A Manual of the Operations of Surgery. Joseph Bell
causing gangrene from want of vascular supply, or, on the other, expose the vein to the danger of injury by the aneurism-needle in their attempts to force it round an uncleaned vessel.
The needle should in most cases be passed from the inner side, care being taken to avoid including the vein which is on the inner side and behind the vessel; the internal saphenous nerve, if seen, should be avoided. The needle must not be passed quite round the vessel raising it up, still less must the vessel be held up on the needle, as used to be done, as if the surgeon was surprised at his own success, but the needle should be passed just far enough to expose the end of the ligature, which must be seized by forceps and cautiously drawn through. It must then be tied very firmly and secured with a reef knot.
The edges of the wound must be brought into accurate apposition, and secured by one or two stitches. If antiseptics are used, drainage should be provided for.
From the very fact that ligature of the superficial femoral is a remarkably successful operation in causing consolidation of the aneurism and a rapid cure, there is also a corresponding danger that the limb be not sufficiently supplied with blood at first. The limb may very possibly become cold, and remain so for some hours at least after the operation. To avoid this as far as possible, it should be wrapped in cotton wadding, and very great care should be taken that it be not over-stimulated by hot applications, friction, or the like, any of which measures might very likely excite reaction, which would result in gangrene.
Complete rest of the limb and of the whole body must be enjoined; the food must be nourishing and in moderate quantity. The chief danger is from gangrene of the limb, which is especially apt to result when the vein is wounded, or even too much handled during the operation.
When properly performed, and in suitable cases, the operation is very successful. Mr. Syme tied this artery for aneurism thirty-seven times, and of these every one recovered. The statistics of Norris and Porta, who collected all the cases in which ligature of the femoral had been employed for any cause, show a mortality of somewhat less than one in four. Rabe's table up to 1869 with the additional cases collected by Mr. Barwell to 1880 gives 297 cases with 53 deaths.9 Mr. Hutchinson's table, again, of fifty cases collected from the records of Metropolitan Hospitals, shows the very startling result of sixteen deaths out of the fifty cases, or a mortality, in round numbers, of one-third.
Certain anomalies have been observed in the distribution of the femoral vessels, of some importance as affecting the possibility of applying, and the result of, ligature; such as—1. A high division of the branches which afterwards become posterior tibial and peroneal. 2. A double superficial femoral, both branches of which may unite and form the popliteal, as in Sir Charles Bell's well-known case. 3. Absence of the artery altogether, as in Manec's case, where the popliteal was a continuation of an immensely enlarged sciatic.
In such a case the absence of pulsation in front, and the presence of increased pulsation behind the limb, ought to prevent any fruitless attempt at search.
Ligature of the Superficial Femoral below the Sartorius Muscle.—This operation, though once common in France, and though the one recommended by Hunter himself, is now comparatively little used in this country; and rightly so; for while it has no advantage over the upper position, it is at once nearer the seat of disease, and the vessel is more deeply buried under muscles, and has a more distinct fibrous sheath, which requires division.
It is, however, by no means a difficult operation, and is thus performed:—
The limb being laid as before on the outside, and slightly bent, the skin shaved and the pulsation of the artery detected, an incision (Plate I. fig. 6) must be made from the lower edge of the sartorius muscle just as it crosses the vessel, along the course of the vessel, avoiding if possible the internal saphena vein.
The sartorius when exposed must be drawn inwards. The fibrous canal filling the interspace between the abductor magnus and vastus internus is then recognised, and must be fairly opened; the artery is now seen lying in it, and over the vein which is posterior to it, but projects slightly on its outer side; the internal saphenous nerve is lying on the artery. The needle is best passed from without inwards so as to avoid the vein. The anastomotica magna is sometimes a large trunk, and has been mistaken for the femoral in this situation, and tied instead of it.
Ligature of the Popliteal.—This operation is now hardly ever performed for aneurism, ligature of the superficial femoral having quite superseded it, and it is very rarely required for wounds, from the manner in which the vessel is protected by its position.
Before the invention of the Hunterian principle of ligature at a distance, the old operation for popliteal aneurism consisted in cutting into the space, clearing out the contents of the aneurismal sac, and tying both ends of the vessel; from the depth of parts and the close connection of the popliteal vein, this operation was very rarely successful, and is now quite given up. If the vessel is wounded the bleeding point is the object to be aimed at, and is generally sufficient guide.
In cases of hæmorrhage for suppuration of an aneurismal sac, it might possibly be advisable, and there are certain cases of rupture of the artery, without the existence of an external wound, in which attempts have been made to save the limb by tying the vessel.10 From the complexity of the parts, the numerous tendons, veins, and nerves crowded together in a narrow hollow, and chiefly from the great depth at which the artery lies, any attempt at ligature is very difficult. It is least so at the lower angle of the space, where, between the heads of the gastrocnemius, the vessel comes more to the surface, but is still overlapped by muscle.
Operation.—The patient lying on his face, a straight incision (Plate III. fig. 1), at least four inches in length, should be made over the artery, and thus nearer the inner than the outer hamstring; a strong fibrous aponeurosis will require division after the skin and superficial fascia are cut through, the limb is then to be flexed, and the tendons drawn aside with strong retractors; fat and lymphatic glands must next be dissected through, and then the vein and artery, lying on a sort of sheath of condensed cellular tissue, are seen, the vein lying above the artery and obscuring it. The vein must be drawn to the outside, and the thread passed round the artery, which lies close to the bone, on the ligamentum posticum of Winslowe.
It is a very difficult subject to decide what operations should be described in a work of this character, on the vessels of the leg and foot. A very large number of distinct methods of operations on the various parts of the three chief arteries of the leg have been described by surgeons and anatomists, but specially by the latter.
The fact is, however, that these complicated procedures are rarely required, for aneurisms of the arteries of the leg and foot are almost unknown, while in cases of wound of the vessel, or rupture resulting in traumatic aneurism, the proper treatment is not to tie the vessel higher up, but by dilating the wound and clearing out the clots, if required, to secure the bleeding point, and tie the vessel above and below.
Again, a wound of the sole of the foot often gives rise to very severe and persistent hæmorrhage, while the fasciæ and complicated tendons render ligature of the vessel at the spot very difficult; yet ligature of either the anterior or posterior tibial would probably be insufficient; and to tie both these vessels, with possibly the peroneal and interosseous as well, would be a much more severe and dangerous procedure than ligature of the superficial femoral; while probably careful plugging of the wound, combined with flexion of the knee, will be found to stop the hæmorrhage sooner than either of the more formidable methods.
A competent knowledge of the anatomy of the part, and of the ordinary methods of checking hæmorrhage, such as ligatures, graduated compresses, and styptics, aided by position, specially flexion of the knee after Mr. Ernest Hart's method, will suffice to enable the surgeon to check any hæmorrhage of the foot or leg, without it being necessary to burden the memory with the three positions in which to tie the peroneal, or the various methods, more or less bloody and tedious, by which the posterior tibial in its upper third may be secured.
Note.—While, as a matter of surgical principle to guide our practice on the living, I still hold very strongly the opinions here expressed