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

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.

LECTURE XV.

THE COMMON CAROTID ARTERY, ETC.

230. The carotid artery may be tied, in almost any part of its course, in the following manner: The patient being seated, with the shoulders supported, so that the light may fall on the neck, the head is to be bent a little forward, to relax the muscles on the fore part. An incision is then to be made on the line of the inner edge of the sterno-cleido-mastoideus muscle, by which the integuments, the platysma myoides, and the superficial cervical fascia are to be divided. The extent of this incision, in persons with long necks, may be from a line beginning parallel with the cricoid cartilage to within about half an inch of the sternal end of the clavicle: when the neck is very short, it must be begun as high up as the lower edge of the thyroid cartilage, so as to be as nearly as possible three inches in length. The sterno-cleido-mastoideus muscle is then to be drawn outward, with any vein which may be seen attached to its under edge. The pulsation of the artery under the finger will point out its situation, and the sterno-hyoideus and sterno-thyroideus muscles being drawn and kept inward, the omo-hyoideus will be seen crossing in the upper part of the hollow thus formed by the separation of these parts. The central tendinous portion of this muscle is attached and fixed by the deep cervical fascia, and lies immediately over the sheath of the vessels, particularly over the jugular vein. This fascia, which is strong although thin, is to be carefully divided below the muscle, immediately over the center of the artery, the position of which is to be accurately ascertained by the finger. At or beneath the same spot, the sheath of the artery is to be opened; and the long, thin nerve, the descendens noni, which runs upon the sheath, will at this part be seen inclining to the tracheal side of the artery. It is to be separated and drawn inward with the muscles. If the sheath of the artery be carefully opened immediately over its center, the jugular vein will scarcely interfere with it. But as it has been known to enlarge suddenly under the exertions or excitement of the patient so as to overlap the artery, it has been recommended to make gentle pressure on the vessel at the upper part of the incision, and below if necessary, in order to prevent that occurrence. The aneurismal needle is then to be introduced and passed under the artery from without inward, by which the jugular vein and the par vagum nerve will be avoided, more particularly if the sheath of the vessels has been undisturbed, save where it has been opened immediately over the artery. The point of the aneurismal needle is to be brought out close to the inside of the artery within its sheath, by which means all danger will be avoided of injuring either the recurrent or the sympathetic nerves which lie behind or to the inside of it. As to the œsophagus, thoracic duct, or thyroid artery, they are not likely to be injured by any common operator; but he should be aware that on the left side, if he be obliged to operate low down, he may meet with greater inconvenience from the jugular vein, which is more anterior to the artery, and rather overlaps it, while on the right side it inclines outward from it.

The carotid artery may be tied higher up in the following manner: The incision in this instance should be begun a little below where the former one was commenced, and should be continued upward for the same length of three inches, in a line extending toward the angle of the jaw. The head should be laid back to enable this to be done, and ought to be kept in that position by an assistant. The artery at this part of the neck is covered by the integuments, the platysma myoides muscle, and the fascia. After the muscle has been divided, the strong fascia must be carefully raised with the forceps and opened, and the operator will do wisely if he divide it upward and downward on a director. With the end of the scalpel or a blunt knife he should separate the cellular tissue from the veins, which appear in this situation, and are often the source of much embarrassment. The sheath of the artery is to be opened over the center of the vessel, and the ligature is to be passed around it as before. The descendens noni nerve runs in general on the outside of the artery in this part of the neck, and afterward crosses over to the tracheal side. The par vagum, which lies in the angle formed posteriorly by the apposition of the carotid artery and jugular vein, to which latter it is more particularly attached, is to be avoided on introducing the aneurismal needle; and on bringing it out on the inside, the same attention must be paid to prevent injury to the great sympathetic or any of its branches. The surgeon in both these operations should draw the ligature first a little outward and then inward, so as to enable him to ascertain that he has included in it nothing but the artery, which is to be tied with two knots; one end may be cut off, or both may be twisted together, and brought out of the wound opposite where the vessel has been tied. The integuments should be accurately closed by adhesive plaster, and the patient put to bed with the head bent forward, and properly supported. He should eat as little solid food as possible until after the ligatures have come away, and observe even greater precautions as to quietude than in other instances.

231. The external carotid artery may be tied by an operation conducted in a similar manner. After the first incisions have been made, and the strong cervical fascia divided, the operator must feel for the pulsating vessel, which will be found on a line parallel with the cornu of the os hyoides, below which part the common trunk usually divides into the external and internal carotids, the external being the more superficial and internal of the two at their origin. The external carotid turns with its convexity inward; nearly opposite to but rather above the os hyoides it is crossed by the ninth or lingual nerve, the digastric and stylo-hyoid muscles; it should be tied below this part.