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 A. 
 
 PRACTICAL TREATISE 
 
 ON 
 
 THE ARTERIAL SYSTEM. 
 

 PRACTICAL TREATISE 
 
 
 ON 
 
 * 
 
 r-h. 
 
 THE ARTERIAL SYSTEM. 
 
 INTENDED TO ILLUSTRATE THE IMPORTANCE OF 
 STUDYING THE ANASTOMOSES, IN REFERENCE 
 
 to the Rationale of the new operation 
 
 FOR ANEURISM; AND THE SURGICAL 
 TREATMENT OF HCEMORRHAGE. 
 
 WITH ORIGINAL COLOURED PLANS. 
 
 BY THOMAS TURNER, 
 
 Member of the Royal College of Surgeons of London ; Lecturer on 
 Anatomy; and Author of “ Outlines of a System of Medico- 
 Chirurgical Education,” ik.c. Sec. Sec. 
 
 LONDON: 
 
 PRINTED FOR LONGMAN, HURST, REES, ORME, BROWN, 
 AND GREEN; AND J. ASTON, MANCHESTER. 
 
 MDCCCXXV. 
 
Manchester : 
 
 Printed by J. Aston, Herald Office. 
 
TO 
 
 WILLIAM HENRY, M.D. F.R.S., &c. 
 
 LAI'E PHYSICIAN TO THE MANCHESTER INFIRMARY. 
 
 My Dear Sir, 
 
 Although the sanction of your name will 
 secure for this Volume a degree of attention, to 
 which its own merits may not entitle it ; yet my 
 chief motive in inscribing it to You, is to avow 
 the sense of gratitude which I feel, for many acts 
 of confidence and friendship. 
 
 Believe me. Dear Sir, 
 
 Your obliged and obedient Servant, 
 
 THE AUTHOR. 
 
 * 
 
 Manchestep., 22, Piccadilly, t 
 October, 1825 . $ 
 

 
 
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CONTENTS. 
 
 INTRODUCTION. 
 
 SECTION I. 
 
 Preliminary Observations on the Structure, Functions, and 
 Diseases of the Arterial System. 
 
 General Character of Arteries, p. 1 — Origins of the Arterial 
 System, 2— General description, 2 — Terminations of the Arterial Sys- 
 tem, 2 — Structure of Arteries, 3 — Functions of Arteries, 4 — Diseases 
 of Arteries, 5. 
 
 SECTION II. 
 
 On the Origin, Course, and Distribution, of the Arteries of 
 the Human Body. 
 
 Pulmonary Artery, 11 — Aorta, 12 — Coronary Arteries, 12 — Arteria 
 Innominata, 13 — Right Common Carotid Artery, 13 — Internal Carotid, 
 14 — Its branches, 14 — External Carotid, 14 — Its branches, 15 — Subcla- 
 vian Arteiy, 16 — Its branches, 17 — Axillary Artery, 19— Its branches, 
 19 — Brachial Arteiy, 20 — Its branches, 20 — Radial Artery, 21 — Its 
 branches, 21 — Ulnar Artery, 21 — Its branches, 22 — Aorta Descendens, 
 22 — Thoracic portion, 23 — Its branches, 23 — Abdominal portion, 23— 
 Its branches, 23 — Common Iliac Artery, 24 — Internal Iliac Artery, 24 
 —Its branches, 24 — External Iliac, 25 — Its branches, 25 — Femoral 
 Artery, 25 — Its branches, 26 — Popliteal Artery, 26 — Its branches, 27 
 — Anterior Tibial Artery, 27 — Its branches, 28 — Posterior Tibial, 28— 
 Its branches, 29. 
 
 SECTION III. 
 
 Practical Application of the Study of the Anastomoses to the 
 Surgical Treatment of Aneurism and Hcemorrhage. 
 
 Prefatory Remarks on the importance of studying the Anastomo- 
 ses, 30 — Increase of size of the Anastomosing Branches, 30— Mr. Rams- 
 
II 
 
 den doubted the necessity of this change to the preservation of the 
 limb, 32 — Argument against this opinion, 32 — Medical Treatment of 
 Aneurism, 33 — Surgical Treatment of Aneurism, 33 — First case in 
 which Mr. Hunter operated according to his new method, 34 — Second 
 case, 35 — Alteration in the mode of operating suggested by Mr. Aber- 
 nethy and the late Mr. John Bell, 35— Effects of the operation in the 
 cure of the disease, 36 — Application of the preceding observations to 
 the treatment of Haemorrhage, 36 — General Principles in the treat- 
 ment of Wounded Arteries, 36 — Deductions from the study of the 
 Anastomoses, 37 — Mr. Hodgson’s opinion as to the application of two 
 ligatures, 38 — Cases by Mr. Lawrence and Mr. Earle, confirmatory of 
 the same, 38 — Cases in which this practice may he deviated from, 39 
 — The ineliicacy of. tying the trunk at a distance from the wound, il- 
 lustratecLby a case from M. Roux’s “ Parallele,” 39 — Inferences, 41. 
 
 Aorta. — Anastomosing branches when the Aorta is obliterated by 
 disease, 44 — M. Paris’ case, 45 — Dr. Graham’s case, 47 — Have we a 
 right to infer from these cases, that the Aorta may ire tied f 4! — Rea- 
 sons why not, in certain situations, 49 — Reasons why it may, in one 
 situation, 50 — .Operation of tying the Aorta in the dog, 50 — Success- 
 ful cases, 50 — Deduction, 51 — Sir A. Cooper’s operation in the Hu- 
 man Subject, 52 — Reasons why the operation cannot succeed, unless 
 performed in a certain situation, 56 — Nature can accommodate herself 
 to certain changes, when they take place in a gradual manner, 56 — 
 This observable not only in the aiterious, but in the venous system — 
 Proofs, 56 — Practical conclusions, 58. 
 
 Arteria Innominata. — Dr. Mott’s case, 61 — M. Graef's case, 61 — 
 Inferences, 61 — Mr. Allan Burns' opinion of the practicability and 
 safety of tying the Arteria Innominata, 63 — Anaotomo ing branches, 
 64 — Reasons why a ligature on the Arteria Lnnouiinala is a precarious 
 operation, 65 — Practical deductions, 65. 
 
 Carotis Communis. — Circumstances which encouraged Surgeons 
 to try the safety of tying the Common Carotid Artety. 67 — Sir \. 
 Cooper’s operations on a dog, 67 — Haller’s ease. 68 — Dr. BaRlic’s 
 case, 69 — Mr. Abernethy's first case. 69 — Sir A. Cooper’s fir.-t case, 
 
Ill 
 
 69 — Sir A, Cooper’s second case, 69 — Mr. Cline’s case, 70 — Mr. Tra- 
 vers’ case, 70— -Mr. Dalrymple’s case, 70— Mr. Goodlad’s case, 70— 
 Mr. Thorpe’ case, 71 — Operation no longer considered very doubtful 
 in its issue, 71 — Anastomosing branches, when one carotid is oblite- 
 rated, 71 — Reasons for supposing that both Common Carotids cannot 
 be tied at the same time, with much probability of success, 74 — Prac- 
 tical inferences, 75. 
 
 Arterial Subclavia et Axillaris.— The first case in which the 
 Subclavian Artery was tied by Mr. Keate, 77 — Mr. Hall’s case, 77— 
 Desault’s and White’s cases, 78— Mr. Ramsden’s case, 78 — Sir W. 
 Blizard’s case, 79 — Mr. Chamberlaine’s case, 79 — Dr. Colles’ cases, 
 
 79 — Dr. Post’s case, 79 — Mr. Liston’s case, 79 — Mr. Wishart’s case, 
 
 80 — Operation performed by other Surgeons, 80 — Mr. Key’s case, 81 
 — Mr. Green’s case, 82 — Mr. Teale’s case, 84 — Inference, 87 — Diffi- 
 culty in the operation, 87 — Circumstances which influence the success 
 or failure of the operation, 87 — Anastomosing branches, 89 — Cases 
 which may interfere with the direct communication, shown to exist 
 between the Subclavian and Axillary Branches, 92 — Ligature on the 
 tracheal side of the scaleni, 97 — Ligature on the humeral side, 98 — 
 Preference to be given to the latter operation, 98 — Practical con- 
 clusions, 100. 
 
 Arteria Brachialis. — Wounds of the Brachial Artery, 102 — 
 Circumstances affecting the collateral passages for the blood, when 
 different portions of the Brachial Artery are wounded, 103 — Artery 
 punctured in the operation of venesection, 104 — Consequences, 104 — 
 Distinctions between diffused aneurism and aneurismal varix, 104 — 
 Treatment of diffused aneurism and aneurismal varix, 108 — True 
 aneurism of the Brachial Artery, 1 10. 
 
 Arte ri_* Radialis et Ulnaris. — Usual division of the Brachial 
 Artery into the Radial and Ulnar Branches, 111 — Varieties, 111 — 
 Practical deductions, 114— Free communications between the arteries 
 of the fore-arm and hand, 116 — Application of the anastomoses to the 
 urgical treatment of hoemorrhage, 117 — Mr. Ainsworth’s case of 
 aneurism of the radial artery , 118 — Practical inferences to be drawn 
 
IV 
 
 from it, 119 — Necessity of two ligatures, 121 — Danger of interfering 
 with the palmar fascia, 122 — Mr. Lizars’ case, 122 — Treatment of 
 wounds of either of the arteries of the palm, 123. 
 
 Arteria Iliaca Communis. — Anastomoses when the Common 
 Iliac Artery is tied, 125. 
 
 Arteria Iliaca Interna. — Dr. Stevens’ case, 126 — Not a case of 
 glutaeal, but of ischiatic aneurism, 127 — Other cases in which the 
 Internal Iliac Artery has been tied, 128 — Mr. John Bell’s case, 128 — 
 Dr. Jeffrey’s case, 131. 
 
 Arteria Iliaca Externa — Baron Larrev on tying the External 
 Iliac, 133 — M. Riclierand’s opinion, 133 — M. Roux’s, 135 — Mr. Aber- 
 nethy first tied it, 135 — Cases in which he operated, 133 — Mr. Freer’s 
 case, 138 — Mr. Tomlinson’s case, 138 — Mr. Abernethy’s fourth case, 
 138 — Other Operators, 139 — Cases in which the Author witnessed the 
 operation, 139 — Results, 139 — Opinion formed on a review of cases, 
 140 — Frequent cause of failure in the operation illustrated by Mr. R. 
 Thorpe’s case, 140 — Interesting case communicated by Mr. Grainger, 
 142 — Anastomosing branches, 143 — Sir A. Cooper’s accounts of the 
 anastomoses, 144 — Inferences, 146. 
 
 Arteri.-e Femoralis et Poplitea. — A crell’s opinion of the ope- 
 ration for Popliteal Aneurism, 148 — Scarpa’s opinion, 148 — The latter 
 opinion most probable, 149 — Mr. Samuel Cooper’s opinion, 149 — Mr. 
 Hunter first performed it in England, 149 — Mr. George Bell first per- 
 formed it with success in Scotland, 149 — His case, 150 — Examination 
 of the Anastomoses in this case, 150 — Anastomosing branches, when a 
 ligature is applied to the Femoral immediately below Poupart’s liga- 
 ment, 151 — When applied about the middle of the thigh, 151 — States 
 of the Femoral Artery after the application of a ligature, 152 — ? r. C. 
 Bell on the importance of the Profunda and its branches in different 
 states of the Femoral Artery, 15 1 — An inference that might he drawn 
 from this, 156 — Not, however, a just one. 156 — More to be apprehend- 
 ed, from the Anastomosing branches being very numerous, than from 
 their being scanty, 156 — Scarpa’s opinion, 157 — Only correct in a li- 
 
V 
 
 mitecl point of view, 158 — Circumstances influencing the success and 
 failure of the operation, 160 — Dr. Monteath’s case illustrative of a fre- 
 quent cause of failure, 162 — Mr. Jeffrey’s case illustrative of the same, 
 165 — Mr. Richard Smith’s case to the same effect, 170 — Mr. Goodlad's 
 case, 172 — Conclusions, 173 — Practical Inferences to be drawn relative 
 to the operation, 174 — Causes of failure, 176— How obviated, 177— 
 Interesting cases by Mr. Lawrence, 179 — Mr. Travers’ case, 184 — In- 
 ferences, 184 — Haemorrhage from wounds of the Femoral Artery, 185 
 Treatment, 185. 
 
 Arteri.c Tibiales.— Arteries of the leg and foot bear a resem 
 blance to those of the forearm and hand, 187 — Practical deduction, 
 187— Aneurism of these Arteries, 187 — Anastomoses, 188— Wounds of 
 these Arteries, 189— Case of wound of the Anterior Tibial high up, 189 
 — Mr. Guthrie’s case of gun-shot wound of the Fibular Astery, 190 — 
 Wound of the Anterior Tibial on the dorsum of the foot, 191 — Con- 
 cluding observations on the study of the Anastomoses, and the present 
 state of Surgery with respect to Aneurism and Haemorrhage, 193, 
 

 
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INTRODUCTION, 
 
 It was the intention of the Author to have 
 embodied much of the following matter in the 
 Work which he has recently published, entitled, 
 — “ Outlines of a System of Medico-Chirurgical 
 Education, or Illustrations of the Application of 
 Anatomy, Physiology, and other Sciences, to the 
 principal Practical Points in Medicine and Sur- 
 gery;” but he was induced to abandon that 
 intention, from the practical study of the Arterial 
 Anastomoses being considered by his medical 
 friends a subject so important and interesting, as 
 to deserve a separate volume. Besides, to en- 
 large so much on the application of a particular 
 point of anatomy, would not have been consis- 
 tent with the design of the volume referred to, 
 which is meant merely as an Index to the objects 
 which have a claim upon the Student’s attention, 
 
VIII 
 
 whilst he is engaged in his anatomical, physio- 
 logical, and pathological researches. 
 
 In the first section of the present volume, 
 the Author has given, in an aphoristic form, the 
 structure, functions, and diseases of the arterial 
 system. In the second section, he has described 
 the usual origin and course of the main arteries of 
 the body, and the distribution and terminations 
 of the branches arising from them. And in the 
 third and last section, he has applied the study of 
 the anastomoses, or communications of branches, 
 to the rationale of the new operation for aneurism, 
 and the surgical treatment of hoemorrhage. 
 
 In the description of the inosculations, the 
 Author has limited his enquiries to the conspi- 
 cuous arterial branches, as it is chiefly upon the 
 knowledge of them, that the Surgeon must esta- 
 blish the principles of practice, which ought to 
 guide him in the surgical treatment of aneurism, 
 and of wounded arteries : but he must here impress 
 
IX 
 
 on the mind of the Student, that there are myriads 
 of vessels of so small a size, as to be invisible ; 
 all of which, however, form links in the great 
 chain of actions set up for the maintenance of 
 life and health ; and for the reparation of injuries 
 from accident and disease. 
 
 To facilitate comprehension, and to assist 
 the Student in retaining in his memory what he 
 reads, the Author has annexed two original 
 Plans, exhibiting the manner in which the prin- 
 cipal arterial branches communicate with each 
 other. At first view, from their colouring, they 
 may appear more fanciful than useful, but he can 
 speak of their utility from having employed chalk 
 diagrams, similarly coloured, at his Public Lec- 
 tures; and from having thus been enabled to 
 illustrate points, which, if attempted by descrip- 
 tion only, would have been extremely difficult ; 
 and, if at the time understood, the impression 
 made in that way, would not have been so 
 lasting, as he has reason to know it became, bv 
 
X 
 
 the assistance of so clear, and simple a mode 
 of demonstration. The number of anastomoses 
 might have been multiplied, but it would have 
 rendered the Plans too confused; and for the 
 same reason, certain muscular branches have 
 been omitted. In a word, thev are to be con- 
 sidered as Plans, and not as finished views of the 
 whole series of arterial communications. 
 
 The object of the publication is to shew the 
 importance of studying the anastomoses, and the 
 influence which this study ought to have in guid- 
 ing the Surgeon to a right practice for the radical 
 cure of aneurism, and for the suppression of 
 hoemorrhage. 
 
 With respect to the treatment of aneurism, 
 the Author will attempt to prove ; 
 
 First , — That the apprehension which some 
 Surgeons entertain, that the anastomosing 
 ranches, in certain situations, are not sufficient 
 
XI 
 
 to support the life of the part, when the main 
 vessel is obliterated, is entirely groundless ; ex- 
 cepting in one case, namely, when the aorta is 
 obstructed by ligature at any point of its course 
 between its origin, and the passing off of the 
 lumbar branches. 
 
 Secondly , — That more is to be feared from 
 their being too abundant, than from their being 
 few in number. 
 
 Thirdly , — That if the aneurism be of the 
 common kind, and of a small size, it is reason- 
 able to expect, that the operation of tying the 
 arterial trunk, at a distance from the disease suf- 
 ficient to ensure a sound condition of the vessel, 
 will have the effect of curing the aneurismal 
 swelling. 
 
 Fourthly , — That should it not succeed in 
 doing so, the failure is to be attributed, either 
 to the circumstance of the sac being fed from 
 
XII 
 
 above, in consequence of some inosculating 
 branches entering the artery between the liga- 
 ture and the disease, or from below, by the re- 
 current circulation; — to the presence of a large 
 mass of coagula; — or to this last, united to ex- 
 tensive suppuration. 
 
 Fifthly , — That to obviate the first cause of 
 failure, the anastomoses should be studied, and 
 the artery tied at such a point as the knowledge 
 thus gained may dictate; and further, to do away 
 with the chance of not succeeding, the blood, 
 which probably would otherwise enter the sac, 
 should be diverted from it, by pressure applied to 
 the aneurismal swelling. 
 
 Sixthly , — That when the aneurism is circum- 
 scribed — of a very large size — and contains a good 
 deal of coagula, with or without pus; besides 
 tying the artery, an opening should be carefully 
 made into the sac at its most dependent part, 
 and its contents evacuated ; this will remove that 
 
XIII 
 
 source of irritation which, in many cases, is the 
 cause of death. 
 
 Seventhly , — That when the aneurism is dif- 
 fused, or results from the rupture of a vessel, and 
 the Surgeon is called early ; his practice should 
 consist in cutting down on the ruptured, or 
 wounded artery, removing the coagula, and 
 securing the vessel with two ligatures. 
 
 Eighthly , — That when diffused — of consi- 
 derable magnitude — and of long standing, it is 
 probable that the wound in the artery is, in part, 
 or wholly obstructed ; in which case, it is probable, 
 that a ligature on the main trunk will so far break 
 the force of the current, as to prevent further 
 extravasation. 
 
 Ninthly , — That after tying the main trunk, 
 it is advisable, in most cases, to give exit to the 
 coagula, especially if a suppurative process has 
 commenced in the sac, and there is reason to be- 
 
XIV 
 
 lieve, that the soft parts, forming its boundaries, 
 have become much disorganized. 
 
 Tenthly , — With respect to the treatment of 
 hoemorrhage, it will be shown, that two ligatures 
 on the wounded vessel are required, or that the 
 cases are few in which this practice can be de- 
 parted from with safety. 
 
 To do away with the impression that it is 
 too presumptuous in a young Surgeon to have any 
 thing to do with so difficult a subject as aneu- 
 rism, the Author must disclaim all pretensions to 
 attempt more, from his individual experience, 
 than to establish general principles on the basis of 
 anatomy. Little novelty can be expected from 
 him, on a disease which has engaged the particular 
 attention of Hunter, Scarpa, Abernethy, Cooper, 
 Bell, Hodgson, and other eminent Surgeons ; 
 but by collecting and arranging (for a specific 
 purpose) the facts individually recorded ; and by 
 the assistance of experienced men, who have. 
 
XV 
 
 ill the most handsome manner, communicated 
 to him the results of their practice, he hopes to 
 render some service to the junior members of the 
 profession. 
 
 If, in a few instances, the Author has pre- 
 sumed to differ from the opinions urged by Sur- 
 geons of celebrity, he has done so from the fairest 
 motives, and the best feelings of respect ; for 
 although it may be amiable in a man. and per- 
 haps, safer for his reputation, to yield to such 
 authorities, yet it would be blameable in him not 
 to exercise the privilege of thinking for himself. 
 
 The Author has not entered on the subject 
 of tying the arterial trunks, nor has he given any 
 description of the parts concerned in these ope- 
 rations, as those points are fully considered in his 
 “ Outlines,” which is their proper place : but as 
 the Student will stand in need of a more extended 
 account of the Arterial System, he is recom- 
 mended to peruse the works of Dr. Barclay and 
 
XVI 
 
 Mr. Harrison : and as Views, which will assist 
 him in obtaining a knowledge of the parts con- 
 nected with the main trunks, the Author begs to 
 mention Lizars’, Alcock r s, and Dermott’s Illus- 
 trations, as well worthy of his attention. 
 
XVII 
 
 PLAN, No. L 
 
 REFERENCES TO THE LETTERS AND FIGURES. 
 
 A. — Aorta Ascendens, with the 3 semilunar valves. 
 
 Fig. 1. — Arteria Coronaria depctra. 
 
 ]B. — Aorta Thoracica, sending off 
 
 2. — Arterise intercostales inferiores, the free 
 anastomoses of which are seen on the right 
 side. 
 
 C. — Aorta Abdominalis, sending off, in addition to 
 
 the visceral branches, the following anastomosing 
 vessels : 
 
 3. — Arteria phrenica ; the distribution and 
 communications of which are seen on the right 
 side. 
 
 4. — Arterise lumbales ; their communications 
 with branches from above, and with those of 
 the circumflexa ilii are shown on the right — • 
 those with the gluteal on the left side. 
 
 D. — Arteria Innominata, dividing into the right 
 
 carotid, and right subclavian trunks. 
 
 E. E. — Arterle Carotides Interne, dividing in- 
 to internal and external carotids. 
 
XVIII 
 
 F. — Arteria Carotis Interna, which enters the 
 foramen carotideum. 
 
 G — Arteria Carotis Externa, seen ascending on 
 the right side, and sending off 
 
 5. — Arteria thyroidea superior. 
 
 6. — Arteria lingualis. 
 
 7. — Arteria facialis, which branch passes over 
 the base of the jaw to the face — sends off 
 branches to the lips and side of the nose — and 
 eventually communicates with some of the 
 brandies of the anterior temporal. 
 
 8. — Arteria occipitalis, seen on the right side 
 to anastomose with the cervicales, and with 
 some small deep muscular branches of the ver- 
 tebral ; the posterior branches join the oppo- 
 site occipital branches. 
 
 9. — Arteria auralis, anastomosing with the oc- 
 cipital branches. 
 
 10. — Shows the continuation of the main trunk, 
 which sends off the internal maxillary branch, 
 and terminates by dividing into the anterior 
 and posterior temporal branches ; the former 
 communicating with the ultimate branches of 
 the facial ; the latter with the occipital and au- 
 ral branches. 
 
 H. — Arteria Subclavia ; its branches are, 
 
 11. — -Arteria vertebralis, which in its course up- 
 wards distributes some small branches to the 
 
XIX 
 
 deep muscles. Two ox- three of these are shown 
 communicating with the occipital, &c. The two 
 vertebral arteries unite and form the basilar 
 trunk, which supplies the cerebellum, and pos- 
 terior lobes of the cerebrum ; some of its 
 bx-anches communicate with the branches of 
 the internal carotids, in the Avay described in 
 the text. 
 
 12. — Arteria thyroidea inferior. 
 
 13. — Arteria mammaria interna , et arteria in- 
 tercostalis superior. These branches are seen 
 communicating with each other — with the in- 
 tercostals, &c. 
 
 11. — Arterise cervicales. 
 
 15. — Arteria supra-scapularis, having commu- 
 cating with it, above, some of the cervical 
 branches, and below, the circumflex and infra 
 scapular bi - anches. 
 
 I. — Arteria Axillaris. 
 
 16. — A rteria infra-scapularis. 
 
 17. — Arteria mammaria externa. 
 
 18. — Arteria circumflexa externa, sending some 
 branches upwards to inosculate with the su- 
 pra -scapular ; branches about the shoulder 
 joint ; and others downwards to communicate 
 with some of the ascending branches of the 
 profunda superior. Corresponding to the ex- 
 teimal circumflex, is seen the circumflexa inter- 
 na, and its anastomoses. 
 
XX 
 
 J. — Arteria Brachialis, sending off, besides the 
 smaller muscular branches, 
 
 19. — Arteria profunda superior, which, after 
 sending a few branches upwards, descends and 
 inosculates freely with the recurrent radial. 
 
 20. — Arteria prof unda inferior, communicating 
 with the anastomotic branches, and the recur- 
 rent ulnar. 
 
 21. — Ramus anastomoticus, freely uniting with 
 the profunda inferior, recurrent ulnar, and re- 
 current interosseal branches. 
 
 K. — Arteria Radialis, giving off, besides some 
 small muscular branches, 
 
 22. — Arteria radialis recurrens. 
 
 23. — Superfcialis voire. 
 
 24. — Arte rise poll ids. 
 
 25. — Radialis indicis. 
 
 26. — Portion contributed to the arcus pahnaris 
 superfcialis. 
 
 27. — Arcus palmaris profundus. 
 
 L. — Arteria Ulnaris, giving off, besides some 
 
 small muscular branches, 
 
 28. — Arteria ulnaris recurrens. 
 
 29. — Arcus pahnaris superfcialis, 
 
 30. — Rami dig it ales. 
 
 31. — Ulnaris indicis. 
 
 M. — Arteria Ixterossea, giving off, besides the 
 
XXI 
 
 recurrent and muscular branches, 
 
 32 . — Several branches to communicate with the 
 radial and ulnar at the carpus , and in the 
 palm of the hand. 
 
 N. — Arteria Iliaca Communis, dividing into the 
 Internal and External Iliac. 
 
 O. — Arteria Iliaca Interna, giving off, 
 
 33. — Arteria ileo lumbalis, anastomosing with 
 the circumflexa ilii branches. 
 
 34. — Arteria glutsea, sending branches upwards 
 to anastomose with the lumbar ; and others out- 
 wards and downwards to communicate with the 
 branches of the profunda, and the ischiatic 
 branches. 
 
 35. — Arteria obturatoria, anastomosing with the 
 circumflex branches, and with the profunda. 
 
 36. — Arteria ischiadica, anastomosing with the 
 circumflex, obturator, and with some of the de- 
 scending branches of the glutseal. 
 
 P. — Arteria Iliaca Externa, giving off, 
 
 37. — Arteria epigastrica, anastomosing very 
 abundantly with the internal mammary branch 
 of the subclavian ; with the inferior intercostals ; 
 with the phrenic, and the lumbar branches. 
 
 38. — Arteria circumflexa ilii, inosculating with 
 the inferior intercostals, with the phrenic, with 
 the lumbar, and with the ileo lumbar branches. 
 
XXII 
 
 Q. — Arteria Femokalis, giving off, 
 
 39. — Arteria profunda , from which pass off, 
 
 40. — Arterise circumjlexze , having free commu- 
 nications both above and below. 
 
N’XIII 
 
 PLAN, No. 2. 
 
 REFERENCES TO THE LETTERS AND FIGURES. 
 
 A. — Arteria Femoralis, sending off, 
 
 Fig. 1 . — Arteria profunda, from which branch 
 arise, 
 
 2. — A circumflexa interna. 
 
 3. — A circumflexa externa. 
 
 4. — Rami of the latter, descending to anastomose 
 with the superior outer articular branch. 
 
 5. — Rami perforantes. 
 
 After the profunda branch, the femoral artery 
 sends off many muscular branches in its de- 
 scent ; one, more considerable than the rest, is 
 
 6. — Ramus anastomoticus , w hich forms numerous 
 communications with the perforantes of the pro- 
 funda, and with the upper articular branches. 
 
 B. — Arteria Poplitea, sending off, 
 
 7. 8 . — Rami articulares superiores. 
 
 9. 10 . — Rami articulares inferiores. 
 
 The superior articular freely inosculate with the 
 branches of the femoral and profunda ; — the 
 superior articular branches, with those of the 
 inferior articular ; — and the inferior articular 
 with the recurrent tibial, &c. 
 
 11 . — Arterise su rales. 
 
 i 
 
XXIV 
 
 C. — Arteria Tibialis Antica, sending off, 
 
 12. — Arteria recurrens tibialis. 
 
 13. — Arterise malleolares. 
 
 14. — Arteria metatarsea. 
 
 15. — Arterise interossese. 
 
 16. — Anastomoticus profundus, contributing to 
 the plantar arch. 
 
 17. — Arteria dorsalis pollicis. 
 
 D— Arteria Tibialis Postica, sending off, 
 
 18. — Arteria plantaris interna. 
 
 19. — Arteria plantaris externa. 
 
 20. — Arcus plantaris. 
 
 21. — Arterise digitales. 
 
 E. — Arteria Peronea. 
 
 22. — Anastomoses of the anterior tibial, poste- 
 rior tibial , and peroneal branches about the 
 tarsus and foot. 
 
 \ 
 
The Reader is requested to correct the folio-wing Errata. 
 
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 4. 
 
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 18. 
 
 158 
 
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 25. 
 
 185 
 
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 1 . 
 
 176 
 
 — 
 
 15. 
 
 After “ stomach,” read liver. 
 
 For onwards, read outwards. 
 
 After “ superior,” read and inferior. 
 For branches, read branch. 
 
 For in, read on. 
 
 For great, read greater. 
 
 For its, read their. 
 

 
 j (■ I 
 
 
 
 
 O' •' 
 
 ;*• 
 
 
 : .'I 
 
 
 - 
 
 
 i • 
 -• 
 
 ■ - 
 
 
 
 
 . 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ON THE 
 
 ARTERIAL SYSTEM. 
 
 » 
 
 %* 
 
 SECTION 1 
 
 PRELIMINARY OBSERVATIONS ON THE STRUCTURE, 
 FUNCTIONS, AND DISEASES, OF THE ARTERIAL 
 SYSTEM. 
 
 1. — The Arterial System is composed of a 
 series of vessels, which carry the blood from the 
 heart to the different structures of the body. 
 
 2. — The arteries are tubes of a cylindrical 
 form, which form they retain on being divided 
 across, owing to the elasticity of one of their 
 tunics, or coats. 
 
 B 
 
2 
 
 3. — This property is one of the distinguish- 
 ing characters of an artery. 
 
 4. — The arterial system originates in two 
 trunks} the pulmonary artery, and aorta. 
 
 5. — The pulmonary artery distributes its 
 branches to the lungs, where the blood under- 
 goes the changes, which respiration is intended to 
 effect. 
 
 6. — The aorta supplies all the parts of the 
 body, and therefore may properly be called, the 
 systemic artery. 
 
 7. — The arterial trunks of the neck, upper 
 extremities, and lower extremities, run for the 
 most part in a straight direction, but the branches 
 of these trunks are more or less tortuous in their 
 course ; and the same is the case with the arteries 
 of the viscera, particularly with those of the sto- 
 mach and uterus. 
 
 8. — The arteries terminate in six wavs, 
 namely ; first, in anastomoses, or communica- 
 tions with each other} secondlv, in veins} thirdly. 
 
3 
 
 in cells, as in the spleen ; fourthly, in exhalent 
 orifices, as on the dura mater, pleura, peritoneum, 
 and other serous membranes; fifthly, in the excre- 
 tory ducts of glands; and, sixthly, in colourless, 
 or serous branches. 
 
 9. — An artery is composed of coats, blood 
 vessels, absorbents, and nerves. 
 
 10. — The coats are three in number; an 
 externa], or elastic; a middle, or muscular; and 
 an internal, or membranous, coat : — this last 
 seems to be a continuation of the lining mem- 
 brane of the heart. 
 
 11. — The blood vessels of these coats are 
 called the vasa vasorum, and derived from the 
 neighbouring trunks. 
 
 12. — The ulcerative process of which the 
 arteries are susceptible, proves the existence of 
 absorbents. 
 
 13. — And as the presence of nerves can be 
 demonstrated in the larger, it is just to presume 
 that they are present, too, in rhe smaller branches 
 of the arterial system. 
 
4 
 
 ]4. — The function, or office of the arteries is 
 to convey the blood from the heart to the different 
 parts and organs of the body, for the purposes of 
 nutrition and secretion. 
 
 1 5 . — The first impulse given to the blood 
 results from the systole, or contraction of the left 
 ventricle of the heart. 
 
 16. ' — The blood thus driven forwards pro- 
 duces two movements in the arteries ; first, they 
 are elongated by the progressive motion of this 
 fluid ; and, secondly, they are dilated by the 
 pressure of the current against their sides. 
 
 17- — During the diastole, or dilatation of the 
 left ventricle of the heart, the arteries return to 
 their natural length and size: the former effect 
 arises from the elastic ; the latter, partly from the 
 elastic, and partly from the muscular property 
 with which these vessels are endued. 
 
 18. — The movement of the blood is not uni- 
 formly rapid throughout the whole series of ar- 
 terious vessels, for in some parts it is retarded 
 by the angles and tortuosities which the arteries 
 make. 
 
5 
 
 19- — And although there is unquestionably 
 an inherent power of action in the arteries, the 
 vis a tergo force must be the prime and principal 
 agent of circulation, from whence we are to infer, 
 that the rapidity of the blood’s motion must di- 
 minish in proportion to the distance of the artery 
 from the heart. 
 
 20. — As the arteries are not inorganized 
 tubes, but composed of coats, and furnished with 
 arteries, veins, absorbents, and nerves, they are 
 susceptible of the same diseases as structures in 
 general ; besides which, their function disposes 
 them to undergo particular morbid changes. 
 
 21. — Inflammation of an artery is denomi- 
 nated arteritis, and is usually seated in the inter- 
 nal, or membranous coat. 
 
 22. — This internal coat is analogous in 
 structure to the pleura, peritoneum, and other 
 serous membranes; and an inflammation pro- 
 duces similar effects in the one structure, as in 
 the other. 
 
 2 3 . — The effects of inflammation in an ar 
 
0 
 
 tery may be adhesion, suppuration, ulceration, 
 or mortification, 
 
 24 — The great tendency to the termination 
 in adhesion, strikingly illustrates the analogy 
 above referred to, between the lining membrane 
 of an artery and the lining and reflected mem- 
 branes of the great cavities of the body. 
 
 25. — The adhesion between surfaces, natu- 
 rally not contiguous and adhering, arises from 
 the effusion of a lymph differing in its properties 
 from the common serum which lubricates them. 
 
 26. — This lymph is capable of coagulation, 
 and of thus becoming the matrix of new vessels. 
 
 27* — The obliteration, then, of the calibre 
 of an artery, may not only arise from the adhesion 
 of surfaces, but also from the deposition of lymph, 
 which in time forms a plug of organic matter. 
 
 28. — When a vessel is obliterated by the 
 application of a ligature, it is the effect of the 
 former : when sealed by nature after the infliction 
 of a wound, the obstruction is attributable to the 
 
 latter process. > 
 
29- — The adhesive inflammation is the'most 
 common kind to which arteries are liable. 
 
 30.-— When arteritis terminates in suppura- 
 tion or ulceration, it is probable that not only the 
 membranous, but the other coats, have been in- 
 volved in the inflammatory action. 
 
 3J. — Mortification is seldom the sequela of 
 inflammation set up in, and confined to, an ar- 
 tery : more frequently the vessel is involved in 
 the sphacelus which has taken place in the sur- 
 rounding parts. 
 
 32. — The coats of arteries undergo changes 
 
 o o 
 
 from chronic inflammation, and other causes. 
 
 33. — The principal changes are, thickening ; 
 calcareous and cartilaginous depositions; and 
 morbid dilatation. 
 
 34. — Aneurism is a disease dependent on a 
 wound, or some peculiar alteration in the coats 
 of an artery. 
 
 35. — When an artery has been wounded. 
 
8 
 
 and the blood escapes into the surrounding cellu- 
 lar structure, a tumour is formed, which is called 
 a spurious aneurism. 
 
 36. — This disease occurs at the bend of the 
 arm, when the brachial artery is punctured in the 
 operation of venesection. 
 
 37- — When the coats of an artery become 
 disorganized, so as to dilate and form a pouch, 
 the disease is called true aneurism ; and the coat 
 or coats remaining entire, constitute the aneuris- 
 mal sac. 
 
 38. — When the coats give way, the neigh- 
 bouring parts form the boundaries of the sac. 
 
 39. — The causes of true aneurism are seve- 
 ral ; but very often it is a constitutional disease. 
 
 40. — Aneurisms from local causes may spon- 
 taneously get well, or be removed by medical or 
 surgical treatment ; but tjiose from constitutional 
 causes must eventually prove fatal. 
 
 41. — A spontaneous cure seldom happens. 
 
9 
 
 and medical treatment is for the most part insuf- 
 ficient when employed alone. 
 
 42. — The surgical means of treating aneu- 
 risms are compression and the ligature. 
 
 43. — When compression succeeds, its action 
 is the same as that of the ligature, viz. — to divert 
 the current of the circulation into the anastomo- 
 sing branches. 
 
 44. — The immediate effect of a ligature, is 
 the division of the internal and middle eoats of 
 the artery : the cut edges are brought into con- 
 tact, and adhere. 
 
 45. — After the artery is sealed by the adhe- 
 sive inflammation, the ligature is disengaged from 
 its connexions by ulcerating through the cellular 
 coat, or is thrown off with a sphacelated portion 
 of the vessel. 
 
 46. — The remote effect is an obliteration of 
 the trunk, usually to the first branch given off 
 above the ligature ; and, by a gradual dilatation 
 of the inosculating branches, the blood is trans- 
 
 c 
 
10 
 
 knitted to the part below the point, where the 
 ligature was applied. 
 
 Finally — If the anastomoses be not sufficient 
 to carry on, to a certain extent, a collateral cir- 
 culation ; the operation of tying a main arterial 
 trunk will be followed by the death of the part, 
 which the trunk and its branches supplied. 
 
SECTION IT. 
 
 ON THE ORIGIN, COURSE, AND DISTRIBUTION, OF 
 THE ARTERIES OF THE HUMAN BODY. 
 
 The pulmonary artery and aorta are consi- 
 dered by anatomists as the main trunks of the 
 arterial system. 
 
 The Pulmonary Artery arises from the 
 right ventricle of the heart, and can only be seen 
 when the pericardium is laid open. It is then 
 observed to pass from before backwards, and to 
 cover the origin of the aorta. After going about 
 two inches, the artery divides into two branches, 
 which enter the lungs, the right branch passing 
 behind the aorta. In the lungs they divide al- 
 most to infinity ; and the principal of these ter- 
 minate in the radicles of the pulmonary veins, 
 which unite and form four large venous trunks, 
 which open into the left auricle of the heart. 
 
1*2 
 
 The Aorta arises from the left ventricle ot 
 the heart, and between it and the ventricle are 
 the three semilunar valves. From its origin it 
 passes upwards, and, opposite to the first bone 
 of the sternum, makes a curvature, or arch. It 
 then descends, on the left of the dorsal vertebrae, 
 through the chest — enters the abdomen between 
 the crura of the diaphragm — and, at the fourth 
 or fifth lumbar vertebra, terminates by dividing 
 into the two common iliac arteries. That por- 
 tion of the aorta, which is situated between the 
 heart and arch, is called the aorta ascendens ; 
 after making its curvature it is named the aorta 
 descendens, which is divided into thoracic and 
 abdominal portions. 
 
 A little above the three semilunar valves, the 
 aorta furnishes the two Coronary Arteries. It is 
 by these vessels that the walls of the heart, and 
 the coats of the aorta and pulmonary artery, are 
 supplied with blood. 
 
 From its curvature arise three large trunks ; 
 named the arteria innominata, the left carotid, 
 and the left subclavian. 
 
13 
 
 The Arteria Innominata passes off from 
 the right side of the arch, and soon divides into 
 the right carotid and right subclavian. Its root 
 is crossed by the left subclavian vein. 
 
 The Right Common Carotid Artery is 
 shorter than the left. It ascends in the neck by 
 the side of the trachea, and, opposite to the upper 
 part of the thyroid cartilage, divides into the in- 
 ternal and external carotids. 
 
 The following structures are found in the 
 neighbourhood of the common carotid : — The 
 artery is situated on the inner side of the sterno 
 cleido mastoideus muscle in the middle of the 
 neck ; but lower down it is covered by that 
 muscle, the omo hyoideus, and sterno hyoideus. 
 On the inner side of the sheath, are the larynx, 
 trachea, and oesophagus; and behind it, are the 
 grand sympathetic nerve, the inferior thyroideal 
 artery, and some of the deep muscles of the neck. 
 External to the cellular sheath, which surrounds 
 the vessels and nerve, we find a branch of the 
 lingual nerve, named the deseendens noni ; and 
 within the sheath, are the artery, internal jugular 
 vein, and par vagum : the artery is on the inner 
 
14 
 
 side of the vein, and the nerve between, and rather 
 behind the two blood vessels. 
 
 The Internal Carotid Artery is one of 
 the arteries of the brain. From its origin it runs 
 towards the basis of the skull, enters the cranium 
 by the foramen carotideum of the temporal bone, 
 and traverses the tortuous carotid canal, in which 
 situation it sends off a few small branches. 
 
 The artery then penetrates the cavernous 
 sinus of the dura mater, where it sends off a few 
 small twigs; but its principal branches are now 
 to be enumerated. They are : The ophthalmic , 
 which passes through the optic hoie in company 
 with the optic nerve ; — the anterior branch of 
 the cerebrum j — the middle branch of the cere- 
 brum ; — the arteria communicans , which anas- 
 tomoses with the ramus communicans of the 
 basilar artery. All these branches freely com- 
 municate with those of their opposite fellows. 
 
 The External Carotid Artery" at its com- 
 mencement, lies on the inner side of the internal 
 carotid, and then passes outwards towards the 
 angle of the jaw, where it is surrounded by the 
 intricate structures of that part. 
 
35 
 
 it is first concealed by the digastricus and 
 stylo hyoideus muscles, and afterwards by the 
 parotid gland. In its course it sends off nume- 
 rous branches. The first branch is the superior 
 thyroideal , which ultimately ramifies on the up- 
 per part of the thyroid gland, and anastomoses 
 with the opposite thyroideal, and the inferior 
 branches on the same side. 2. The lingual to 
 the tongue. 3. The external maxillary or fa- 
 cial to the muscles and glands under the lower 
 jaw — to the chin — to the lower lip — the upper 
 lip — the ala of the nose — the corner of the eye — 
 and forehead : all which branches freely commu. 
 nicate with those of the opposite side. 4. The 
 ascending pharyngeal. 5. The occipital to the 
 soft parts about the angle of the jaw — to the 
 sterno cleido and other muscles to communicate 
 with the ascending cervical and deep cervical of 
 the subclavian, and with the deep muscular 
 branches of the vertebral artery. After emerg- 
 ing from the muscles of the neck, the occipital 
 artery ramifies on the back part of the head, and 
 terminates in frequent anastomoses with the op- 
 posite occipital — with the temporal branches — 
 and with the posterior aural. 6. The posterior 
 aural branch , which anastomoses with the occi* 
 
16 
 
 pital and temporal branches. 7. The temporal 
 giving off the transversal is faciei, the deep tem- 
 poral, and the frontal and occipital, or anterior 
 and posterior branches, which communicate with 
 the opposite anterior temporal — the terminating 
 branches of the facial — the occipital — and pos- 
 terior aural. Lastly, The infernal maxillary , 
 which furnishes the artery of the dura mater — 
 supplies in part the muscles of the lower jaw and 
 cheek — the teeth — and some ether parts in their 
 vicinity. 
 
 The Subclavian Artery, on the right side, 
 is a branch of the arteria innominata: the left 
 subclavian originates from the arch of the aorta. 
 This difference in origin causes differences in the 
 length and course of these vessels. It will be ob- 
 vious on reflection, that the left must be longer 
 than the right, and less direct in its passage to 
 the axilla. The former passes first vertically, and 
 then suddenly bends outwards: the latter goes 
 almost straight ; but after escaping from between 
 the scalenus anticus and scalenus medius muscles, 
 their direction is nearly the SAtne, and both de- 
 scend to the arm-pit, above, and rather behind, 
 the axillary plexus of nerves. After passing 
 
17 
 
 under the clavicle, they lose the name of subcla- 
 vian, and take that of axillary arteries. 
 
 The branches of the subclavian are large 
 and important. They are: — 1. The vertebral, 
 which passes through the hole in each transverse 
 process of the six superior cervical vertebrae, and 
 enters the cranium by the foramen magnum. In 
 its course up the neck, it gives off several small 
 muscular branches, which unite with some of the 
 branches of the cervicaies and occipital artery. 
 
 Soon after entering the cranium, the vertebral 
 arteries unite to form one artery, named the 
 Basilar, which supplies the cerebellum, or lesser 
 brain, the posterior part of the cerebrum, and 
 sends off two branches to communicate with 
 branches sent off from the internal carotids. The 
 appearance produced by the four communicating 
 brandies, is named the Circulus Willisii. 
 
 The second branch of the subclavian is the 
 inferior thyroideal, which supplies the inferior * 
 
 part of the thyroid gland, and anastomoses with 
 its fellow r , and the branches of the superior thyroi- 
 deal artery. 
 
 J 
 
 D 
 
18 
 
 The third branch is the internal mammary , 
 which distributes its branches to all the parts met 
 with in its course, and forms numerous inoscula- 
 tions with the superior intercostal, and other in- 
 tercostal arteries; with the external mammary of 
 the axillary artery; with the phrenic — lumbar — 
 epigastric — and circumflexa ilii branches. 
 
 The fourth branch is the superior intercos- 
 tal, which, after supplying two or three of the 
 intercostal spaces, anastomoses with the other 
 intercostals — the internal mammary — and exter- 
 nal mammary arteries. 
 
 The fifth, sixth, and seventh branches, are the 
 cervicales , which are distributed to the muscles, 
 and anastomose with the occipital, vertebral, and 
 neighbouring branches. 
 
 The eighth branch is the supra scapular, an 
 artery of much importance. In its passage to 
 the notch in the superior costa of the scapula, it 
 is covered by the sterno cleido mastoideus, and a 
 part of the trapezius, to which muscles it often 
 gives some small branches. It then sends off 
 branches to the deltoid, and other muscles about 
 
19 
 
 the .shoulder joint ; and terminates by anastomos- 
 ing with the other muscular branches, but princi- 
 pally with those of the infra scapular artery. 
 
 The subclavian artery is called the axillary 
 after it has emerged from under the clavicle. 
 
 The Axillary Artery is situated in the 
 hollow of the arm pit, a triangular cavity, bound- 
 ed laterally by the tendons of the pectoralis ma- 
 jor, latissimus dorsi, and teres major muscles. 
 
 In this situation it is embedded in fat, and 
 accompanied by the axillary vein, which is before 
 the artery, and the plexus of nerves which nearly 
 surrounds it. 
 
 The branches of the axillary artery are — 
 1. The thoracic i to the muscles about the joint, 
 and the walls of the chest. One of these branches 
 is called the external mammary, which is rather 
 an important anastomosing vessel. 
 
 2. — The infra scapular, which is a consi- 
 derable branch, and sends off the internal scapu- 
 lar to the suhscapuhins and other muscles ; and 
 
20 
 
 the' inferior dorsal, or external scapular, to the 
 muscles of the dorsum scapulas. The branches 
 of this last division of the trunk are the principal 
 anastomosing vessels with the supra scapular ar- 
 tery. 3. The anterior and posterior circumflex 
 branches, which communicate with some of the 
 branches of the supra scapular — with the small 
 branches in the vicinity — and with each other. 
 
 The Brachial Artery commences at the 
 inferior margins of the tendons of the muscles 
 forming the lateral boundaries of the axilla. It 
 descends on the inner edge of the biceps muscle 
 to the bend of the elbow, where it usually bifur- 
 cates into the radial and ulnar arteries, and in 
 its course is inclosed in a sheath with the median 
 nerve and brachial vein. The chief branches of 
 this artery are, the profunda superior, profunda 
 inferior, and ramus anaslomoticus magnas . — ■ 
 The profunda superior gives off muscular branch- 
 es to the triceps and biceps, and anastomoses 
 with the recurrent radial branch. The profunda 
 inferior, or minor, joins with the recurrent ulnar 
 branches; and the anaslomoticus magnus inos- 
 culates, with the recurrent ulnar and interosseal 
 arteries. 
 
21 
 
 The Radial Artery is commonly a smaller 
 branch than the ulnar. In its course it corres- 
 ponds with the fore part of the radius,, from which 
 bone it is separated, at the commencement, by 
 the supinator brevis ; lower down, by the prona- 
 tor radii teres j and still lower, by the flexor 
 sublimis, and the flexor Iongus pollicis. At the 
 upper two-thirds of the fore arm, the radial artery 
 is covered by the supinator Iongus muscle 5 it - 
 then becomes superficial, and at the wrist can be 
 felt pulsating. Leaving the fore part of the arm 
 at the wrist, it appears again as the deep palmar 
 arch. 
 
 The branches of the radial artery are : — 
 The recurrent radial , which joins the ultimate 
 branches of the superior profunda : — muscular 
 branches in its descent : — the superficialis voice : 
 — the arteries of the thumb : — the radialis in - 
 diets; — and a branch of communication with the 
 ulnar, to form the superficial palmar arch. 
 
 The Ulnar Artery, like the radial, is ac- 
 companied by its venae comites and nerve. At 
 its origin it is concealed by the muscles which 
 arise from the internal condyle of the os humeri: 
 
lower down, it is found between the flexor carpi 
 uinaris and flexor digitorum communis : at the 
 wrist, it is on the inner side of the os pisiforme, 
 from whence it is continued onwards to form the 
 superficial palmar arch. 
 
 Its branches are : — The recurrent, which 
 unites with the branches of the profunda inferior 
 and anastomoticus magnus : — the interosseal, 
 which gives off the recurrent interosseal to com- 
 municate with the anastomoticus; and branches 
 to the muscles, and about the wrist, to inosculate 
 with the radial and ulnar branches : — a branch of 
 communication with the radial to contribute to 
 the deep palmar arch -and the digital branches 
 from the superficial arch, which go to the little, 
 ring, and middle lingers, and to one edge of the 
 index finger. This last branch joins the radialis 
 indicis, and is called the uinaris indicis artery. 
 
 After the aorta has made its curvature, from 
 which pass off the arteries to the neck, head, and 
 upper extremities, and which have alieady been 
 described, it takes the name of Aorta De- 
 scenders, which is divided into the thoracic and 
 abdominal portions. 
 
23 
 
 From the Thoracic Portion t lie bronchia! 
 vessels arise, which are vessels distributed to the 
 lungs: — the (esophageal branches : — and there are 
 nine, sometimes ten pair of intercostal arteries. 
 
 The intercostal arteries run in the groove on 
 the inner side of the inferior margins of tire ribs, 
 in company with their nerves and veins, and form 
 free and frequent anastomoses with tire internal 
 mammary — external mammary — diaphragmatic, 
 and other branches. 
 
 From the Abdominal Portion of the aorta 
 arise the phrenic or diaphragmatic arteries, the 
 cceliac , which supplies the stomach, spleen, and 
 pancreas; the superior mesenteric, which is dis- 
 tributed to the small, and to some of the larger 
 intestines; the emulgent or renal to the kidnies; 
 the spermatic arteries; the inferior mesenteric 
 to the colon and rectum ; the four lumbar on 
 each side to the walls of the abdomen, which are 
 important anastomosing vessels ; and, lastly, the 
 middle sacral. 
 
 The abdominal portion of the aorta divides, 
 at the fourth or fifth lumbar vertebra, into the 
 two common iliac arteries. 
 
‘24 
 
 Each Common Iliac Artery, as all the ar- 
 teries of the abdomen and pelvis, lies behind the 
 peritoneum. In its course it is crossed by the 
 ureter, and accompanied by the common iliac 
 vein. At the junction of the sacrum with the 
 ilium, the artery forks into the internal and ex- 
 ternal iliac branches. 
 
 The Internal Iliac Artery sends off 
 branches to the pelvic viscera ; the common pu- 
 dic to the organs of generation; the ileo lumbar, 
 which anastomoses with the lumbar and circurn- 
 flexa ilii ; the glutceal, which anastomoses with 
 the lumbar, circumflex, and ischiadic branches ; 
 the obturator, which joins the internal circumflex 
 branches; the ischiadic, which unites with 
 branches of the glutasal, the external and in- 
 ternal circumflex arteries, and some other less 
 important branches. The four last mentioned 
 branches of the internal iliac artery are princi- 
 pally distributed to muscles : the ileo lumbar 
 gives off branches to the lumbar and abdominal 
 muscles; the glulaeal supplies the glutmi ; the 
 obturator, the obturator externus and internus 
 muscles ; the ischiadic, the glutaeus maximus, 
 and the muscles about the hip joint. 
 
2-3 
 
 The External Iliac Artery descends 
 obliquely on the inner edge of the psoas raagnus 
 muscle, and, after passing under Poupart’s liga- 
 ment, becomes the femoral artery. The external 
 iliac vein is situated on its inner side, and both 
 vessels lie under the peritoneum. In its course 
 it sends off small twigs to the psooe and iliacus 
 muscles ; and, at or near the ligament, we observe 
 an ascending branch named the epigastric , and 
 another passing onwards, which is the circnrnflexa 
 ilii artery. The epigastric ascends on the inner 
 side of the internal abdominal ring, and is situated 
 between the fascia transversalis and peritoneum. 
 Just below the umbilicus, it ramifies, and some 
 of its ultimate ramifications join those of the in- 
 ternal mammary, the intercostal, the lumbar, and 
 circurnflexa illi. The circurnflexa ilii artery fur- 
 nishes branches to the iliacus interims, lumbar, 
 and abdominal muscles, and inosculates with 
 the internal mammary, lumbar, and ileo lumbar 
 branches. 
 
 The Femoral Artery begins at Poupart’s 
 ligament, and from this part, descends obliquely 
 over the pectinaeus and triceps muscles. About 
 the middle of the thigh, it is crossed by the sar- 
 
 CD y J 
 
 E 
 
26 
 
 torius muscle; soon alter which, it perforates the 
 tendon of the triceps, and is observed as the ar- 
 tery of the ham. The femoral artery is enclosed 
 in a sheath, together with the femoral vein, and 
 a branch of the anterior crural nerve, denomina- 
 ted the nervus saphenus. The vein is situated 
 on the inner side of the artery. 
 
 The brandies of the femoral artery are : — 
 1. The external puclie. 2. The profunda, which 
 gives off the external circumflex to the glutaeus 
 maxim us and muscles about the joint, and anas- 
 tomoses, above, with the glutaeal and ischiatic ; 
 and below, with the superior external articular 
 branches. 3. The rami perforantes. 4. The 
 ramus anastomoticus magnus. These branches 
 freely communicate with each other — with the 
 circumflex — and upper articular branches. 
 
 After perforating the triceps tendon, the fe- 
 moral artery takes the name of popliteal. 
 
 The Popliteal Artery lies close upon the 
 capsule of the knee joint. The accompanying 
 vein is a little on the outer side of the artery, and 
 the nerve is situated above it, — so that, in coin- 
 
27 
 
 pressing the popliteal artery, the nerve must be 
 first pressed on. The branches of this vessel are, 
 — the superior outer and inner articular j and 
 the surales. 
 
 The superior outer articular branch anasto- 
 moses, above, with the external circumflex; and be- 
 low, with the recurrent branch of the tibial, and the 
 inferior outer articular. The superior inner arti- 
 cular communicates, above, with the perforating 
 branches of the profunda, and the ramus anasto- 
 moticus magnus ; and below, with the inferior 
 inner articular : — thus all the articulars unite 
 freely with each other. The surales are long 
 branches, sent principally to the gastrocnemii 
 muscles. At the lower edge of the poplitreus 
 muscle, the popliteal artery divides into the an- 
 terior and posterior tibial branches. 
 
 The Anterior Tibial passes through a hole 
 in the upper part of the interosseous ligament, 
 and appears in the front of the leg. To expose 
 it above, the tibialis muscle must be separated 
 from the extensor longus digitorum ; and lower 
 down, it is seen between the former muscle and 
 the extensor proprius poll inis. It then passes 
 
28 
 
 forwards, over the aukle joint and tarsus, to a 
 space between the metatarsal extremities of the 
 great toe and the toe next to it, where it dips 
 into the sole of the foot. 
 
 The branches of the anterior tibial artery 
 are: — the recurrent , which is distributed about 
 the knee joint, and anastomoses with the articu- 
 lar branches ; — muscular branches , which com- 
 municate with the muscular branches of the pos- 
 terior tibial and peroneal vessels. At the ancle, 
 sends off the malleolar branches , which join 
 other branches at this part ; the metatarsal 
 branch j the interosseal branches ; the artcria 
 dorsalis pollicis, to the great toe, and toe next 
 it ; and the deep branch , which, uniting with 
 the outer plantar of the posterior tibial, forms 
 the arcus plantaris. 
 
 The Posterior Tibial Artery descends 
 between the gastrocnemius interims and the 
 flexor longus digitorum. It becomes superficial 
 in its descent, and after passing behind the inner 
 ancle, terminates by dividing into the two 
 plantar arteries. 
 
 The branches of the posterior tibial artery 
 
are: — the fibular or peroneal, which sends otY 
 muscular branches, and ends at or near the ancle, 
 by inosculating with branches of the anterior and 
 posterior tibial vessels ; — muscular branches ; — the 
 inner plantar, which supplies some of the muscles 
 of the great toe; — the outer plantar, which sends 
 branches to the muscles of the sole, and forms 
 the arcus plantaris, from which go off the digital 
 branches. 
 
 This, then, is a brief description of the 
 origin, course, distribution, and communications 
 of the Arterial System, but it is sufficiently mi- 
 nute for the purpose intended. I have described 
 the arteries as originating and terminating in 
 the manner they most commonly do, and have 
 avoided to mention the varieties that have been 
 observed in these particulars. If, however, the 
 student wishes to gain information on these sub- 
 jects, I must beg to refer him to the splendid 
 Fasciculi of the learned Haller, and to other 
 works on the Anatomy of the Blood Vessels. 
 
SECTION III. 
 
 PRACTICAL APPLICATION OP THE STUDY OI THE 
 ANASTOMOSES TO THE SURGICAL TREATMENT OP 
 ANEURISM AND HCEMORRHAGE. 
 
 I have j in the preceding section, given a 
 collective view of the Arterial System; and shall 
 now endeavour to explain, in a clear and concise 
 manner, the rationale of the new operation for 
 Aneurism; and the surgical treatment of Haemor- 
 rhage from wounds of arteries, so large as to re- 
 quire t lie application of a ligature. 
 
 This subject is extremely important and 
 interesting, and one with which the surgeon 
 must make himself thoroughly acquainted. An 
 inquiring student will not rest satisfied with be- 
 ing told, that- an artery may be surrounded and - 
 closed with a ligature, and that the circulation 
 can he carried on afterwards.; but he will ask, 
 
31 
 
 how this is accomplished ? and what the resources 
 of nature are, when her regular functions are thus 
 interfered with ? — To answer these questions, he 
 must know, that arteries, besides ending in veins, 
 cells, and otherwise, have a mode of termination 
 by anastomoses, or inosculations, id esf, by com- 
 municating with each other: — it is bv means of 
 this arrangement of vessels, that the economy of 
 the limb is preserved, in case of local pressure ; 
 and that the circulation is continued, when the 
 main artery is rendered impervious by accident 
 or disease. 
 
 * 
 
 If a ligature be applied to a main trunk, (as 
 the femoral,) it is obvious that the lower extre- 
 mity would perish, if the blood could not pass b}' 
 collateral vessels, — that is, by means of branches 
 originating from the trunk, above, uniting with 
 some of those which arise from the trunk, below 
 the ligature. Thus — it is by the anastomosing, 
 inosculating, or communicating branches, -that 
 fatal consequences are prevented ; and though 
 these branches are small at first, they will in 
 time increase in size, so as to supply the place 
 of the original trunk. .. This fact has been long 
 known ; but we are indebted to modern surgery 
 
for introducing the scientific application of it to 
 operative surgery — and for the refutation of the 
 erroneous opinion entertained by the ancients, 
 that when a main artery is obstructed, the limb 
 must perish for want of nourishment. 
 
 The increase in size of the anastomosing 
 
 Q 
 
 vessels, above alluded to, is an argument employ- 
 ed in justification of delaying the operation for 
 aneurism, from a supposition that the chances of 
 recovery to the patient are proportionate to the 
 time which can be allowed for that purpose. That 
 the vessels do enlarge, there can be no question, 
 lor dissection has shown it in numerous cases ; — 
 but Mr. Ramsden, wdio wrote on Aneurism in 
 1810 , believes that this is not to be viewed as a 
 provision necessary to the preservation of the 
 limb, but as a consequence which has taken place 
 long after the limb has recovered its natural 
 powers. I must beg to differ from this opinion 
 in its general application; for in almost every 
 instance in w hich I have seen a main artery tied, 
 I have seen the pouters of the limb for a time 
 diminished, and that the strength has increased 
 gradually, in proportion, we may suppose, to 
 the increase of diameter in t lie inosculating 
 branches. 
 
33 
 
 In the first section of this volume, and in 
 my “ Outlines,” I have mentioned the most 
 striking characteristics of aneurism, and made 
 allusions to the medical treatment of this most 
 formidable disease. I have said, that medical 
 treatment, — comprising medicinal and dietetic 
 means, — may, by moderating vascular action, 
 retard a fatal issue; but little more is to be ex- 
 pected from such remedies ; and it is admitted, 
 in the present day, by all experienced practition- 
 ers, that the operation proposed by Hunter is 
 the safest and only method that can be relied on, 
 and that if it fails, it is owing to a disorganized 
 state of the arterial system, or to constitutional 
 circumstances that cannot be controuled or re- 
 medied. 
 
 I am not so ignorant of the history of my 
 profession, as to assert that Hunter was the In- 
 ventor of the operation of tying the artery above 
 the aneurismal tumour, with a view to the cure of 
 the disease. Desault, a celebrated French sur- 
 geon, is said to have practised it before Hunter; 
 but the difference consisted in this : — Desault 
 applied the ligature immediately above the sac, 
 and the frequent consequence was hoemorrhage, 
 
 F 
 
because the morbid condition of the vessel ex- 
 tended for some way above the aneurismal tumour. 
 Reflecting on the cause of failure, Hunter pro- 
 posed to tie the artery at a distance from the seat 
 of the disease,— which practice now prevails, and 
 bears the name of the Hunterian, or New Opera- 
 tion for aneurism. 
 
 A patient labouring under popliteal aneu- 
 rism was the first person operated on by Mr. 
 Hunter, according to his new method. He took 
 up the femoral artery a little below the middle of 
 the thigh. The attempt succeeded, and the patient 
 got quite well ; but his recovery was slow, owing 
 to the great number of ligatures that was em- 
 ployed. About fifteen months after the opera- 
 tion, the man died of fever, when an opportunity 
 occurred for examining the state of the limb. On 
 dissection, the femoral artery was found imper- 
 vious, from the giving off of the arteria profunda, 
 down to the place of the ligature, and an ossifi- 
 cation had taken place for an inch and a half 
 along the course of this part of the vessel. Be- 
 low this portion, the artery was pervious, till just 
 before it came to the aneurismal sac, when it 
 was again closed. 
 
35 
 
 In the second operation, Mr. Hunter includ- 
 ed both the artery and vein in one ligature. The 
 man died of hcemorrhage, which event was at- 
 tributed to his having dressed the wound from 
 the bottom, instead of uniting it at once. In 
 every subsequent operation, he tied the artery 
 alone, with one ligature, and united the edges of 
 the wound with adhesive plaster. 
 
 Since the time of, Hunter, other surgeons 
 have suggested alterations in the mode of opera- 
 ting : thus — Mr. Abernethy proposed to apply 
 two ligatures, one a little apart from the other, 
 and afterwards to divide the artery between 
 them. This practice was supposed to prevent 
 such a retraction of the vessel as would endanger 
 a too speedy separation of the ligature, and con- 
 sequently hcemorrhage. That excellent surgeon 
 Mr. John Bell, was, too, an advocate for this me- 
 thod, from considering that by it, we put the tied 
 artery in the same condition as that tied upon the 
 face of an amputated stump : — but whether the 
 application of two ligatures, and the division of 
 the artery, is safer than the application of one, 
 and (of course) leaving the artery undivided, is 
 very questionable. 
 
However much at variance surgeons may be 
 on this point, and others, connected with the steps 
 of the operation, its effects, as explained by Hun- 
 ter, remain incontrovertible. The effects are 
 simply, to prevent the ingress of blood into the 
 aneurismal sac, by diverting the current into the 
 anastomosing vessels ; after which, the tumour is 
 gradually removed by the absorbents, and the 
 disease is cured. 
 
 Some of the preceding remarks on the treat- 
 ment of aneurism, do most forcibly apply to the 
 surgical treatment of hoemorrhage. Leaving all 
 the means inferior in power to compression, and 
 the ligature, in suppressing a flow of blood from 
 a wounded artery, unmentioned, as they are 
 not concerned in our present inquiry, I shall 
 here lay down certain general principles. 
 
 When a small artery is wounded, natural 
 means alone will suffice to put a stop to the flow 
 of blood. The first effect, if a small vessel is cut 
 across, is a retraction within the cellular mem- 
 brane enveloping it ; the blood is entangled, 
 coagulates, and the bleeding is checked. If the 
 artery be simply punctured, the retraction does 
 
37 
 
 not take place, but still the coagulation of the 
 effused blood suppresses the hoemorrhage : but 
 in the former case, the effect is more immediate 
 and certain, than in the latter. The permanent 
 security against the return of bleeding is accom- 
 plished by the wounded artery becoming inflamed, 
 and the aperture closed by the adhesive inflam- 
 mation. When a main artery of any of the in- 
 ternal organs is injured, or gives way, we have to 
 apprehend fatal consequences. A wound of the 
 pulmonary artery — aorta — arteria innominata — 
 common carotid, common iliac, and internal and 
 external iliacs — will prove fatal ; but a hoemor- 
 rhage from the other arteries may in a general 
 way be commanded by the ligature ; and if infe- 
 rior in size to the temporal, commonly by com- 
 pression only. 
 
 On studying the anastomoses, we must na- 
 turally seek to determine the question, whether 
 the ligature should be applied to the main trunk, 
 — at a distance from the wound — to the wounded 
 extremity nearest the heart — or both to the upper 
 and lower extremities of the vessel ? If our judg- 
 ment were alone biassed by a knowledge of the 
 anastomoses, we should not hesitate to subscribe 
 
38 
 
 to the opinion of Mr. Hodgson, that in every in- 
 stance in which an artery of considerable size is 
 wounded, each extremity of the vessel should be 
 tied as near as possible to the wound in its coats, 
 as the anastomoses in all parts of the body are so 
 extensive, as to furnish a supply of blood, which 
 may pass through the lower extremity of the 
 wounded vessel in a sufficient stream to produce 
 an alarming, and, in some instances, a fatal hoe- 
 rnorrhage. 
 
 Mr. Hodgson adds two cases, one commu- 
 nicated to him by Mr. Lawrence, in which the 
 bleeding from the lower extremity of a divided 
 brachial artery, was sufficient to cause the death 
 of the patient; and another bj' Mr. Henry Earle, 
 where a punctured wound, received mid way be- 
 tween the elbow and wrist, was treated by two 
 ligatures on the brachial artery in the middle of 
 the arm ; but on the eighth day a copious bleed- 
 ing took place from the wound in the fore arm, 
 and it was found necessary to expose the vessel 
 (the radial artery), and to apply a ligature at each 
 extremity. 
 
 The principle of applying two ligatures at 
 
39 
 
 the wounded part appears admissible as a general 
 one — and I have no hesitation in saying, that it 
 should always be adopted when a vessel of such a 
 size is wounded, as to give rise to a serious hoe- 
 morrbage. But it now and then happens that 
 there is considerable difficulty in reaching the 
 wounded portion of the vessel, and then the fob 
 lowing practice may be attempted ; and, if the 
 artery be not large, will be certain to succeed. — 
 In a wound of the palmar or plantar arteries, for 
 example, it is often difficult to expose the vessel : 
 the treatment in this case, provided compression 
 fails, must consist in tying the trunk which sup- 
 plies the wounded branch, and using firm pressure 
 on the injured part. 
 
 The inefficacy of tying the main artery at a 
 distance from the wound, is well illustrated by 
 the cases above referred to ; but to impress it 
 forcibly on the mind of the student, and to show 
 that even the application of a ligature to the up- 
 der extremity only is not sufficient, I shall add 
 another case from Roux’s “ Parallelle de la 
 Chirurgie Angloise, avec la Chirurgie Fran- 
 coise,” given by him, however, for another purpose. 
 A man was brought to “ La Charile,” almost at \ he 
 
40 
 
 very moment lie had received a stab with a knife, 
 in the fore part of the thigh, a little below the 
 middle; the instrument had made a deep narrow 
 wound, and opened the crural, or femoral artery. 
 Instead of endeavouring to discover it at the 
 wound, for the purpose of placing one ligature 
 immediately above, and another below the open- 
 ing*, M. Roux preferred tying it at some distance 
 from the point at which it was opened. He made 
 the aperture, therefore, in the lower part of the 
 inguinal space, as if he had been adopting Scar- 
 pa’s plan, in the manner practised by Hunter. 
 On the 10th day after the operation, a hocmor- 
 riiage occurred ; he used, without effect, the 
 “ ligature d’attente,” which he had placed above 
 the two ligatures with which he stopped the cir- 
 culation in the artery, and was obliged to lay 
 open the artery above the place where it had been 
 tied. Fresh ligatures were applied immediately 
 below the origin of the profunda ; this put an im- 
 mediate stop to the bleeding which had its rise in 
 the side nearest the heart; but on the following 
 day a fresh haemorrhage took place from the lower 
 end of the artery, even perhaps from the infe- 
 rior orifice, which as M. Roux supposed had 
 been completely cut across bv the stab of the 
 
41 
 
 knife in the first instance. The surgeon was then 
 under the necessity of laying open the artery be- 
 low the wound, and of applying ligatures near the 
 opening in the triceps muscle. No farther bleed- 
 ing occurred, and on the 15th or 18th day after 
 the two last operations, the ligatures came away. 
 
 This case (and there are on record others of 
 a similar kind) proves that placing a ligature on 
 the main trunk, or even at the upper extremity 
 of the wounded vessel, will not secure the patient 
 against a return of hcemorrhage, if the artery 
 be of considerable size : it may temporarily put 
 a stop to it, as in the case above cited, but the 
 bleeding will recur, owing to a speedy re-estab- 
 lishment of the circulation by anastomosing ves- 
 sels. But if the artery be of a small calibre, or 
 the muscular branch of a main trunk, tying the 
 artery as near as possible to the wound may suf- 
 fice, provided compression be used on the place 
 of injury. Compression alone will now and then 
 succeed, but it is not safe in a general way to 
 trust to it. 
 
 Mr. Charles Bell, in the second volume of 
 his “Operative Surgery,” mentions a case which 
 
 F 
 
42 
 
 illustrates the importance of the rule just laid 
 down. His assistant was called to take up the 
 radial artery, where it turns from the fore part of 
 the wrist. He found a man with a deep wound 
 of a knife between the fore finger and thumb ; 
 and already much blood had been lost. The ar- 
 tery was taken up by the side of the extensor 
 tendons of the thumb. After this operation the 
 bleeding stopped, yet in a short time it recurred ; 
 but when the wound was tied up with a compress 
 laid in the course of the wound, all was well. It 
 appears from this, that when a man is bleeding 
 from an artery of the hand, or wrist, or foot, tying 
 the trunk of the artery only diminishes the im- 
 pulse, and does not entirely stop the flow of blood, 
 which comes round by the free inosculations. But 
 the direct course of the blood being interrupted, 
 our dressing is sufficient to stem the force of the 
 hoemorrhagy by the anastomosing vessels. If the 
 artery be not taken up, a sponge must be thrust 
 deep into the wound, and a tedious sore is the 
 consequence : but if the main supply be stopped, 
 the lips of the wound can be brought together, 
 and the compress put over the integuments (not 
 into the flesh), and the wound heals by the first 
 intention. I might select a great number of 
 
43 
 
 cases, from published records, and my own prac- 
 tice, which would serve to illustrate these general 
 rules in the treatment of wounded arteries. 
 
 Having made the necessary prefatory re- 
 marks, I shall now endeavour to illustrate, by a 
 reference to anatomy, the rationale of the Surgi- 
 cal Practice to be adopted in Aneurism and Hae- 
 morrhage. 
 
44 
 
 AORTA. 
 
 In the general description of the Arterial 
 System, I mentioned, that the aorta, soon after 
 its origin, makes a curvature, from which go off 
 three large trunks, which are distributed to the 
 neck, head, and upper extremities. The sys- 
 temic artery then descends through the chest 
 and abdomen, and at the fourth or fifth lumbar 
 vertebra, bifurcates into the two common iliac 
 arteries, which subdivide into the internal and ex- 
 ternal iliacs, to supply the pelvic viscera and lower 
 extremities. 
 
 Some of the arteries of the superior parts of 
 the body send off branches, which anastomose 
 with those proceeding from the inferior, and they 
 form frequent and free communications with 
 some of the branches arising from the thoracic 
 and abdominal portions of the aorta : thus, the 
 superior intercostal and internal mammary arte- 
 ries (13) inosculate with each other, and with the 
 external mammary (17) of the axillary artery. — 
 All these inosculate with the intercostals (2) ; and 
 
45 
 
 the internal mammary with the phrenic, or dia- 
 phragmatic (3), the epigastric (37), the lumbar 
 (4), and circumflexa ilii (38), and it is principally 
 by means of these anastomoses that the circula- 
 tion is carried on when the aorta is obliterated. 
 
 In the second volume of Desault’s “ Journal 
 de Chirurgie,” a case is given of an obstruction 
 of the aorta just below its arch. In the year 1789 
 M. Paris injected the body of a very lean old wo- 
 man, of about 50 years of age, whose arterial 
 system was found to be singularly deranged. M. 
 Paris had his attention excited to the consideration 
 of this subject by the unaccountable enlargement 
 of the small arteries on the fore part of the chest*, 
 Pie had filled the arteries with an injection com- 
 posed of equal parts of suet and rosin, coloured 
 with lamp black; and this injection, thrown in at 
 the aorta, passed along so easily, that, far from 
 suspecting any obstruction, he felt that more 
 injection could have been sent into the vessels 
 than is usually required to fill an adult body. The 
 subject was so meagre, that without dissection 
 M. Paris felt the thoracic, arteries running down 
 the sides of the chest, tortuous, and remarkably 
 enlarged. He found the aorta, immediately be- 
 
46 
 
 yond the arch, contracted to the size of a writing 
 quill. The coats of the artery were of their usual 
 thickness, and its cavity, of course, extremely 
 small : the arch of the aorta, above this constric- 
 tion, was but very slightly dilated, and the part 
 below, had lost nothing of its natural size. No- 
 thing could be found, either in its own structure 
 or in the condition of the neighbouring parts, 
 to account for this condition of the artery. 
 The carotids were natural. The arteria innomi- 
 nata and left subclavian were enlarged to twice 
 their natural diameter, and all their smaller 
 branches had increased in the same proportion. 
 The internal mammary and phrenic arteries were 
 greatly enlarged, and very tortuous. The trans- 
 verse arteries of the neck were twice their natural 
 size; their posterior branches were tortuous, ex- 
 tending to a great distance over the back, with 
 lone: inosculations, which u'ere met from below, 
 by the branches of the upper intercostal arteries, 
 which were also remarkably enlarged. The tho- 
 racic and scapular arteries, which go along the 
 sides of the chest, were of twice their natural size. 
 Below the constriction, the lower intercostals 
 were increased even to three or four times their 
 natural size; each of them was dilated, but those 
 
47 
 
 were most so, which came off highest and nearest 
 to the contracted parts ; and the posterior branch 
 of each which penetrates to the muscles of the 
 back, was more dilated than that which runs be- 
 twixt the ribs; and the inosculations of those 
 posterior branches with the branches of the trans- 
 versalis eervicis were very striking. The lower 
 phrenic artery was enlarged, and inosculated with 
 the superior phrenic. The epigastric was dilated 
 to the size of the enlarged mammary, and was 
 joined with it by very numerous, and very conspi. 
 cuous anastomosing branches. 
 
 In the fifth volume of the “ Medico Chirur- 
 gical Transactions,” Dr. Graham, of Glasgow, 
 gives the particulars of a case where the aorta was 
 obstructed at the part just below its union with 
 the canalis arteriosus. Beyond the obliterated 
 point, the artery received three trunks about the 
 , size of crow quills, and near them three smaller 
 ones ; the aorta then resumed its natural size. 
 These three trunks were evidently the uppermost 
 of the inferior intercostals, and their coats were 
 as thin as those of veins. The arteria innomina- 
 ta, the left subclavian, the superior intercostals, 
 and the mammary arteries, were much enlarged. 
 
48 
 
 The epigastric is reported to have been of its na- 
 tural size, — proving therefore, that, in this case, 
 the inferior extremities did not receive blood in 
 any material quantity through the inosculations 
 of the mammary and epigastric arteries, as must 
 happen in some cases, but chiefly by the commu- 
 nications of the superior intercostals and the mam- 
 mary arteries, with the three large branches en- 
 tering the aorta below the stricture; also from 
 the mammaries and thoracics, through others of 
 the intercostal and diaphragmatic arteries. Here 
 the epigastric arteries had undergone no change, 
 but in the case given by Paris, where the contrac- 
 tion of the aorta below its arch was to such an 
 extent as to admit only a writing quill, it was 
 discovered that the epigastric arteries were con- 
 siderably dilated. 
 
 Dr. Graham, in his remarks on the above 
 case, thinks it of some practical importance to 
 determine whether it had been a lusus naturae, or 
 the effect of disease; for if the latter, it is an ad- 
 ditional case to prove, that even where the great 
 artery of the body is obliterated, there is no risk 
 from defective circulation in the parts below, and 
 therefore the surgeon may be emboldened to tie 
 
49 
 
 any artery within the reach of his knife, without 
 fear about the transmission of the blood. Let us 
 investigate this point. 
 
 First, I would ask the question. Have we a 
 right to infer from the above, and such like cases, 
 that the aorta may be tied, and that the blood 
 will find its way by collateral passages? Suppose 
 a ligature was applied to the aorta, immediately 
 below its curvature, — the lungs, the walls of the 
 chest, the abdominal and pelvic viscera, and lower 
 extremities, could only be supplied with blood 
 through the media of the superior intercostals, in- 
 ternal mammary, cervical and external mammary 
 vessels, inosculating with the inferior intercostal, 
 the diaphragmatic, lumbar, epigastric, and cir- 
 cumflexa ilii branches. We may, I think, with- 
 out hesitation, say, that this operation could not 
 succeed, if (as it is certain) the danger of oblitera- 
 ting a main trunk is in proportion to the number 
 and size of the anastomosing vessels, and the 
 distance the blood has to run through collateral 
 channels 3 nor would the chance of success be 
 materially increased, if the ligature were put on 
 the aorta, immediately on its entering the abdo- 
 men : but if applied a little above the bifurcation, 
 
 H 
 
oO 
 
 the prospect would be fairer, for in this case, the 
 natural source of supply would be cut off from 
 some of the pelvic viscera and lower extremities 
 only, which parts might be furnished by means 
 of the anastomoses existing between the vessels 
 of the superior, and those of the inferior parts of 
 the body ; and the inosculations between the 
 inferior intercostals, and lumbar arteries, and the 
 branches of the external iliac. 
 
 Sir A. Cooper, and other Surgeons, have tied 
 the aorta of the dog; and in the second volume 
 of the “ Medico Chirurgical Transactions,” 
 some remarks on this subject are appended to a 
 paper on Popliteal Aneurism ; and at the end of 
 the volume there is a plate, showing the arterial 
 anastomoses in a successful experiment. The 
 aorta was divided just below the two first lumbar 
 arteries, and the lumbar branches above the obli- 
 terated point are seen beautifully anastomosing 
 with those below it, and forming free communica- 
 tions upon the posterior part of the spine: besides 
 the lumbar, there are other inosculating branches. 
 —Mr. Ainsworth, one of the Surgeons of our In- 
 firmary, tied the aorta in a dog, a few years ago, 
 with perfect success. In the preparation, which 
 
51 
 
 lie has kindly sent me for examination, I observe 
 that the aorta is obliterated to the extent of two 
 inches, the obliteration beginning immediately 
 below the passing off of the first pair of lumbar 
 arteries. These vessels, and the other lumbar 
 branches below the obstructed part of the aorta, 
 are amazingly enlarged, and anastomose by nu- 
 merous branches with each other, and with the 
 inferior intercostals. The internal mammary and 
 epigastric are much increased in size, and unite 
 very freely. — I have seen another instance in 
 which the operation succeeded : the preparation 
 is in the possession of Mr. Jordan, Surgeon and 
 Lecturer on anatomy, in this town. Here the in- 
 osculating vessels are distinctly seen, particularly 
 those of the internal mammary and epigastric 
 arteries. 
 
 It is not always fair, however, to calculate on 
 the success of an experiment on the human body, 
 from the circumstance of its succeeding in brutes. 
 Animals can bear with impunity what would be 
 destructive of life in man, as their powers of re- 
 paration are more active : but from experiments 
 on brutes, we can derive such information, and 
 draw such conclusions, as will justify our reason- 
 
52 
 
 ing from analogy, when desperate occurrences 
 can only be met by desperate measures. One of 
 the aphorisms of Hippocrates applies here — “ Ad 
 extremos morbos , extrema remedia exquisite op- 
 tima .” 
 
 We cannot, then, censure Sir A. Cooper for 
 the formidable operation which he performed at 
 Guy’s Hospital, in 1817; the particulars of which 
 are detailed in one of the late volumes of the 
 “ Medico Chirurgical Transactions.” I shall 
 mention a few of the most interesting, for the in- 
 formation of those who have not the opportunity 
 of consulting the author’s own account of his 
 case. 
 
 The subject of the operation was a porter, of 
 38 years of age, who had an aneurism in the left 
 groin, situated partly above, and partly below, 
 Poupart’s ligament. For this disease he was ad- 
 mitted into Guy’s Hospital, on the 9th of April, 
 1817- At the beginning of June, the integu- 
 ments shewed a disposition to slough, and a 
 bleeding more than once occurred. At length 
 an alarming hoemorrhage took place, so as to 
 threaten the patient’s death; but pressure kept 
 
53 
 
 it within bounds for a time. Seeing the preca- 
 rious state of the patient, and finding from a 
 careful examination, that it was not practicable 
 to do any thing to prevent a recurrence of the 
 hcemorrhage and death, but to tie the aorta. 
 Sir A. Cooper, boldly resolved to give his pa- 
 tient the only hope of safety. The operation 
 was performed at 9 o’clock, p. m., on the 25th of 
 June. On the morning of the 26th, the patient 
 complained of great insensibility of the affected 
 limb, indeed of both extremities. At noon the 
 temperature of the right leg was 94; that of the 
 left 87|. At 6 o’clock, p. m., he vomited, and 
 vomiting returned at intervals till near his death. 
 At 7 o’clock, a. m., of the 27th, it was reported 
 that the patient had passed a restless night ; his 
 pulse was 104, weak and fluttering. He com- 
 plained of pain all over his body, but more par- 
 ticularly in his head, and the carotids beat with 
 considerable violence. At 8, a. m., the aneuris- 
 mal limb appeared livid and felt cold, but the 
 right leg remained warm. At 11, A. m., his pulse 
 *was 120. At 18 minutes past 1 , p. m., he ex- 
 pired, having survived the operation 40 hours. 
 
 The body was inspected by Sir A. Cooper, 
 
54 
 
 Mr. Brookes, Mr. Travers, and others, and the 
 following were the appearances : — On opening 
 the abdomen, no mark of peritoneal inflammation 
 was discovered, excepting at the edges of the 
 wound. The ligature had been passed around 
 the aorta, about 3-4ths of an inch above its bi- 
 furcation. Upon carefully cutting open the ves- 
 sel, a clot of more than an inch in diameter was 
 found above the ligature ; below the bifurcation 
 another, an inch in extent, sealed the right iliac 
 artery ; and the left was occupied by a third, 
 which extended as far as the aneurism. The 
 aneurismal sac reached from the common iliac 
 vessel to below Poupart’s ligament, and extended 
 to the other side of the thigh. The artery was 
 deficient, from the upper to the lower part of the 
 sac, which was occupied by an immense quantity 
 of coagulum. 
 
 These are the principal facts which need be 
 detailed here. The operation failed ; but it is 
 presumed that it might have succeeded, had it 
 been done before the tumour had acquired any' 
 considerable magnitude — and the fact that the 
 opposite limb recovered its natural heat and 
 sensibility, is certainly in favour of such an 
 opinion. 
 
55 
 
 Reasoning from this case, it seems probable, 
 that the aorta may be tied a little above the bi- 
 furcation, with some chance of success ; and that 
 the operation is a justifiable one, when the case 
 is hopeless, and beyond all the other resources of 
 our art. But to tie it in the chest, or in the up- 
 per part of the abdomen, would, I think, be an 
 act of inexcusable rashness. 
 
 The discovery of an obliteration of the aorta 
 beyond its arch, and the knowledge that the 
 anastomoses before mentioned did carry on the 
 circulation, do not at all bear upon the question. 
 The viscera, and inferior parts of the body, may 
 be supplied with blood by those collateral chan- 
 nels, in a degree adequate to their purposes, when 
 the obstruction has been effected in a gradual 
 manner, — because the diameter of the inosculat- 
 ing branches is proportionately increased : but in 
 a sadden obstruction the case is quite different. 
 
 My argument against the operation is founded 
 on anatomy. But it may be opposed to it, that it 
 is not always fair to reason from what we know of 
 the conspicuous arterial branches : nor is it — for, as 
 Scarpa justly remarks, “ The whole body may be 
 
regarded as an anastomoses of vessels, a vascular 
 circle:” — and if we did, it might now be doubt- 
 ed, as it once was, whether the life of the upper 
 extremity can be preserved after a ligature on the 
 subclavian : but this we do know, that the tem- 
 porary abstraction of a certain quantity of blood 
 from the extremities is not incompatable with the 
 life of these parts — and that not only the conspi- 
 cuous branches, but those that are not so, will 
 in time enlarge, and supply the loss of the origi- 
 nal trunk. The same hope, however, cannot be 
 reasonably entertained, when the vital organs 
 have their functions thus interfered with. 
 
 The cases of Paris, and of Dr. Graham, can 
 only be regarded as remarkable examples of the 
 power of nature in accommodating herself to 
 changes, provided such changes are slow and 
 gradual. This accommodating power is often 
 evinced in a striking manner in the circulating 
 system, and not only in the arterial, but in the 
 venous part of it. The following remarkable ano- 
 maly was found by Dr. Bailiie in the latter: — 
 The vena cava was obliterated from the kid- 
 ney to the diaphragm ; the vessel was closed at 
 that very place where it should immediately dis- 
 
charge the whole congregated blood of the lower 
 extremities, and pelvis, into the heart ; and so 
 entire was the obstruction, that air could not pass. 
 In this case, the blood went by a very circuitous 
 route : — the emulgent vein was dilated ; the small 
 lumbar veins were enlarged ; the thoracic veins, 
 especially the vena azygos, were distended, so 
 as to receive all the blood of the lower cava. 
 That blood which should have passed in under 
 the liver, ascended to the subclavian vein, and 
 the lower cava was represented by the small 
 thoracic veins and vena azygos. These changes 
 were doubtless s/ow in taking place; and doubt- 
 less, too, the distension of the veins by which the 
 blood was returned to the heart, kept pace with 
 the progressive diminution of the main venous 
 trunk. 
 
 \ 
 
 Mr. Cline found in the body of a man, the 
 inferior vena cava obliterated a little above its 
 bifurcation, in consequence of a steatomatous tu- 
 mour, which had formed in the cellular substance 
 behind the peritoneum, and which occupied a 
 part of the pelvis and lumbar region. Here the 
 epigastric veins were become as large as the lit- 
 tle finger — and the superficial veins of the abdo- 
 
 i 
 
•58 
 
 men, as well as the lumbar, and those of the in- 
 ternal cavity of the abdomen, were in a similar 
 manner very much dilated. The internal mam- 
 mary vein (likewise greatly enlarged) and also 
 the epigastric, with which it anastomosed, opened 
 as usual into the superior cava, near to the origin 
 of the subclavian veins; by which circumstance 
 the venous blood of the lower extremities was 
 poured into the superior cava by means of the 
 mammary vein, and into the inferior cava by the 
 lumbar veins, situated above the compression 
 caused by the steatomatous tumour. 
 
 Mr. Mackenzie, Surgeon and Lecturer, at 
 Glasgow, has obligingly communicated a case, 
 where the vena cava abdominalis was wanting, 
 and its place supplied by the vena azygos, which 
 is as large as the cava ordinarily is. This, how- 
 ever, was a congenital variety of distribution, and 
 not the result either of accident or disease. 
 
 The deductions that we are to draw from 
 this section of the work are — 
 
 First, That the cases where the upper part of 
 the aorta was found impervious after death, with- 
 
59 
 
 out a derangement of the general system, ought 
 not to be admitted as evidence of the probable 
 safety of passing a ligature about the superior 
 portion of this main trunk. 
 
 Secondly, That the anastomoses can be de- 
 monstrated as not sufficient to continue the cir- 
 culation, when the aorta is tied much above the 
 origins of the lumbar arteries. 
 
 Thirdly, That the frequent success which 
 has attended the operation of tying the aorta in 
 the dog, at a point between or immediately above 
 the lumbar arteries, furnishes a presumptive proof 
 that the same might have a happy issue in the 
 human subject. But, 
 
 Lastly, This measure is a desperate one, and 
 only sanctionable when the case is beyond all the 
 other resources of our art. 
 
00 
 
 ARTERIA INNOMIX AT A. 
 
 The Arteria Innominata originates on the 
 right side of the arch of the aorta, and is about 
 an inch and | in length. Its division is into the 
 right carotid, and right subclavian arteries. 
 
 Dr. Mott, of America, has tied the arteria 
 innominata, and the result seemed to prove that 
 Vhe operation could succeed, so far as the anasto- 
 moses are concerned — for the patient got so well 
 as to be able to walk daily in the garden of the 
 hospital. The case was an aneurism of the sub- 
 clavian artery, which, however, was found so dis- 
 eased, that there was no alternative but to tie the 
 the common trunk, namely, the innominata. In 
 the operation there were three arteries divided, 
 a branch of the internal mammary, and two 
 branches severally from the inferior and superior 
 thyroid. Immediately after the ligature was put 
 on the artery, the patient is reported to have felt 
 quite well ; the pulse was 69, and the tempera- 
 ture of the arm nearly the same as the other. 
 From this period to the 22d day after the opera- 
 
61 
 
 tion, he continued to improve ; the suppuration 
 went on well, the ligature came away without * 
 accident, and the pulse (which had at one time 
 risen to 120) was reduced by venesection to its 
 natural standard ; cicatrization was going on 
 properly, and the swelling becoming gradually 
 less. All on a sudden, however, on the 24th day 
 after the operation, a hcemorrhage from the wound 
 took place; and though it was soon got under, 
 and there was little loss of blood, it recurred 
 twice in the next two days — respiration became 
 painful — and the patient died on the 26th day. 
 In examining the part, there was no trace found 
 of inflammation in the arch of the aorta, the ori- 
 gin of the arteria innominata, or in the lungs. 
 The internal membrane of the innominata was 
 smooth and soft, and its parietes were so thick 
 that there was only room for a crow-quill to pass; 
 The subclavian artery opened into the tumour, 
 and the carotid was filled with coagulated blood. 
 Death was attributed to extensive suppuration. 
 
 M. Graef, of Berlin, has, too, tied the arteria 
 innominatafor an aneurism of the brachio-cephalic 
 trunk, attended with excessive pain and suffering, 
 and which increased in such a manner as to render 
 
62 
 
 death inevitable. Immediately on tightening the 
 ligature, the pulse ceased in the arteries of the 
 the right arm, and in the right carotid and tem- 
 poral vessels : at the same time the throbbing 
 in the aneurism stopped, and it became flaccid. 
 The patient is reported to have felt himself much 
 relieved, and not the slightest disturbance of any 
 function took place, as might have been expected 
 from an operation which intercepted so large a por- 
 tion of the current of blood issuing from the heart. 
 Several weeks after the operation, when the inci- 
 sion was almost wholly healed, bleeding took 
 place at different intervals, rendering recovery 
 doubtful. Having ceased, hopes were again en- 
 tertained, until the symptoms re-appeared, and 
 the patient died on the 6/th day, consequently 
 more than two months after the operation. — 
 Dissection showed that the cure was nearly com- 
 pleted, by deposition within the aneurismal sac. 
 The arteria infiominata was closed below the 
 point of ligature by means of a thrombus, and 
 the brain and right: arm were supplied with blood 
 by anastomosing vessels. 
 
 These cases are most interesting, and suffi- 
 ciently prove not only the practicability of tying 
 
63 
 
 the arteria innominata, but also the probable 
 success of the operation. 
 
 Mr. Allan Burns, in his excellent work on 
 the “ Surgical Anatomy of the Head and 
 Neck,” published in 181 1 , expressed an opinion 
 that there was no dread of the circulation being 
 supported in the right arm after a ligature has 
 been applied to the arteria innominata 5 indeed 
 he reduced it to demonstration by the following 
 experiment on the dead subject. He tied the 
 arteria innominata with two ligatures, and cut 
 across the vessel in the space between them, with- 
 out hurting any of the surrounding vessels. Af- 
 terwards even coarse injection, impelled into the 
 aorta, passed freely by the anastomosing branches 
 into the arteries of the right arm, filling them and 
 all the vessels of the head completely. So con- 
 vinced was he, that the circulation might be conti- 
 nued, that he was almost encouraged to put it to the 
 trial in a supposed case of subclavian aneurism, but 
 which, on post mortem examination, proved to be 
 an aneurism of the arch of the aorta, involving a 
 part of the arteria innominata ; and the only con- 
 sideration which seemed to have deterred him, 
 was the deficiency of data, whereon to estimate 
 the probability of its issue. 
 
64 
 
 Mr. Burns did not fear the want of a due 
 supply of blood to the right arm ; but there was 
 a point which could not be answered for — namely, 
 the effects which would be produced on the brain 
 by suddenly cutting off the supply of blood from 
 two of its vessels. It was well known, that the 
 circulation along the carotid artery might be 
 intercepted wtthout detriment to that organ ; but 
 we possessed no testimony that both it and the 
 vertebral artery might be tied with equal impu- 
 nity ; yet Mr. Burns thought that in so desperate 
 a disease as aneurism of the subclavian artery, 
 especially where it had a decided tendency to 
 extend towards the chest ; it was allowable to 
 risk applying a ligature round the arteria innomi- 
 nata, but that it was an operatiori which ought 
 not to be rashly undertaken. The cases of Drs. 
 Mott and Graefe prove that Mr. Burns’ reason- 
 ing was correct, and that to pass a ligature around 
 this vessel, is one of the justifiable operations in 
 Surgery. 
 
 On reference to the plan, it will be seen how 
 the circulation is continued. The anastomoses 
 are free : — thus, the inferior thyroideal (12), the 
 superior thyroideal (5), the facial (7), the occipi- 
 
(>5 
 
 pital (8), and the temporal arteries on one side, 
 freely communicate with those on the other ; fur- 
 nishing, therefore, blood to the right subclavian, 
 and to the neck, face, and scalp ; and the inos- 
 culations between the vertebrals, and internal 
 carotids, are adequate to the purposes of the 
 brain. 
 
 But although there is not much ground for 
 apprehension as to the after circulation, there are 
 two reasons why passing a ligature on the arte- 
 teria innominata is a precarious operation, viz. — 
 its proximity to the heart, and its being in the 
 neighbourhood of other important organs. 
 
 Of these reasons the first is the most weighty, 
 as the impulse of the blood must be so great as to 
 endanger a premature separation of the ligature, 
 and hoemorrhage, the occurrence of which was 
 probably the proximate cause of death in the 
 above cases; — but these considerations, though 
 weighty, ought not, perhaps, to deter us from 
 performing it under urgent circumstances. 
 
 The practical deductions to be drawn from 
 the preceding observation, are — 
 
 K 
 
66 
 
 First , That so far as the anastomoses are con- 
 cerned, we have no ground for declining to tie the 
 arteria innominata. But, 
 
 Secondly , The local condition of the vessel is 
 unfavourable ; and therefore we ought not to be 
 very sanguine in our expectations of success. 
 
67 
 
 CAROTIS COMMUNIS. 
 
 The Right Common Carotid Artery is a branch 
 the arteria innominata; the left arises from the of 
 arch of the aorta. — For relative position of this 
 vessel, vide page 13. 
 
 The circumstances which encouraged Sur- 
 geons to try the safety of tying the carotid ar- 
 tery, were the success of the operation in brutes, 
 and the discovery of frequent cases in which this 
 large and important vessel was obstructed by 
 disease. 
 
 Sir A. Cooper had long been in the habit of 
 tying the carotid arteries in the dog, in his Sur- 
 gical Lectures, to show the falsehood of the pre- 
 vailing idea, that a ligature upon these arteries 
 produces sleep or coma in the animal. In a 
 healthy dog, which had been the subject of this 
 experiment, he made ligatures upon both the 
 femoral arteries; and when these ligatures had 
 separated, and the wounds had perfectly healed, 
 he tied one brachial artery — and that wound 
 
68 
 
 having closed, the other brachial was cut down 
 upon, and, as he supposed, divided and tied. 
 The animal survived these different experiments, 
 and lived about a year afterwards. Immediately 
 after death it was injected, and the injection had 
 passed so successfully in the neck, and in the 
 the thighs, as to make beautiful preparations of 
 the anastomosing vessels; but the injection failed 
 in one of the fore extremities, so as to leave a 
 doubt whether the brachial artery had been di- 
 vided, or the radial or ulnar under a high divi- 
 sion of the brachial artery. This, however, was 
 certain, that the animal lived for more than a 
 year, with the two carotids, the two femorals, 
 and one brachial artery, obliterated. 
 
 Haller, in the year 1749, in examining the 
 body of a woman, found the left carotid plugged 
 up with coagulum, which extended up the exter- 
 nal carotid to the origin of the labial artery, 
 and filled the internal carotid to its entering the 
 foramen in the petrous portion of the temporal 
 bone* 
 
 Since Haller’s case, others have been pub- 
 lished, where the common carotid was imperme- 
 
69 
 
 able, and where the functions of the brain did not 
 seem to suffer from such an accident. Indeed 
 Dr. Baillie, in the first volume of the “ Trans- 
 actions of a Society for the Improvement of 
 Medical and Chirurgical Knowledge,” relates 
 an instance in which one carotid was entirely ob- 
 structed, and the diameter of the other consider- 
 ably lessened, without any apparent ill effects on 
 the brain. 
 
 The first case in which the common carotid 
 artery was tied, was in a patient who came under 
 the care of Mr. Abernetby, for an extensive la- 
 cerated wound in the neck, involving the inter- 
 nal carotid, and all the branches in front of the 
 external one. For a short time the patient went 
 on well ; but he became convulsed, and died 
 thirty hours after the operation. 
 
 In 1805, it was tied for the first time for 
 aneurism : the operator was Sir Astley Cooper. 
 The patient died on the 21st day. 
 
 In June, 1808, the same Surgeon operated 
 in another case : the patient got quite well, and 
 resumed his occupation as a porter. 
 
70 
 
 In December, 1808, Mr. Cline tied the 
 common carotid ; but the patient survived the 
 ^ operation only three days. 
 
 In 1809, Mr. Travers passed a ligature 
 about the carotid, in a large aneurism by anas- 
 tomosis in the left orbit. The patient recovered, 
 and the disease was cured. 
 
 Mr. Dalrymple, of Norwich, performed this 
 operation in 1812, for a similar disease; but here 
 the success was partial, for, although the aneu- 
 rism was cured, the eyesight was irrecoverably 
 lost. — With respect to the state of the local cir- 
 culation in this case, Mr. Dalrymple remarks, 
 that there is no pulsation to be felt in any of the 
 branches of the temporal and facial arteries, on 
 the side on which the ligature was applied; but 
 (as in the case treated by Mr. Travers) the artery 
 may be distinguished beating very feebly below 
 the angle of the jaw; and a very brisk action of 
 collateral branches, lying near the surface, is visi- 
 ble in the vicinity, and along the course of the 
 cicatrix. 
 
 In 1816, Mr. Goodlad, of Bury, tied the 
 
71 
 
 common carotid, for the purpose of obviating all 
 danger of hoemorrhage in the removal of an im- 
 mense tumour from the neck of a female. 
 
 In 1819, Mr. Thorpe, sen., tied this vessel 
 for aneurism : the patient died a short time after- 
 wards of a pulmonary affection, under which he 
 had long laboured. 
 
 Within the last five years, the operation of in- 
 cluding this artery in a ligature has been frequently 
 undertaken in the hospitals of London, and large 
 provincial towns, and in many cases with such 
 complete success, as to render it no longer pro- 
 blematical whether it can be safely done. — In the 
 Museum at St Thomas’s Hospital, there is a pre- 
 paration of the first case in which Sir A. Cooper 
 tied successfully the carotid artery ; but the anas- 
 tomoses are not distinctly made out. 
 
 The anatomy of the blood vessels, however, 
 shows, that the arteries which furnish blood to 
 one side of the neck, face, scalp, and brain, freely 
 anastomose with those of the other : hence, one 
 of the carotid arteries may be obliterated with 
 almost as little danger as the main trunk of either 
 
of the extremities. When a ligature is placed on 
 one of the common carotids, an obstruction is set 
 up in one of the four large arteries which trans- 
 mit the blood to the brain. By this operation 
 we should cut off the supply from one-half of the 
 neck, one-half of the face and scalp, and one-halt 
 of the anterior and middle lobes of the brain, — if 
 the branches arising from the external and inter- 
 nal carotids, on one side, did not communicate 
 with those of the other; the internal carotids with 
 the vertebral, and some of those of the external 
 carotid artery. 
 
 As it is, we see a direct route for the blood 
 into the respective branches of the external and 
 internal carotids, although the main channel (the 
 common carotid) should be obstructed. First, 
 the common carotid of the opposite side (E) is 
 open ; it divides into the internal (F), and external 
 carotid (G). The first branch of the external ca- 
 rotid is the superior thyroideal (5), which anasto- 
 moses with the opposite superior thyroideal ; and 
 this is one channel by which the blood can arrive 
 at the external carotid on the obstructed side. — 
 The other arteries of the external carotid of one 
 side inosculate with those of the opposite trunk ; 
 
73 
 
 the facial with the facial, the temporal with the 
 temporal, &c. 
 
 Besides the communications between the 
 branches of the external carotids, the subclavian 
 arteries send off important auxiliary branches, 
 namely — the vertebral (11), which in their course 
 distribute twigs to the deep muscles of the neck, 
 and anastomose with the cervical and occipital 
 branches : — the inferior thyroideal (12), which 
 inosculates with the opposite inferior thyroideal 
 and superior thyroideal of the same side : — and 
 the cervicales (14), which unite with branches of 
 the occipital and deep muscular twigs of the ver- 
 tebral. 
 
 Thus the channels open for the passage of 
 the blood to the neck, face, and scalp, are, the 
 untied common carotid — the vertebral arteries — 
 the inferior thyroideal — and the rami cervicales. 
 
 Within the cranium, the inosculations be- 
 tween the branches of the internal carotids are 
 numerous and free, and the carotids anastomose 
 with the branches of the basilar, which is formed 
 
 L 
 
74 
 
 by the coalition of the two vertebral arteries : — 
 thus a particular connexion is established between 
 the arteries of the anterior and posterior portions 
 of the brain. The anastomoses mentioned is so 
 free, that if coarse injection be thrown into one 
 carotid, it will not only fill all the arteries of the 
 brain, but will pass down the opposite carotid 
 and the vertebral into the aorta and subclavian 
 arteries ; and if wax be thrown in by the subcla- 
 vian, it will circulate through the brain, and re- 
 turn by the opposite vertebral and the common 
 carotids. 
 
 The above fact, and the result of experiments 
 on dogs, may induce a belief that both carotids 
 may be tied with impunity ; but in my cc Out- 
 lines” I have ventured to express an opinion, 
 that, as the only resources left for the circulation 
 in this case would be the vertebral, inferior thy- 
 roideal, superficial and deep cervical branches ; 
 and as the vertebral arteries, from running through 
 bony canals, cannot become dilated, as in the 
 common law of anastomoses, after a main trunk 
 has been obliterated, it is probable that the brain 
 would not receive a sufficient quantity of blood 
 
75 
 
 for permanent purposes, unless the infeferior thy- 
 ro ideal and cervical branches could undergo such 
 an augmentation in size, as to supply the inter- 
 nal carotids through a recurrent circulation. 
 
 Having proved the practicability and safety 
 of tying one of the carotids, it will be evident, 
 that the external carotid, or either of its minor 
 branches, may be tied with impunity. When 
 anv of these branches are affected with aneurism, 
 it is necessary to open the sac, and to apply a 
 ligature at each extremity. 
 
 The inferences to be deduced from the pre- 
 ceding observations on the common carotid ar- 
 tery are — 
 
 Fii'st, That modern experience has confirm- 
 ed the opinion that this vessel may be secured by 
 ligature, without any permanent injury to the 
 animal economy. 
 
 Secondly , That the inosculations of the 
 branches of the. opposite external and internal 
 carotids with each other, and with some of the 
 
76 
 
 branches of the subclavian, can furnish an ade- 
 quate supply of blood to the neck, face, scalp, 
 and brain. But, 
 
 Thirdly, It still remains an unsettled point, 
 whether both common carotids can be obliterated 
 at the same time, with any hope of success. 
 
77 
 
 ARTERIyE SUBCLAVIA ET AXILLARIS. 
 
 The Right Subclavian Artery arises, in com- 
 mon with the right carotid, from the arteria in- 
 nominata ; the left is a branch from the arch of 
 the aorta. When the subclavian artery has pass- 
 ed under the clavicle, it takes the name of axil- 
 lary, — which terminates in the brachial, at the 
 'inferior margins of the tendons of the muscles 
 which form the boundaries of the arm-pit. — 
 For Relative position of this vessel, and the 
 branches which arise from it, vide the 16th and 
 succeeding pages. 
 
 The subclavian artery was first tied for aneu- 
 rism in the year 1801, by Mr. Keate ; but prior 
 to that period, a ligature had been passed about 
 it, in cases of wounds of the axillary. The only 
 case in which mortification did not supervene, 
 was in the one given by Mr. Hall, of Cheshire, 
 where the artery was included in a ligature, in 
 consequence of a wound made in the axilla by 
 a scythe : the man recovered the use of his arm, 
 though he had ever afterwards a weak and trem- 
 
73 
 
 bling pulse. Desault, and the late Mr. White 
 of this town, had occasion to tie the axillary 
 artery, but in both instances the arm mortified, 
 and the patients died ; but on examining the 
 bodies, the fatal termination was easily accounted 
 for — as, together with the artery, Desault tied the 
 brachial plexus of nerves; and Mr. White included 
 three of these nerves in the ligature. 
 
 Mr. Keate’s operation was performed in a 
 case of axillary aneurism. The artery was tied 
 immediately below the clavicle, and the patient 
 got well. 
 
 Mr. Ramsden, in his “ Practical Observa- 
 tions on Sclerocele,” &c., gives us an account of 
 the first operation of tying the subclavian above 
 the clavicle. It was performed by himself on a 
 man admitted into St. Bai tholomew’s Hospital 
 in 1809, for an axillary aneurism of the right 
 arm. Although the circumstances of the patient 
 did not augur favourably as to the result, Mr. 
 Ramsden preferred exposing himself to a failure, 
 rather than omit the only possible means of sav- 
 ing his patient’s life. The patient died on the 
 fifth day. 
 
79 
 
 The subclavian artery was tied by Sir W. 
 Blizard, in 1811, but failed on account of ths age 
 of the patient. 
 
 In 1815, the subclavian artery was secured 
 below the clavicle, in Kingston, Jamaica, by Mr. 
 Chamberlaine. The operation was performed on 
 the 17th of January. On the 27th (ten days af- 
 terwards) the ligature came away spontaneously; 
 and on the 22d of February the wound healed. 
 At this time the aneurismal tumour was nearly 
 as large as a turkey’s egg, and very solid. 
 
 In the Edinburgh Medical and Surgical 
 Journal, for January, 1815, there are some 
 highly interesting cases, by Dr. Colies of Dublin, 
 to which I shall beg to refer the student. 
 
 Dr. Post, of New York, operated in 1817. 
 On the 18th day, the ligature came away with 
 the dressings; in four days more, the wound was 
 nearly healed ; the tumour had entirely disap- 
 peared, and the pulsation of the artery at the 
 wrist was distinctly felt. 
 
 Mr. Liston, of Edinburgh, operated in the 
 
80 
 
 month of April, 1820, on a man who had an 
 aneurism in the left axillary artery; the tumour 
 was of the size of a smali melon, of a conical 
 form, and situated rather above the level, imme- 
 diately under, and closely in contact with the 
 left clavicle ; the ligature separated on the twelfth 
 day, and in 35 days the wound was cicatrized, 
 and the tumour rapidly diminishing in size. 
 
 In 1823, Mr. Wishart, one of the Surgeons 
 of the Edinburgh Infirmary, tied the subclavian 
 artery, in a porter, 47 years of age. The opera- 
 tion was performed on the 23d of August, and 
 on the 24th of October the patient was pro- 
 nounced cured. 
 
 Within the last three years, this artery has 
 been tied by Mr. Brodie, Mr. Green, Mr. Key, 
 and other Surgeons; and in some of these cases 
 with success. 
 
 Mr. Green informs me, in a letter, that the 
 subclavian artery has been secured four times at 
 the Borough Hospitals : two of these cases were 
 unsuccessful ; but the subjects of the operation 
 died at too early a period, to ascertain any 
 
81 
 
 thing satisfactory respecting the collateral circa- 
 lation. 
 
 Mr. Key, Surgeon at Guy’s, has been so 
 obliging as to communicate a case in which he 
 operated, about two years ago. The subject of 
 the operation was a man about 36 years of age, 
 who, in lifting a weight in his occupation (which 
 was that of an extra tide-waiter at the Custom- 
 house), felt something in the axilla give way, and 
 a pulsating tumour from that time began gradu- 
 ally to appear between the axilla and the clavicle. 
 The patient underwent some rough attempts to 
 cure it by pressure; but the pain, irritation, and 
 swelling of the limb, that ensued, soon induced 
 him to discontinue it. Two months after the 
 appearance of the disease, he came under the care 
 of Mr. Key, at Guy's Hospital, and submitted to 
 the operation. The first time Mr. Key saw the 
 tumour, it pulsated strongly, and occupied the 
 whole space between the clavicle and axilla, 
 pushing up the former, so as to deepen the site 
 of the subclavian artery. The veins of the neck 
 were varicose, and the whole limb oedematous.— 
 Of the nature of the disease there was no doubt, 
 and the man immediately consented to the ope- 
 
 M 
 
ration, when it was proposed to him. The pa- 
 tient felt easier afterwards; the excessive pain 
 in his arm (from distension) quickly subsided, 
 and the tumour diminished in size. The pro- 
 gress of the case, from the operation to the period 
 of his convalescence, was unmarked by any thing 
 untoward, with the exception of slight febrile 
 excitement on the second and third days, which 
 was relieved by purgatives. The ligature came 
 away about the fifteenth day, and the wound im- 
 mediately closed. The tumour was gradually 
 absorbed, and nothing but a hardness remained 
 when he left the hospital. The radial artery 
 could not be felt at the wrist, but the pulsation 
 of the brachial on that side (the right) is distinct. 
 The man is now in perfect health, and works at 
 his former employment. 
 
 Mr. Green has lately had a case at St. Tho- 
 mas’s of a very extraordinary kind. Mr. G. tied 
 the subclavian artery, and after a week there 
 came on an arterial hcemorrhage, to the amount 
 of about twenty ounces — which was described by 
 the attendants to be of a large column, and con- 
 siderable projectile force. Tne patient being 
 much exhausted, and the ligature seeming loose, 
 
85 
 
 created much alarm, as nothing farther seemed 
 admissible, or indeed practicable, if, as was gene- 
 rally expected, the bleeding returned ; however, 
 by great quiet, and a most abstemious regimen, 
 the hoemorrhage did not recur. 
 
 This case is of a most interesting, and I 
 would say, inexplicable kind. From whence did 
 the hoemorrhage proceed ? — The size and force 
 of the stream could not well indicate any other 
 source than the point of the trunk next the heart ; 
 yet if so, is it not very surprising that the bleed- 
 ing should have ceased, and not returned ? The 
 recurrent circulation by the vertebral, inferior 
 tbyroideal, and the cervical branches, might have 
 furnished blood to the humeral or outer extremity 
 of the artery ; but in this case we can scarcely sup- 
 pose that the stream would have been projected to 
 a considerable distance. It is one of those ano- 
 malous occurrences in which conjecture must sup- 
 ply the place of actual proof : the man is fortu- 
 nately doing well ; and though curiosity must be 
 awakened as to the cause of the phenomenon, 
 and which a post mortem examination only can 
 satisfactorily explain, it is to be hoped that an 
 opportunity will not be allowed us, and that we 
 
84 
 
 shall ever remain in doubt respecting it. As it 
 is Mr. Green’s intention to publish the particu- 
 lars of this case, I shall look forward with great 
 interest to the appearance of his paper, which, 
 •I doubt not, will contain many valuable reflec- 
 tions. 
 
 Mr. Teale, jun., of Leeds, has kindly favour- 
 ed me with an account of the case where he tied 
 the subclavian artery for an aneurism of the axil- 
 lary, which at first was circumscribed, but after- 
 wards became diffused, in consequence of the 
 bursting of t lie sac. The operation was proposed 
 to the patient when the disease was in the former 
 state j but he objected, and persisted in doing so, 
 until the aneurismal sac had given way, when the 
 necessity of it was again urged in the strongest 
 terms, and the patient consented. The sensation 
 and motion of the arm became much diminished 
 immediately after the application of the ligature, 
 but on the third and fourth days, sensation and 
 motion in some measure returned. For several 
 days after the operation, the vital powers appear- 
 ed to be rapidly sinking, and the patient died on 
 the ninth day. On examination, the divided ex- 
 tremities of the subclavian artery were not sepa- 
 
86 
 
 rated more than one-fourth of an inch; they were 
 imbedded in a tough substance formed by the 
 surrounding cellular membrane, into which coa- 
 gulable lymph had been effused. The extremity 
 of the artery nearest the heart was closed by firm 
 coagulable lymph, which extended as far as the 
 arteria innominata. The vertebral artery was 
 filled with a tough ash-coloured substance, which 
 adhered so firmly, that it could not be separated 
 without being lacerated; and the internal mammary 
 was obliterated in the same way as the vertebral. 
 Opposite the internal mammary, about an inch 
 from the arteria innominata, a trunk arose, which 
 almost immediately divided into three branches, 
 which branches remained pervious. The axil- 
 lary extremity of the artery was even better se- 
 cured than the other, being more firmly plugged 
 with coagulum, and having a more copious depo- 
 sition of solid matter around it. No branch could 
 be traced passing from this portion of the artery. 
 About an inch from the ligature, immediately 
 after the artery had passed the first rib, the aneu- 
 rismal tumour commenced; its length was about 
 3 inches, its breadth about 1^: on opening it, it 
 was found filled with coagula. From its infe- 
 rior extremity the brachial artery arose rather less 
 
36 
 
 than its usual size, being perfectly pervious, and 
 having its coats healthy. At the posterior surface 
 of the tumour was an aperture large enough to 
 admit the tip of the little finger ; through this 
 aperture the coagulum filling the aneurismal sac 
 could be seen. This opening communicated with 
 a large cavity extending under the scapula, pec- 
 toral muscle, and integuments, which contained 
 between three and four pints of coagulated blood ; 
 the pressure of this mass produced great mischief 
 in the neighbouring parts. This cavity extended 
 upwards along the cellular substance, to the im- 
 mediate vicinity of the incision ; and indeed an 
 opening of communication was detected bv means 
 of a probe, which opening was in all probability 
 the source of the profuse hoemorrhage (during the 
 operation) which yielded to compression; and also 
 of the discharge of bloody serum, which occurred 
 in the two last days of the patient’s life. Mr.Teale 
 attributes the death of his patient to the irritation 
 produced bv so large a mass of extravasated blood 
 acting as an extraneous body, on which account, 
 it is a subject of regret, that the patient’s consent 
 to the operation could not have been obtained 
 before the extravasation took place. 
 
From the preceding accounts of the cases in 
 which the operation of tying the subclavian has 
 been performed, we are warranted in saying, that 
 it is a less formidable undertaking than surgeons 
 once considered it. 
 
 The chief difficulty complained of, has been 
 experienced in passing the ligature under the 
 artery; but this has, in a great measure, been 
 obviated by the ingenious instrument contrived 
 by Mr. Weiss, on a principle suggested by Mr. 
 Kirby, of Dublin. 
 
 The ease with which an operation can be 
 executed, is, however, not the only circumstance 
 which influences the success or failure of it. The 
 situation and connections of the artery operated 
 on, must, in some cases, lead us to fear the re- 
 mote, as much, if not more, than the immediate 
 consequences of the operation. 
 
 Dr. Barclay, who wrote a most excellent 
 work on the arteries, in 1812, when the results of 
 tying the subclavian had not proved very encou- 
 raging, mentions the following anatomical facts, 
 as likely to explain it : — “ No other artery,” says 
 
lie, that has yet been tied is so near the heart, 
 or in the neighbourhood of such a number of im- 
 portant organs, as t he par vagum, the great in- 
 tercostal, the descendens noni, the axillary plexus, 
 the subclavian vein, the interna! jugular, and cava 
 superior; — no other artery t hat has yet been tied 
 gives out, in so small an extent of space, such a 
 number of large and important branches, or so 
 irregular as to the exact point of their origin; — 
 no other artery that has yet been tied is so little 
 susceptible of being raised from its /situation ; — and 
 no other artery that has yet been tied is found in 
 a direction so different from the muscles by which 
 it is covered, or in a situation where the incision 
 Can be less extended, or the operation more apt 
 be impeded by the motions of such a bone as the 
 clavicle.” 
 
 These circumstances, as connected with the 
 subclavian artery, must certainly tend to diminish 
 the chance of a happy issue, and therefore the 
 operation of tying it must always be considered 
 of rather a serious character. When we look, 
 too, to the anastomosing vessels, we should be 
 almost inclined to despair of success ; but ex- 
 perience has proved that we have little to appre- 
 
bend from the apparent scantiness of the inoscu- 
 lations. The failures, in the earlier cases of ty- 
 ing the subclavian, did not depend on this cause, 
 but on errors in the mode of operating — on the 
 constitutional circumstances of the patient- — or 
 on one or more of the reasons given by Dr, 
 Barclay. 
 
 J 
 
 W e will now point out thp routes which the 
 blood took to arrive at the upper extremity, when 
 the axillary was obliterated by disease; and af- 
 terwards demonstrate the anastomoses when the 
 ligature is applied to different portions of the 
 subclavian and axillary vessels. 
 
 Mr. Hodgson mentions, that the late Mr. 
 Taunton, Surgeon and Lecturer in London, 
 showed him two preparations, taken from a 
 subject in the dissecting-room, in which both the 
 axillary arteries were obliterated. The left axilla 
 contained a cluster of diseased glands; but there 
 was no morbid appearance on the coats of the 
 artery, or the surrounding parts, which would 
 account for the obliteration of the vessel on the 
 right side. The right arm was injected, and it 
 was found that the supra scapular communicated 
 
90 
 
 by large anastomoses with the subscapular artery. 
 These communications were principally situated 
 close to the bone on the supra spinous fossa of 
 the scapula. A considerable branch of the supra 
 scapular passed underneath the bone, and anas- 
 tomosed with a branch of the subscapular in that 
 situation. A twig which arose from the axillary 
 artery, below the obliterated portion, proceeded 
 upwards and anastomosed with the supra scapu- 
 lar artery. The transversal is humeri passed along 
 the basis of the scapula, and contributed to sup- 
 ply the branches of the supra scapular artery. — 
 The aggregate of the anastomosing branches was 
 more than equal to the calibre of the brachial 
 artery. 
 
 From this description of the vascular appear- 
 ances in a limb where the axillary artery was ob- 
 structed by morbid causes, we learn the routes 
 which nature took to furnish blood to the upper 
 extremity, and they are just such as we should 
 have expected. The transversal is artery of the 
 neck receives the blood from the subclavian, and 
 anastomoses with the supra scapular (15), which 
 is also a branch of the same trunk. The supra 
 scapular anastomoses with the infra scapular (16), 
 
9i 
 
 and thus, by collateral channels, the blood arrives 
 at the axillary artery, below the obliterated point. 
 
 The transversalis cervicis, the supra scapu- 
 lar, and infra scapular, are, then, the principal 
 anastomosing branches ; but they are not the 
 only ones — the internal mammary and superior 
 intercostal (13), and the inferior intercostals (2), 
 inosculate with one of the thoracici, called the 
 external mammary (17), and the circumflex 
 branches (18) freely communicate with the other 
 branches about the shoulder joint. 
 
 As a proof how free the anastomoses are 
 between the subclavian and axillary branches 
 about the shoulder joint, I shall here mention 
 some of the particulars of a case, which is fully 
 detailed in the “ Manual,” by Mr. Shaw. — A 
 young girl, a patient of Mr. Smith, of the Leeds 
 Hospital, had a secondary hoemorrhage from the 
 stump, after the arm had been torn off by ma- 
 chinery. Mr. Smith secured the axillary artery, 
 in cutting for which, he divided and tied several 
 small arteries and veins with two ligatures. The 
 axillary artery was at length secured by means of 
 two ligatures, and divided. In time the patient 
 
died, in consequence of hoemorrhage from the 
 face of the stump, notwithstanding the calibre of 
 the artery was properly obliterated by the liga- 
 ture. On dissection, the bleeding was discovered 
 to have come from the subclavian above the liga- 
 ture, through the supra scapular branch. This 
 is highly important to recollect — because, as Mr. 
 Shaw observes, it is a proof that in a case of 
 axillary aneurism, even though the subclavian has 
 been tied, still the aneurisrnal tumour may be 
 supplied with blood from the anastomosing 
 branches, and may at last burst, even though 
 the main trunk should be obliterated above the 
 aneurism. I accord with Mr. Shaw in this opinion ; 
 and although we should haidly suspect that the 
 inosculations about the shoulder are so abundant 
 as to induce an apprehension of this kind, the fact 
 is strongly corroborative of a principle which I 
 shall by and bye attempt to establish — namely, 
 that we have less to fear, in some cases, from the 
 anastomoses being few, than from their being 
 numerous. 
 
 Having considered the general anastomoses, 
 let us now contemplate cases which may interfere 
 with the direct communication which we have 
 
93 
 
 shown to exist between the subclavian and axil- 
 lary branches. If the student will observe the 
 origins of these branches, he will see, after the 
 subclavian artery has sent off the internal mam- 
 mary, the inferior thyroideal, the superior inter- 
 costal, and the vertebral, — which may be consi- 
 dered as tolerably regular branches, and as usually 
 passing off from the main trunk, in the order 
 mentioned, — that there are some branches less 
 regular in their origin; namely, the cervicals and 
 supra scapular. Below this last, there are a few 
 less important muscular branches, and we then 
 arrive at the subscapular (or infra scapular) artery, 
 which is a branch of considerable size. From this 
 view he will satisfy himself, that if a ligature be 
 applied to any portion of the subclavian, or axil- 
 lary artery, at any point intervening betwixt the 
 origin of the supra scapular, and that of the infra 
 scapular, the anastomosing vessels will be nearly 
 the same. — But what will occur, if the subclavian 
 artery be tied on the inner side of the supra 
 scapular, or before any other branch is given 
 off? There are some cases recorded, where the 
 subclavian artery was found obliterated at its 
 origin, and yet the limb was nourished and sup- 
 ported. — Suppose the obliteration to be limited 
 
94 
 
 to that part of the vessel, how would the blood 
 find its way into the main trunk ? If the plan 
 be examined, it will appear, that the course of 
 the blood will be this : — it will pass, by the infe- 
 rior and superior thyroideal arteries of the oppo- 
 site side, and the superior thyroideal of the same 
 side, into the inferior thyroideal of the obstructed 
 subclavian, and, by this branch, to the subclavian 
 itself ; — it will pass into the vertebral artery of 
 the obstructed side, through the medium of its 
 various communications with the arteries of the 
 brain, and those of its deep muscular branches 
 with the occipital branches; — it will pass into the 
 cervical arteries, through their anastomoses with 
 the occipital branches ; and by all these means 
 the blood enters the subclavian trunk, to pass to 
 the extremity. 
 
 But what happens if all the subclavian branches 
 are obstructed at their origin, and an aneurismal 
 tumour exists in the axilla ? The route of circu- 
 lation will be this: — the superior thyroid and oc- 
 cipital branches of the external carotids, anasto- 
 mose with the inferior thyroid, the cervicales, and 
 the supra scapular of the subclavian trunk; but 
 the mouths of these vessels are obstructed, hence 
 
the blood could not pass directly into the subcla- 
 vian ; but the ultimate ramifications of these 
 primary branches have free communications with 
 those of the infra scapular, and articular arteries, 
 and other branches about the shoulder, by means 
 of which, the blood will be transmitted into the 
 axillary trunk. Besides the branches of the ca- 
 rotids, the branches of the opposite subclavian 
 are open ; and one of these (the vertebra!) must, 
 by its union with the opposite vertebral, and the 
 branches of the internal carotids, supply the ver- 
 tebral branch of the obstructed side ; and though 
 its opening into the subclavian trunk w r ere oblite- 
 rated, the branches which go to the deep muscles 
 of the neck still inosculate with the correspond- 
 ing branches of the opposite vertebral, and other 
 branches in its vicinity, and thus assist in the col- 
 lateral circulat ion of the blood. 
 
 In the chief features, Mr. Teale’s case was 
 similar to this. He states, however, “ that, op- 
 posite to the internal mammary, a trunk arose, 
 which almost immediately divided into three 
 branches: these branches were not filled with 
 solid matter, but remained pervious.” — This 
 trunk must have been either the inferior thyroid. 
 
or one of the cervicale.% which are often irregular 
 iu their origin; and although all communication 
 with the innominata was completely prevented he 
 the plug in the subclavian, the ultimate branches 
 would form an intermediate series of vessels, which 
 would convey the blood to the branches with 
 which they anastomosed ; and these, by means 
 of their ultimate ramifications with those arising 
 from the trunk below the aneurisma! tumour, 
 would carry the blood into the main artery of 
 the upper extremity. 
 
 This, then, appears to me to be the circui- 
 tous route of circulation, when the subclavian is 
 tied, and the whole of its branches obliterated. — 
 I think there is reason to believe that this is the 
 route in almost all cases; for it is probable that 
 the branches of the subclavian are seldom avail- 
 able, judging from the effect of a ligature on 
 other arteries, which is to render the vessel an 
 impervious cord, for some extent beyond the 
 point to which the ligature was applied. 
 
 There is one fact, however, in favour of our 
 supposing that the branches of the subclavian 
 will remain open, and that the obliteration of the 
 
97 
 
 artery will be limited to a small space — namely, 
 the immediate passing off of branches. In com- 
 mon cases, we find the artery obstructed to the 
 first anastomosing branch above and below the 
 ligature : now, as in the subclavian a number of 
 branches arise very near each other and the liga- 
 ture, it is possible, that the apertures of these 
 arteries will remain patulous, and therefore be 
 subservient to the after-circulation in the limb. 
 
 When a ligature is placed on the subclavian 
 artery, on the tracheal side of the scaleni muscles, 
 before any branch is given off, the mouths of the 
 branches (if they continue open) wil receive a 
 supply through the various anastomoses of their 
 extreme branches with the branches of the caro- 
 tids, and the opposite subclavian ; and thus the 
 subclavian trunk will be supplied with blood be- 
 tween the ligature and the aneurismal sac. The 
 supply might, in this case, be sufficient, I con- 
 ceive, to render the operation doubtful, as it re- 
 gards the disease ; but the reasons why the ope- 
 ration of tying the subclavian in this situation is 
 more dangerous, are, the proximity of the ligature 
 to the heart, and its being in the neighbourhood 
 
 o 
 
98 
 
 of other important parts, — resembling, in these 
 respects, the operation of tying the arteria inno- 
 minata, which is hazardous on these accounts, 
 and not on account of the want of anastomoses, 
 as facts have proved that the circulation can be 
 continued. Reasoning on the analogy between 
 these two cases, I should as much calculate on 
 success in the one as in the other; but, I fear, our 
 hopes will always be disappointed in both. 
 
 When the subclavian artery is tied on the 
 outer side of the scaleni, its principal branches 
 have been given off ; there is no communication 
 of vessels between the ligature and the sac, hence 
 the latter cannot be fed from above ; yet, as the 
 branches inosculate with those sent off from the 
 axillary trunk, the recurrent circulation may have 
 some influence on the aneurismal tumour — but 
 the inosculations are not, I think, so abundant as 
 to lead us to entertain much fear on this head. 
 
 When the ligature is applied in this situation, 
 it is at a greater distance from the heart and other 
 important parts, and is not so forcibly acted upon 
 by the column of blood sent out by the contrac- 
 
90 
 
 tiou of the left ventricle, because there are colla- 
 teral channels for carrying it off : — thus the weight 
 of evidence seems very much in favour of our giv- 
 ing the preference to tying the subclavian artery 
 on the outer side of the scaleni muscles. There 
 are instances of the success of this operation ; but 
 there is not one example, that 'I am acquaint- 
 ed with, where success followed the operation, 
 when performed on their inner, or tracheal side. 
 
 I would not, however, positively interdict 
 the operation of tying the subclavian in this last 
 situation, as it is better to incur the risk of failure, 
 than to allow the patient to die unassisted. 
 
 Dr. Colies, who first performed this operation 
 in the year 1813, did not undertake it as a matter 
 of choice, but as a matter of necessity, — as the 
 tumour, which was on the right side, extended 
 from the sternal origin of the sterno mastoid 
 muscle, along the clavicle, to a little beyond the 
 arch of that bone. On dissection it was found, 
 that the aneurism reached so far as to leave only 
 about one- fourth of an inch of the artery in a 
 sound state. 
 
100 
 
 Dr. Colles, therefore, was obliged to do 
 what he did, or to abandon the patient to his 
 fate. 
 
 The efforts of nature to accommodate her- 
 self to changes, and to obviate or overcome the 
 effects of disease, are, however, so extraordinary, 
 that we cannot wonder at the boldness of sur- 
 geons in reposing much trust in her; but we are 
 not justified in doing so, unless called for by des- 
 perate and emergent circumstances. 
 
 The conclusions which I would draw from 
 this section of the work, are — 
 
 First, That the safety of tying the subcla- 
 vian artery, under certain circumstances, has been 
 proved by many successful cases. 
 
 Secondly, That when the ligature is applied 
 on the humeral side of the scaleni muscles, the 
 artery has given off its principal anastomosing 
 vessels ; we have, therefore, nothing to fear, as to 
 a due transmission of blood to the upper extre- 
 mity. But, 
 
101 
 
 Thirdly, When the ligature is put on the 
 vessel, at the tracheal side of the scaleni, it is 
 anterior to the passing off of branches, and in 
 the vicinity of important parts — hence the opera- 
 tion is not free from danger. 
 
 J 
 
102 
 
 ARTERIA BRACHIALIS. 
 
 The Brachial Artery commences at the lower 
 margins of the tendons of the pectoralis major, 
 the latissimus dorsi, and teres major muscles, 
 and commonly terminates at the bend of the 
 elbow, by dividing into the radial and ulnar 
 branches. — For the Relative Position of this 
 vessel, and the branches which arise from it, vide 
 page 20. 
 
 It may be necessary to tie the brachial arte- 
 ry on two accounts — namely, wounds and aneu- 
 rism — but in both cases it is a matter of inquiry, 
 how, and where, the ligature should be applied. 
 1 have laid it down as a grand principle, in the 
 treatment of hoemorrhage, that when a vessel of 
 considerable size is wounded, one ligature is not 
 enough ; because, if a ligature be put on the up- 
 per extremity of the divided vessel, bleeding will 
 continue from the lower, from its being fed by anas- 
 tomosing branches. Suppose the brachial artery 
 was cut through in the middle of the arm, below 
 the origins of the arteriae profundas, and a ligature 
 
103 
 
 was placed on the upper extremity of the divided 
 artery, the blood would pass by the profunda su- 
 perior (19), and profunda inferior (20), into the 
 branches of the ramus anastomoticus (21), the 
 recurrent radial (22), and recurrent ulnar (23) ; 
 by the mouths of those vessels, it would enter the 
 trunks of the brachial, radial, and ulnar arteries ; 
 and thus, by a recurrent circulation, would escape 
 by the inferior extremity of the divided brachial. 
 
 It is, therefore, so obvious as to require no 
 additional illustration, that one ligature cannot 
 suffice. 
 
 The anastomoses mentioned, are those con- 
 cerned in carrying on the circulation, when the 
 brachial artery has been tied about the middle of 
 the arm : but the vessel may be wounded higher 
 up — say above the origins of the deep branches — 
 what then is the course of the blood ? The subcla- 
 vian and axillary arteries, with all their branches, 
 are open ; but a ligature to the upper extremity 
 of the wounded vessel will intercept the current 
 in the main channel, hence there must be a com- 
 munication between the branches of the axillary 
 and those of the brachial, otherwise the limb would 
 
104 
 
 mortify. Fortunately this communication exists ; 
 therefore, if the brachial artery be wounded at its 
 commencement, the same treatment is indicated 
 as in the preceding case, and the anastomoses 
 between the branches of the axillary, and those 
 of the brachial, will transmit the blood to the in- 
 ferior part of the limb. 
 
 The brachial artery is sometimes transfixed, 
 in the operation of opening one of the superficial 
 veins at the bend of the arm. The most common 
 situation of the artery at this part, is immediately 
 under the median basilic; therefore caution is 
 necessary when this vein is selected : but as va- 
 rieties occur in the situation of the artery, its pre- 
 cise course should be ascertained ere any vein be 
 opened, and it is always better to avoid the one 
 in its immediate vicinity. When the artery is 
 punctured, the accident gives rise to a disease, 
 named the spurious, or diffused aneurism, or 
 aneurismal varix. 
 
 There is, however, a distinction to be made 
 between diffused aneurism and aneurismal varix, 
 though they are very often confounded together. 
 The distinction is this : — although both arise from 
 
105 
 
 a wounded artery, it is not necessary to the forma- 
 tion of the first, that a vein should lie over or near 
 the artery. An artery may be wounded in any 
 part of the body, and the blood escaping into the 
 cellular membrane, will form a tumour, which is 
 a spurious or diffused aneurism, and this may 
 happen at the bend of the arm, or elsewhere. 
 But to produce an aneurismal varix, properly so 
 called, a vein must lie over the artery, and a di- 
 rect communication must exist between the two 
 vessels : then, if the external wound heals by ad- 
 hesion, the blood will pass into the vein, dilate 
 it into a pouch, and cause the disease in ques- 
 tion. 
 
 This distinction between spurious aneurism 
 and aneurismal varix, is a very important one : the 
 disease which commonly succeeds to a wounded 
 artery, is the former ; with respect to the produc- 
 tion of the latter, it is necessary that an artery 
 be opened through a vein — that the external 
 wound should heal — and that the artery and vein 
 should still communicate, by means of the inter- 
 nal wound in the vein corresponding with the 
 puncture made in the artery. 
 
 p 
 
1QG 
 
 Dr. William Hunter was the first to give an 
 accurate description of that condition of the ves- 
 sels observed in aneurismal varix. In the first 
 and second volumes of the ££ Medical Obser- 
 vations and Inquiries,” he has given some 
 interesting papers on this disease. The first 
 case for which he was consulted arose from 
 bleeding. The veins at the bending of the arm, 
 and especially the basilic, which was the vein 
 that had been opened, were prodigiously enlarg- 
 ed, and came gradually to their natural size at 
 about two inches above, and as much below the 
 elbow. When emptied by pressure, they filled 
 again almost instantaneously, and this happened 
 even when a ligature was applied tight round the 
 fore arm, immediately below the affected part. 
 Both when the ligature was made tight, and when 
 it was removed, they shrunk, and remained of a 
 small size, while the finger was kept tight upon 
 the artery at the part where the vein had been 
 opened in bleeding. There was a general swell- 
 ing in the place and in the direction of the 
 artery, which seemed larger and beat stronger 
 than what is natural, and there was a tremulous 
 jarring motion in the vein, which was strongest 
 
107 
 
 at the part that had been punctured, and became 
 insensible at some distance, both upwards and 
 downwards. 
 
 The attendant circumstances in this case 
 were well marked, and characterized the state of 
 this disease after the elapse of some years, du- 
 ring which the symptoms bad undergone little or 
 no change. One of the distinguishing peculiari- 
 ties of aneurismal varix is, — it has been known 
 to remain the same for years, and, in point of fact, 
 ought not to be considered a dangerous complaint. 
 The case is widely different in Spurious Aneu- 
 rism: this grows worse and worse every hour, 
 and if it be not early treated on the same prin- 
 ciple as that laid down for wounded arteries, the 
 extravasation will be so extensive as to endanger 
 mortification, or to oblige the surgeon to ampu- 
 tate the limb ; as happened in a case of spurious 
 or diffused aneurism, which occurred at the siege 
 of Dantzic, and detailed by Mr. Charles Bell, in 
 his " System of Operative Surgery.” 
 
 The disease, which follows the puncture of the 
 brachial artery in venesection, is often of a mixed 
 
108 
 
 kind ; the blood passes from the artery into the 
 vein, and escapes by the external orifice in a jerk- 
 ing stream ; but besides doing this, it usually be- 
 comes effused in the cellular membrane of the 
 part. When the external opening is closed, the 
 effusion is increased, and will go on increasing, 
 until an operation is performed, unless the hoe- 
 morrhage from the artery is temporarily stopped 
 by a coagulum. This case is not the true aneu- 
 rismal varix; it is not the indolent disease that 
 will continue harmless for years ; it is not a dis- 
 ease that can always be cured by pressure ; but, 
 in a general way, it demands an operation, which 
 is to cut down on the part — to clean away the 
 coagulated blood — and to tie the wounded artery 
 above and below the orifice. 
 
 When I state that an operation is demanded, 
 I lay it down as a principle whereon to found our 
 practice; and though circumstances may occa- 
 sionally induce us to depart from it, and the 
 means resorted to, be equally efficacious, the rule 
 is not weakened in its validity. — Mr. Todd, of 
 Dublin, treated a diffused aneurism, of a large 
 size, by depletion, moderate compression of the 
 
109 
 
 limb, and an horizontal position, and latterly by 
 friction and compression more directly applied to 
 the tumour ; and by these means the aneurismal 
 swelling was entirely absorbed. — Mr. Richard 
 Smith, of Bristol, a Surgeon of extensive hospital 
 and private practice, has mentioned, in a letter 
 to me, that he has met with cases where compres- 
 sion succeeded ; but in those cases that I have 
 seen, the operation was necessary : it is proper, 
 however, first to try the effect of pressure, and, 
 should that not succeed, to have recourse to the 
 operation above referred to. 
 
 It has been conjectured by some surgeons, 
 that it is sufficient to pass a ligature about the 
 brachial artery, in the middle of the. arm. No 
 remark can be necessary to illustrate the ineffi- 
 cacy of this practice, after what I have said on 
 the anastomoses, and the treatment of arterial 
 hoemorrhage founded on the study of them. — 
 When the artery is tied at the bend of the arm, 
 the blood continues to circulate by means of the 
 inosculations of the profunda superior (19) with 
 the recurrent radial branch (22), and the pro- 
 funda inferior (20) and ramus anastomoticus (21) 
 with the recurrent ulnar (28). 
 
110 
 
 A true aneurism is a rare occurrence in the 
 course of the brachial artery ; but when it does 
 form, the vessel must be tied at a certain dis- 
 tance from the tumour, for the reason which led 
 to Hunter’s improvement. 
 
 
Ill 
 
 ARTERIiE RADIALIS ET ULNARIS. 
 
 At, or near, the bend of the elbow, the brachial 
 artery commonly divides into two considerable 
 branches, named the Radial and Ulnar Arteries. 
 — For the Relative Position of these vessels, and 
 the branches which arise from them, vide page 
 21, and following. 
 
 I have said, that the division of the brachial 
 artery usually takes place at, or near the bend of 
 the elbow, but it not unfrequently happens that 
 the bifurcation takes place higher up — sometimes 
 about an inch above the elbow, sometimes half 
 way down the arm, and occasionally nearly as 
 high up as the axilla. 
 
 In my ct Outlines,” I have mentioned, that, 
 in two of the subjects received into my dissecting- 
 room during the winter of 1823, there were varie- 
 ties in the origin of the arteries of the fore arm. 
 In one, the brachial artery divided into the radial 
 and ulnar branches, a little below the arm-pit j 
 the radial branch descended behind the median 
 
112 
 
 basilic vein, and took the same course that the 
 brachial ordinarily does. In the other, the bifur- 
 cation took place about the middle of the arm, 
 and the radial branch passed downwards, imme- 
 diately along-side, and nearly as superficial as the 
 cephalic median vein. In these cases we find, that 
 the muscular branches of the upper arm are sent 
 off from the radial and ulnar arteries ; the radial 
 usually gives off the profunda superior, and the 
 ulnar the profunda inferior artery, and ramus 
 anastomoticus ; but below the joint, they furnish 
 their recurrent, and other branches, in the com- 
 mon way. 
 
 With respect to this high division of the bra- 
 chial artery, it occurs very frequently : but I have 
 here to mention two very extraordinary varieties 
 in the origin of one of the arteries of the fore arm. 
 They are in the possession of Mr. Ransome, one 
 of the Surgeons of our Infirmary, who has kindly 
 allowed me to examine the blood vessel prepara- 
 tions in his private museum. In one instance, I 
 find the ulnar artery arising from the infra sca- 
 pular branch. The axillary trunk sends off the 
 infra scapular in the usual way, but certainly the 
 branch is of unusual size. From it goes off a 
 
113 
 
 large artery, which runs down the arm on the 
 inner side of the brachial, and, in some part of its 
 course, in immediate contact with it; and in 
 size it is little inferior to the brachial itself. At 
 the bend of the arm, it seems to be united to the 
 brachial, and then to continue onwards as the 
 proper ulnar artery. This union is not a state of 
 contiguity merely, but an absolute coalition, for 
 the ulnar artery is much larger in diameter in the 
 fore arm than it is in the arm. This case might, 
 on a superficial examination, be regarded as one 
 of those rare instances in which the brachial ar- 
 tery is double, and the belief would seem to 
 be somewhat strengthened by the circumstance 
 that this unusual branch furnishes the deep 
 branches, and ramus anastomoticus, — the conti- 
 nued trunk of the axillary giving off only two 
 or three very small muscular branches : but on 
 close inspection it is evident, that the anomalous 
 branch is the ulnar, -having this very uncommon 
 origin. I cannot find on record an instance simi- 
 lar, in all respects, to this, nor have I ever before 
 seen a preparation in which this variety existed. 
 Mr. Green, Surgeon at St. Thomas’s Hospital, 
 
 r 
 
 and Lecturer on Anatomy and Surgery, men- 
 
 Q 
 
! 14 
 
 tions in a letter, that he has seen it in one in- 
 stance. 
 
 Dr. Barclay states, that the appearance of 
 a double artery is often occasioned by a branch 
 arising from the humeral artery, near the axilla, 
 or at least high in the region of the humerus, 
 and which, after running in a parallel direction, 
 enters the humeral artery again, or some of its 
 branches, near the bend of the arm. In four pre- 
 parations, this branch entered the radial artery; 
 in three of them opposite the bend of the arm ; in 
 the fourth some inches beyond it : but these ex- 
 amples bear only a distant analogy to the above 
 variety. 
 
 In another preparation I find the ulnar ar- 
 tery arising from the subclavian, which is unique; 
 and in this same subject, the interosseal branch 
 springs from the radial, instead of the ulnar 
 trunk. 
 
 I am not aware of any other practical deduc- 
 ^ tions that can be drawn from these cases, besides 
 w'hat are drawn from those in which a high divi- 
 sion of the brachial occurs. As in both instances 
 
115 
 
 vve find two large arteries in the arm, instead of 
 one, embarrassment might be produced in case of 
 hosmorrhage from wound; and as we might mis- 
 take the seat of aneurism, there would be some 
 danger of tying the wrong vessel. 
 
 When speaking of a high division of the 
 brachial artery, and the operation of tying it for 
 aneurism, Mr. Hodgson says, if the operator dis- 
 covers two arteries instead of one, it will be doubt- 
 ful by which of these vessels the tumour is sup- 
 plied. He recommends, therefore, under these 
 circumstances, that one of the vessels should be 
 compressed, so as to ascertain the effect produced 
 upon the tumour by suspending the circulation 
 through that channel. If the pulsation cease (he 
 continues) it is evident that the disease is supplied 
 by this vessel ; if not, it is equally certain that the 
 tumour arises from the other branches ; upon 
 which the ligature must therefore be applied. 
 This mode of operating is, he thinks, unquestion- 
 ably preferable to that of including both arteries 
 in a ligature. 
 
 I am disposed to agree with Mr. Harrison, 
 that this expedient will not answer in every case. 
 
116 
 
 for sometimes there are two or three cross 
 branches uniting these arteries as they descend 
 along the arm, and these would pour a sufficient 
 quantity of blood into the aneurismal sac, to keep 
 up a degree of pulsation that might deceive us. 
 I must also entertain a doubt whether it will not 
 be more advantageous to tie both arteries, al- 
 though we are certain of the one in which the 
 disease is seated. The only objection that can 
 be urged against it, is the effect which this mea- 
 sure would have on the after-circulation ; but 
 fears on this head are entirely unfounded, for the 
 anastomosing branches are fully capable of esta- 
 blishing a free collateral course for the blood. 
 
 The radial and ulnar arteries in their descent 
 to the hand, send off many muscular branches. 
 The deep palmar arch is formed by the radial ar- 
 tery. The superficial principally by the ulnar, 
 and from these arise the digital and other branches. 
 The radial and ulnar arteries, and the interosseal, 
 which is a branch of the latter, very freely anas- 
 tomose with each other down the fore arm. On 
 reference to the plan, it will be seen that the 
 superficialis volae (23) of the radial, joins the other 
 branches about the palm: that the radialis indicia 
 
117 
 
 (25) of the same artery anastomoses at the tip of 
 the fore finger with the ulnaris indicis (31) of the 
 ulnar artery: that the arteria profunda volae (27), 
 after distributing branches to the interosseal mus- 
 cles, and deep seated parts of the palm, termi- 
 nates by communicating with the arteria ulnaris 
 profunda, and that the radial and ulnar unite to 
 form the superficial palmar arch (29) ; thus in 
 whatever part the radial or ulnar artery should be 
 obstructed by ligature, there will remain ample 
 resources for the circulation in the fore arm and 
 hand, independent even of the interosseal branches, 
 which inosculate freely with each other about the 
 wrist and hand, and with branches of the radial 
 and ulnar vessels. 
 
 Let us now apply our knowledge of the 
 anastomoses between the radial, ulnar, and inter- 
 osseal branches to the surgical treatment of aneu- 
 rism, and hoemorrhage. Aneurism sometimes 
 forms in the course of one of the arteries of the 
 fore arm, but it more frequently occurs at the 
 wrist or near it, than at any other part. The 
 recurrent circulation in those cases will prevent 
 success if the ligature be applied to the vessel at 
 any great distance from the aneurismal sac ; ex- 
 
118 
 
 perience has proved this, and observation has 
 convinced me, that the operation may fail when 
 the ligature is applied at no great distance from 
 the disease. About four years ago, I saw’, with 
 Mr. Ainsworth, one of the Surgeons of our Infn- 
 mary, a case of aneurism of the radial artery, 
 situated in the vessel under the extensor tendons 
 of the thumb. The patient, who was nearly 70 
 years of age, had had a small tumour in this situ- 
 ation for some time, and at length shewed it to 
 a Surgeon, who pronounced it to be an aneu- 
 rism. When Mr. Ainsworth saw it, he proposed 
 to perform an operation, to which the patient con- 
 sented. Reasoning on the result of tying the 
 artery in other cases a little above the aneurismal 
 sac, and from the diminution of pulsation in the 
 tumour when the artery was compressed at the 
 wrist, it was thought justifiable in the present 
 instance to cut down on the radial artery at 
 the carpus, and to surround the vessel with a 
 thread; this, how'ever, did not destroy the pul- 
 sation in the tumour, and it became, in a few 
 minutes, nearly as distinct as it was, before the 
 radial artery was tied. Finding that the sac was 
 thus fed by anastomoses, and so abundantly as 
 to render the success of the operation too doubt- 
 
J 19 
 
 Ail ; it was immediately resolved to tie the ulnar 
 trunk, on doing which, all pulsation ceased, but 
 in a little time a faint tremulous motion was per- 
 ceptible in the aneurismal swelling, which, how- 
 ever, gradually went off, and the disease was 
 cured. This is a very instructive case ; it shows 
 that when an aneurism is situated in either of the 
 arteries of the hand, that the operation of cutting 
 off the main supply of blood, by tying the trunk 
 of the diseased artery, is not always sufficient ; 
 that the inosculations are so free, as to feed the 
 sac in a way that would prevent the coagulation 
 of the blood which enters it, and consequently 
 the success of the operation. 
 
 The question now to be asked, is, as to 
 whether in such cases, it is ever safe to trust to 
 one ligature on the trunk of the vessel near to the 
 aneurism? — whether it is preferable to open the 
 aneurismal sac, and apply a ligature at each ex- 
 tremity ? — or, whether it is better to tie both the 
 radial and ulnar trunks ? I think one ligature 
 can never succeed : that the operation of open- 
 ing the sac, and applying two ligatures, is a dif- 
 ficult and dangerous operation where the sac is 
 bound down by tendinous structures, as in this 
 
120 
 
 instance : and therefore that tying both the radial 
 and ulnar trunks is the safest, and most certain 
 practice. That there can be no risk as to the afier- 
 circuiation, the case above cited proves beyond 
 all dispute; for the interosseal arteries, and their 
 communications with the branches of the two 
 main trunks are fully adequate to the nourish- 
 ment of the hand. 
 
 Scarpa mentions, that although the Hun- 
 terian operation is wonderfully efficacious in the 
 cure of aneurism of the bend of the arm ; of that 
 in the ham ; and at the upper part of the calf of 
 the leg; it is not equally effectual in the cure of 
 aneurism on the back or palm of the hand ; in the 
 dorsum, or sole of the foot; and for the reason 
 which has been explained, namely the free inos- 
 culations of the extreme branches of the trunks of 
 the extremities. He recommends, as the best 
 practice in these cases, to tie the artery above and 
 below the disease; but when that cannot be done, 
 owing to the situation of the tumour, a ligature 
 should be passed around the artery which supplies 
 it, and thus, having stopped one of the currents 
 of blood which distended the aneurismal sac, the 
 other might be restrained by compression, with- 
 out the necessity of tying the trunk. 
 
321 
 
 The circumstances connected with the situa- 
 tion of the aneurism in the above case, contra- 
 indicated the first measure ; and with respect to 
 the second, as the difficulty of maintaining a suf- 
 ficient degree of pressure on the ulnar artery the 
 length of time necessary for the absorption of the 
 aneurismal tumour in an old subject, would have 
 been great, and the operation extremely pain- 
 ful, I think it very questionable whether Scarpa’s 
 recommendation is preferable to the method 
 adopted. Waiving the difficulty and pain, it is 
 more than probable that by such means the 
 calibre of the ulnar artery would not have been 
 obliterated ; and if not, there would have been 
 some danger, on the pressure being discontinued, 
 of a recurrence of the disease. 
 
 With respect to the treatment of hoemor- 
 rhage, it is clear, that in order to suppress, in an 
 effectual manner, a bleeding from a wound of 
 either the radial or ulnar trunk, it is necessary 
 to secure both extremities of the vessel. If a 
 wound were inflicted on the radial, about half 
 way down the fore arm, one ligature would 
 not in a general way succeed in suppressing 
 the haemorrhage, nor would one suffice in a 
 
 R 
 
122 
 
 wound of the ulnar at the same part. In a 
 wound of either of the branches of the palm of 
 the hand, it is extremely difficult to find the ar- 
 tery at the bleeding point, in consequence of the 
 cellular substance of the palmar fascia becoming 
 filled with blood, and the structures of the palm 
 are such as to render it extremely imprudent to 
 make a random thrust with a needle. 
 
 Mr. Lizars, in the third part of the physio- 
 logical and pathological observations which ac- 
 company his “ System of Anatomical Plates,” 
 advises, that when the artery is wounded in the 
 palm of the hand, it should not be attempted 
 to be secured there, in consequence of the prone- 
 ness of the fascia palmaris to inflammation, but 
 taken up proximate to the carpus. He mentions 
 the case of a patient who had the ulnar palmar 
 arch wounded, and which was cut down on by 
 the surgeon, but both the facia and artery ulcer- 
 ated, and amputation, at the middle of the fore 
 arm, was the final result. 
 
 With respect to tying the ulnar artery, in 
 such a case, “ proximate to the carpus,” the stu- 
 dent is not to suppose that this alone will put a 
 
123 
 
 stop to the flow of blood ; I have proved that the 
 anastomoses of the branches of the radial and 
 ulnar arteries about the hand are such, that there 
 will be a recurrent circulation, if pressure be not 
 used in addition to the ligature. The ligature 
 on the trunk of the ulnar will break the force o r 
 impetus of the current, but it will not succeed 
 alone in suppressing the hcemorrhage. 1 do not 
 advocate the application of ligatures to the 
 wounded vessel in the palm, unless the mouth 
 of the artery can easily be exposed, which some- 
 times happens when the surgeon is called early ; 
 but besides tying the trunk which supplies the 
 bleeding branch, it is required that firm pressure 
 should be made at the wound— and then all will 
 be well. 
 
 Mr. John Bell, in his “ Principles of Sur- 
 gery,” says, “ that he never saw it necessary to 
 tie the lower end of the artery, which he thinks 
 is important to mention, as it is an exception to 
 the rule commonly laid down of tying both ex- 
 tremities — but it is evident that he was aware 
 that one ligature could not stop the bleeding, for 
 he adds — “ a small piece of sponge must be put 
 into the place,” (meaning the wound). With due 
 
124 
 
 deference to the opinion of the late Mr. Bell, I 
 must think, that the approximation of the edges 
 of the wound, and pressure, are preferable to the 
 sponge, as the use of the latter will be a source of 
 considerable irritation, and be certainly followed 
 by a suppurative wound, — a consequence which 
 should be carefully avoided in the palm, where 
 there are so many tendons, and so much ten- 
 dinous structure. 
 
125 
 
 ARTE HI A 1 LI AC A COMMUNIS. 
 
 At the fourth or fifth lumbar vertebra, the 
 abdominal aorta bifurcates into the two Common 
 Iliac Arteries. 
 
 I am not aware of a single instance in which 
 the Common Iliac Artery has been secured by 
 ligature, but we can imagine that the operation 
 would be required for an aneurism of the external 
 iliac, which extends so high as to render it unsafe 
 to apply a ligature to the external iliac itself. — 
 Should a case of this kind terminate successfully, 
 it must be by the opposite internal iliac supplying 
 the pelvic viscera ; by a recurrent circulation fur- 
 nishing blood to the branches of the internal iliac 
 on the obliterated side ; and by the lower ex- 
 tremity deriving its blood principally from the 
 inosculations of the internal mammary (13), the 
 intercostal (2), and lumbar arteries (4), with 
 the epigastric (37), the circumflexa ilii (38), and 
 glutaeal branches (34). 
 
126 
 
 ARTERIA ILIACA INTERNA. 
 
 At the junction of the sacrum with the ilium, 
 which is called the sacro iliac symphysis, each 
 common iliac artery divides into two branches, 
 named the Internal and External Iliac Arteries. 
 — For Relative Position, and the branches of the 
 Internal Iliac, vide page 24. 
 
 Dr. Stevens, in the West Indies, tied the in- 
 ternal iliac artery, in 1812, for a supposed case of 
 glutaeal aneurism. Maila, a negro woman, was 
 imported as a slave in the year 1790. Dr. Stevens 
 saw her first in the beginning of December 1812, 
 when she had a tumour in the left hip, over the 
 sciatic notch, which was nearly as large as a 
 child’s head, and pulsated very strongly. It had 
 commenced about nine months before, with 
 slight pain in the part, and had gradually in- 
 creased to its present size. On the 27th of De- 
 cember, 1812, Air. Stevens passed a ligature 
 about the internal iliac artery. When the artery 
 was tied, the tumour disappeared almost imme- 
 diately, and the wound healed kindly. About 
 
127 
 
 the end of the third week, the ligature came 
 away, and in six weeks the woman was perfectly 
 well. 
 
 This was the first time that the internal iliac 
 artery had been tied, and the operation does Dr. 
 Stevens great credit. The principal caution ne- 
 cessary was to avoid the ureter, and this was not 
 difficult in the present instance, for on turning the 
 peritoneum inwards, the ureter followed it. 
 
 When we observe the arterial anastomoses, 
 we find no reason there why the operation should 
 not have succeeded. The pelvic viscera would 
 be amply nourished by the recurrent circulation, 
 and by the branches of the other internal iliac, 
 which anastomose with those of its opposite 
 fellow. 
 
 I have said that the above was a supposed 
 case of glutaeal aneurism, because, through the 
 kindness of Mr. Mackenzie, of Glasgow, I have 
 been informed, that post mortem examination 
 shewed the disease to have been seated in the 
 ischiatic, and not in the glutaeal branch. The 
 woman died some time ago, and was dissected 
 
128 
 
 by Drs. Stevens and Kerr. The trunk of the in- 
 ternal iliac was found longer than common, and 
 gave off the obturator above the place where the 
 ligature had been applied ; it then continued its 
 course for a longer space than usual before giving 
 off any other branches. The vessel below the 
 ligature, and the aneurismal sac were perfectly 
 obliterated ; but a large hernial tumour occupied 
 the seat of the incision up to the period of the 
 woman’s death. 
 
 Mr. Averill, in his useful Manual of ‘ c Ope- 
 rative Surgery,” informs us that the internal 
 iliac artery has been tied in two other instances, 
 by Mr. Atkinson of York, and by a Russian army 
 Surgeon. In the latter case the operation was 
 successful, and it is stated that the Emperor 
 Alexander settled a pension on the surgeon as a 
 reward for the dexterity and skill which he dis- 
 played in the treatment of his patient. 
 
 It was once thought that in case of wound 
 of the glutaeal artery, which is a considerable 
 branch, it might be necessary to tie the internal 
 iliac ; but in an aneurism from an accident, 
 Mr. John Bell passed a ligature about this ves- 
 
129 
 
 sel, and saved his patient. The operation, which 
 is detailed in his “ Principles of Surgery,” 
 was the most formidable that can be conceived ; 
 and as it shows what may be done in cases of 
 emergency, and as it has not been extracted for 
 any other work, I shall undertake to give a brief 
 account of it. A poor man, who was by trade a 
 leech-catcher, fell as he was stepping out of a boat, 
 and pierced his hip with a scissors, exactly over 
 the place of the sciatic notch. The artery was 
 struck with the point of the instrument, it bled 
 furiously, and the patient fainted. The wound 
 was cured ; but a large tumour formed, for which 
 he was admitted into the Edinburgh Infirmary. — 
 The swelling was of a prodigious size, and had 
 lost all the characteristics of aneurism. There 
 was no pulsation, and no retrocession of the 
 blood when the tumour was pressed upon; but 
 from continual pain and lameness, and from 
 having some hopes of cure, the patient was 
 willing to submit to any thing. There was little 
 doubt of this being a great aneurism, but there 
 was a possibility of its being a vast abscess. It 
 was, however, resolved in consultation, that a 
 small incision should be made; that the skin 
 
 s 
 
1 3D 
 
 being cut, the bag itself should be touched with 
 the point of a lancet ; if found to contain matter, 
 it should be fully opened, but if blood, it was to 
 be considered as an aneurism, of so particular a 
 kind as to call for a full consultation. An in- 
 cision, 2x inches in length, was made over the 
 surface of the tumour, and when its coat was ex- 
 posed, the knife was struck into it. Firm black 
 blood rolled out — for such was the tenseness of 
 the tumour, that it began to emit the clots in 
 this way the moment it was punctured. After 
 removing a few more clots, warm and fluid blood 
 began to flow, which at once showed the nature 
 of the case. 
 
 A second consultation was called, when 
 the following operation was performed : — The 
 tumour was opened with an incision eight 
 inches in length, and the clots turned out. On 
 doing this, the blood was thrown out with a 
 whishing noise, and with such impetus, that the 
 assistants were covered with it. Attempts were 
 made to stop it, by filling the wound with 
 sponges and cloths, but the blood continued to 
 flow, and the man fell as it were lifeless over the 
 
131 
 
 side of the table. Seeing, in this critical moment, 
 that if the man was to be saved, it was to be only 
 by a sudden stroke, Mr. Bell ran the bistoury 
 upwards and downwards, and at once made an 
 an incision two feet in length j he thrust his hand 
 down to the bottom of the tumour — turned off the 
 sponge, which was over the artery — felt the warm 
 jet of blood, and pulse of the artery — and then 
 only was he assured that the man was still alive. 
 The mouth of the vessel being exposed, Mr. Bell 
 introduced a needle, and surrounded it with a 
 ligature. 
 
 I need not add more, than that the man 
 recovered from this terrific operation. The 
 wound healed in less than seven months, not- 
 withstanding the foul suppuration of the sac, 
 and extensive exfoliations from the bones of the 
 pelvis. 
 
 Another case is mentioned, where a nail 
 was thrust into the glutaeal artery. Dr. Jeffery 
 proposed that the vessel should be tied, but at 
 first the friends of the patient objected : after a 
 time, however, consent was given ; but while 
 
132 
 
 matters were preparing for the operation, the 
 young man having occasion to go to stool in the 
 night, rose from his bed, the wound burst, and in 
 a few moments he expired. 
 
133 
 
 ad: ,ih)!Jk;s.,: ... » ■ ■ ; •’ 
 
 adbt ni •:oo;te 01 '>y of iiofesn^o ,•*;»>. mnu >v:-mC>Y‘ 
 
 ARTERIA ILIACA EXTERNA. 
 
 The External Iliac is the main trunk of 
 the lower extremity ; it commences at the sacro- 
 iliac symphysis, and terminates at Poupart’s or 
 Fallopius’ ligament. — For Relative Position and 
 branches, vide page 25. 
 
 Prior to the year 1796, when Mr. Abernethy 
 tied the external iliac artery, few Surgeons could 
 have credited the possibility of its success ; and 
 even till within the few past years, the French 
 Surgeons were sceptical about it. Baron Larrey, 
 in his “ Memoires de Chirurgie Militaire,” 
 objects to the operation, on the ground of its 
 inutility ; in consequence, he says, of the dissec- 
 tion of almost all the subjects who had undergone 
 the operation having exhibited the characters of 
 an aneurismal diathesis. But if this were a tena- 
 ble objection, it would have as much weight in 
 other cases, and all attempts to cure aneurism 
 would be abandoned. 
 
 Monsieur Richerand, in the fourth edition of 
 
134 
 
 his “ Nosographie Chirurgicale,” published in 
 1815, expresses his doubts respecting the opera- 
 tion. After mentioning a few of the recorded 
 instances in which the external iliac was tied, 
 he asks, “ Les malades operes en Angleterre vi- 
 vent ils encore? Ne s’est-on point trop hate d’an- 
 noncer leur guerison totale ? Les malades ne 
 seroient — ils pas morts, gueris ? La ligature de 
 ce vaisseau est d’une execution facile ; mais le 
 succes de l’entreprise est il assez avere pour qu’on 
 s'y decide hors lescas d’une urgente necessite ?” — 
 I shall by and bye answer some of these ques- 
 tions by a relation of some of the cases in which 
 the operation was undertaken with success, and 
 shall show, that, in the unsuccessful ones, the 
 failure could not be attributed to what M. 
 Richerand apprehended, namely, defective circu- 
 lation. He ascribes the death of Bouchet’s pa- 
 tient to this cause ; but the fact is, he survived 
 the operation more than a year, and died in con- 
 sequence of an inguinal aneurism on the opposite 
 side. Indeed, 1 shall have no difficulty in prov- 
 ing, in the sequel, that, so far from the anastomo- 
 ses being insufficient for the support and nourish- 
 ment of the limb, we have to fear a failure of the 
 operation from the opposite cause — namely, from 
 
135 
 
 their being so abundant as to supply the sac, by 
 the recurrent circulation with so much blood as 
 to prevent the coagulation of its contents, and 
 hence the preparatory process to the obliteration, 
 absorption, and cure of the disease. 
 
 Roux is the first French Surgeon that seems to 
 have taken an enlightened view of this operation, 
 and to have entertained English notions respect- 
 ing it. He blames the indifference with which 
 mention is made of it in some of the works of 
 Surgery published in France, and acknowledges, 
 in his “ Paralele,” published in 1816, that there 
 were at that time twenty-three cases in which the 
 ligature of the external iliac had been practised, 
 and that it had completely succeeded in fifteen 
 patients. These facts have convinced his Conti- 
 nental brethren, that the operation is not only a 
 practicable, but a safe one; as I shall further en- 
 deavour to demonstrate. 
 
 The honour of first tying the external iliac 
 artery is due to Mr. Abernethy : it was done 
 without much deliberation, for the imminent pe- 
 ril into which his patient was thrown required 
 that there should be no delay. He tied the right 
 
136 
 
 femoral artery in a man, for the cure of an aneu- 
 rism in the calf of the leg; the same person was 
 also afflicted with an aneurism of the left femoral 
 artery. The femoral aneurism increased so rapid- 
 ly, that, about five weeks after the first operation, 
 it was necessary to tie the artery in the groin. 
 Every thing went on well until the loth day, 
 when the upper ligature separated, and the blood 
 gushed in a full stream from the open extremity 
 of the vessel. The bleeding was restrained by 
 pressure, whilst Mr. Abernethy proceeded to tie 
 the artery above Poupart’s ligament. On the 
 fifth day after the operation, a hoemorrhage of 
 arterial blood took place, in such quantity, that 
 there was no doubt but that it arose from the 
 principal artery : it was stopped by the applica- 
 tion of compresses and bandages ; but the pa- 
 tient’s strength declined, and he died on the 
 eighth day. In the dissection, the external iliac 
 artery was found surrounded by a number of large 
 lymphatic glands ; the external surface of one of 
 them, next the wound, ulcerated, and the ulcera- 
 tion penetrated through the gland, and commu- 
 nicated with the artery, as was afterwards made 
 evident by cutting open that vessel. It was 
 through this aperture the blood had escaped ; for 
 
137 
 
 the ligature still remained firm, upon the part of 
 t*he artery which it had enclosed 
 
 In the second operation, which was perform- 
 ed for a large aneurism, situated close to Pou- 
 part’s ligament, the patient went on favourably, 
 both in respect to his general health and the 
 state of the limb, until the eighth day, when there 
 supervened a high degree of constitutional irrita- 
 tion. For several days the discharge from the 
 wound had beem tinged with blood, rendered 
 fluid and highly foetid by putrefaction. The cyst 
 was washed out with warm water, and an open- 
 ing made into it, to afford to the discharge a more 
 ready exit. During a week the powers of the con- 
 stitution appeared to rally ; but after that time 
 the patient’s strength gradually declined, and he 
 died on the twenty-third day after the operation. 
 A few days before his death both ligatures (for 
 Mr. Abernethy used two, and divided the space 
 between them) came away with the dressings. 
 
 In 1806, M. Abernethy tfied the external 
 iliac artery the third time, and the patient com- 
 pletely recovered, notwithstanding her constitu- 
 tion had been impaired by habits of intemperance. 
 
 T 
 
138 
 
 The recovery was so perfeet, that there remained 
 no distinguishable difference in the size and 
 strength of the two extremities. 
 
 In the same year, and in the same month of 
 the year, Mr. Freer undertook tlie operation in 
 the Birmingham Infirmary. His mode of pro- 
 ceeding varied from Mr. Abernethy’s in some 
 particulars, but chiefly in his applying one liga- 
 ture instead of two. The case succeeded, and 
 the patient regained the use of the limb. 
 
 In 1807, Mr. Tomlinson, of Birmingham, 
 tied the external iliac: a single ligature was em- 
 ployed, and the patient recovered without any 
 unfavourable symptom. 
 
 In 1809, Mr. Abernethy operated for the 
 fourth time. The ligatures came away as early 
 as the tenth day, and the wound healed. When 
 discharged from the hospital, the man was capable 
 of walking with little infirmity. 
 
 The above, I believe, are the earliest cases 
 in which the operation was performed ; but since 
 their occurrence, it has been executed upwards 
 
339 
 
 of twenty times. The operators in London have 
 been, Mr. Ramsden, Sir A. Cooper, Mr. Aber- 
 nethy, Mr. Brodie, Mr. Lawrence, the late Mr, 
 Henry Cline, Mr. Lucas, Mr. Travers, Mr. Key* 
 Mr. Green, and others. In France, it has been 
 undertaken by M. Delaporte, M. Bouchet, M. 
 Dupuytren, Mr. Collier, and some others. In 
 the principal towns of England it has been per- 
 formed ; also in Scotland and Ireland ; and in by 
 far the majority of cases with complete success. 
 It is now indeed become a common place operas 
 tion, and therefore is seldom given publicity to, 
 unless attended with curious and anomalous cir- 
 cumstances. 
 
 I have seen the external iliac artery tied in 
 three instances; in two of them the patients did 
 well; in the third, the man died from hoemor- 
 rhage, in consequence of a wound of the epi- 
 gastric artery. The bleeding was stopped by 
 pressure, but it recurred, and the patient, who 
 was in a delicate state of health, sunk under the 
 loss of blood. A similar accident, it is said, oc- 
 curred to M. Dupuytren, when performing the 
 operation at the Hotel Dieu, in Paris, in the au- 
 tumn of 1821 : the hoemorrhage was so copious. 
 
140 
 
 that two ligatures were required on the wounded 
 vessel. 
 
 On reviewing the history of the operation of 
 tying the external iliac, and the result of the 
 cases in which it has been executed, no man can 
 fail to be impressed with a conviction, that it is 
 one of the justifiable operations in surgery. — 
 There are two or three instances recorded, in 
 which the limb mortified, but in so many cases 
 has the lower extremity been freely nourished, 
 that we should be inclined to attribute the morti- 
 fication to morbid causes, rather than to defective 
 anastomoses. 
 
 A cause of failure, worthy of being noticed, 
 is the nourishment of the disease by the recurrent 
 circulation, and this may go on so far as to oc- 
 casion the death of the patient, by the distension 
 and bursting of the sac. A ease of this kind 
 occurred at the Manchester Infirmary in the year 
 1820, for the particulars of which I am indebted 
 to Mr. Robert Thorpe, one of the Surgeons to 
 that Institution. A man, aged 34, who was a 
 discharged soldier of the 2d Dragoon Guards, 
 was admitted in January, 1820, in consequence 
 
141 
 
 of inguinal aneurism. On the 12th of January, 
 Mr. R. Thorpe performed the operation in the 
 usual manner, and secured the artery with one 
 ligature- On the 21st day after the operation, 
 the ligature came away, the wound healed soon 
 afterwards, and the man so far recovered as to be 
 able to walk about by the aid of a stick, though 
 he complained of a sensation of coldness in the 
 great toe and heel. On the 30th of May, the 
 cicatrix inflamed ; on the 1st of June, a vesicle 
 formed, which soon burst, and a quantity of 
 blood rushed from the wound : the patient must 
 have sunk under the hcemorrhage, had he not had 
 the presence of mind to make considerable pres- 
 sure until the arrival of the House Surgeon, who 
 directed constant compression by means of a key 
 and pad for forty-eight hours, when the bleeding 
 ceased. From this time io the patient’s death, 
 which happened on the 25th of June, hoemor- 
 rhage came on occasionally, and he sunk from 
 exhaustion. Mr. R. Thorpe was very anxious to 
 ascertain the cause of such a disaster, and, on 
 examination, found that the aneurisma! sac had 
 been filled by the recurrent blood from the 
 femoral artery, which was proved by throwing 
 water, by means of a syringe, down the internal 
 
142 
 
 iliac. That part of the artery which had been 
 secured by the ligature, was completely oblite- 
 rated to an inch and a half above and below the 
 point to which the thread had been applied. 
 
 With respect to the fact that mortification 
 has supervened on the application of a ligature to 
 a main arterial trunk, I question much whether 
 this can always be attributed to defective circula- 
 tion in the limb. Mr. Grainger, Lecturer on 
 Anatomy in the Borough, has obligingly sent me 
 some of the leading points of a case of singular 
 interest. He was present at an operation, in 
 which the external iliac was tied for aneurism. 
 The man went on exceedingly well till the liga- 
 ture separated, which was about the 18th day. 
 There was no bleeding, and the wound was 
 almost healed. In a few days, the left leg (the 
 right had been operated upon) became cold, and 
 then discoloured ; the same circumstances occur- 
 ed in the upper extremities ; and last of all, the 
 right leg was attacked. When the patient died, 
 his whole frame was similarly affected. On exa- 
 mining the body, the artery was plugged up with 
 coagulable lymph, above and below where the 
 ligature had been applied ; and there was nothing 
 
143 
 
 found that could throw any light on the above 
 phenomena. The case is extremely interesting, 
 and, if connected with the operation, seems to 
 involve some law in the pathology of the arterial 
 system, with which we are not acquainted. 
 
 On the whole, the success of tying the ex- 
 ternal iliac is equal to that of any other ope- 
 ration of a capital description. 
 
 We have abundant proof that the arterial 
 anastomeses about the hip and upper part of the 
 thigh are adequate to the support of the limb 9 
 when the main artery is obliterated. Let me 
 here refer the student to the Plan, and he will 
 there see how numerous and large branches inos- 
 culate. The two, or sometimes three, lumbar 
 branches (4) unite with the ascending branches 
 of the glutseal artery (34), the ilio lumbar ( 33 ) 
 join the branches of the eircumflexa ilii (38 ) ; the 
 lower branches of the glutseal (34) anastomose 
 with the circumflex arteries (40) of the profunda 
 femoris (39), the obturator artery (35) with the 
 circumflex (40), the ischiatic (36) with the same, 
 and with some of the descending branches of the 
 glutaeal (34) ; by these inosculations, the blood 
 
144 
 
 passes below the aneurismal sac. We may rea- 
 sonably conclude then from this view, that the 
 sources of supply are sufficient ; but the fact has 
 been demonstrated in Nature. 
 
 In the fourth volume of the “ Medico Chi- 
 rurgical Transactions,” Sir Astley Cooper has 
 published a minute account of the anastomoses 
 of the arteries of the groin, which is accompanied 
 by two engravings. In a case where the opera- 
 tion of tying the external iliac had been per- 
 formed ten weeks and six days, it was found that 
 the femoral tibial and fibular arteries were still 
 open, and that the blood was conveyed into the 
 femoral artery by the following inosculations : 
 — The internal pudendal artery (which I have 
 omitted to show in the Plan) formed several large 
 branches upon the side of the bulb of the penis, 
 and these branches freely communicating with the 
 external pudendal, had determined the blood 
 into that artery, and by this channel into the 
 femoral. The lateral sacral artery sent a branch 
 on the iliacus internus muscle into the femoral 
 artery, and the ilio lumbar artery freely commu- 
 nicated with the circumflexa ilii, so that by these 
 three routes, the blood found direct ingress to 
 
145 
 
 the femoral artery. Numerous branches of arteries 
 also passed from the lateral sacral to the obtura- 
 tor and epigastric vessels; and, besides these, a 
 free communication existed between the arteria 
 profunda and circumflex arteries with the 
 branches of the internal iliac: — First, the glutasal 
 artery sent a branch to the external circumflex . 
 Secondly, the ischiatic gave two sets of branches, 
 one to the arteria profunda, and another to the 
 internal circumflex; the internal pudendal also 
 sent a brarich of communication to the internal 
 circumflex ; and lastly, the obturator freely com- 
 municated with the same vessel. 
 
 . 
 
 In the second case published by Sir A. 
 Cooper in the same volume, the external iliac and 
 femoral arteries were obliterated, excepting about 
 an inch of the latter artery, just below Poupart’s 
 ligament, which still remained open, and conti- 
 nued to convey a portion of the blood ; but below 
 this part it had simply become a ligamentous 
 cord. The internal iliac artery sent, first, a very 
 large artery of communication to the epigastric 
 and obturator artery ; secondly, the internal iliac 
 sent an artery of communication upon the sciatic 
 nerve to the internal circumflex artery ; the glu- 
 
 v 
 
14(i 
 
 taeal artery gave a large branch to the origin of 
 the profunda; lastly, the internal pudendal artery 
 largely anastomosed with the obturator; the ob- 
 turator, in this case, sprang from two new 
 sources, viz. from the internal iliac, and from 
 the internal pudendal artery ; and the obturator 
 thus formed, sent two branches of communica- 
 tion to the internal circumflex artery. The arte- 
 ria profunda was in this case supplied from two 
 sources; directly from the glutasal, and more in- 
 directly from the internal circumflex by the obtu- 
 rator and ischiadic arteries. Here we observe 
 varieties in the origin of certain arteries, and 
 therefore varieties were to be expected in their 
 course, and anastomoses ; but tve learn from it, 
 what the main channels of the circulation are, 
 and how the blood arrives at the inferior part of 
 the limb. 
 
 In this second case of Sir A. Cooper, the 
 patient survived the operation nearly three years; 
 the principal anastomosing branches were not so 
 numerous as in the preceding instance; a fact 
 worthy of mention, as it contradicts what hypo- 
 thesis would incline us to, viz. that the anasto- 
 moses are numerous in proportion to the time 
 
147 
 
 which had elapsed from the operation. The 
 reverse, however, is the truth ; for at first many 
 vessels convey the blood originally conducted by 
 the principal artery ; but gradually the number 
 of these channels becomes diminished, and after a 
 length of time, a few vessels, conveniently situated 
 for the circulation, so much enlarge as to be capa- 
 ble of conveying an equal portion of blood to 
 that which passed through the original trunk. 
 
 This detail on the inosculating vessels, in 
 cases of ligature on the external iliac artery above 
 Poupart’s ligament, the student cannot fail to 
 understand. I will now lead him to the conside- 
 ration of what takes place when certain portions 
 of the femoral artery are obstructed. 
 
J 48 
 
 ARTERXJ5 FEMORALIS ET POPLITEA. 
 
 The Femoral Artery begins at Poupart’s 
 ligament, and ends after perforating the triceps 
 tendon. It then takes the name of popliteal 
 artery, which soon divides into the branches of 
 the leg and foot. — For Relative Position, and 
 branches of the femoral artery, vide page 25. — 
 For the same of the popliteal, vide page 26. 
 
 The operation of tying the femoral artery 
 for aneurism and wounds has been so frequently 
 performed in England, Scotland, and on the 
 Continent, as to leave no doubt on the mind as 
 to its freedom from danger, and as to its efficacy 
 in the cure of popliteal aneurism, when undertaken 
 in the early stage of the disease. 
 
 Acrell is of opinion that the operation can. 
 not be deferred, without great danger, beyond a 
 month after the appearance of the tumour ; but 
 Scarpa is inclined to believe that the possibility of 
 the success of the operation extends to a much 
 longer period than that which has been fixed by 
 
149 
 
 that (in most respects) justly celebrated Surgeon. 
 This last opinion is certainly true, and not only 
 in accordance with observations on popliteal 
 aneurism, but on aneurism of ether arteries. It 
 is a principle laid down by some surgeons, that 
 it is better to wait as long as possible, in order to 
 give time for the enlargement of the inosculating 
 branches; but I believe delay on this account 
 is rather hazardous than useful, and I ques- 
 tion even the propriety of deferring it for 
 the trial of compression and other means 
 that have, in a few instances, been known 
 to cure the disease. At all events, I will not 
 concede much more th&n in agreeing with the 
 opinion expressed by Mr. Samuel Cooper in his 
 “ First Lines,” when speaking of compression, 
 viz. that if by a skilful application of this means, 
 the communication between the aneurismal sac 
 and artery does not become obliterated before the 
 end of a fortnight, there is no great reason to 
 expect that it will do so in a longer time. 
 
 Mr. Hunter, the author of the improved 
 method of operating in aneurism, was the first to 
 perform it in England 5 and in a former part of 
 the volume, a detail is given of his mode of con- 
 ducting it. Mr. George Bell, of Edinburgh, was 
 
150 
 
 the first who performed the operation with success 
 in Scotland, in the year 1793, — the popliteal ar- 
 tery was the vessel affected. The femoral artery 
 was tied just where it begins to be enveloped by 
 the tendinous expansion of the triceps, so that 
 the incision was on the anterior edge of the sar- 
 torius muscle. Mr. Bell’s reason for performing 
 the operation in that situation, was the wish to 
 have as much space as possible of the artery un- 
 touched, in order that if the ligature came away 
 without adhesion and obliteration of the portion 
 secured, room might be afforded for repeating 
 the attempt. The operation was successful, and 
 the patient lived for twelve years afterwards. 
 Dr. Barclay secured the body, and had the limb 
 injected, and on examining it he found the canal 
 of the artery obliterated for about two inches in 
 the vicinity of the ligature, and also in the ham, 
 the situation of the aneurismal tumour j between 
 these two parts, the vessel was of its natural size. 
 The profunda, its long descending muscular 
 branches, and the rami which anastomose with 
 the ascending branches of the anterior femoral, 
 between the obliterated portions of the artery, are 
 much dilated ; and the two tibial arteries, the 
 peroneal artery, and their branches, are of a due 
 magnitude. 
 
151 
 
 If a ligature be applied to the femoral vessel 
 at its origin, that is, immediately below Poupart’s 
 ligament, the anastomosing vessels must be the 
 same as when a ligature is applied above it, ex- 
 cepting our cutting off in this case two direct 
 sources of supply to the femoral, viz. through the 
 epigastric and circumflexa ilii arteries, which are 
 branches of the external iliac ; but I can conceive 
 that in an aneurism of the upper part of the 
 thigh, the mouths of these vessels may be com- 
 pressed or obstructed by the coagulum accumu- 
 lated in the aneurismal sac, and that they can- 
 not always be auxiliaries to the collateral circu- 
 lation ; if so, the sources of supply are similar in 
 the one instance, as in the other. 
 
 The usual situation for the application of a 
 ligature in popliteal aneurism is at, or about the 
 middle of the thigh, — what happens in this case ? 
 The first branch given off by the femoral is the 
 profunda (1, Plan No. 2). This considerable 
 branch will derive a direct supply from the femo- 
 ral, and from its anastomoses with the branches 
 of the internal iliac, as already shown. The 
 blood will circulate by the profunda and its 
 branches, and arrive, by means of its communi- 
 
cations with the muscular branches, into the fe- 
 moral, and by means of other inosculations, into 
 the popliteal artery; but should the femoral artery 
 degenerate into a mere ligamentous cord at the 
 interspace between the ligature and the sac, the 
 blood must pass by the descending branches (4) 
 of the circumflex (3) into the branches of the 
 upper outer articular artery (8), and by the per- 
 forating branches (5) anastomosing with the same, 
 aud with the ultimate branches of the ramus anas- 
 tomicus(6), some of which join the superior inner 
 articular branches (?). If the aneurism be situated 
 between the origins of the two superior (7, 8) and 
 
 t wo inferior (9, 10) articular arteries, and the coacrula 
 in the sac prevent the passage of blood through it. 
 the blood to get below the knee must, in this 
 case, circulate by means of the superior articular 
 arteries, inosculating with the inferior, and the 
 recurrent tibia] (12) anastomosing with the same, 
 and it is thus that this fluid gets below the aneu- 
 rismal sac without passing through it. In the 
 account given in the second volume of the “ Me- 
 dico-Chirurgical Transactions,” of the dissec- 
 tion of a limb, in which the femoral artery was 
 converted into a cord from the origin of the arte- 
 ria profunda to beyond the ham, and thus the 
 
153 
 
 natural channel of the blood from the groin to the 
 lower part of the knee entirely destroyed ; the 
 muscles which usually receive blood vessels from 
 the femoral artery, as the sartorius, the rectus, 
 and the vasti, had no branches but from the ar- 
 teria profunda and circumflex arteries ; and the 
 articular arteries of the popliteal, although they 
 were still capable of receiving blood, derived it 
 not from the popliteal artery, but from the com- 
 municating vessels of the profunda. The arteria 
 profunda formed the new channel for the blood : 
 considerably enlarged in its diameter, although 
 still not equal in size to the femoral artery at the 
 groin, it took its usual course to the back of the 
 thigh on the inner side of the bone, and sent 
 branches of a larger size than usual to the flexor 
 muscles of the leg ; and just midway on the back 
 of the thigh it began to send off three arteries, 
 which became the support of the new circulation. 
 These arteries anastomosed with the superior ar- 
 ticular branches of the popliteal — with the infe- 
 rior articular, and recurrent branches. 
 
 When the femoral artery remains pervious 
 below the ligature, it has been shown by injec- 
 tion, in one case, that it is the femoral and it3 
 
 x 
 
154 
 
 branches, and not the perforantes of the profunda 
 anastomosing with the articular and recurrent 
 arteries, which carry on the circulation. 
 
 In a case which occurred to the late Mr. 
 Forster, Surgeon at Guy’s Hospital, the femoral 
 artery was tied in August, the man died in Ja- 
 nuary following; and when the limb was injected 
 the femoral artery, below where the ligature had 
 been applied, was found to have received a part 
 of the injection by communicating vessels. This, 
 however, cannot be admitted as universal, for the 
 profunda and its branches must generally be more 
 or less concerned. 
 
 Mr. Bell, in his “ Anatomy of the Human 
 Body,” gives a full exposition of the importance 
 of the profunda, which he thinks might with more 
 propriety be named the Femoral Artery, since 
 it is the proper artery of the thigh ; and though 
 Heister, and some of the best amongst the old 
 surgeons, spoke of this division as one which only 
 sometimes took place, we know that a leg would 
 no more do without a profunda, than without 
 what we call the femoral artery ; and we also 
 perceive, notwithstanding the doubts and fears of 
 
155 
 
 some modern Surgeons, that when the femoral 
 artery is wounded, it is, after all, only a wound of 
 the artery of the leg. The large branches which 
 the profunda sends upwards, round the haunch, 
 inosculating with the sciatic and pudic arteries, 
 and the branches which it sends downwards to 
 the knee, inosculating round that joint with the 
 arteries of the leg, make this branch of peculiar 
 importance to the Surgeon ; for when the artery 
 is wounded in the groin, above the profunda, this 
 branch saves the thigh, by its inosculations round 
 the haunch and when the artery is wounded in 
 the thigh below the profunda, as in the ham, it 
 saves the leg by its inosculations round the knee ; 
 and when the whole line of femoral artery has 
 been obliterated, it has saved the whole extremi- 
 
 ty, by receiving the blood from the arteries round 
 the haunch, and conveying it down to the arteries 
 below the knee, — being thus an intermedium be- 
 twixt the internal iliac artery and the arteries of 
 the leg, capable of forming a new line of circula- 
 tion behind the thigh, when that before it is shut 
 
 up. This is a summary view of the use of the 
 profunda in preserving the economy of the lower 
 extremity, when the femoral artery is impervious 
 from accident, disease, or ligature. 
 
156 
 
 Seeing the importance of this branch, which 
 is almost equal in size to the trunk from which 
 it arises, what influence ought it to have on our 
 practice ? According to commonly received opi- 
 nion, we should, in operating for popliteal aneu- 
 rism, always select a point below the origin of the 
 profunda, for the application of a ligature to the 
 femoral artery. If this opinion were tenable, it 
 would be of importance to possess a rule of guid- 
 ance to the place below the bifurcation. 
 
 Mr. Benjamin Bell, of Edinburgh, in a letter 
 to me, proposes, in order to be assured of this, 
 that we should observe the relative situation of 
 the vein to the artery : “ So long,” he says, “ as 
 the crural vein is exactly collateral with the artery, 
 we are certainly above the bifurcation; but so 
 soon as the vein begins to wind behind the artery, 
 we may be assured that the profunda has been 
 given off.” This rule is good ; but let us examine 
 its importance in a practical point of view. I 
 wonld first ask the question, From what have we 
 the most to fear, — from the anastomoses of 
 branches being very free ? or from their being 
 scanty ? The success which has attended the 
 operation of tying the external iliac, and the 
 
157 
 
 femoral artery immediately below Poupart’s liga- 
 ment, proves that we have nothing to apprehend 
 from the latter ; but when the anastomoses are 
 very abundant, the operation may fail to cure 
 the disease, from the influence of the recurrent 
 circulation on the sac, as in Mr. Robert Thorpe’s 
 case already given ; and when the main trunk 
 below the ligature has opening into it some large 
 inosculating branches, the sac may be so far fed 
 as to prevent the suspension of the circulation 
 through it — the coagulation of its contents — and 
 therefore the preparatory process to the removal 
 of the disease ; or if cured, the anastomoses may 
 occasion a reproduction of rhe aneurismal tumour. 
 The cases are not few in which the limb has been 
 amputated, soon after the main artery has been 
 tied, from the circulation through the aneurismal 
 sac becoming re-established. We may question, 
 perhaps, whether this is sound surgery, but the 
 fact is sufficient for my purpose. 
 
 Scarpa seems inclined to doubt the effects of 
 this re-establishment of the circulation on the 
 aneurismal tumour. He says, “ When the trunk 
 of an artery is tied a considerable way from the 
 root of the aneurism, the column of blood which. 
 
158 
 
 from any of the anastomosing vessels, endeavours 
 to enter into the trunk below the ligature, and 
 to pass from thence into the aneurismal sac, has 
 never force sufficient to distend the sac, and over- 
 come the resistance opposed to the clots contain- 
 ed in it •” — from whence he infers, “ When the 
 pulsation of the aneurism after a ligature of a 
 large artery of the second order, such as the fe- 
 moral, continues or re-appears, instead of recur- 
 ring, as some Surgeons have done, for the expla- 
 nation of the phenomenon to the lateral vessels 
 anastomosing with the trunk below the ligature, 
 and above the aneurism, the more simple, and 
 true explanation of this phenomenon is, that the 
 arterial trunk has not been tied with sufficient 
 force to bring the sides of it into complete con- 
 tact with each other.” 
 
 This opinion, I conceive, may be quite cor- 
 rect, so far as it relates to the recurrence of pulsa- 
 tion immediately after the ligature has been applied, 
 for it is scarcely probable that the blood entering 
 the femoral artery by the anastomosing branches 
 between the ligature and the sac could so soon 
 acquire such an impulse as to have any sensible 
 cllect in the parietes of the aneurismal swelling. 
 
159 
 
 But if the blood does at all pass into the sac, in 
 time, from the inosculating branches enlarging in 
 calibre, it may circulate with a force and column 
 sufficient to keep it in a state of distension, and 
 to cause a return of the pulse. Thus we have to 
 fear a failure when the anastomoses are too abun- 
 dant from the aneurismal swelling being fed 
 from above. 
 
 I do not mean to lay it down as invariably 
 happening, that under the above circumstances 
 an obstacle will be set up to the cure of the dis- 
 ease, for there are instances in which a radical 
 removal of the aneurism by absorption, had been 
 effected, notwithstanding some small branches 
 were pervious between the obliterated portion of 
 the artery and the sac. I have related the parti- 
 culars of the case in which Mr. G. Bell, of Edin- 
 burgh, operated with success, where the artery 
 was of its due diameter for some distance between 
 the point where the ligature was applied, and the 
 situation of the aneurism. 
 
 Monsieur Boyer dissected the body of a 
 man who died of an acute disease eight years 
 after the operation for popliteal aneurism, per- 
 
1G0 
 
 formed according to Mr. Hunter’s method. Des- 
 champ had been the operator, and Boyer had 
 assisted him, and the patient was perfectly cured. 
 On examining the limb, it was found that the 
 obliteration extended a little above and below 
 the ligature, and was limited, both above and be- 
 low, to the place from which a middling sized 
 branch arose. The portion of artery included 
 between the obliterated point, and the aneurism 
 was not obstructed, and the branches, which 
 went off from it, communicated with those which 
 came off from the crural artery, below the part 
 obliterated. The obstruction of the popliteal ar- 
 tery extended about 15 or 16 lines, and the artery 
 then resumed its natural size. 
 
 If we consider these cases, and I presume 
 the same obtains in all other successful cases, 
 under similar circumstances, we can assign a 
 reason why they succeeded ; for it is to the quan- 
 tity of blood, as well as the impulse of its column 
 on the sac, that we may attribute the failure of 
 the operation. When we place the ligature a 
 little above the sac, as was done in the preceding 
 cases, we diminish the quantity, for the number 
 of the anastomosing branches must be in propor- 
 
161 
 
 tion to the extent of the space left between the 
 ligature and the disease ; the impulse too is dimi- 
 nished, as the blood has no great distance to cir- 
 culate. But there is another circumstance which 
 operated favourably in Descham p’s case, and I 
 doubt not in all successful cases of the same kind, 
 namely, the passing off of branches from the 
 inferior portion of the pervious part of the artery: 
 these branches, which are probably either the ramus 
 anastomoticus, and the upper articular branches, 
 or one or more of these, are capable of carrying off 
 the blood which enters the pervious trunk, and 
 thus lessening the power of the current on the 
 aneurismal sac. When a portion of the artery 
 remains of its due diameter between the place of 
 the ligature and the disease, we must always sup- 
 pose that these branches are pervious, or that the 
 circulation through the aneurismal sac is not sus- 
 pended, for the blood must have the means of 
 egress as v/ell as ingress. If neither the one nor 
 the other of the above outlets existed, it must 
 regurgitate and escape by the same vessels by 
 which it entered, which is difficult to be con- 
 ceived. When the blood can pass by collateral 
 vessels arising from the lower part of the pervious 
 artery, it will do so, without attempting to over- 
 
 Y 
 
come the resistance which the coagula in the sac 
 will oppose; but when no such vessel or vessels 
 exist, the current will act directly on the contents 
 of the sac, and force a passage through them, 
 provided the anastomoses, which enter the arterv, 
 are large and numerous. 
 
 When a ligature is applied to the femoral 
 artery, and the whole tract of the vessel, from the 
 point of the ligature to the aneurismal swelling, 
 degenerates into an impervious and ligamentous 
 cord, the radical cure of the aneurism must be 
 more certain ; but when this does not happen, 
 the ends of the operation may be frustrated, and 
 the disease not cured ; or if temporarily removed, 
 will be liable to return. 
 
 In the appendix to Mr. Wish art’s Transla- 
 tion of Scarpa’s work, we find a case communi- 
 cated to the translator, where the aneurism return- 
 ed, after being, to all appearance, radically cured. 
 The case was under the care of Dr. Monteath, 
 jun., of Glasgow, and the following are some of 
 the particulars connected with it. A man con- 
 sulted Dr. M. for a popliteal aneurism, about the 
 size of a large orange, which had commenced 
 
163 
 
 about three months before. A single ligature 
 was applied to the femoral artery, in the upper 
 third of the thigh ; the pulsation ceased, the 
 wound healed by the first intention, except where 
 kept open by the ligature, which came away on 
 the 30th day. By this time the tumour was di- 
 minished to one-half of its original size, and in 
 other two months was as completely removed, as 
 aneurismal tumours usually are, — a small hard 
 knot only remaining. About nine months after 
 the operation, the patient again called on Dr. 
 Monteath, and informed him that the tumour 
 had re-appeared, and was rather larger in size 
 than a plum. The pulsation in it was distinct, 
 though not so strong as in ordinary aneurism. 
 For a month the tumour and strength of the pul- 
 sation increased progressively, when Dr. M. tried 
 the effect of bandaging the limb, with a compress 
 over the tumour, allowing the patient to walk 
 about : some weeks’ trial of this, however, was 
 sufficient to convince Dr. M. of the necessity of 
 enjoining strict confinement, to which the 
 patient consented, after he had paid a visit to his 
 relations at Edinburgh. On his return to Glas- 
 gow, fie was confined to his bed, bled, and put 
 on a spare diet. A thick compress was placed 
 
164 
 
 over the tumour, and the Jimb firmly bandaged 
 by a roller, from the toes to the groin. Three 
 days’ trial of very firm bandaging and confine- 
 ment seemed to produce no good effect ; a tour- 
 niquet was therefore applied over the tumour, and 
 screwed as tight as the patient could bear it. 
 In half an hour it became insupportable, causing 
 violent irritation and tingling in the leg and foot. 
 It was accordingly removed, and from this mo- 
 ment he was not sensible of the pulsation. Next 
 day, on examination, the tumour was without 
 pulse, and its contents firm from coagulation. 
 It daily diminished in bulk, and was at length 
 perfectly cured. 
 
 Mr. Wishart concludes, that the return of 
 the disease was probably owing to some large 
 branch going off above the place where the liga- 
 ture had been applied, communicating with the 
 popliteal artery in the vicinity of the sac ; but as 
 the ligature was applied high up on the femoral 
 artery, it is more than probable that many 
 branches opened into the artery, between the 
 ligature and the sac. That the main artery 
 was effectually obliterated, proof is furnished 
 by the observations made by Mr. "W ishart 
 
165 
 
 on the patient when at Edinburgh. This was 
 after the return of the disease, when the tumour 
 was as large as a magnum plum, and pulsated 
 very strongly. On examination, Mr. W. found 
 that the femoral artery beat strongly as far as the 
 cicatrix, but no pulsation could be felt below that 
 place; and by compressing the artery firmly 
 above the cicatrix, the pulsation in the tumour 
 was stopped : this arose from Air. Wishart making 
 pressure on the trunk prior to the passing off of 
 the profunda branch. 
 
 I am indebted to the kindness of Mr. Jef- 
 frey, of St. George’s Hospital, for the full account 
 which I subjoin, of an extremely interesting 
 case which has lately fallen under his care ; and 
 as it is so fully corroborative of the opinion I 
 have advanced, and has excited so much interest 
 amongst the members of the profession in Lon- 
 don, I shall give it in detail. 
 
 R. Buck, 47 years of age, a stout healthy 
 man, of full habit, and by trade a gardener, was 
 admitted into St. George’s Hospital, on the 23 d 
 of April, 1821, under the care of Mr. Gunning, 
 for a popliteal aneurism in the right leg. The 
 
166 
 
 tumour, which pulsated strongly, occupied the 
 whole cavity of the ham, bulging out on each 
 side of the limb, and extending some way up the 
 thigh. The leg and lower part of the thigh were 
 excessively swollen and cedematous and the pa- 
 tient complained of much pain in the aneurism, 
 and in the situation of the saphenus nerve at the 
 ancle, The limb had nearly its natural colour, but, 
 if any thing, it was rather paler than usual. He 
 said, that, six weeks before, a tumour appeared in 
 the ham, without any assignable cause ; that it 
 soon became painful, and about a fortnight be- 
 fore his admission, he first observed the oedema- 
 tous swelling of the leg. 
 
 On the 27th of April, Mr Gunning tied the 
 femoral artery in the middle of the thigh, with a 
 single ligature, and afterwards brought the edges 
 of the wound together with adhesive plasters and 
 a roller. The ligature came away on the 14th 
 of May, and by the end of the month the wound 
 was entirely closed. On the 20th of June, only 
 a comparatively small tumour was remaining in 
 the ham ; but the patient was unable to use the 
 limb so as to walk upon it, and there was still a 
 slight degree of oedema about the foot. On the 
 
167 
 
 30th of June, he was dismissed from the hospital 
 as cured. 
 
 On the 20th of July, 1825, this man was 
 again admitted into the hospital, with a return of 
 his disease, and became Mr. Jeffrey’s patient. — 
 He stated that the tumour had entirely disap- 
 peared soon after he was discharged from the 
 hospital, in 1821. ^ About five or six weeks be- 
 fore his re-admission, he first observed that the 
 swelling had returned in the upper part of the 
 ham, and was at that time nearly the size of a 
 hen’s egg. The tumour now occupied the lower 
 third of the thigh, filling up the whole of the pop- 
 liteal space, and projecting considerably on each 
 side of the limb between the hamstrings, and the 
 exterior muscles situated on the fore part of the 
 thigh. It appeared to consist of three lobes, and 
 was altogether as big as an ostrich’s egg. The 
 pulsation in the tumour was feeble, but distinct, 
 and the skin covering it was of its natural colour. 
 He did not complain of much pain — the limb was 
 kept in the half bent position — and there was no 
 swelling or oedema of the leg. The patient said 
 that he was otherwise in perfect health, but he 
 had a pale sallow complexion, far from confirma- 
 tory of his assertion. 
 
108 
 
 A consultation was held on the case, and it 
 was proposed to endeavour to get at the artery 
 between the part where it had been tied in the 
 former operation, and the anetlrismal sac; and 
 in the event of failure, to amputate the limb. 
 This was submitted to the patient’s consideration - 
 but as the first operation had not succeeded, lie 
 preferred undergoing amputation at once, rather 
 than endure the pain and risk of two operations. 
 In the beginning of August, he was attacked with 
 a diarrhoea, for which he took a scruple of rhu- 
 barb and five grains of calomel, which produced 
 a most severe salivation, with such swelling and 
 ulceration of the mouth, as to render it necessarv 
 to postpone the operation for several weeks. On 
 the 5th of September, his mouth having got quite 
 well, Mr. Jeffrey amputated the limb, between 
 the tumour and the part where the femoral artery 
 had been tied by Mr. Gunning. A large vessel, 
 which appeared to be the femoral, and seven or 
 eight smaller ones, were tied. Whilst the stump 
 was being dressed, the man became faint and 
 sick. After being put to bed, he complained of 
 pain in the small of the back, a pillow 7 w’as placed 
 under him, which gave him relief, and he took 
 thirty drops of laudanum. His spirits, however. 
 
169 
 
 did not rally ; he told a fellow patient that he 
 should never get over it. At seven in the even- 
 ing, his countenance assumed a yellow hue, and 
 at nine o’clock he expired, having survived the 
 operation eight hours. 
 
 On the following day, the femoral artery and 
 profunda were injected from the groin, and after- 
 wards examined. The former vessel was found 
 
 j 
 
 to be obliterated for the space of half an inch, at 
 the part where the ligature had been applied four 
 years ago ; and immediately below it, two small 
 branches are observed to enter the continued 
 trunk of that vessel. These branches were equal 
 to half the diameter of the femoral artery. The 
 anastomosing branches given off above the obli- 
 terated portion, were a good deal enlarged. 
 
 The amputated limb was also injected, and 
 afterwards dissected. The sae seemed to have 
 been formed by the giving way of the internal 
 coats of the artery, and the dilatation of its outer 
 or cellular one ; and it was inferred from the ap- 
 pearances, that the circulation through the aneu- 
 rism had never been wholly suspended, and that 
 
 z 
 
170 
 
 the disease in the last instance was a reproduction 
 of the original tumour. 
 
 Mr. Jeffrey has kindly sent me a drawing, 
 shewing the peculiarities of the case, accom- 
 panied with his permission to use it as 1 please ; 
 it shall appear at some future period, together 
 with other illustrations of much interest. 
 
 Mr. Richard Smith, Senior Surgeon of the 
 Bristol Infirmary, has favoured me with the par- 
 ticulars of the following case, which came under 
 the care of his colleague, Mr. Nathaniel Smith: — 
 James Wallis, aged 38, was operated on at the 
 Infirmary, for popliteal aneurism of the left side, 
 on the 12th of January of the present year. The 
 tumour projected considerably beyond the line of 
 the ham-strings, pulsated strongly, and gave very 
 distinctly the sensation of aneurism The disease 
 commenced, spontaneously, about nine months 
 before, and gave him but little uneasiness until a 
 few weeks prior to the operation. The man was 
 tall and muscular, by trade a ship carpenter, bis 
 work very heavy, and requiring excessive exer- 
 tion. The operation was performed, and the 
 artery tied with one ligature. The progress of 
 
171 
 
 the case was attended with some untoward cir- 
 cumstances : thus, a large abscess formed along 
 the line of the femoral artery, which proved very 
 troublesome. On the 20th day of January, with- 
 out any obvious cause, a sudden gush of blood 
 took place from the wound, very speedily amount- 
 ing to six or eight ounces; but the hoemorrhage 
 spontaneously ceased. The blood was rather 
 darker than arterious blood, but not decidedly 
 venous. It appeared to the patient, as if it came 
 up the thigh to the wound. On the following 
 day, the ligature separated, without any recur- 
 rence of hoemorrhage, and the wound slowly 
 healed. The man was eventually discharged 
 from the Infirmary on the 23d of March, tole- 
 rably well. The aneurismal tumour did not di- 
 minish much, till some weeks after the operation, 
 when it subsided rather rapidly. Soon after the 
 patient left the hospital he went to work; the 
 tumour immediately began to pulsate, and has 
 continued to do so ever since. “ At present,” 
 Mr. Smith writes, “ (October 7th), there is no 
 whizzing, but a regular, and moderately strong 
 stroke, and, to appearance, there is very little 
 tumour. We are making moderate and elastic 
 
172 
 
 pressure upon the ham, and the man goes on 
 with his work.” Mr. Smith has kindly promised 
 to keep an account of the progress of the case, 
 and to communicate the same to me. 
 
 Mr. Goodlad, of Bury, in this County, has 
 obligingly sent me a case, where he secured the 
 artery for a popliteal aneurism about the size of 
 an orange. After the operation, the pulsation 
 ceased, the tumour decreased, and the patient 
 returned to his employment without a complaint, 
 excepting a degree of weakness in the affected 
 limb. Mr. Goodlad thought however, but he 
 could not satisfy himself, that there was a trifling 
 undulation where the tumour had been. In the 
 course of five or six weeks, the patient called again 
 on Mr. Goodlad, expressing the utmost pain, 
 with anxious countenan ( e and heat, redness, 
 and violent pulsation in the aneurismal sac, which, 
 though not so large as heretofore, was accompa- 
 nied with more swelling around it, and a much 
 higher degree of inflammation. However, on 
 enjoining rest, a low diet, cold applications, &c. 
 the inflammation subsided, the pulsation decreas- 
 ed, and soon became imperceptible, and now 
 
173 
 
 there is not a vestige of tumour discoverable by 
 any external examination. 
 
 These cases are confirmatory of the fears we 
 have a right to entertain, from the anastomoses 
 being too free, and therefore are favourable to the 
 opinion, that we may err, if we are not guided in 
 our choice of situation for the application of 
 the ligature, by reflecting on the inosculating 
 branches. 
 
 I repeat then, that we have more to dread 
 from the anastomoses being very abundant, than 
 from their being few ; that when too free, the 
 aneurismal sac may be fed by the recurrent cir- 
 culation, and go on distending to absolute burst- 
 ing, which gives rise to hoemorrhage and death ; 
 or a current of blood may pass through the sac 
 which will be sufficient to continue the disease, 
 or, to reproduce it. 
 
 When a ligature is applied to the external 
 iliac, for femoral aneurism, a little below Pou- 
 part’s ligament, we have to apprehend bad con- 
 sequences from the recurrent circulation ; as only 
 the epigastric and circumflexa ilii arteries open 
 
174 
 
 between the ligature and the sac, and when the 
 aneurism extends as high as Poupart’s liga- 
 ments, it is more than probable that the mouths 
 of these branches will be closed by the coagula, 
 and coagulable lymph of the sac. When the 
 aneurism is seated below the origin of the pro- 
 funda, and the ligature is put on the vessel below 
 the groin, we have to fear the influence both of the 
 direct and recurrent circulation, as ail, or the prin- 
 cipal branches of the internal iliac, inosculate 
 with those of the profunda ; and the descending 
 branches of the profunda anastomose with the 
 muscular rami of the femoral, and other branches 
 passing off below the aneurismal swelling. — 
 But when the disease is situated in the ham, we 
 have to fear the action of the direct circulation 
 on the sac, particularly when the femoral trunk 
 is pervious to a great extent between the ligature 
 and the tumour. In the absence of an aneu- 
 rismal tendency, or a great disorganization of 
 the coats of the vessel, and when the swelling is 
 small, we have not much to care for, in a general 
 way, from either the recurrent or direct circula- 
 tion ; but when the aneurismal diathesis exists, 
 and the aneurism is of a large size, our only 
 chance of curing the disease, consists in placing 
 
175 
 
 the ligature on the main trunk, at no great 
 distance from the aneurism, then supposition 
 would lead us to believe, that the coats of the 
 artery are sound, and in their natural state. We 
 may then, fairly question the propriety of tying 
 the femoral artery, for popliteal aneurism, in the 
 situation which Scarpa directs, viz. in the upper 
 third of the thigh; above where Hunter proposed. 
 His reason for this practice, viz. to avoid the 
 necessity of removing the sartorius muscle too 
 much from its position, or of turning it back for 
 the purpose of exposing the artery, is good so far 
 as it facilitates the operation; but we have in 
 view the removal of the disease, and therefore 
 we should look to the effects, of operating so high 
 up, on the anastomosing vessels. In this case, 
 the ligature is applied below the bifurcation of 
 the femoral artery ; a considerable space is left 
 between the ligature and the aneurismal swelling, 
 and from the femoral trunk included in this space 
 pass off many muscular branches, which freely 
 communicate with those of the profunda; on these 
 accounts, I believe Scarpa’s proposal to be more 
 objectionable than that of Hunter ; for the latter 
 incurs little risk of failure from a morbid state of 
 the artery, another reason assigned for Scarpa’s 
 
176 
 
 deviation. If we choose to deviate, from a fear 
 that the disease in the coats of the artery may 
 have extended to the point where Mr. Hunter 
 proposed that the application of the ligature 
 should be made, I should prefer tying the femo- 
 ral artery above where the profunda is given off, 
 — nay, even the external iliac. By doing this, 
 we effectually break the impetus of the current in 
 the profunda and femoral branches, as they could 
 only receive their supply through the medium of 
 comparatively small anastomosing vessels j and 
 before their enlargement, the coagula of the sac 
 would oppose such a resistance to the entrance 
 of the blood as will not be afterwards overcome ; 
 notwithstanding, the blood will, in the event of its 
 enlargement, pass with much more freedom to- 
 wards it. When the aneurism is of a large size 
 whether of the circumscribed or diffused kind, the 
 success of the operation of tying the main trunk 
 in any situation is more doubtful. It is true, 
 aneurisms of considerable magnitude have thus 
 been cured ; but many, too, have resisted the 
 common treatment. The failure is attributable, 
 in some cases, to constitutional, and in others to 
 local causes. When the general health is much 
 impaired, there is not sufficient vigour in the 
 
177 
 
 system to repair the mischief, and the patient 
 sinks under the disease. With regard to local 
 causes, they are chiefly three, viz. too great a 
 supply of blood, the presence of putrid coagula, 
 and extensive suppuration in the sac. 
 
 The means of obviating the first cause of 
 failure, are to be sought for in the anastomoses; 
 this will teach us where to apply the ligature, in 
 order to prevent too great an afflux of blood to- 
 wards the sac; and further to remove all chance of 
 this, I propose that pressure should be made on 
 the aneurismal swelling from the time of the ope- 
 ration. This will act by diverting the blood into 
 the anastomosing vessels above the sac; it will 
 expedite the formation of coagula, and thus lay 
 the foundation for the cure of the disease. Some, 
 perhaps, will object to the practice, from suppo- 
 sing that the swelling cannot be compressed inde- 
 pendently of the neighbouring parts, and to do 
 this would be to prevent the free circulation of the 
 blood through the articular branches ramifying 
 about the knee joint. I believe, on the contrary, 
 that it is possible, by a very simple apparatus, 
 (making the patella the fulcrum,) to localize the 
 pressure ; and the same is practicable in the vici- 
 
 a 2 
 
178 
 
 nity of all the joints, where only is such a 
 contrivance necessary. Of the use of pres- 
 sure, independently of a ligature on the main 
 trunk, I do not place any great degree of confi- 
 dence; but that it lias succeeded in curing the 
 disease is certain ; and this is sufficient to prove 
 the influence that this means has on the aneu- 
 rism al swell ing. Dr. J ames Hope has commu- 
 nicated to me a case which lately came under his 
 observation at the Royal Infirmary, Edinburgh, 
 where pressure on the tumour, and in a more 
 moderate degree to the whole course of the femo- 
 ral artery, had the happy effect of curing the 
 disease. The aneurism and artery were gradu- 
 ally obliterated, and during the progress of cure, 
 the increasing magnitude, and stronger pulsation 
 of the articular branches were daily more and 
 more sensible. 
 
 To obviate the two last causes of failure, one 
 practice is applicable, which is to make an open- 
 ing into the sac, after the main artery is tied. I 
 am aware, that there exists in the minds of some 
 Surgeons, an insuperable objection to doing this; 
 but the objection perhaps arises from their asso- 
 ciating with it, the application of a ligature at 
 
179 
 
 each extremity, thereby insulating the sac, and 
 practising the old operation for aneurism, which, 
 for just and proper reasons, has been abandoned. 
 By making an incision into the most dependent 
 part of the tumour, we give exit to the coagula 
 (and pus, if any,) and thereby remove a source of 
 irritation, which often proves fatal. I am of 
 opinion then, that in circumscribed as well as in 
 diffused aneurisms, when the tumour is very large, 
 the sac should be punctured, and its contents 
 evacuated ; the process of cure will then be 
 partly by adhesion, and partly by granulation. 
 A most interesting case, in which tying the main 
 trunk, and giving exit to the contents of the sac, 
 had a happy termination, although the disease 
 was very extensive, has been kindly transmitted 
 tome by Mr. Lawrence. The case is highly in- 
 structive; first, as affording much insight into the 
 diagnosisof certain aneurismal tumours: secondly, 
 as shewing the efficacy of the above practice: 
 and thirdly, as proving what Nature can do, when 
 she is assisted by the skilful exercise of our art. 
 
 In the eighth volume of the “ Medico-Chi- 
 rurgical Transactions,” p. 497, Mr. Lawrence 
 gives a case in which an erroneous notion of the 
 
 ¥ 
 
180 
 
 disease was induced, in consequence of the ab- 
 sence of pulsation in the swelling; and amputa- 
 tion was performed, under the impression that the 
 disease was not aneurism, but a fleshy tumour. 
 Whilst the circumstances of the case were still 
 fresh in Mr. Lawrence’s recollection, he was re- 
 quested to see a patient with a large chronic ab- 
 scess of the thigh, for the purpose of deciding 
 whether it should be opened. He was a very 
 thin and delicate young man, about 28 years old. 
 H is whole thigh was enormously swollen, and the 
 leg oedematous. He said, that his complaint 
 began with pain of the hip and thigh, and that 
 after three or four weeks, he observed a lump 
 about the size of the thumb, a little below the 
 groin. Mr. Lawrence could not ascertain that 
 he had noticed any pulsation in it, but he did 
 not seem to have attended to it minutely. The 
 swelling underwent a sudden and great increase, 
 and the limb continued to enlarne. This history, 
 combined with the state of the thigh, and absence 
 of pulsation in the arteries below, convinced Mr. 
 Lawrence that it was an aneurism, which had 
 been at first circumscribed, and then became dif- 
 fused, and he operated immediately, although 
 there was no pulsation in the tumour; the femo- 
 
J 8 1 
 
 ral artery was tied above the profunda. The pa- 
 tient did well, and enjoys the use of the limb at 
 this time, although suppuration occurred in the 
 swelling, and the gradual discharge of an im- 
 mense quantity of coagula shewed that the whole 
 limb, evendown to the knee, had been converted 
 into an aneurismal tumour. Mr. Lawrence 
 found it necessary to make an opening near the 
 knee, in order to get rid of the putrid coagula, 
 and the finger introduced at this aperture could 
 be passed nearly round the bone. 
 
 Last summer, Mr. Lawrence operated on 
 an aneurism of the femoral artery, situated on 
 the inside of the limb, and rather below the mid- 
 dle. The swelling had pulsated strongly at first ; 
 the beating stopped after a time, but the aneu- 
 rism went on increasing, and the limb became 
 more and more oedematous and painful. At the 
 time oj the operation , there teas not the slightest 
 pulsation. Jn this case, the tumour was not dis- 
 tinctly circumscribed ; it was not, however, large 
 or extensive enough for diffused aneurism, nor 
 had it undergone the sudden augmentation ob- 
 served in such cases. 
 
182 
 
 la the 12th number of the seventh, and the 
 first number of the eighth volume of the “ Lan- 
 cet,” under the report of Bartholomew’s Hospital, 
 another instance is given of that peculiarity in an 
 aneurismal tumour, which is above referred to. 
 A man was admitted into the hospital, under Dr. 
 Latham, and, complaining of pain in the limbs, 
 he was treated for rheumatism. At the upper, 
 and front part of thigh, there was a large tu- 
 mour, hard and incompressible, which was sup- 
 posed to be an enlargement of the inguinal 
 glands. He was now placed under the care of 
 Mr. Lawrence, who, on examining the tumour 
 minutely, thought he felt the fluctuation of mat- 
 ter, and proceeded to examine with both hands, 
 to decide on the propriety of letting it out ; but 
 to his astonishment, he felt the strong and 
 decided pulsation of an aneurismal swelling; no 
 pulsation could be felt in the arteries of the foot ; 
 and this, with the oedematous state of the limb, 
 left no doubt on Mr. Lawrence’s mind as to the 
 true nature of the case, viz. Aneurism of the fe- 
 moral artery. On questioning the man, he said, 
 the tumour had commenced “ Like a pulse," that 
 when it first came, if he laid the palm of the hand 
 
183 
 
 on it, he found it thumping “ in grand style;” but 
 that afterwards it became quite hard, and he 
 could not at all feel it. During his stay in the 
 hospital, several surgeons had examined the tu- 
 mour, but no pulsation was felt, which is a cir- 
 cumstance worthy of observation, viz. its having 
 pulsated in the commencement, — ceased to beat 
 for five or six weeks, — and after such cessation, to 
 re-commence. A consultation was held on the 
 case, and Mr. Lawrence tied the external iliac 
 artery. The pulsation in the swelling ceased im- 
 mediately, and the tumour felt more elastic and 
 soft. The man died the eighth day after the 
 operation, and on inspecting the parts, it was 
 found that the ligature was passed exactly mid- 
 distance between the division of the common iliac 
 and the origin of the circumflexa ilii and epi- 
 gastric. A clot of more than an inch in length 
 had formed above the ligature, not however so 
 far up as the origin of the internal iliac. The 
 portion of the artery below the ligature, admitted 
 of the passage of a probe, on employing a little 
 force. The aneurism was of the diffused kind ; 
 its walls being formed by the surrounding mus- 
 cles, without any appearance of a regular sac, 
 and filled with coagulated blood mized with pus. 
 
184 
 
 The artery below the aneurism resembled an im- 
 pervious fibrous cord. To this closure of the ar- 
 tery, which is produced by the pressure of the 
 aneurismal tumour, Mr. Lawrence attributes the 
 cessation of the pulsation in such cases. 
 
 There has lately occurred at St. Thomas’s 
 Hospital, under the care of Mr. Travers, a case 
 similar in some respects to the above, and from 
 the absence of pulsation, there were great doubts 
 entertained as to the nature of the disease. The 
 limb was amputated, and on examining it, it was 
 found to be a diffused aneurism, occasioned bv 
 an opening in the popliteal artery, which appear- 
 ed to be the result of ulceration. 
 
 These cases, as showing that aneurismal 
 tumours sometimes undergo changes which put a 
 stop to their pulsation, w'ithout preventing their 
 increase, or rendering the operation less necessary, 
 are extremely important, and teach us that we 
 ought to be guided by the history of the disease, 
 as much as the feel of the swelling, in determin- 
 ing the nature of the case A good diagnostic 
 mark of aneurism of the kind we have been de- 
 scribing, is the want of pulsation in the arteries 
 below the tumour. 
 
185 
 
 When the aneurism is extensive, and of the 
 diffused kind, as those above mentioned, the soft 
 parts become disorganised to such a degree, that 
 reasoning a priori would lead us to despair of 
 curing the disease by tying the main trunk, since 
 by doing so, we, for a time, diminish the quantity 
 of blood in the extremity below the ligature, 
 and therefore enfeeble its restorative powers. 
 
 . But Mr. Lawrence’s successful case proves that 
 this opinion is fallacious ; for although the quan- 
 tity of blood is lessened by the obliteration of the 
 main artery, yet the quantity sent to the limb 
 cannot be small, as it was found sufficient for the 
 reparative purposes of nature. 
 
 The femoral artery, when wounded, gives 
 rise to a serious hoemorrhage, which, if not im- 
 mediately restrained, must in a general way prove 
 fatal. The treatment is to tie the vessel with two 
 ligatures at the wounded point. There are, 
 however, cases on record, where this practice was 
 deviated from, and yet the hoemorrhage was 
 checked; but the issue, though fortunate, was 
 scarcely to be expected, when we reflect on the 
 anastomoses. To stem the impetus of the cur- 
 rent of blood by a ligature on the main trunk at 
 
 b 2 
 
186 
 
 the upper extremity of the cut artery, or at the 
 usual place, about the middle of the thigh, might 
 under circumstances succeed; but on such success 
 in one or more instances, we have no right to 
 found a principle of practice. 
 
187 
 
 ARTERIiE TIBIALES. 
 
 The popliteal artery divides into the anterior 
 and posterior tibia!, which vessels supply the leg 
 and foot : — the fibular or peroneal artery is a 
 branch of the latter. These are tb three main 
 branches of the soft parts below the knee. — 
 For Relative Position and branches of the ante- 
 rior tibial, vide page 27 ; and the same of the 
 posterior tibial, page 28. 
 
 The arteries of the- leg and foot bear a strik- 
 ing resemblance to those of the fore arm and 
 hand, and we may draw the same practical de- 
 ductions from the study of them. 
 
 It is a practice established by experience, 
 that when either the anterior tibial, or posterior 
 tibia!, or peroneal artery, is affected with aneu- 
 rism at its upper part, a ligature on the femoral 
 will generally cure the disease; but when an aneu- 
 rism is situated in the inferior portion of either of 
 them, the artery must be tied as near as possible 
 to the sac, for the same reasons as those given 
 when speaking of the upper extremity. 
 
188 
 
 When we trace the arterial branches of the 
 leg and foot, we find that they very abundant- 
 ly inosculate with each other. The muscular 
 branches in the leg freely communicate. At the 
 ancle, the anterior tibial (C), sends off the rami 
 malleolares (13), which inosculate with branches 
 given off about the joint by the posterior tibial 
 (D) and peroneal (E) arteries. The anterior ti- 
 bial is then continued forwards, under the annu- 
 lar ligament, and gives off the arteria metatarsea 
 (14), which furnishes the interosseal branches (15). 
 The anastomoticus profundus (16) dips down to 
 inosculate with the external plantar artery (IQ) 
 to form the arcus plantaris (^0), which supplies the 
 digital branches [ 2 1). The inner plantar artery 
 (18) of the posterior tibial, furnishes branches to 
 the great toe, and anastomoses with the arteria 
 dorsalis pollicis (17) of the anterior tibial artery. 
 It is evident, from this view, that either the ante- 
 tior tibial, the posterior tibial, or peroneal artery 
 may be obliterated, without endangering, in the 
 least, the after-circulation in the leg and foot. 
 
 When considering the arteries of the fore 
 arm and hand, I mentioned that the inoscula- 
 tions between the branches of the radial, ulnar, 
 
189 
 
 and interosseal vessels were so copious, that in 
 case of wound of either of the trunks, a ligature 
 was called for at each extremity of the wounded 
 vessel ; but that if either of the branches of the 
 palm should be injured, tying the trunk and 
 making pressure on the injured part will, in a 
 general way, be all-sufficient. These remarks 
 apply to the treatment of haemorrhage of the leg 
 or foot. 
 
 I have heard of a case where the anterior 
 tibial artery was wounded with a scythe, at the 
 upper part of the leg, almost at the point where 
 the vessel perforates the interosseous ligament. 
 Much blood was lost ; but by compression, and 
 the coming on of syncope, the bleeding was sup- 
 pressed. It however soon recurred, and another 
 Surgeon was sent for. On his arrival, he found 
 the limb swollen from the extravasated blood ; 
 and reflecting on the difficulty which this circum- 
 stance would occasion, and the possibility that 
 the upper extremity of the vessel had so retracted 
 as not to be easily reached, he resolved on tying 
 the femoral artery on the inner side of the thigh; 
 this was done. During nearly a week, the pa- 
 tient, who was kept in a state of absolute quiet, 
 
seemed to be going on weil j but when he began 
 to exert himself a little, a considerable hoemor- 
 rhage took place from the wound ; the bleeding 
 was commanded by means of firm pressure, but 
 it frequently returned, to the embarrassment of 
 the Surgeon in attendance, and to the injury of 
 the patient’s health. Should another case of this 
 kind occur to the same Surgeon, he will, in spite 
 of all difficulties, endeavour to secure the vessel 
 at the wounded part. 
 
 It might hardly be contemplated by the 
 student, that a wound of the peroneal artery, 
 which is a branch of the posterior tibial, would 
 give rise to so serious a haemorrhage as to require 
 that the artery should be cut down upon at the 
 wounded part, and secured by two ligatures. Yet 
 such was the case in a soldier, who was wounded 
 at the Battle of Waterloo. In the seventh vo- 
 lume of the “ Medico-Chirurgical Transac- 
 tions, ” Mr. Guthrie gives an account of it. The 
 wound was by a musket-shot, which entered the 
 right leg immediately behind and below the inner 
 head of the tibia. No haemorrhage followed at the 
 time, and therefore it was considered one of the 
 slighter cases. On the 1st of July, a conside- 
 
191 
 
 rable haemorrhage took place, which was sup- 
 pressed by the tourniquet, and did not immedi- 
 ately recur on its removal. It bled, however, at 
 intervals during the night, and in the morning of 
 the 2d, it became necessary to re-apply the tour- 
 niquet, and to adopt some means for the perma- 
 nent relief of the patient. The practice adopted 
 was, to tie the artery with two ligatures, one 
 above, and the other below the wounded part, 
 and the hoemorrhage did not return. 
 
 .1 have mentioned in my “ Outlines,” a case 
 of hoemorrhage from a wound of the anterior tibial 
 on the dorsum of the foot, for which the Surgeon, 
 who was consulted, cut on the trunk of the 
 vessel, half way down the leg, and passed a liga- 
 ture about it; but as the operation did not suc- 
 ceed in suppressing the flow of blood, he subse- 
 quently secured the artery at the wounded part. 
 The reason why the hoemorrhage was not stop- 
 ped by the first operation, remained unexplained 
 until it so happened that in dissecting an injected 
 limb, he discovered a mal-distribution of the ar- 
 teries of the foot. The anterior tibial terminal ed 
 in numerous branches which were distributed 
 about the ancle joint; and the peroneal artery. 
 
192 
 
 instead of being spent at, or near the ancle, was 
 continued over the dorsum of the foot, and sup- 
 plied the place of the anterior tibial vessel. This 
 discovery induced the Surgeon to believe, that, 
 in the case above related, the arteries were mal 
 distributed in a similar way ; and this was used 
 to explain why the bleeding was not checked 
 when the anterior tibial was tied. I objected to 
 this explanation of the fact, and ventured to sur- 
 mise, that it was not so probable as that the ar- 
 tery was fed by anastomoses and the recurrent 
 circulation, — as the mal-distribution alluded 
 to was extremely rare, since I could not find 
 a similar anomaly in any Anatomical work. 
 Since then, however, I have perused Dr. Barclay’s 
 valuable little work on the Arteries, in which the 
 author states, that the late Mr. Allan Burns, of 
 Glasgow, communicated to him an account of 
 his having found the anterior tibial artery wanting 
 in two subjects, and that the arteria peronea an- 
 tica supplied its place in the dorsum of the foot. 
 These cases bear some analogy to the instance 
 above cited ; but still an opinion founded on the 
 possibility of such an anomaly (for there was a 
 total absence of proof), cannot be admitted in 
 preference to that, founded on the basis of Ana- 
 tomy. 
 
193 
 
 I have now completed the views which I 
 intended giving of the arterial anastomoses, — 
 pointed out the manner in which the blood cir- 
 culates when a main trunk is obliterated, — and 
 applied that subject to the most important and 
 useful points in the theory and practice of a parti- 
 cular branch of operative Surgery. But the student 
 must not suppose that the vessels are arranged in 
 the manner we have described, as a mean to en- 
 able the Surgeon to overcome disease ; — the free 
 inosculations of the arteries and veins are essen- 
 tial to the well doing of the animal economy, for, 
 by allowing a retrograde course to the blood, 
 they contribute to the functions of secretion, nu- 
 trition, and growth. 
 
 It has been left to Modern Surgery to apply 
 this grand anatomical principle to practice; and 
 the brilliant success which has attended the appli- 
 cation, must convince the most sceptical indivi- 
 dual, that the study of Anatomy and Physiology 
 is the key-stone to Pathology and the Healing Art ; 
 and that without them. Medicine and Surgery 
 would be mere empirical pretensions. 
 
 From our knowledge of the arterial anasto- 
 moses, (which minute research only could have 
 
 s \ 
 
194 
 
 taught us,) we can say, that almost any artery 
 in the body can be tied in cases of expediency; 
 but it is not long that this confidence in the re- 
 sources of nature has been entertained by Sur- 
 geons. The late Dr. Monro, who was a most 
 excellent anatomist, considered that it was dan- 
 gerous to trust to common anastomoses round 
 the elbow, and intimated, that the success of ty- 
 ing the brachial artery was chiefly owing to a 
 lusus naturae. Modern Surgeons, however, have 
 carried their confidence so far as to tie, not only 
 the brachial, and arteries of that class; but the 
 common carotid, the subclavian, the external iliac, 
 the internal iliac, the arteria innominata, and, 
 most wonderful of all, the aorta. Thus, the 
 operation of including a main trunk in a liga- 
 ture for aneurism and haemorrhage, is divested of 
 its fearful consequences — and Surgery has been 
 brought to triumph over death. 
 
 FINIS. 
 
 ASTON, PRINTER, MANCHESTER . 
 
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