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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Popliteal.This operation is now hardly ever performed for aneurism, ligature of the superficial femoral having quite superseded it, and it is very rarely required for wounds, from the manner in which the vessel is protected by its position.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 against special operations for ligature of the arteries of the leg, and allow the sentences to stand as in the first edition of this work, I insert in a note a brief description of the more important ones, in deference to the advice of friends and the urgent request of pupils, as these operations are used by Examining Boards as tests of the operative dexterity of candidates:
1. Anterior Tibial Artery in lower half of Leg.Anatomical Note.This vessel is related on its tibial side to the tibialis anticus, and on its fibular, to the extensor longus digitorum above, and the extensor pollicis below. The anterior tibial nerve lies first on its outer side, then crosses the artery, and eventually reaches its inner side near the foot. Operation.An incision, at least three inches long, parallel with the outer edge of the tibia, and about three-quarters of an inch from it, exposes the deep fascia. This being divided, the outer edge of the tibialis anticus must be found, and will be the guide to the artery, which, surrounded by its venæ comites, lies very deeply between the muscles.
2. Posterior Tibial.A. In middle third of leg. Here the artery is separated from the inner border of the tibia, by the flexor longus digitorum, and is covered by the soleus. Operation.An incision at least four inches long, along the inner margin of the tibia, exposes the edge of the gastroenemius; then divide the tendinous attachment, then expose the soleus, and divide its attachment also; the deep fascia will then be seen; slit it up, and the vessel will be found about an inch internal to the edge of the bone. The nerve is there just crossing it.
Guthrie's, or the direct operation, has the very high authority of the late Professor Spence in its favour. An incision through skin and fascia in the middle of the back of the leg allows the two heads of the gastrocnemius to be separated to the same extent. The soleus is then to be scraped through in same direction, and its deep aponeurotic surface carefully slit up. The artery and vein are then easily seen.
B. In lower third of leg.This is an easier and more scientific operation, as it does not involve the division of great tendons. An incision midway between the internal malleolus and the tendo Achillis, parallel with both, will expose the very deep and strong fascia in which the tendons lie. The artery, with its venæ comites, occupies a central position, having the tendons of the tibialis posticus and flexor communis in front between it and the internal malleolus, and the posterior tibial nerve behind it, while the flexor longus pollicis lies still nearer the tendo Achillis.