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.
A Portuguese sailor applied at the Civil Hospital, at the Cape of Good Hope, with a large aneurismal tumor over the site of the external iliac artery.
"The tumor now presents the greatest size and prominence immediately above Poupart's ligament, in the site of the external iliac artery. The most prominent part is tense, shining, and circumscribed, about the size of an orange, and its hard irregular base extends upwards to an imaginary line drawn from the umbilicus to the lower ribs, and downwards to a couple of inches below Poupart's ligament; its lateral boundaries being formed by the ilium and linea alba. Pulsation is felt in the prominent part of the tumor, and a sort of whizzing sound is indistinctly discovered in it on the application of the ear or stethoscope; but there appears to be no circulation in the femoral artery. He does not complain of much pain in the tumor at present, but says it is often excruciatingly severe along the thigh-bone and in the knee. The limb is much swollen, and he keeps it constantly in the bent position, and cannot bear to have it extended. The skin is nearly insensible to the touch, and even to pinching, particularly on the inner part of the thigh; yet he describes having a feeling as if worms and flies were creeping over it. Temperature of the diseased limb, 92 degrees, and of the sound one, 97. Pulse 96, and intermittent; and the action of the heart has a corresponding irregularity. Two or three days ago he had an attack of epistaxis. Tongue covered; respiration natural; intellect clear. Has had scarcely any sleep for many nights, and no motion in his bowels for eleven days".
* Med. Ch. Trans., vol. xvi. p. 1.
He was accordingly taken into the Hospital, and medicines calculated to palliate his symptoms were exhibited. After a few days, however, matters were getting manifestly worse. His features were shrunk and exsanguine, limb cold and insensible, and the tumor enlarging and assuming a dark-bluish appearance at its prominent part. He complained that the friction employed to preserve the temperature of the limb was only increasing his pain, and the greatest agony was felt in the thigh and knee. Under these circumstances, it was resolved no longer to defer the operations.
" The operations had to be performed by candle-light, and, moreover, as he lay in bed, that he might not be put to the pain of being moved before and after it.
" The size and position of the tumor precluding the possibility of reaching the aorta by cutting from the right side of the abdomen, rendered this necessary to be done from the left, which fortunately, at the same time, had the advantage of affording the readiest and easiest access to the vessel, on account of its anatomical situation, but greatly increased the difficulty of reaching the right common iliac, to tie it, which it was hoped might be found possible.
"The patient lying inclined to the right side, the first incision was commenced a little in front of the projecting end of the tenth rib, and carried for more than six inches downwards, in a curvilinear direction, to a point an inch in front of the superior anterior spinous process of the ilium, its convexity being towards the spine. The skin, the subcutaneous cellular tissue, and the aponeurosis of the external oblique muscle, were first incised; next the fibres of this muscle; and successively afterwards the layers of the internal oblique and transversalis muscles were displayed and divided; which was found rather a delicate part of the operations, as their fibres contracted spasmodically when touched by the scalpel. The fascia transversalis was now brought beautifully into view, and cautiously divided by a pair of scissors upon a director, to avoid wounding the peritoneum. This membrane being now completely laid bare to nearly the whole extent of the external wounds, was next detached from the fascia covering the iliacus internus and psoae muscles, chiefly by the hand, introduced flat between these parts, to separate the loose cellular substance connecting them, which was easily effected.
"Whilst detaching the peritoneum in the fossa of the psoae, I found my fingers get into a soft pulpy mass, and a good deal of dark bloody fluid began to ooze out by the side of my hand, which made me withdraw it and examine the parts by throwing a ray of candle-light into the bottom of the wound, when, from the dark appearance of the parts, my first impression was that they were in a gangrenous state; but I soon discovered that it was caused by ecchymosis, or effusion of bloody serum into the loose cellular texture. I then reintroduced my hand, and gradually prosecuted the detaching of the peritoneum in the direction of the spine, till I came to a large pulsating vessel, which I found to be the upper part of the left common iliac, and in another minute the aorta itself was under my finger; to satisfy myself of which, I requested one of the gentlemen assisting me to place his ear on the tumor, and his hand on the left femoral artery, when he heard and felt the pulsation to stop and recommence in each, as I compressed the vessel, or the contrary. I now endeavored to reach the right common iliac, but found that the walls of the tumor extended nearly close up to the bifurcation of the aorta; and, even had this obstacle not existed, I do not think there is scope for the hand to perform the necessary manipulations to place a ligature upon that vessel from the left side, without using a degree of force, and causing a laceration of parts, that would be inconsistent with due professional caution, humanity, and judgment.
" A tedious and rather difficult part of the operations succeeded; viz., the making a division in the aortic plexus of nerves, and in the membranous sheath covering the aorta, to get betwixt the vessel and the spine, which I effected partly by the steel end of an elevator cranii, but chiefly by my nails, with my mind at my fingers' ends; and I was not a little rejoiced when I had got a sufficient separation, to be able to insert the point of the aneurism-needle beyond and behind it; after which I was soon able to get it, with the ligature, round the vessel, without including any portion of nerve or other extraneous substance. In this manoeuvre it was with difficulty that the longest-handled aneurism-needle could be made to reach the necessary depth. The ends of the ligatures being brought out, the aorta was gently raised upon it, which enabled us, by holding up the peritoneal bag, to see this great vessel pulsating at an awful rate.
" The noose of the ligature was then gradually tightened till all pulsation and circulation was found to have decidedly ceased in the left groin; and we anxiously watched the general effect upon the patient whilst this and the second knot were being tied.
" The pulse at the wrist, during the time, underwent no sensible alteration, either in strength, fulness, or frequency; nor did the vascular organization of the head seem to be abnormally congested or excited by the sudden check to this great stream of the circulation. The tightening of the knot did not seem to occasion him any great pain, nor to cause any unusual sensation or shock in the vascular, nervous, or respiratory systems. His first complaint was, that his left leg had become as benumbed and -useless as his right, and that we had done him bad service in laming his good leg, which he did not expect, and lamented it bitterly: on feeling the aorta, it was found to be full, and pulsating with very great strength, above the ligature, but empty and motionless below it. The ends of the ligature were now brought out exteriorly, and the lips of the wound drawn together by three sutures and adhesive straps, over which a compress and bandage were applied.
"The operations was more tedious than difficult; and being effected chiefly out of sight by the hand, it had not the terrific appearance which that by the method of cutting into the cavity of the abdomen must have, and it was accomplished with the loss of less than two ounces of blood. At one time, during its performance, he required to get some brandy and water to support him; but when it was over, he seemed quite as well as before its commencement; and the pulse was 128, steady and regular".
After the operations he felt deadness of the left thigh and leg, and complained of painful distention of the bladder, though it was empty. Afterwards he became easier, and smoked a cigar, and slept a little at intervals. Soon, however, he began to complain of violent pain in the pubic region and loins. Tongue was now dry and dark, strong pulsation of the carotid, and feeble pulse at the wrist, followed by jactitation: cold clammy sweats. No natural warmth ever returned to the lower limbs, and he died twenty-three hours after the operation. On dissection, it was found that the artery had been secured opposite the interval between the fourth and fifth lumbar vertebrae; no extraneous substance was included, and "the aortic plexus of nerves had been accurately divided." Specks of ulceration were observed on the mucous membrane of the bladder.
The vessels of the lower part of the body having been injected, a few drops of the size injection were found in a small anastomosing vessel, discovered passing between the inferior mesenteric artery and left internal iliac; it arose about two and a half inches below the origin of the mesenteric artery, (from the hemorrhoidal branch of it, which seemed larger than usual,) and joined one of the upper branches of the internal iliac, being in length about two inches; but its calibre was so small, having only admitted two or three drops of the colored size, that it probably never carried red blood during life. No corresponding vessel was to be found on the right side, nor could any further anastomoses be discovered between the arteries of the abdominal aorta and those of the pelvis or lower extremities. The branches of the thoracic aorta were not injected, and therefore not examined.*