The most improved method of securing the su perficial femoral artery for popliteal aneurism, is that recommended by Walker, which appears pre ferable to that of Abernethy, Sir A. Cooper, Hodgson, C. Bell, Shaw, C. Hutchinson, Harrison, or Averil. To prove the necessity of measurement in this and all other operations for aneurism, the reader is referred to an unusual distribution of the superficial femoral artery operated on by C. Bell, and described in Journal of Medical Science, vol. iv.; also to Tiedemann, Barclay, Turner, Harrison, and Lizars's anatomical works.
The patient should be placed on a firm table, with the feet at right angles to each other, but the affected separated from the sound limb. The space between the anterior superior spinous pro cess of the os ilium and the spine of the os pubis is to be divided into ten proportional parts, when five and a half measured from the pubes are made the base of an equilateral triangle, which is to be con structed downwards on the thigh, the apex being therefore distal, the base proximad; and the outer or iliac side of this triangle should be extended downwards from the apex twice its length, when the artery will be found to run beneath this line throughout. An incision should then commence at the apex of the triangle, and be continued down the thigh proportionally to the depth of skin and cellular substance of the patient, the latter of which is often infiltrated with serum; a second incision, equal in length to the first, should cut through the fascia lata, and this cautiously, when the pulsation of the artery will be felt; the artery is then to be denuded to the smallest possible extent of its cellular sheath, the latter of which is to be held up with the dissecting forceps in the left hand, and the scalpel in the right held parallel to the vessel, with its cutting edge pointing outwards or fibulad. The operator seeing satisfactorily the artery, vein, and nerve or nerves lying together, inserts the aneurismal needle, delineated in Fig. 5, Plate DXV. armed with a ligature, on the inner or tibial aspect, between the artery and the vein, and carries it round to the fibular aspect, as depicted in Fig. 2 of Plate DXVII. securing the artery with a single ligature of common unbleached linen thread, waxed and tied in the manlier of the reef-knot of the sailor; and both ends of the ligature ought to be cut off close to the knot, and the lips of the wound approximated with adhesive plaster; the limb rolled with an eighteen-tailed flannel bandage (see Fig. 4, Plate DXVIII), from the toes to the groin, and applying an ordinary sized compress in the course of the artery from a little above its point of securement downwards, for five or six inches, and a larger one over the sac in the poples. The chief points to be attended to in operations for aneurism are, making clean free incisions, disturbing or in sulating the artery as little as possible, and seeing distinctly the contiguous veins and nerves before throwing the ligature around; and if any nervous threads, as the nervus saphenus, so interfere as to impede the application of the ligature, they should be divided without hesitation. The surgeon judges
of the artery being secured by the tumour becoming flaccid, and being divested of pulsation, with a diminution of the pain; and soon afterwards by a strong pulsation of the articular arteries. In the majority of cases, the temperature of the limb is rather higher after than before the operation. When an artery is thus secured, the ligature di vides its muscular and serous tunics, the vessel shrinks, coagulable lymph is effused, and the ad hesive inflammation excited, by which its sides and the wound throughout unite. Some days, or even weeks afterwards, we have known it six weeks, the noose or knot thus left behind, excites the most trifling degree of suppuration, the matter of which is chiefly absorbed, and advances slowly, and unfelt by the patient to the skin, like a plant growing to the light, and appearing like the smallest possible pimple, is ultimately discharged, the patient fre quently not observing it.
Various kinds of ligatures have been invented and used, such as fine silk, inkle, dentist silk, twine, tailor's twist, catgut, and other animal matters, but one and all are ejected, consequently that which is smallest in diameter, and of sufficient strength is the hest, and therefore we prefer un bleached linen thread, waxed. Mr. Fielding of Hull, has lately employed silk-worm-gut, and found it to be absorbed, but Dr. Crampton lost a patient in consequence of using it. If the operator should insulate the artery too great an extent, and thus cut off its connection with the contiguous structures, and destroy many of its vasa vasorum, he ought to throw two ligatures around it, at sufficient distance from each other, and divide the artery between them. if he wounds an arterial branch during the operation, it should be secured with a ligature as in ordinary operations. The wound is to be dressed on the third day, and every day afterwards until healed; the patient to remain quiescent in bed on low or farinaceous diet, until the wound is quite consolidated, avoiding every exertion, even in the change of his linens, which ought to be made to slip on and off so as to occasion the least possible disturbance, and using a urinal and bed-pan when required; three weeks at the very least should be allowed to transpire, before allowing him to sit up in bed, and to have more nourishing food, but even this only provided the wound be healed. The patients of Mott and Graefe, wherein the arteria in nominata was secured, evidently fell victims to their being allowed to walk about too early. In such large arteries, and so near the source of the circu lation, the patient should be kept in the horizontal attitude, on farinaceous diet, between three and four months.