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

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.