A case of aneurysm involving the innominate, the right subclavian, and the right common carotid arteries : treatment by proximal ligature ... aneurysm to the middle cerebral artery / by Charles A. Ballance.

  • Ballance, Charles Alfred, Sir, 1856-1936.
Date:
1902
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Licence: In copyright

Credit: A case of aneurysm involving the innominate, the right subclavian, and the right common carotid arteries : treatment by proximal ligature ... aneurysm to the middle cerebral artery / by Charles A. Ballance. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    out of the list of justifiable operations, for under certain circumstances it may be the only possible means of arresting a haemorrhage. Whether there is any justification for the operation in cases of large aneurysm of the subclavian remains, in spite of the single successful case—that of Smith—very doubtful.”1 Some anatomical points.—It goes without saying that a clear appreciation of the anatomy of the region is of the first importance in the performance of the operation. “ I always determine in my own mind,” said the sculptor Chantrey, “ the expression to be given, and unless I can see the face distinctly and with that expression when 1 close my eyes I can do nothing.”2 The position of the great arteries is shown in Fig. 4 and in the drawings of transverse sections of the neck (Figs. 6 and 7), the levels of which are indicated in Fig. 4. Anatomical study shows, therefore, that ligature of the innominate is a cervical operation by no means difficult of performance. There is no risk of injury to the pleura if the vessel be approached from the front and from the tracheal side and if the knife is not used outside the limits of the pulsation area. Moreover, there need be no division of muscular fibres. Section of the sternum.—For the ligation of the artery this is unnecessary. Curtis’s modification of Milton’s method is, no doubt, admirably adapted for the exposure of the superior mediastinum, but for the purpose of dealing with the great arteries as they come off' from the aorta it is not only unnecessary but inadvisable. The difficulties of the operation are by no means insuperable, and in my case, though it might be thought to have been a matter of great anxiety, I cannot say that the operation was specially difficult. I scarcely like, however, to adopt the “ gay comparison ”3 of Sir W. Mitchell Banks, who in contrasting the ligation of the innominate with another operation subsequently performed upon the same patient says that it was “ a mere surgical amusement.”4 Choice of the ligature — The ligature employed was of gold-beater’s skin. This is pure white fibrous tissue and is slowly absorbed from the surface.5 These ligatures were made for Mr. Edmunds and myself by MacFarlan of Edinburgh. The gold-beater’s skin ligature seems to be an appropriate material since it is of white fibrous tissue of which the outer coat of an artery consists. It is strong, inelastic, round, smooth, pliable, and easily tied into a knot, absorbable and yet not too readily so, but it cannot be boiled Floss silk, which possesses the above characteristics, can be boiled and can therefore be certainly sterilised; hence gold-beater’s skin ligature cannot be considered superior to fioss silk. Choice of the force.—The force necessary to occlude the innominate artery by means of a stay-knot without rupture of its coats is about three pounds, whereas the force necessary to rupture is about 10 pounds, so that a fairly large margin is allowed, and it should not need a large experience of the ligation of great arteries in order to ligature the innominate without rupture of its coats. 1 “Lehrbuch der Speciellen Chirurgie,” vol. i, p. 54. 2 H. P. Robinson, “The Studio and What to do in It,’: p. 49 (1885). 3 “ Antony and Cleopatra,” Act iii, scene 2. 4 Jacobson, op. cit. 5 See Figs. 129 and 130 in “ Ligation in Continuity.1’ A 3