?54 



FEMORAL ARTERY. 



when followed upward for a very short dis- 

 tance. 



Lastly, the structures to be divided or put 

 aside in order to expose the artery are, 1 . the 

 skin; 2. the subcutaneous cellular stratum; 

 3. the super6cial lamina of the fascia lata, 

 forming the anterior wall of the sheath of the 

 sartorius; 4. the sartorius itself; 5. the deep 

 lamina of the fascia forming the posterior wall 

 of the sheath of the sartorius, and the anterior 

 wall of the femoral canal ; and, 6. the proper 

 sheath of the vessels. 



The difference between the anatomical re- 

 lations of the operation in the middle and 

 inferior stages of the artery depends upon the 

 modifications to be observed in the relations 

 of the vessel at the two points, and also in 

 some of the parts concerned. The number 

 and order of the structures interposed between 

 the surface and the artery are the same as in 

 the third, but their disposition and relations 

 differ in some important particulars so much 

 as to authorize a difference in the proceedings 

 to be adopted, and to justify a preference in 

 favour of the former. 1. The artery is nearer 

 to the anterior surface of the limb, and the 

 more so the nearer to the commencement of 

 the stage : it is therefore more easily reached 

 and in the same proportion. 2. It is nearer 

 to the inner than the outer margin of the sar- 

 torius, and, in like manner, the more so, the 

 nearer to its upper extremity; and hence it 

 may be brought into view with more ease and 

 with less disturbance of the muscle by dis- 

 placing its inner margin outward, than its 

 outer inward. 



The latter proceeding is advocated by Hut- 

 chison for the purpose of avoiding the sa- 

 phena vein and the lymphatics. That the 

 vein will be effectually secured from danger 

 by cutting upon the outside of the sartorius 

 will be at once admitted ; but it appears to the 

 author that the advantage contemplated will 

 be more than counterbalanced by the dis- 

 advantages attending it, and on the other hand 

 that the proceeding is not necessary: for, 1. 

 if the outer margin of the muscle be cut upon 

 in the middle of the vessel, the incision must 

 be made considerably external to the line of 

 the artery's course, and thereby the guide to 

 the vessel otherwise afforded by that line must 

 be lost, and uncertainty and consequently 

 embarrassment be likely to ensue in seeking 

 for the artery after having displaced the muscle. 

 2. Much more disturbance and violence are 

 likely to be inflicted upon the artery and the 

 adjoining parts by the plan in question, in- 

 asmuch as the vessel is so much nearer to the 

 inner than the outer margin of the muscle ; 

 in consequence of which the muscle must be 

 displaced to a much greater extent in proceed- 

 ing from without inward, and the obstruction 

 offered by it to the performance of the other 

 steps of the operation must lead to greater 

 violence either to the artery or to the muscle ; 

 and afterward a valvular wound must be left, 

 a circumstance very unfavourable in the event 

 of the occurrence of inflammation and sup- 

 puration in the vicinity of the track of the 



vessel, and those objections are the stronger 

 because the artery is usually sought at the 

 upper part of the stage, where it is but little 

 overlapped by the muscle. On the other hand 

 the saphena vein ought not to be endangered 

 in the operation, for it is situate so far internal 

 to the artery that the incision ought not to fall 

 upon it. The case is different from that of cut- 

 ting upon the inner margin of the sartorius 

 during the third stage of the vessel ; for there 

 the vein is for the most part close to the edge 

 of the muscle, and the wound must be in- 

 clined in depth from within outward, by which 

 direction the vein is interposed between the 

 surface and the artery ; whereas, in the second 

 stage, whether the operator, in proceeding by 

 the inner margin of the muscle, cut directly 

 upon the artery's course or upon the edge of 

 the sartorius, there is sufficient space between 

 it and the vein to leave the latter safe. The 

 course of the artery may be crossed at any part 

 by the superficial femoral veins, as has been 

 explained, and they, if they present, will be 

 in danger of division ; but this inconvenience 

 would not be removed by the plan in question, 

 whereas both it and the danger to the saphena 

 may be avoided by an easier and less ob- 

 jectionable proceeding than that of cutting 

 upon the outer edge of the sartorius, viz. 1. 

 by ascertaining, through means of pressure, 

 the situation and course of the veins ; and, 2. 

 by proceeding with somewhat more caution, 

 where there is reason to expect their presence, 

 dividing first only the skin and continuing the 

 incision through the subcutaneous structure, 

 not by a single stroke, by which the vein if in 

 the way must necessarily be divided, but gra- 

 dually, until the vessel has been exposed and 

 drawn aside. It seems therefore to the author 

 not only unnecessary, but very objectionable 

 to cut upon the outer margin of the sartorius, 

 in exposing the femoral artery above the mid- 

 dle of the thigh. 3. The anterior wall of the 

 femoral canal is much thinner than in the 

 third stage, and therefore more easily ma- 

 naged. 4. The vein is directly behind the 

 artery, and therefore the needle may be passed 

 with equal safety from either side, according 

 to circumstances : in operating by the inner 

 margin of the sartorius it will be more easily 

 done from the inside : the position of the vein 

 and its close connection to the artery render 

 it especially necessary that the extremity of 

 the needle be kept in contact with the artery 

 in being carried behind it. The saphenus 

 nerve requires the same attention as in the 

 third stage. 



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 



