But the situation in which it is at present generally considered most eligible to expose the artery for the application of a ligature, when circumstances do not forbid a choice, is that recommended by Scarpa, viz. in the upper third of the thigh, and in the first stage of the artery's course as described in the account of the anatomical relations of the vessel. In his description of the details of the operation, Scarpa directs thus : " The surgeon pressing with his fore-finger will explore the course of the superficial femoral artery, from the crural arch downward, and when he comes to the place where he does not feel any more, or very confusedly, the vibration of the artery, he will there fix with his eye the inferior angle or ex tremity of the incision which he proposes to make for bringing the artery into view. This lower angle of the incision will fall nearly on the internal margin of the sartorius muscle, just where this muscle crosses the course of the femoral artery. A little more than three inches above the place pointed out, the surgeon will begin his incision and carry it along the thigh in a slightly oblique line from without inwards, following the course of the femoral artery as far as the point fixed with the eye." By this incision the skin and cellular substance are to be divided, and the fascia lata exposed, " then with another stroke of the bistoury, with his hand free and unsupported, or upon a furrowed probe, he will divide along the thigh, and in the same direction as the external wound the fascia, and introducing the fore-finger of his left hand into the bottom of the incision, he will imme diately feel the strong beating of the artery, and this without the necessity of removing the in ternal margin of the sw-toriusfrom its position, or at least very little. With the point of the fore-finger of the left hand already touching the artery, the surgeon will separate it from its lateral connexions and from the vein;" after which the ligature is to be carried round it by means of a blunt aneurism-needle. The author has introduced the preceding account in order to fix the precise situation of the operation as performed by Scarpa, because it appears to him that it has been to a certain degree lost sight of, and also to direct attention more strongly to the advantage proposed by that distin guished surgeon in the adoption of the method which he has recommended. A very brief consideration of the descriptions given by se veral writers* of the proceedings to be adopted in the operation of taking up the artery in the upper part of the thigh will suffice to show either that Scarpa's method has been con founded more or less with the operation at a lower point, or that its advantages have been disregarded: thus, while it is stated that the part of the limb in which the femoral artery can be tied with the greatest facility is between four and five inches below Poupart's ligament, and which is Scarpa's point,t the displacement of the sartorius is accounted a part of the ope ration, and it has even been debated whether the incision should not be made on the outer edge of the sartorius, and the artery exposed by drawing the muscle inward ; but the dis placement of the sartorius is not only not a necessary part of Scarpa's plan, but is that particular the avoidance of which he proposed to himself by the method he selected ; from whence it will appear that the operation, as described in the accounts alluded to, refers, strictly speaking, to the second and not to the first third of the vessel's course, within the latter of which it must be performed in order to avoid the sartorius. The structures to be divided in this operation are, 1. the skin, 2. the subcutaneous cellular structure, 3. the fascia late, forming the anterior wall of the femoral canal. The extent of the superficial incisions need not exceed three inches, com mencing above either according to the rule of Scarpa or about two inches below Poupart's ligament : the direction in which they should be made ought to correspond as nearly as pos sible with the course of the artery. The extent to which the fascia lata is to be divided is stated differently by different writers : by some it is directed to be divided to the extent of about an inch : the direction of Scarpa is not precise upon the point in the text, though it is plain that he intended it should be divided to a much greater length than an inch, but in a note it is strongly insisted that the division of the fascia should correspond in extent to that of the external wound. Two reasons present for this : I. greater facility in the performance of the operation, and less disturbance in con sequence to the artery ; 2. the avoiding the injurious effects which must be produced by the confinement consequent upon too limited a division of the fascia in the event of the supervention of inflammation. It cannot be doubted that a division of an inch is altogether too short to meet those considerations, and that the fascia ought to be divided to a greater ex tent ; on the other hand it does not appear that advantage would be gained by so free a divi sion as that recommended by Scarpa ; and the rule of Guthrie seems the best calculated to ac complish the ends in view : he advises the fascia to be divided for the space of two inches. The division may be effected either with or without the assistance of the director. It will be well to recollect here that, at the point at which the sartorius is about to overlap the artery, a du plicature of the fascia takes place in order to enclose the muscle, and hence that, if the opening of the canal be attempted at the lower extremity of the stage, and close to the muscle, two layers of the fascia may require to be di vided before this purpose can be accomplished. The femoral canal having been opened by the division of the fascia lata, the next step in the operation is the division of the proper sheath of the vessels and the insulation of the artery. Previous to this, should the internal genicular nerve be found to cross the canal superficial to the artery at the part, at which the vessel is to be detached from the contiguous parts, it should he separated and drawn outward. The insulation of the artery Scarpa recommends to be effected with the finger, raising the vessel from the wound even along with the vein if necessary ; such a proceeding, however, must be very objectionable, as inflicting great dis turbance and violence upon the artery. It is to be recollected that in order to insulate the artery it is necessary to divide or lacerate the investment, which immediately encloses the two vessels and connects them to each other, and which has been elsewhere denominated the, femoral sheath ; this, though thin, is dense, and is to be expected to offer resistance to the separation of the artery from the vein: the best method of effecting this, as it seems to the author, will be, after having opened the sheath directly over the centre of the artery either by a touch of the knife or first nipping up a part of it with the forceps ; making an aperture into it with the blade of the knife held horizon tally, and extending the opening upon a di rector to the length of " three-quarters or an inch," as recommended by Guthrie ; then with the forceps to take hold of each portion of the sheath in turn and drawing it to its own side, outward or inward as the case may be, to de tach the artery from it with the extremity of a director or of the aneurism-needle, moving the extremity of the instrument gently upward and downward at the same time that the vessel is carried, by means of it, in the opposite direc tion from the side of the sheath which is in the forceps ; by this proceeding the artery may be easily and safely insulated almost, if not quite, round, and with little if any disturbance to it. That done, the needle and ligature may be carried round the artery: the performance of this, which is the most delicate step in the operation, will be found much facilitated by the separation of the artery as recommended ; in fact, little more will then remain than to pass the needle, the passage having been al ready opened. In doing so it will be well to hold the inner portion of the sheath, with the forceps, inward and backward, by which the vein will be drawn away from the artery, and at the same time to insinuate the blunt extre mity of the aneurism-needle round the artery from within outward, because of the situation of the vein, moving it, if any obstruction be encountered, upward and downward, while it is also carried forward, and bearing the artery somewhat outward with it at the same time; when the extremity of the needle has appeared on the outside of the artery it may be liberated, if necessary, by a touch of the scalpel upon it. In the execution of this manoeuvre two acci dents are to be avoided, viz. injury of the vein, and inclusion of the saphenus nerve: the close juxtaposition and attachment of the former to the artery render much care neces sary to leave it uninjured; but the proceeding recommended will, if carefully executed, cer tainly preserve it from being wounded. The
saphenus nerve is here on the outside of the artery, and might be included within the liga ture if the extremity of the needle were carried too far outward; the operator should therefore assure himself, before tying the ligature, that the nerve has not been included; but the risk of this accident ought not to be great at this part of the artery's course, certainly not so much so as at a lower point, inasmuch as the nerve has as yet hardly entered the femoral canal, and is therefore separated from the ar tery by more or less of its outer wall; and with the precautions recommended in insulating the vessel and passing the ligature it will almost certainly be excluded at every part : the possi bility of the accident is, however, not to be lost sight of. The needle having been carried round the artery, the ligature is to be taken hold of with the forceps, and one end drawn out, after which the needle is to be withdrawn. The advantages of the part chosen by Scarpa for this operation are numerous and obvious : 1. the artery is nearer to the surface and has fewer coverings; there is therefore less to be divided in order to bring it into view; 2. the vessel being more superficial, its pulsations can be more distinctly felt and its course ascer tained previous to operation, a guide wanting in the lower parts of the thigh ; 3. " the ope ration is done," as Guthrie observes, " on that part of the artery which is not covered by muscle, and all interference with the sartorius is avoided: this method obviates all discussion as to placing the ligature on the outside of the muscle." The plan of cutting upon the out side of the sartorius in the upper stage of the artery must be, if contemplated by any, a pro ceeding hardly defensible in the ordinary dis position of the muscle, for all the reasons ad vanced already against its use in the second stage apply with much greater force to it in the former case ; but it is at the same time to be observed that the distance of the point at which the muscle crosses the femoral artery is not ab solutely regular, and that great deviation in this respect might render it necessary even to cut upon the outer margin of the muscle in order to expose the artery in the first third of its course. The distance from Poupart's liga ment at which the muscle ordinarily crosses is, according to the stature, from three and a half to five inches, but it may in certain cases be found to cross so much sooner that the artery could not be exposed below the origin of the profunda without displacing the muscle ; thus Burns* mentions that he has seen, in conse quence of malformation of the pelvis, the artery covered by the muscle, before it had reached two inches below the ligament, and the author has witnessed the same from retraction of the thighs, consequent apparently upon long con finement to bed ; in the latter case it would certainly have been more easy to expose the vessel from the outer than from the inner side of the muscle; but such cases are to be re garded only as exceptions to be borne in mind, but not to influence our general conduct.
4. The performance of the last and most de!i cate parts of the operation must be much more easy and less embarrassed, the interference of the sartorius being avoided; while, on the other hand, all apprehension on account of the pro funda is removed, since that vessel seldom, if ever, arises farther than two inches from Pou part's ligament, and the course of the case after operation is more likely to be favourable and exempt from untoward occurrences, since much less violence must be done, and the superven tion of injurious inflammation or its conse quences thereby prevented.
The operation for taking up the femoral ar tery above the origin of the profunda is not often required, and, except in case of wound, may pro bably give place altogether to that of tying the external iliac : it presents no advantage over the latter, it does not promise more successful results: should secondary hemorrhage succeed to it, there is little prospect that the ligature of the iliac would afterward succeed, and the uncertainty existing with regard to the point of origin of the profunda raises a very strong ob jection against it, inasmuch as we cannot know whether the origin of that vessel be above, below, or at the point at which the ligature is to be applied: it is further exposed to the difficulty, before adverted to, which is likely to arise in cases of high origin of the profunda, in which that vessel may be taken for the femoral, and thus another source of embar rassment be encountered.
In the performance of it the following struc tures will present: 1. the skin ; 2. the subcu taneous cellular stratum along with the inguinal glands and the superficial inguinal vessels of the latter: those which are most exposed to be divided are the superficial epigastric and its branches ; the superficial anterior iliac and the superficial pudics may be encountered, but they are less likely; 3. the superficial lamina of the iliac portioo of the fascia lata; and 4. the prolongation of the fascia transversalis, which forms the front of the femoral sheath.
An incision three inches long will suffice; it should commence above Poupart's ligament, and be continued in the line of the vessel for two inches below it.
If the superficial vessels bleed, on division, so much as to interfere with the course of the operation, they should be at once secured; otherwise they will probably cease themselves, and give no further trouble.
The lymphatic glands, if in the way of the incisions, may be either held aside or removed. The fascia lata and sheath may be treated in the same manner as in the other operations described; they can be easily distinguished in consequence of the thin stratum of fat which is usually interposed.
The insulation of the artery and the passage of the needle require the same precautions as in the operations at other parts of the vessel's course. The vein being placed along the inside of the artery the needle should be passed from that side.
The crural nerve and its branches are here altogether safe, as they lie without the femoral canal, but, as has been before pointed out, the crural branch of the genito-crural nerve may be included in the ligature; it will be most certainly avoided by the careful insulation of the artery: the operator should also assure himself, before tying the ligature, that no fila ment is enclosed.
Should two arteries present, as described in the anatomy of the profunda, and a question arise as to which is the femoral, the criteria pointed out will enable the operator to decide (see profunda artery); and the difficulty will, almost certainly, be altogether avoided by cut ting directly upon the centre line of the femoral as ascertained by its pulsations.
Operation on the prifunda artrry.—From the anatomical details it follows that in the ma jority of cases the profunda is situate, in the first stage of its course at least, at the outer or iliac side of the femoral artery, though upon a plane posterior to that vessel : it has also, at the same time, the same coverings, differing only in being contained in a sheath proper to itself; and hence, if necessary, the profunda might be reached in that situation by an opera tion similar to that for exposing the femoral itself at the same place, in which much advan tage would be obtained by first exposing the latter vessel, and following it as a guide to the origin of the former ; which, if in its usual situation, will be exposed by displacing the femoral inward, and then the proper sheath of the profunda should be opened to a certain ex tent, in order to allow the application of the ligature at a sufficient distance from the origin of the vessel. But in the inferior stages of its course it may be laid down, as a general rule, that it cannot be reached from the front of the thigh, inasmuch as, with the exception of those cases in which it is throughout external to the femoral, and in which, from its deep position and the want of a guide to its exact situation, the rule will yet equally apply, it is not only more deeply seated, but it is separated from the anterior surface of the limb by the super ficial femoral artery, and by the femoral, pro funda, and circumflex veins, as well as by the coverings of the femoral vessels, and lastly by the adductor longus muscle. In any case, did circumstances render necessary the attempt to tie the profunda, it would be an operation in which much uncertainty and difficulty must be anticipated, in consequence of the varieties presented by that artery in its origin and course.
For Bibliography see ANATOMY (INTRODUC TION), and ARTERY.
( B. Attack.)