Part 8

To obviate this train of miseries; to give ease and satisfaction to the operator, by conferring precision and success upon his operation, and to rescue from death, or rather from torture and agony, innumerable sufferers, are the results which I confidently expect from the adoption of the following method. Nor can I say more in proof of its importance. I doubt not, that it will, ultimately, constitute the basis and direct the genius of surgery.

* * * * *

There exists no other method of effecting this, than by the enunciation of the following principle; namely, that there is, especially in such parts as are not liable to be deranged by voluntary motion, an invariable relation between the arrangements of internal and the situation of external parts, which may justly be considered as accurate signs of them; in consequence of which, by adopting, on each side of the nerve, artery or other subject of operation, a fixed point, or one rendered fixed by particular positions of the body; and by dividing, according to a line or rule, the space between these fixed points into a given number of proportional parts, i. s. parts, not equally large in all subjects, but uniformly of the same size, with relation to the whole which they compose, and generally differing in the male and female—by these means, I say, the situation of any given subject of operation, in any given part of the body, may be most accurately indicated, as being undeviatingly a certain number of proportional parts distant from the one, and a certain number from the other of these points.

Thus does anatomy, by what I term precise or real proportional measurements between fixed points, afford an obvious and simple, though hitherto unobserved, general means of rendering the operations of surgery perfectly precise and easy.

Indeed, such wonderful precision and ease do these real proportional measurements confer, that, by means of them, the finest instrument may be passed from the surface of the body through any great nerve or vessel that is liable to be the subject of surgical operation.

Having stated this principle, I may merely observe, that, proceeding with all the ease and security, such accuracy must infallibly confer, it is, in all operations the first duty of the operator to ascertain by feeling, as nearly as possible, the thickness of cellular substance situate immediately under the skin of the patient, and then, with a bold and steady hand, to make an incision, deep in proportion to the thickness of that substance, and long in proportion to its depth, as well as to the additional depth and extent of the part to be operated upon.

These general principles excepted, other subordinate rules are chiefly applicable to particular operations.

* * * * *

In order to illustrate this general principle, I cannot adduce a fairer or a better example than that which, according to it, is necessary to direct the taking up of the subclavian artery above the clavicle.

The patient must, in this operation, rest on the fundament, his body slightly inclining backward, so as to form an obtuse angle with the thighs, and his neck and head inclined backward so as to form with the trunk an angle similar to that formed by it with the thighs; the inferior of these angles being concave, the superior convex. This last may indeed be more properly called an irregular segment of a circle, formed in consequence of the vertebrae of the neck bending in that direction. In this position, therefore, the neck is, in general, in the same parallel with the thighs. The head of the patient is to be turned to the opposite side from that in which the operation is to be performed, where also the operator must stand. The light must fall directly downward from the head of the patient.

In this case then, the bringing of the shoulder forward and downward, which I deem indispensible, however necessary to the ease of the operator, is not very material to the correctness of the measurement. It is however of some consequence; for, as the subsequent measurement is dependent on the clavicle, and as that bone describes a portion of a circle in having its lateral end brought forward, every single point of it would, in that position, have a different relation to the vessels beneath from that which each would have had, if kept in its usual position.

Here then, the shoulder being in this position, and the arm held by the side, the measurement commences, and the fixed point chosen on each side of the immediate subject operation are the two ends of the clavicle; as nearly between these as can be done, consistently with keeping quite clear of the bone, a line must be drawn superior and internal to it, and the given number of proportional parts, into which this line must be divided, are seven in number both in the male and female; and now the situation of the artery may be most accurately indicated as being undeviatingly three of these proportional parts distant from the inner, and four from the outer end of the clavicle; in consequence of which, if a fine instrument, held at right angles to the clavicle, were directed downward and inward, it would at 1 and ¼ of the above mentioned parts from the surface of the clavicle, reach the artery, and being pushed farther, would pass through it.

This is an absolute demonstration of the precision and ease attending the principle I have announced, and of its applicability even to the most difficult of all operations.

In order, however, to perform the operation throughout, the point which I have indicated must be the center of an incision through the integuments made in the line above mentioned, and must extend at least two parts inward and two outward from the central point. Over the Trapezius outward, and over the clavicular attachment of the Sterno-cleido-mastoid muscle inward, it is not adviseable to cut deeper than the integuments, which sufficiently relieves the hand of the operator, without the present execrable practice of dividing the last mentioned muscle, which is not only unnecessary, but highly faulty, as this attachment serves as one of those particular points, above alluded to, incidental to certain operations, which, by means of its edge, kept lax during the operation, very nearly directs the knife to a small protuberance on the superior anterior surface of the first rib to which the scalenus primus is attached, and immediately external to which the artery itself lies.

Above all, the incision ought to be cautiously continued on the inner side, in order to avoid the large veins situate there; various branches of these veins may come in the way, and the more considerable may be easily avoided, but if not, they may be tyed.

In continuing the incision inward and downward, an ascending branch of the vein is in the way, which, when it is considerable, may also, previous to the continuance of the incision, be tyed. The incision itself, as you pass inward, must be very limited indeed, as the jugular vein is internal to it; and external to it there is a twig of the brachial nerve, both of which are much exposed to injury.

When the incision has been made one and a fourth of these proportional parts inward from the outside of the clavicle, you have reached the artery. It lays external to that protuberance of the first rib into which, as already observed, the scalenus primus is inserted, and consequently to the insertion of the muscle itself. The twig of the nerve actually crosses the artery immediately below the point where the latter ought to be tyed. The course of the artery is, in descending, obliquely outward, and the precise space in which it lays resembles an isosceles triangle formed by the clavicle, clavicular portion of the sterno-cleido-mastoideus and the omo hyodeus; its base being the clavicular portion of the sterno-cleido-mastoideus. The nerve is external and anterior to the artery, particularly its branch. Both the twig and trunk of the nerve ought to be seen by the operator before he attempt to take up the artery.

These directions are so precise, that, were the operator blind and the artery destitute of pulsation, he need not scruple to take up that which presents itself in the above mentioned situation.

By similar measurements, may every great artery in the body, liable to be the subject of surgical operation, be discovered with similar ease and precision, nor does there exist any other method of effecting this purpose.

I shall now then state the objections which may be urged against this principle.

* * * * *

It may be objected to the adoption of this fundamental principle of all surgical operation.

1st, That the accidental and probable fracture of the bone affording the fixed points, would, by deranging these points, render all such measurement inapplicable.

2d, That varieties in the distribution of arteries, and those deviations which are often produced by disease, would have the same effect.

I know not of any other objection that can be urged against it, and these I shall immediately answer.

* * * * *

1st, To the objection that the accidental and probable fracture of the bone affording the fixed points would, by deranging these points, render all such measurements inapplicable, I answer, that, to chuse as an example the operation I formerly described, it is, in such a case, only necessary to transfer the measurement to the sound clavicle, and to convert the three inner or four outer proportional parts into absolute inches, quantities similar to which may then be measured from the corresponding ends of the fractured one, and thereby indicate the situation of the vessel or nerve with as great precision as if no fracture were involved.

2d, To the objection that varieties in the distribution of arteries, and those deviations which are often produced by disease, would have the same effect, I answer, that variety of distribution does not at all take place in some of those parts in which the most important operations have to be performed; namely, high in the groin, above and below the clavicle, &c. and that, wherever great deviation is caused by disease, it will generally be attended by external signs, according to which the operator may modify his measurements. I also further answer, that wherever deviation, from either of these causes, occurs, he who, by means of these measurements, knows the precise situation, according to the most usual and regular structure, will have the most decided advantage over him who is ignorant of it: the former will possess data, from which he can calculate probable deviations, the latter none; the former, even at the worst, will have to calculate, the latter will be unable to do more than guess.