Case of a ruptured external iliac aneurism treated by ligature of the common iliac artery / by A.M. Edwards.

  • Edwards, A. M. (Alexander Mackenzie)
Date:
[1858]
Catalogue details

Licence: Public Domain Mark

Credit: Case of a ruptured external iliac aneurism treated by ligature of the common iliac artery / by A.M. Edwards. Source: Wellcome Collection.

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    agony, begged that a cut might be made to relieve the tension, and even volun¬ teered^ to do it himself if we had any hesitation. But towards the afternoon the pain abated, and he dosed a good deal, so we contented ourselves with the aconite and rest. When, at 9 p.m. he again complained of severe pain, and the tumour considerably increased in size. At 8 A.M. the following morning we found him evidently much weaker, with a small frequent pulse, and complaining of great pain. The tumour now ex¬ tended from Poupart’s ligament below to the last rib above, then crossed up¬ wards and inwards to the umbilicus, curving to the left of the middle line down again to the pubes. The skin covering the tumour was red and tender, and the abdomen distended with flatus. Dr Brodie administered chloroform to the patient, and we then lifted him from his bed to a table placed in front of the window, his head and shoulders raised on pillows, and his legs hanging over the end of the table. Dr Brodie kept up the ansethesia, and Mr Lizars, Mr Mac- kinnon, and Mr Nunn, were good enough to assist me. I began by making an incision, which curved forwards from above Poupart’s ligament a couple of inches internal to the anterior superior Operation. iliac spine, as far as the last rib dividing the external oblique. The internal oblique now appeared bruised, and, as it were, in¬ jected with blood, which gave it the appearance of unusual thickness, so that I almost doubted at one time whether I was not dividing transversalis with it; but a branch of deep circumflex, and the ilio hypogastric nerve, the white line of which contrasted well with the purple colour of the muscle, showed me where I really was. So I tied the arterial twigs, as it was necessary to economise blood, and divided transveralis fascia. The peritoneum now appeared, covered Muth purple stains, as the surface of the bowel sometimes is in a hernial sac. It was but slightly adherent to the tumour, and 1 commenced peeling it off, Mr Nunn, with his fingers in the wound, endeavouring to support it with the intestines, and so give me more room to manipulate. I greatly prefer the fin¬ gers to any description of spatula, for such a purpose. It was impossible to de¬ termine the limits of the tumour, which evidently occupied the whole right iliac fossa, and extended more to the left than I imagined, from external exa¬ mination. It was clear that I must get at the artery through this superincum¬ bent mass, or not at all. So I passed my finger through the thin covering of cellular tissue, and found the mass consisted of recent clots, the escape of which I endeavoured to restrain with the right hand, while I tried to “ touch bottom” with the forefinger of the left, but every now and then a clot would slip past my finger, followed by a little blood. I took the umbilicus as my guide, but for some time could feel nothing but clots wherever my finger passed up or down, or to one side. But I knew I could trust its familiarity with the parts, and that the least touch of any fixed point vrould at once guide it to the vessel. At last it touched what I took to be the fourth lumber vertebra, and in another instant it was resting on the common iliac artery. Being now in a position to control the bleeding, I turned out the clots with my right hand, and got the right forefinger also to the artery, the sheath of which Ipicked with my nail, and cleared it for about the breadth of my finger-tip. There wms a good deal of diffi¬ culty in passing a ligature round it, as the intestines being distended, so forced the peritoneum into the wound in spite of Mr Nunn’s efforts to restrain it, and got over the handle of the aneurism needle so as to prevent my elevating it. I managed at last to get a silk thread round the artery, tied it, and then holding the ligature in one hand, and lifting the peritoneum with the other, I could see for the first time, and show to those present the common iliac trunk pulsating violently. It was uncovered for about i of an inch, and looked white and healthy. This vein I did not see, the ureter w^as adhering to the peritoneum. The wound was stitched up, and dressed with wet lint, and the patient laid upon his back in bed. The operation lasted about half-an-hour. The leg was wrapped in cotton wool. Shortly after his return to bed, the pulse rose to 100.