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.