Part 52

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.

The axillary artery may be tied on account of wounds, either immediately upon the infliction of the injury, or some time afterwards. The dissection is difficult, the vein being much in the way, and the vessels surrounded by nerves, and intimately connected with them by dense cellular tissue. The artery is more involved at the middle portion of the axilla than at the superior and inferior; at that point, too, the cephalic vein, as well as the axillary, impedes the operator.

To reach the upper portion of the artery, much muscular substance must be divided. An extensive incision, in the course of the vessel, is made through the integuments. The pectoralis major is got through by separation and division of the fibres, the incision in it being made with as little cross-cutting as possible. Part of the pectoralis minor, probably the superior half of the muscle, must also be cut. The parts are then exposed, the vein to the inner side of the artery, and the nerves interlaced. The vessel is carefully isolated at one point, and there secured.

It is almost impracticable to reach the middle portion of the axillary—supposing the vessel to be divided into three equal portions—without injurious interference with the nerves. If operating with the view of tying the extremities of the vessels wounded at this point, the probability is that the nerves have been divided along with the artery, and then the proceedings are more simple. The incisions are made in the direction of the bleeding point; this is reached, and each extremity of the vessel securely tied.

The lower third of the artery is less involved with the vein and nerves, and can be reached without division of muscular fibres. The arm is abducted and elevated as much as possible. The axilla is thus exposed. A free incision is made in the course of the vessel, which, by cautious dissection, is brought into view; it can then be dealt with as may be required.

Spontaneous aneurism is of rare occurrence, lower in the brachial artery than its axillary portion. However, it is sometimes met with at the bend of the arm. But the aneurismal tumour in this situation is more frequently the consequence of wound of the vessel, inflicted whilst opening a superimposed vein. The mode of proceeding in venesection, the precautions to be employed, and the evils that sometimes follow this little operation, will be treated of by and by. Wounding of the artery is not so common an accident now as formerly. Venesection is not so universally and unnecessarily resorted to as formerly, and is performed by better instructed practitioners.

Puncture of the brachial artery, at the bend of the arm, is not uniformly followed by extravasation of blood, or by the formation of aneurism. That it is wounded is known by the impetuous and saltatory flow of florid blood, accompanied with a wheezing noise. In such circumstances, the thumb is placed firmly over the wound; the fingers separately, the hand and the forearm of the patient are all supported by uniform bandaging; and a graduated compress, supplying the place of the thumb, is firmly applied, and must be retained for many days. Thus extravasation is effectually prevented. But the measures must be adopted instantly, before the edges of the opening are rounded, and any quantity of blood has escaped into the cellular tissue; the apparatus must be well applied and retained. When pressure is required on any point, it is absolutely necessary to give support to the lower part of the limb, as was formerly insisted on; and the proceeding is, if possible, more necessary in this case, the requisite pressure being very great. If ordinary compression only, sufficient to prevent the flow of blood through the opening in the integuments, is applied, blood is extravasated into the cellular tissue, breaking it up, and causing condensation beyond; fluid blood accumulates in the space thus formed; the surrounding cellular tissue is more and more condensed, at length constituting a firm sac, confining the fluid, and communicating with the opening in the artery; in fact, a pulsating and gradually increasing aneurism is established.

Or a sac is formed, into which blood is propelled from the artery, and which also communicates with the opening in the vein. This state of parts is denominated varicose aneurism; it is very rare.

Or, again, no extravasation takes place, and the artery and vein unite by lymph effused around the openings, the wounds remaining unclosed, and forming a permanent communication between the vessels. Thus, a portion of the arterial contents is constantly being injected into the vein, producing a thrilling sensation, but little or no tumour. The passage of the blood through the narrow aperture is also accompanied by a peculiar noise, closely resembling that caused by the motion of the fly-wheel in a musical box. This disease is termed aneurismal varix, and is not so rare as the preceding. For this treatment is seldom requisite.

In recent cases of false aneurism, the sac may be cut into, the vessel exposed, and tied above and below the opening. This is recommended from its being found that the tumour is sometimes slow of disappearing after ligature of the vessel at a distance above. But when the tumour is of considerable duration and size, containing coagula, and the surrounding parts are separated and altered in structure, there is no doubt as to the propriety of tying the humeral near its middle—as also, in the case of spontaneous aneurism. The vessel is not deep, but much entangled with nerves and veins. A free incision is made over its course, dividing the skin, cellular tissue, and fascia; the sheath is opened, and a ligature passed round the exposed artery. But it must be recollected that high division of the humeral is not uncommon, and, before casting the knots, pressure should be made on the vessel with the finger against the loop of the ligature, and the effects on the tumour watched; if pulsation cease, and the tumour become flaccid, the ligature should be secured; but, if no effect is produced on the swelling, high division is demonstrated, and the other branch must be looked for. Pulsation is certain to return in the tumour, after a few days, and if slow in again disappearing, gentle pressure should be employed—the arm, hand, and fingers being previously bandaged, to prevent infiltration of the limb.[43]

Wounds of the radial and ulnar arteries may require their being exposed and tied at various points and at various periods—shortly after the accident, or after the lapse of many weeks—on the occurrence of secondary bleedings, or after the formation of false aneurism. This is accomplished by incision in the course of the wounded vessel, sacrificing as few muscular fibres as possible. Nevertheless, the incision must always be free, to enable the surgeon to effect his purpose readily.

_Wounds of the Palmar Arches_, and of the branches proceeding from them to the extremities of the metacarpal bones, are exceedingly common; as also wounds of the radial artery betwixt the thumb and forefinger, of the arteria radialis indicis, and of the superficial volar branch. The opening in the integuments and palmar aponeurosis is usually narrow, and the hemorrhage copious; it is generally arrested by pressure, not always well or efficiently applied. From these circumstances, blood is extravasated extensively into the deep cellular tissue, blood continuing to escape from the artery, and being either imperfectly discharged, or completely confined. Great swelling, with tension and acute tenderness, takes place; in fact, rapid inflammatory action is kindled in the infiltrated parts, and unhealthy abscesses form; the matter ultimately reaches the surface, but by that time ulceration or partial sloughing has taken place at the wounded part of the vessel; profuse and repeated hemorrhages take place, and are with difficulty controlled. The patient becomes weak and pale. The greater part of the forearm may become involved in the inflammation, terminating in infiltration of the cellular tissue, and the formation of diffuse abscesses.

In the first instance, instead of trusting to pressure,—which almost uniformly disappoints expectation, does not prevent internal bleeding, and leads to a severe form of inflammatory action,—it is better at once to enlarge the wound, and tie the wounded vessel above and below the injured point. Thus all bleeding is effectually prevented, and the risk of unfavourable consequences done away with. But after inflammatory swelling has commenced, such a proceeding is difficult, often almost impossible, and generally fruitless. The parts are then full of blood, lymph, serosity, and pus, separated from each other, and changed both in appearance and structure; the vessel is either not visible on account of the infiltration around, or its coats are so diseased as to be incapable of holding a ligature. At any period, it is unsafe and unwarrantable to dive, pretty much at random, with a sharp needle, amongst tendons, nerves, arteries, and veins, with the hope of so including the wounded branch. In some cases of secondary bleeding—if no great inflammatory action has taken place, and no abscesses have formed—the wound may be dilated freely, and compression made on the bleeding point by dossils of lint filling the wound completely, and supported by a bandage. This dressing, retained for some days, often succeeds perfectly; permanent obstruction of the vessel, and consolidation of the parts immediately around, having been accomplished by the effusion and organisation of lymph. When this method fails—and when the case is more advanced, with pain, and swelling, and abscess—weakening of the circulation in the part is found to be effectual. The main artery is to be obstructed at a distance from the wounded part. It is needless to tie the radial, or the ulnar, or both; for still blood will be poured in by the interosseous and its anastomoses. The humeral must be secured in the middle of the arm, as has been practised in many instances, and with uniform success. Thus the bleeding is arrested until the wounded vessel recovers, and becomes permanently closed by salutary effusion; then the inflammatory action, and its consequences, in the surrounding parts, must be treated on the general principles of surgery.

_Paronychia_, or _Whitlow_, designates inflammatory action and its consequences, in the structures composing the fingers. The mere surface may be the seat of the inflammation of the cellular tissue, or the fibrous structure betwixt that and the sheath of the tendons; or the firm and true sheath of the tendons, and the synovial surface; or the investing membrane of the bone, the bone itself, and the articulating surfaces and apparatus may be involved secondarily, or from the first. The inflammatory action may commence in any of these structures, but, if uncontrolled, ultimately attacks the greater number, or all of them. The deeper seated the action, the more violent are the symptoms, and the greater the danger to the member. In the cutis vera of the fingers, there is a plentiful distribution of nerves of sensation; and, consequently, in superficial whitlow, the pain is often severe, with throbbing, and an occasional feeling of itching. The part is swelled and red, and the redness is diffused. After a short continuance, the swelling increases at some points, often about the root of the nail, from effused fluid betwixt the cuticle and rete mucosum; the fluid is sometimes serous, generally sero-purulent. In the deeper-seated inflammation, the pain, throbbing, heat, and swelling, are all greater. The pain is more intense, and almost intolerable, allowing the patient little or no rest; and the throbbing extends to the vessels of the hand and forearm. A considerable degree of fever attends. The action either involves one phalanx, or extends over the whole finger, and ultimately attacks the hand. The palm is hard, pained, and swelled; and, in advanced cases, swelling takes place above the annular ligament. Often the surface of the back of the hand is also inflamed, and the cellular tissue loaded with serum. The disease, if not actively and properly treated, terminates in a very short time; in two or three days suppuration takes place, with sloughing of the cellular tissue, of the sheaths of the tendons, and of the tendons themselves. Either ulceration or necrosis—often both in combination—occurs in the phalanges; or the apparatus of one or more of the articulations is destroyed. Abscesses also form in the palm, on the back of the hand and finger, and sometimes under the fascia of the forearm. The separation of portions of one of the tendons is not always followed by loss of motion in the finger; neither is exfoliation of the greater part of the distal phalanx always attended with much deformity or shortening, a nucleus being often left from which bone may be reproduced. But destruction of the whole flexor or extensor tendons of one of the middle or proximal phalanges, or destruction of one of the articulations connecting them, is not only attended with great suffering, but followed by total uselessness of the part. The wounds may, after a tedious process, heal up; but the finger remains deformed and immovable, in a contracted or extended position, as may be.

The disease may be occasioned by bruises or punctures, the instrument with which the puncture is inflicted being impregnated, or not, with some putrid animal matter. Violent inflammatory action almost uniformly follows opening of the articulations, and also lacerated wounds over the joints. Compound fractures and dislocations of the phalanges are certainly followed by a severe form of inflammation. But the disease is met with in all degrees of intensity, occurring without any assignable cause. It prevails in spring and autumn; and is common in hard-working people, in butchers, cooks, &c.

In superficial whitlow, the bowels must be attended to, and blood may be abstracted locally, either by punctures or by the application of leeches along the side of the finger, hot fomentation being assiduously and regularly employed afterwards. Or the nitrate of silver may be rubbed lightly over the discoloured parts; frequently the inflammation may be arrested, and resolution speedily effected, by this simple application, laxative or purgative medicines being at the same time administered, as required. The collections which form are evacuated by simple division of the cuticle, and this, when hard, should be clipped away; poultices are used for a short time, and then the raw surface is dressed simply, and the finger bandaged daily. The hand should be kept constantly elevated. The swelling is soon reduced, the cuticle is regenerated, and free motion of the finger returns gradually.

In more severe cases, fomentation and copious abstraction of blood by leeching, at a very early stage, may effectually suppress the inflammatory action; but patients seldom apply till after the opportunity for this treatment has passed. When tension has occurred, whether purulent matter has formed or not, a deep and free longitudinal incision must be made, including the affected tissues. This is uniformly followed by great relief, all the violent symptoms subside, and the action is limited; the effusion, if any, escapes, and the affected bloodvessels are emptied—further suppuration is prevented, and the tissues are perhaps saved from destruction. Fomentation and poultice are used till the swelling begins to disappear, and the discharge to diminish; and the hardened cuticle is removed, when detached. The cure is completed by bandaging, and such applications to the wound as its appearance may render suitable. Should inflammation recommence and extend, or abscess threaten in other parts, recourse must again be had to free incision, followed by the treatment already described.

Destruction of the articulating apparatus, with ulceration of the opposed surfaces of the bones, is indicated by indolent swelling around, by unhealthy and profuse discharge, by distinct grating being produced on motion, and by marked and unnatural looseness of the joint. In such circumstances, amputation of the finger above the diseased part is fully warranted. But if the patient is obstinate in refusing to submit, or if he is in that rank of life where stiffness of the finger is of no great consequence, the member should be kept steady in a convenient position, so as to favour anchylosis. By splints and bandaging it is preserved in a state of semiflexion, so that, after the cure by anchylosis, it may not be in the way when the patient lays hold of anything, as it would be were it bent into the palm, nor exposed when the other fingers are bent, as must be the case were it kept quite straight. Still the finger is often very useless—worse than useless—when stiff either from loss of the tendons or from destruction of the joint; and more particularly when its position is awkward. So much inconvenience does it give rise to, that patients, who peremptorily refused amputation whilst the case was recent, often return, after a tedious and painful cure by anchylosis, soliciting removal of the deformed and annoying member. When the thumb, however, is the seat of disease, it is of great moment to save any part of it. A stiff joint in the thumb is of less consequence than in a finger; it can still be brought to oppose the rest of the hand in seizing and retaining hold of objects. To promote anchylosis, the affected articulation must be kept at perfect rest, and for a very considerable time. By pursuing this practice, the thumb, represented at page 397, though in a very bad state, the joint being thoroughly disorganised, was preserved. In severe cases of whitlow, all the fingers, the whole hand, and even the wrist, long remain rigid; but the rigidity is gradually dissipated by friction, and by motion, at first gentle and passive.

Chronic thickening and contraction of the _palmar aponeurosis_ occurs occasionally, and, in some cases, to such an extent as to disable the hand almost entirely. The fingers are permanently bent, the palm is hard, and the integument puckered. The most severe examples which I have witnessed occurred in those who were in the frequent habit of playing keyed or stringed instruments; in others no cause could be assigned. Frictions with all kinds of oils and compound liniments, plasters, ointments, &c., have been tried as remedies for this affection, but in vain. The tendinous slips passing to the contracted fingers have been divided, and the origin of the palmar fascia has been cut across, but without permanent benefit. Indeed I believe the disease to be incurable.