section
of the vein becomes thrombosed, and contracts in
the course of time into thin cords.
The obliteration of tJic diseased veins by a
multiple division, that is to say, the excision of
numerous small pieces, and by double ligation,
by percutancons ligature, and by compression of
the walls with small pieces of rubber tube tied
upon them {Sehede) usually fail and are no longer
used.
Tillvianns recommends ignipuncture, that is,