690 THE VASCULAR SYSTEMS 



between two or three inches (in one case four) below Poupart's ligament. It would appear, then, 

 that the most favorable situation for the application of a ligature to the femoral is on the super- 

 ficial femoral at the apex of Scarpa's triangle. In order to expose the artery in this situation, 

 an incision between three and four inches long should be made in the course of the vessel, the 

 patient lying in the recumbent position, with the limb slightly flexed and abducted, and rotated 

 outward. A large vein is frequently met with, passing in the course of the artery to join the 

 internal saphenous vein; this must be avoided, and the fascia lata having been cautiously divided 

 and the Sartorius exposed, that muscle must be drawn outward in order to expose fully the 

 sheath of the vessels. The finger being introduced into the wound and the pulsation of the 

 artery felt, the sheath should be opened on the outer side of the vessel to a sufficient extent to 

 allow of the introduction of the ligature, but no farther; otherwise the nutrition of the coats of 

 the vessel may be interfered with, or muscular branches which arise from the vessel at irregular 

 intervals may be divided. In this part of the operation the long saphenous nerve and the nerve 

 to the Vastus internus, which is in close relation with the sheath, should be avoided. The 

 aneurism needle must be carefully introduced and kept close to the artery, to avoid the femoral 

 vein, which lies behind the vessel in this part of its course. 



To expose the artery in Hunter's canal, an incision should be made between three and four 

 inches in length, a finger's breadth internal to the line of the artery, in the middle of the thigh 

 i. e., midway between the groin and the knee. The integument is first divided. The fascia 

 lata having been divided, and the outer border of the Sartorius muscle exposed, it should be 

 drawn inward, when the strong fascia which is stretched across from the Adductors to the Vastus 

 internus will be exposed, and must be freely divided; the sheath of the vessels is now seen, 

 and must be opened, and the artery secured by passing the aneurism needle between the vein 

 and artery in the direction from without inward. The femoral vein in this situation lies on the 

 outer side of the artery and the long saphenous nerve on the anterior and outer side of the artery. 



It has been seen that the femoral artery occasionally divides into two trunks below the origin 

 of the profunda. If in the operation for tying the femoral two vessels are met with, the surgeon 

 should alternately compress each, in order to ascertain which vessel is connected with the 

 aneurismal tumor or with the bleeding from the wound, and that one only should be tied which 

 controls the pulsation or hemorrhage. If, however, it is necessary to compress both vessels 

 before the circulation in the tumor is controlled, both should be tied, as it would be probable that 

 they became reunited, as in the instances referred to above. 



In wounds of the femoral artery the question of the mode of treatment is of considerable 

 importance. If the wound in the superficial structures is a large one, the injured vessel must 

 be exposed and tied; but if the wound is a punctured one and the bleeding has ceased, the ques- 

 tion will arise whether to cut down upon the artery or to trust to pressure. Mr. Gripps advises 

 that if the wound is in the " upper part of the thigh that is to say, in a position where the fem- 

 oral artery is comparatively superficial the surgeon may enlarge the opening with a good 

 prospect of finding the wounded vessel without an extensive or prolonged operation. If the 

 wound be in the lower half of the thigh, owing to the greater depth of the artery and the pos.si- 

 bility of its being the popliteal that is wounded, the search is rendered a far more severe and 

 hazardous operation, and it should not be undertaken until a thorough trial of pressure has 

 proved ineffectual." 



Great care and attention are necessary for the successful application of pressure. The limb 

 should be carefully bandaged from the foot upward to the wound, which is not covered, and then 

 onward to the groin. The wound is then dusted with iodoform or boracic powder and a conical 

 pad applied over the wound. Rollers the thickness of the index finger are then placed along 

 the course of the vessel above and below the wound, and the whole carefully bandaged to a back 

 splint with a foot piece. 



Collateral Circulation. After ligation of the femoral artery, the main channels for carry- 

 ing on the circulation are the anastomoses between (1) the gluteal and sciatic branches of 

 the internal iliac with the internal and external circumflex and superior perforating branches 

 of the profunda femoris; (2) the obturator branch of the internal iliac with the internal circumflex 

 of the profunda; (3} the internal pudic of the internal iliac with the superficial and deep external 

 pudic of the common femoral; d) the deep circumflex iliac of the external iliac with the external 

 circumflex of the profunda and the superficial circumflex iliac of the femoral ; and (5) the sciatic 

 and comes nervi ischiadici of the internal iliac with the perforating branches of the profunda. 



Branches (Figs. 481 and 482). The branches of the femoral artery are: 



Superficial epigastric. Muscular. 



Superficial circumflex iliac. f External circumflex. 



Superficial external pudic. Profunda femoris < Internal circumflex. 



Deep external pudic. I Three perforating. 



Anastomotica rhagna. 



