This section is from the book "Anatomy Of The Arteries Of The Human Body", by John Hatch Power. Also available from Amazon: Anatomy of the Arteries of the Human Body, with the Descriptive Anatomy of the Heart.
The subject of this operations, Isaac Crane, aged 33, was a man of temperate habits, and his disease was a large aneurismal tumor, of nearly three months' standing; filling the iliac fossa, and extending from a little above Poupart's ligament, to near the umbilicus.
" The patient being placed upon a table of suitable height, 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, until it terminated a little beyond the anterior superior spinous process of the ilium, making it in extent about five inches. The integuments and superficial fascia were 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 fore-finger 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 internal oblique muscle, between the rings, and one in the integuments, were all that required ligatures.
"With the tumor beating furiously underneath, I now attempted to raise the peritoneum from it, which we found difficult and dangerous, as it was adherent to it in every direction. By degrees we separated it, with great caution, from the aneurismal tumor, which had now bulged up very much into the incision. But we soon found that the external incision did not enable us to arrive at more than half the extent of the tumor, upwards. It was therefore extended, upwards and backwards, about half an inch within the ileum, to the distance 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 tumor, 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 determined to place our ligature upon it, about half-way between the aneurism 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 ligature 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 impossible to see the vessel we wished to tie. By the aid of curved spatulas, such as I used in my operations upon the innominata, together with a thin piece of board, about three inches wide, prepared at the time, we succeeded in keeping up the peritoneal mass, and getting a 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 tumor, and the interruption it gave to the admission of light.
"When we elevated the pelvis, the tumor obstructed our sight; when we depressed it, the crowding down of the intestines presented another difficulty. In this part of the operations I was greatly assisted 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 fore-finger, and the needle conveying the ligature was introduced, from within outwards, guided by the fore-finger of the left hand, in order to avoid injuring the vein. The ligature was very readily passed underneath the artery, but considerable 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 conveyed up to the artery by the fore-fingers: all pulsation in the tumor instantly ceased. The ligature upon the artery was a very little below a point opposite the umbilicus".
The wound was dressed in the usual way: the operations lasted less than an hour. It was performed on the 15th of March, and the ligature was removed from the artery on the 3d of April following. On the 20th of May, he made a journey of twenty-five miles.*
Sir P. Crampton's patient died on the eleventh day; and the failure of the operations has been attributed to the employment of a catgut ligature, which (as appeared from examination of the body) either broke from the impulse of the blood, or had rotted away.
* Johnson's Med. Chir. Review, vol. viii. 1828, p. 472.