218. The operation for placing a ligature on the aorta should not be
done by making an opening through the front of the abdomen, as has
hitherto been proposed. It should in future be attempted and executed
nearly in the same manner as the operation for placing a ligature on
the common iliac, which has succeeded. The aorta bifurcates usually on
the body of the fourth, or on the inter-vertebral substance between
it and the fifth vertebra, although it may be higher or lower--a fact
which cannot be ascertained previously to the operation; the most usual
place is nearly opposite to the margin of the umbilicus on the left
side. It is about half an inch above this that the ligature should
be placed on the aorta, if this operation is ever done again, rather
lower than higher, on account of the origin of the inferior mesenteric
artery. As the aorta is to be reached by carrying the finger along the
common iliac, the comparative situation of that vessel is next to be
estimated.
The length of the two common iliac arteries varies according to the
stature of the patient, and the place at which the aorta bifurcates.
The common iliacs again divide into the external and internal iliacs,
which division is usually opposite to the sacro-iliac symphysis. The
length of the common iliac artery is therefore tolerably well defined,
as scarcely ever exceeding two inches and three-quarters, and seldom
being less than two inches. The external iliac is a little longer
than the common iliac, and the place of subdivision of the common
iliac into external and internal can always be ascertained, during an
operation, by tracing the external iliac upward to its junction with
the internal to form the common trunk, which proceeds upward and inward
to the aorta. The left margin of the umbilicus being taken as a point
opposite to that which may be presumed to be the part at which the
aorta divides, and the situation of the external iliac becoming femoral
being clearly ascertained, a line drawn between the two will nearly
indicate the course of these two vessels; sufficiently so, at all
events, to enable the operator to mark with his eye, or with ink, the
place where he expects to tie the artery; and to regulate the length of
the incision, so that this ideal spot may correspond to its center. It
is necessary to recollect, also, that the whole of one hand and part
of the other must be introduced into the wound, to enable the operator
to pass a ligature round the artery, and to tie the knots: so that an
external excision of less extent than five inches will not suffice, and
six will afford a facility in operating, which will save pain to the
patient and inconvenience to the operator. In calculating the length
of the incision, allowance must be made for the size, obesity, and
muscularity of the patient. If a rule be placed on the crest of each
ilium, about one inch and a half behind the anterior superior spinous
process, it will pass in a well-formed man across the junction of the
fifth lumbar vertebra with the upper part of the sacrum, and a little
way behind where the common iliac divides into external and internal.
The center of an incision, six inches in length, beginning about half
an inch above Poupart’s ligament, and about the same distance to the
outside of the inner ring, and carried upward, will fall nearly on a
line with this point. The incision should be nearly parallel to the
course of the epigastric artery, but a little more to the outside,
in order to avoid it and the spermatic cord, and having a gradual
inclination inward toward the external edge of the rectus muscle; the
patient being on his back, with the head and shoulders raised, and
the legs bent on the trunk. The aponeurosis of the external oblique
muscle having been opened inferiorly, is to be slit up for the whole
length of the external incision; and the director having been first
passed under the internal oblique muscle, through a small opening
carefully made into it, it is to be divided in a similar manner. The
transversalis is then to be cut through at the under part, and its
tendinous expansion divided at the upper part, the greatest precaution
being taken by the finger to prevent the peritoneum being injured.
The fascia transversalis is then to be torn through at the lower and
outer part, so that the fingers may be passed inward from the ilium,
and the peritoneum detached from the iliac fossa, and turned with its
contents inward, by a gradual and sidelong movement of the fore and
second fingers inward and upward, until, passing over the psoas muscle,
the external iliac artery is discovered by its pulsation. It is then to
be traced upward and inward toward the spine, when its origin and that
of the internal iliac from the common trunk will be felt. The point of
the forefinger will then be nearly in the center of a line drawn from
the umbilicus to the anterior superior spine of the ilium; hence the
necessity for an incision six inches in length, if the artery is to be
tied high up, which is to be accomplished by tracing it in a similar
manner to its origin from the aorta.
The _common trunk_ of the iliac arteries and the _aorta itself_ may
be tied by the same method of proceeding; the only difference which
can be practiced with advantage will be to make the incision a little
longer at its upper part, no inconvenience arising from the addition
to the length of the external wound, while the subsequent steps of
the operation will be much facilitated by it. The following method of
proceeding, adopted in two cases in which I placed a ligature on the
common iliac artery with a successful result, will bring the operation
so graphically before the reader that it cannot be misunderstood,
and may be readily followed in operating: I began the operation,
the patient lying on the back, by an incision on the fore part of
the abdomen, commencing an inch and a half below the inside of the
anterior spine of the ilium, and the same distance within it, carrying
it upward, and diagonally inward toward the edge of the rectus muscle
above the umbilicus, so that the incision was between six and seven
inches long. If the incision be made more outwardly, toward the side
in a straight or vertical line from the ilium toward the ribs, great
difficulty will be experienced in turning over the peritoneum with its
contents, so as to place the finger on the last lumbar vertebra--an
inconvenience which will be avoided by making the incision diagonally,
and of the length directed.
After dividing the common integuments, the three layers of muscles
were cut through in the most careful manner; the division of the
transversalis muscle was attended with some difficulty, inasmuch as
there was but little fascia transversalis, and the peritoneum was
remarkably thin--as thin as white silver paper. On attempting to
reach the under part on the inside of the ilium, so as to turn the
peritoneum over, which in sound parts is always done without the least
difficulty, I found that it could not be done on account of the tumor
which projected inward adhering to it; some bleeding took place from
the large veins which surrounded it, giving rise to the caution not
to proceed further in that direction. At this moment, in spite of the
greatest possible care that could be taken by Mr. Keate, who raised and
protected the peritoneum, a very small nick was made in it, sufficient
to show the intestine through it. Perceiving that I could not tie the
internal iliac as I had at first intended, and that I must place the
ligature on the common iliac, I tried to gain a greater extent of
space upward; but where the tendon of the transversalis muscle passes
directly across from the lower ribs to aid in forming the sheath of
the rectus, the peritoneum is usually so thin and so closely attached
to it that it can only be separated with great difficulty. I knew this
from the operation I had before performed, when, in spite of all the
precaution I could then take, the peritoneum was at this spot slightly
opened. It occurred in the present instance, and the right lobe of the
liver was thus exposed.
The opening thus made on the fore part of the abdomen was not large
enough to admit two hands. The peritoneum being, however, separated a
little from the posterior wall of the abdomen from the outside, by the
fingers, for a cutting instrument was inadmissible, four of the fingers
of one hand were introduced beneath it, and it was turned a little over
toward the opposite side. In doing this it must be remembered that the
peritoneum must be raised, the hand being pushed toward the back as
little as possible, in order to avoid getting behind the fat commonly
found in that part of the body, which would lead to the under edge
of the psoas muscle instead of the upper surface, and thus render the
operation embarrassing.
The peritoneum being carefully drawn over with its contents, I found
I could only get one hand, or a little more, underneath it in search
of the artery, the tumor below preventing any further detachment of
the peritoneum in that direction. I therefore passed my finger across
the psoas muscle, and it rested on the fifth lumbar vertebra. The
common iliac artery was not to be felt, however, even as high up as the
fourth lumbar vertebra, nor was the aorta; they had both risen with the
peritoneum, and my finger resting on the spine was beneath them. Mr.
Keate endeavored to raise or draw over the peritoneum, to give me an
opportunity of seeing the vessels, but it could not be done. However,
he felt the pulsation of the iliac artery, which had been raised with
the peritoneum, to which I found it adhering. Carefully separating it
with the end of the forefinger of the right hand, I passed a single
thread of strong dentists’ silk, as it is termed, in a common solid
aneurismal needle, by the aid of the thumb and forefinger of the left
hand, round the artery without seeing it. I could then bring the artery
a little forward by means of the aneurismal needle, when it appeared
to be perfectly clear, and from the distance of the bifurcation of the
aorta above, which could be distinctly felt, I calculated that the
common iliac was tied exactly at its middle part. All pulsation below
immediately ceased.
The two ends of the ligature were twisted, and the peritoneum replaced
in its proper situation, care being taken that the two small openings
into it should be well covered under the skin, so that they might not
be in the line of the incision, and that they should be covered by
newly divided healthy parts, so that they might thus adhere to each
other. Three strong sutures and three or four smaller ones were put in
through the skin, in order to prevent the parts bursting asunder from
the movements of the patient. This operation was only formidable, as a
whole, from the circumstance that space could not be obtained for the
introduction of both hands; for, strange as it may appear, the safety
of and ease in doing the operation depend on the first incision in the
fore part of the abdomen being so large that the peritoneum containing
the bowels may be freely drawn over by the expanded hands of the
assistant, so that the operator can see what he is doing beneath. In
my first case the whole of the parts under the peritoneum could be
distinctly seen, and several gentlemen (not in the profession) who were
present saw the common iliac artery in its natural situation.
The patient suffered little or nothing from the operation, which was
performed on the Saturday; there was no augmentation of the pulse until
Sunday evening, when it rose to 120; she then experienced some pain,
which was materially diminished, although not altogether removed, by
the abstraction of fourteen ounces of blood. At four in the morning,
Mr. Hancock, now senior surgeon to the Charing Cross Hospital, took
away fourteen ounces more, after which she had not a bad symptom. The
bowels were not moved for the first four days. The temperature of the
limb diminished, but not much, which may be attributed to its having
been constantly rubbed night and day by two persons; and a hot brick,
or bottles of hot water, covered with flannel, having been applied to
the feet, of the temperature of from 120° to 140°. One nurse rubbed the
lower part of the limb, and another the upper, for three days and three
nights; if an interval of a few minutes occurred, a hot flannel was
put on the limb. The friction was very slight, so as not to injure the
cuticle. The patient occasionally dozed a little; still the same gentle
friction was kept up. The ligature came away on the twenty-sixth day
after the operation. The external incision healed very readily, but was
followed, as is usual in all extensive wounds of the muscular wall of
the abdomen, by a slight herniary projection, requiring the support of
an abdominal bandage.
The situation of the ureter and rectum on the left side in this
operation, and of the ureter and cæcum with its appendix on the right
side, should be well understood, and it should be known that the ureter
rises with the peritoneum. The relative situation of the common iliac
artery and vein should be particularly attended to, when passing the
ligature around the vessel. On the left side, the artery lies external
and anterior to its commencement; on the right, the artery passes over
the commencement of the vena cava and the left iliac vein, which do not
follow the peritoneum when drawn toward the opposite side. The bowels
should be thoroughly well evacuated before the operation is performed,
but purgatives should not be given for some days after it has been
done. The food should be liquid, and inflammation should be subdued by
leeches, general bleeding, fomentations, and opium.
219. The _aorta_ may be as readily tied by this mode of proceeding
as the common iliac; and I am satisfied it is in this way such an
operation ought to be performed, provided it become necessary to
attempt it, which I suspect it will not be; for when an aneurism has
formed so high up that it prevents the application of a ligature on
the side on which the disease is situated, the common iliac will be
more readily tied above it, instead of the aorta, by performing the
operation on the opposite or sound side of the body; for as a ligature
can be applied with great ease on the sound side on the middle of
the common iliac artery, it requires very little more knowledge and
dexterity to pass over to the opposite or diseased side, and tie
the artery above the aneurismal tumor, the size of which would have
prevented the operation being done on its own or the affected side.
The placing a ligature on the aorta for an aneurism in the pelvis will
thus be rendered unnecessary--a most important result, deduced from the
operation described.
220. If the _internal iliac_ is to be tied, the operator traces it
downward from its origin, in preference to passing his finger from
the external iliac artery inward in search of it. Having placed the
point of his forefinger on the vessel at the part where he intends to
pass his ligature, he scratches with the nail upon and on each side
of it, so as to separate it from its cellular attachments, and from
the vein which accompanies, but lies behind it. Thus far the operator
proceeds by feeling; but it is now necessary that the sides of the
wound should be separated, and kept apart by blunt spatulæ curved at
the ends, so as to take up as little space as possible, and not to
injure the peritoneum. The surgeon should, if possible, see the artery,
and the ligature carried on the eye of a bent probe, or a convenient
aneurismal needle, should be passed under it from within outward,
when it should be taken hold of with the forceps; the probe or needle
should then be withdrawn, and the ligature firmly tied twice, or with
a double knot. Great care must be taken to avoid everything but the
artery. The peritoneum which covers it and the ureter which crosses it
must be particularly kept in mind. The situation of the external iliac
artery and vein, which have been crossed to reach it, must always be
recollected, and, if there be sufficient space, they should be kept
out of the way, and guarded by the finger of an assistant.
221. The _external iliac_ artery has been so often and so successfully
tied that a description of the two methods of proceeding commonly
adopted will suffice, with a few additional remarks. The first,
recommended by Mr. Abernethy, is in accordance with the operations
on the common, and on the internal iliac. The patient being laid on
his back, with the shoulders slightly raised, and the legs bent on
the trunk, an incision is to be made about three inches and a half in
length in the direction of the artery, terminating over or a little
above Poupart’s ligament. The aponeurosis of the external oblique
muscle will be exposed, and an opening being made into it, a director
is to be introduced, and it is to be slit up to the extent of the
external incision. The internal oblique and transversalis muscles
are then to be “nicked,” so as to allow a director or the point of
the finger to be introduced below them, when they also are to be
divided, the finger separating them from the fascia transversalis
and the peritoneum. The fascia transversalis running from Poupart’s
ligament to the peritoneum is now to be torn through with the nail,
immediately over the pulsating artery, and the peritoneum is to be
separated by the finger, and pushed upward until sufficient room has
been obtained; which in this, as well as in all other operations on the
iliac arteries, is sometimes difficult on account of the protrusion
of the intestines covered by the peritoneum, when the patient is not
sufficiently tranquil. The artery is yet at some depth; it is covered
by a dense cellular membrane, connecting it to the vein on its inside,
which must be torn through with the nail. The anterior crural nerve
is separated from the artery by the psoas muscle, at the outer edge
of which it lies. The aneurismal needle should be passed between the
vein and the artery, and the point made to appear on the outside of the
latter.
In this operation the ligature is placed on the external iliac, above
where it gives off the epigastric and the circumflexa ilii arteries;
as the operation is very much the same as that already described, with
the exception of the incision being shorter and nearer to Poupart’s
ligament, it is obvious, if it were found necessary from disease to tie
the artery higher up, or even to tie the common iliac, that it might be
done by merely enlarging the wound. It is therefore the best mode of
proceeding when the aneurismal swelling in the groin has encroached on
Poupart’s ligament.
Another method has been recommended by Sir Astley Cooper, which is
perhaps more followed where there is little doubt of the artery being
sound.
“The patient being placed in the recumbent posture, on a table of
convenient height, the incision is to be begun within an inch of the
anterior superior spinous process of the ilium, and is to be extended
downward in a semicircular direction to the upper edge of Poupart’s
ligament. This incision exposes the tendon of the external oblique
muscle; in the same direction the above tendon is to be cut through,
and the lower edges of the internal oblique and transversalis abdominis
muscles exposed; the center of these muscles is then to be raised
from Poupart’s ligament; the opening by which the spermatic cord
quits the abdomen is thus exposed, and the finger passed through this
space is directly applied upon the iliac artery, above the origin of
the epigastric and circumflexa ilii arteries. The iliac artery is
placed upon the outer side of the vein; the next step in the operation
consists in gently separating the vein from the artery by the extremity
of a director, or by the end of the finger. The solid curved aneurismal
needle is then passed under the artery, and between it and the vein
from without inward, carrying a ligature, which, being brought out
at the wound, the needle is withdrawn, and the ligature is then tied
around the artery, as in the operation for popliteal aneurism. One end
of the ligature being cut away, the other is suspended from the wound,
the edges of which are brought together by adhesive plaster, and the
wound is treated as any other containing a ligature.”
This method of operating will suffice when the artery is to be tied for
an aneurism which does not extend as high as Poupart’s ligament. When
it does, the operator will be so much inconvenienced by it, while the
sound part of the artery above the tumor will be so much in a hollow
behind it in the pelvis, that a ligature cannot readily be passed
around it; the disturbance to the peritoneum will be much greater, and
much more likely to give rise to peritonitis, than if the incision were
made an inch longer on the face of the abdomen. The surgeon, instead of
searching for the artery, as Sir Astley Cooper has directed, through
the passage by which the spermatic cord quits the abdomen, and thus
passing the fingers directly under the peritoneum, will find it very
much for his own ease, and for the advantage of his patient, to pass
his fingers under the peritoneum from the inside of the wall of the
ilium, from which it readily separates, and thus approach the artery
from the outside instead of from below. He will obtain more room, reach
the artery easily above the origin of the circumflexa ilii, and avoid
that disturbance of the peritoneum, in applying the ligature, which
often leads to inflammation. The ligature should be passed under the
artery from within outward, so as to avoid the vein, which I have seen
injured by passing the needle from without inward.
If the surgeon have unluckily divided the epigastric artery, either in
this or in any other operation, all that he has to do is to enlarge the
incision, and tie both ends of the divided vessel; I have no hesitation
in saying it will not be of any consequence, either in this operation
or in one for hernia.
222. In all cases of aneurism of the gluteal and sciatic arteries,
the internal iliac artery should be tied, instead of an operation on
the part itself. In all cases of wounds of those arteries, which are
the only ones rendering an operation for placing a ligature on these
vessels necessary, the wound should in a great measure regulate the
course of the incision. The operation is an act of simple division,
first through the common integuments for the space of five inches,
then through and between the fibers of the gluteus muscle to the same
extent; a dense aponeurosis covering the vessels is to be next divided,
when the bleeding will lead to the injured vessel. Place the body on
the face, turn the toes inward; commence the incision one inch below
the posterior spinous process, and one inch from the sacrum; carry it
on toward the great trochanter in an oblique direction to the extent of
five inches. Divide the gluteus muscle and the aponeurosis beneath it,
and seek for the artery as it escapes through the upper and anterior
part of the sciatic notch, lying close to the bone. If the vessels
of the gluteus muscle bleed, so as to be troublesome, and cannot be
stopped by compression, they must be secured.
If the sciatic artery be the vessel injured, the incision should be
made in the same direction, but about an inch and a half lower down.
If the course of the wound render it doubtful which artery has been
injured, the incision should be as nearly as possible between the two
lines directed, the wound being always the best guide; care should
be taken in every instance to include nothing in the ligature but the
artery.
Dr. Tripler, of the United States Army, was called to a person who had
fallen backward with great force on a glass bottle, which had thus been
driven into the right buttock, within an inch of the ischiatic notch.
The fingers passed into the wound could be felt on the inside of the
thigh. The man was deluged with blood, and in a state of syncope. The
wound was plugged and bandages applied. Several hemorrhages took place,
and on the thirteenth, five days after the receipt of the injury, the
wound was enlarged, and the gluteal artery tied as it emerged from the
pelvis. The bleeding ceased for three hours, when it returned with as
much force as ever. After various ineffectual attempts to suppress
the bleeding by pressing on the external iliac and femoral arteries,
it was determined to tie the internal iliac, which was done in a very
satisfactory manner, and the bleeding did not return. The man died
three days after the operation, and an examination after death took
place; but, strange to say, no notice is taken, no mention whatever
is made of the wounded vessel. It is simply remarked that the last
ligature was found embracing the internal iliac artery an inch below
the bifurcation, and a firm coagulum already deposited above the point
of ligation.
According to the principles laid down in this work, two errors were
committed in this case. The first, in tying the gluteal artery _as it
emerged from the pelvis_. The second, in tying the internal iliac,
which was unnecessary. The bleeding which caused this operation to
be resorted to is described _as a welling up of the vital fluid_, as
returning _slowly and sluggishly_; the color is not alluded to. It is
probable that the gluteal artery was not divided, but only wounded;
and if the injured part had been sought for, and one ligature applied
above, and another below the wound in it, the hemorrhage would not have
returned, and life perhaps might not have been lost.
The operations were highly honorable to the gentlemen concerned, as
proving their anatomical knowledge. The principle on which they acted I
presume to condemn.
223. Compression should never be made on the femoral artery when a
ligature is about to be placed upon it for aneurism, because the
pulsation is thereby suppressed, and the most important guide to the
vessel is at the same time taken away. When the artery has been wounded
near the groin, and is bleeding, compression must be had recourse to
in the first instance to arrest the hemorrhage; the first incisions
must therefore be made without the information which the pulsation
gives as to the precise situation of the artery, although a finger may
be allowed to rest, or a mark be made on the part, beneath which the
artery could be felt before the pressure was applied. The external
incision should always be made longer or shorter in proportion to the
depth at which the artery is situated. It should be at least one-third
longer in the middle than at the upper part of the thigh; for, while a
long incision always facilitates the subsequent steps of the operation,
it never does harm, unless it is out of all reasonable proportion.
The center of the incision should be, if possible, directly over that
part of the artery on which it is intended to apply the ligature; but
no inconvenience will arise from its being applied nearer its upper
extremity. The patient being laid on his back, and properly supported,
the knee is to be bent and turned outward, by which the head of the
femur will be rolled in the acetabulum, and the femoral artery will be
more distinctly felt at the upper part of the thigh, below Poupart’s
ligament. It lies on the psoas muscle, having the vein on its inside,
and the anterior crural nerve about half an inch on its outside,
having passed between the psoas and iliacus muscles, although some
branches soon approach the artery, and run down on the external part
of the sheath. The relative position of the parts having been duly
considered, an incision is to be made _directly_ in a line over the
pulsating artery, and carried through the skin, cellular tissue, and
superficial fascia, down to the deep-seated or fascia lata of the
thigh. If an absorbent gland should be in the way, it must be turned
aside or removed. The arteria profunda femoris is given off about
two inches below Poupart’s ligament, on the back part of and outside
the femoral, while three or four small vessels spring from half an
inch to an inch below it on the fore part, and one or other of these
may be divided. They are the superficial epigastric, the superficial
pudic, the superficial circumflex of the ilium, and probably an artery
supplying the absorbent glands. If they bleed so as to be troublesome,
they must be secured, more particularly if the femoral artery is to
be tied below them. The fascia lata is now to be divided, with that
part of the fascia transversalis which, descending beneath Poupart’s
ligament, forms the sheath of the artery, when the vessel will be
exposed. In dividing this fascia and sheath, the point of the knife
is always to be directed to the center of the artery, so that if it
be cut by accident it may be seen, when the only result will be the
necessity for the application of a ligature above and one below it. The
artery being fully exposed, as ascertained by the pulsation being felt
by the finger, it is to be separated from its cellular attachment to
the sheath on each side by a blunt or silver knife; and the aneurismal
needle or probe, armed with a strong single thread of dentists’ silk,
is to be passed under it from the inner or pubic side outward, by which
all injury to the vein from the round point of the needle or probe will
be avoided. Two common knots are to be made in the usual manner, when
one thread may be cut off, or the two twisted together and brought
carefully out of the wound; the edges of which are then to be duly
approximated and retained in that situation by sticking-plaster and
a moderate compress, secured in a similar manner. The knee is to be
bent forward to relax the parts, and laid on the outside with a pillow
beneath it.
The needle will pass more easily under the artery if the thigh be bent
on the trunk; before the knots are tied, the surgeon should ascertain
that pressure on the part or artery, which he has nearly surrounded by
the ligature, suppresses the pulsation in the tumor below.
224. The point of a sword entering the anterior part of the thigh two
inches below Poupart’s ligament, and wounding the superficial femoral
artery, will necessitate the application of two ligatures, one above
and the other below the wound in the vessel; but as the profunda under
ordinary circumstances is given off posteriorly at this spot, it is
possible the upper ligature may be placed on the main artery a little
above the bifurcation. The result might, and would probably be, on
some sudden movement of the patient, a recurrence of the hemorrhage by
regurgitation from the profunda into the main trunk below the ligature;
and thus through the wound in the artery, the lower ligature assisting
by the obstacle it offers to the passage of blood through it. In such
a case, the wound should be reopened, and the profunda sought for and
tied. It has been argued that the ligatures, being applied close to
the origin of collateral branches, must fail. This error has been
demonstrated, (Aph. 186,) and need not be further insisted upon. That
it should still be maintained by some surgeons and teachers, who prefer
old jog-trot theories to demonstrated facts, and cannot perceive that
an exception is not a fundamental rule, is much to be regretted.
225. The operation for popliteal aneurism lower down in the thigh is to
be done in the following manner:--
The surgeon, having turned the knee outward and bent the leg inward
into the tailor’s sitting position, to show the course of the sartorius
muscle, should trace the artery from the groin downward, until it
appears to pass under that muscle. The external incision, four inches
in length, made in the course of the artery, should pass over this
point one inch, so that when the fascia lata is divided, the sartorius
muscle may be seen crossing over to the inside at the lower extremity
of the wound. The fascia lata is to be divided upward for the space of
two inches of the incision. The forefinger is then to be introduced
into the wound, and pressure made with it rather outwardly, when it
will readily distinguish the pulsation of the artery, still included in
its sheath. This is to be opened by slight and repeated touches of the
knife directly over the center of the line of the vessel, or it may be
divided on the director, when the artery will be exposed. The point of
the forefinger will easily recognize it from the roundness and firmness
of the feeling communicated by it, as well as by its pulsation; and
the end of the nail, or handle of the scalpel or blunt knife, will
separate it with facility from its attachments, to such an extent as
to admit the blunt point of the solid, unyielding aneurism needle to
be passed beneath it from the pubic side. If the point of the needle
do not readily come through the cellular attachments of the artery on
the outside, this part must be touched lightly with the scalpel, or
rubbed with the nail until the ligature is exposed, which should then
be taken hold of with the forceps and one end drawn out, while the
instrument with the other end is withdrawn. The operator, taking both
ends of the ligature, which has been in this manner passed under the
artery, between the fingers of one hand, presses upon the artery with
the forefinger of the other, so as to arrest the course of the blood in
it, when, if there be an aneurism blow, the pulsation in it will cease.
The ligature is then to be pressed upward as far as the artery has
been detached, and is to be tied with a double knot. The wound is to
be dressed as in the previous case with adhesive plaster and compress,
but without a bandage; and the patient is to be placed in bed, with his
knee bent forward, or resting on the outside, if more agreeable to him.
The operation is done in this manner on that part of the femoral
artery which is not covered by muscle, and all interference with the
sartorious is avoided. It is the improvement on the Hunterian operation
recommended by Scarpa, and ought always to be adopted. This method
obviates all discussion as to placing the ligature on the outside of
the sartorious muscle, or as to the fear of injuring the absorbents;
as to the saphena vein, it can always be seen, and its course traced
up the thigh and avoided. After the first incision has been made and
completed down to the fascia lata, that part is to be divided to the
extent of two inches, but this must be dependent on circumstances; the
object being to obtain a view of the sheath containing the artery,
the opening into which, after the first touch of the knife, may be
completed with the assistance of the director under it. The artery will
be less disturbed in its lateral attachments by an opening into the
sheath, of three-quarters of an inch in length, than by one of half
the extent, as it will admit of the aneurism needle being passed under
it with more facility, and consequently with less disturbance to the
surrounding parts. There is no reason to believe that a free opening
into the fascia of the thigh has ever done mischief, or even one made
in the sheath, provided the artery has not been unnecessarily disturbed.
The warmth of the limb operated upon should be maintained by gentle
friction from the toes upward to the knee; when left at rest it should
be enveloped in flannel. The wound should not be dressed until the
fourth day, the limb being kept quite quiet; the patient should move as
little as possible in bed, and the part of the heel on which the limb
rests should be examined from time to time, as it may under pressure
become gangrenous.
Suppression of the secretion of urine is not uncommon during the first
twenty-four hours after all these operations; it may be gradually
removed by the patient’s taking mild diluent drinks. The constitutional
irritation is frequently great, the pulse rising in forty-eight hours
from 85 to 120; if this continue until the third day, when the fear
of mortification will have passed away, it should be moderated by the
abstraction of a small quantity of blood. In some cases of this kind
I have had occasion to bleed twice, and with the happiest effect,
the pulse having fallen in consequence to its natural standard. The
medicines given at the same time were saline draughts every six hours,
with from four to six or more drops of Battley’s solution of opium. The
ligatures come away on and about the fifteenth day. In many cases they
remain a much longer time without inconvenience.
226. The popliteal artery is never to be secured by ligature, unless
wounded and bleeding. Under ordinary circumstances, an incision should
be made at least three inches long in the course of the wound, the
patient being laid on his face and the limb extended. If the injury
to the artery has been committed where it lies in the ham between the
heads of the gastrocnemius muscle, the bleeding and the pulsation
will point out its situation. The integuments and fascia having been
divided, the posterior saphena vein and nerve, if seen, are to be
avoided and drawn aside, when, by carefully separating some dense
cellular or areolar membrane and drawing the heads of the gastrocnemius
from each other, the bleeding artery will be seen as well as the vein
and nerve. The nerve should be drawn inward with a blunt hook and the
vein carefully drawn outward.
“On the 2d of February, 1855, a young gentleman, aged nineteen, had
a heavy mortising chisel thrown at him, which entered the upper part
of the calf of the leg. There was arterial bleeding, which a man near
him stopped by keeping his finger on the wound. I saw him two hours
after the accident; there was bleeding ‘per saltum;’ presumed that
the posterior tibial was cut. Consulting with two other surgeons, he
was turned over on the table; the limb was distended, and a firm clot
filled up the cavity; I pressed moderately upon either side of the
wound, but there was no return of hemorrhage. The patient was therefore
put to bed, a bandage applied, and an assistant left in charge. The
day following there was less tension in the calf; no hemorrhage.
Having recently read a case by Butcher, in the ‘Dublin Quarterly,’
upon the treatment of wounded arteries by compression, I followed out
his rules. The case did well up to February 13th, when he had a sudden
and severe pain in the calf of the leg, which was much distended, and
the clot pulsating strongly. In a few minutes a large stream burst
out, so large that I was satisfied it could not be from the posterior
tibial. I put my finger in the sinus and found that its direction was
first backward, then backward and upward. I again proposed to dilate
the wound and search for the vessel, when an objection was started by
one of my friends, that if the artery were wounded immediately on its
division, there would not be sufficient space for the clot to form.
As this objection was made, and I failed to combat it, I summoned
the consulting surgeon of the district. After carefully considering
the case, he strongly advised a fair trial should still be given to
compression. Hemorrhage returned upon the 16th. A consultation advised
ligature of the femoral artery, which operation I did. Bleeding
returned on the 25th, and on the 26th I cut down and found a small slit
in the popliteal, and put a ligature above and below it, which saved
the life of the patient.”
227. The posterior tibial, or the peroneal artery, or both, if wounded
at the same time, are to be tied according to the principles laid down
in Aphorism 197, page 231. An incision, from six to seven inches long,
should be made nearer to the inner edge of the leg than to the center,
and should be carried through the gastrocnemius muscle, the plantaris
tendon, and soleus muscle, down to the deep fascia, under which the
arteries lie with their accompanying veins, having the posterior tibial
nerve on the fibular side of the artery. If the incision has been
made in the upper part of the calf of the leg, the peroneal artery
will be exposed by it; but if it be certain that the peroneal artery
is the vessel injured, the incision should be made toward the fibular
side of the leg. When the surgeon has divided the fascia, he will
find this artery covered by the fleshy fibers of the flexor longus
pollicis muscle, at any distance below three inches and a half from
the head of the fibula; these fibers being divided, the artery will be
found close to the inside of the bone. Above that part the artery is
under the fascia, and upon the tibialis posticus muscle. It has not an
accompanying nerve. Both arteries will be readily found by either of
the incisions, if the surgeon be acquainted with their situation.
The posterior tibial artery may require to be tied between the ankle
and the heel. In this situation its pulsation may be felt, and that
will be the best guide to the artery. It has the tendons of the
tibialis anticus, and of the flexor digitorum communis, nearer to the
malleolus than itself, and distant about a quarter of an inch; there is
a vein on each side of the artery. Posterior to this is the posterior
tibial nerve, and nearer the heel the tendon of the flexor longus
pollicis. To tie the artery near the heel, its pulsation should be
felt, and an incision more than two inches long made upon it, through
the common integuments and superficial fascia; a strong aponeurosis
will be found beneath, covering the sheath of the vessels and adhering
to the tendons. This aponeurosis must be carefully opened on a director
passed beneath it, and then the sheath of the vessels: the artery
should be tied with a single ligature, unless wounded. The nerve is
nearer the heel.
The posterior tibial artery may be tied a couple of inches higher up in
the small part of the leg, by making the incision on the tibial edge of
the soleus muscle, under which it lies.
228. The posterior tibial artery, an inch and a quarter or from that
to an inch and a half below the inner ankle, gives off the internal
plantar artery, and assumes the name of external plantar. The internal
and smaller artery passes forward on the inside of the foot, under the
origin of the abductor pollicis, to the outer or metatarsal side of the
great toe.
The external plantar artery, from the point of division, takes a course
curved toward the heel to the metatarsal bone of the little toe, which
is prominent, being a distance of about three inches; during this
course it is covered by the integuments, lateral ligament of the joint,
a quantity of granular fat, the thick plantaris fascia, the origin of
the abductor of the great toe, and the flexor brevis of the other toes.
The artery may then be felt and seen near the os calcis, having the
nerve and vein to the inner side; and lying on the accessorius muscle
and its fascia, at the depth, in ordinary cases, of about an inch and a
half. The plantar fascia extends in considerable strength from the os
calcis forward to the toes, and divides into two portions opposite the
first phalanx of each, which are inserted laterally into the sheaths
of the flexor tendons, and the sides of the ligaments connecting the
phalanges to the metatarsal bones. This fascia should, when necessary,
be slit up at the part injured, or a bent probe forcibly passed under
it to the required extent, when any intervening muscular fibers should
be divided until the bleeding point is perceived, when a ligature
above and another below the wound should be placed upon the artery.
The external plantar artery, on reaching the metatarsal bone of the
little toe, runs forward, in nearly a straight line, between the middle
and outer divisions of the plantar fascia, the section of which will
expose it as far forward as the end of the metatarsal bone.
229. The anterior tibial artery is to be tied at that part of its
course at which it may be wounded. When the operation is done for
aneurism, it should be performed a short distance above the tumor,
and sometimes a second operation below it will become necessary. If
the aneurism should be situated so high up and so close to the origin
of the vessel as not to admit of a ligature being applied anterior to
the interosseous ligament, it may be placed on the femoral artery of
the thigh, and the result awaited. If it appeared likely to succeed at
first, and yet the pulsation returned, the artery should be tied below
the tumor, because the return of pulsation would probably depend on the
blood regurgitating into the vessel.
In order to tie the anterior tibial artery after it has passed from the
back to the fore part of the leg through the interosseous space, and
over the interosseous ligament, and for one-third of its descent toward
the instep, draw a line from the head of the fibula to the base of the
great toe, which will nearly describe its course. An incision four
inches in length is to be made in this line down to the fascia covering
the muscles; if the foot be bent upward, and again extended, the
bellies of the tibialis anticus and extensor digitorum communis muscles
will be more distinctly seen. The fascia is to be divided for the whole
length of the incision between them; they are then to be separated for
the same distance by the scalpel and the finger; the artery will be
found close on the interosseous ligament, between its two venæ comites.
A case has been supposed, in which a knife, a sword, or other narrow
instrument, having penetrated the upper part of the leg, has wounded
the anterior tibial artery just after it has been given off from the
posterior tibial, behind the interosseous space or ligament. The
bleeding is free, and from the wound in the front of the leg, although
the artery cannot be secured, from the narrowness of the space between
the tibia and fibula, behind which space it is situated. This very
peculiar injury, which may, however, occur at any time, cannot be
known until an incision has been made on the fore part of the leg, and
the bleeding point seen so deep between the bones as not to admit of
two ligatures being placed on the artery above and below it. In such
a case, an incision is to be made through the calf of the leg, when
the artery can be secured without difficulty. No great inconvenience,
it is apprehended, would result from the two operations. If the sword
wound should have been a small one, although deep, compression on its
surface would in all probability have been had recourse to in the first
instance; which, while it prevented the flow of blood externally, would
scarcely impede its effusion above the fascia and under the soleus
muscle, the distention of which and of the calf of the leg would, to a
careful observer, point out the evil, and lead to the operation being
done in the first instance through the calf of the leg.
In the middle third of the leg the origin of the extensor proprius
pollicis intervenes between the tibialis anticus and the extensor
communis digitorum muscles. The anterior tibial nerve, a branch of
the peroneal, attaches itself to the artery a little above this
middle part, and is usually found in front of it, although it is not
constantly in that situation: care should always be taken to avoid it.
In the lower part of the leg the artery lies on the tibia, having
the tendons of the extensor digitorum communis on the outside, and
that of the extensor proprius pollicis on the inside, by which it is
overlapped, being also covered by the fascia and the integuments.
On the instep this artery runs over the astragalus, the naviculare,
and the os cuneiforme internum, to the base of the metacarpal bone
supporting the great toe. It here divides into two branches: one
dips down between the first and second metatarsal bones, to join the
terminating branch of the external plantar artery, rendering the
collateral circulation free; the other passes on to the inside of the
great, and the opposite sides of the first and second toes. The artery
is always to be found on the fibular side of the tendon of the extensor
proprius pollicis.