Commentaries on the Surgery of the War in Portugal, Spain, France, and the Netherlands / from the battle of Roliça, in 1808, to that of Waterloo, in 1815; with additions relating to those in the Crimea in 1854-55, showing the improvements made during and since that period in the great art and science of surgery on all the subjects to which they relate.

by G. J. Guthrie

LECTURE XIV.

LIGATURE OF THE COMMON ILIAC ARTERY, ETC.

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.