Part 27
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.
LECTURE XV.
THE COMMON CAROTID ARTERY, ETC.