FEMORAL ARTERY. 



253 



the latter be lost. It will be recollected that 

 in the two inferior stages the artery is covered 

 by the sartorius and by two laminae of the 

 fascia lata, between which the muscle is 

 situate : the vessel is, therefore, similarly cir- 

 cumstanced in this particular throughout both, 

 but in some other important respects the re- 

 lations of the artery are different, l. In its 

 middle stage the vessel is nearer to the anterior 

 plane of the limb. 2. The deep layer of fascia, 

 by which it is covered, is far less thick and 

 strong, particularly at its upper part. 3. The 

 artery is not so completely covered by the sar- 

 torius; and for those reasons the vessel may 

 be more easily reached from before. These 

 constitute the principal anatomical conside- 

 rations why the middle stage should be pre- 

 ferred to the lower for operation, but, since it 

 is at times requisite to tie the vessel in its last 

 stage, it is necessary to examine the influence 

 which its anatomical relations may have upon 

 the conduct of the operation at that part. 

 1. The greater depth of the artery from the 

 anterior surface of the limb renders a more 

 extended incision necessary : in cutting upon 

 arteries " the centre of the incision should be," 

 as directed by Guthrie, " if possible directly 

 over that part of the artery on which it is in- 

 tended to apply the ligature." In the case of 

 the femoral artery in its third stage, the length 

 of the incision should not be less than from 

 four to five inches according to the volume of 

 the limb; its direction should correspond to 

 that of the sartorius, but it must be varied 

 somewhat according to the side of the muscle 

 upon which the operator may purpose to seek 

 the vessel. It should commence somewhat 

 below the middle of the thigh, and be con- 

 tinued as much upon the lower as upon the 

 middle third of the limb. 2. The artery is 

 situate, in its third stage, nearer to the outer 

 than the inner margin of the sartorius, and the 

 more so the nearer to its termination ; hence it 

 may be exposed with greater ease and cer- 

 tainty by cutting upon the outer edge of the 

 muscle and displacing it inward. Hunter, in 

 his operations, selected the inner margin, and 

 displaced it forward and outward; but this 

 proceeding is attended with disadvantages. 

 1. The sapher.a vein is more in the way and 

 exposed to danger of being divided since it 

 lies at this part, along or near the inner mar- 

 gin of the sartorius. 2. The muscle lying more 

 to the inner than the outer side of the artery 

 must be more displaced, and the depth of the 

 wound for the same reason greater when the 

 vessel is sought from its inside.* 3. The ope- 

 ration must be more inconvenient and em- 

 barrassing, as well because of the former 

 difficulties as because it must be performed 

 more from the inside of the limb, and from 

 within outward, than in the method by the 



* The contrary is maintained by Lisfranc and 

 others ; but, according to the experience of the 

 author, without sufficient reason. He has care- 

 fully compared the depth of the wounds as made 

 upon the opposite sides of the muscle, and in the 

 subjects of examination that by the inside appeared 

 to him the deeper. 



outer margin of the sartorius. Those objec- 

 tions are avoided by cutting upon the outer 

 edge of the muscle, against which, however, 

 it has been advanced that in that method the 

 vastus internus may be mistaken for the sar- 

 torius, and that the wound being made from 

 before, there is not a depending and ready 

 outlet afforded to matter should it form, while 

 by the other there is. The former of these 

 objections cannot carry much weight, and for 

 the second the best plan for obviating the 

 dangers of inflammation and suppuration is, 

 as much as possible, to render them unneces- 

 sary, which is best accomplished by selecting 

 that method by which the artery may be ex- 

 posed most easily, and with least disturbance 

 to the parts in its vicinity. To the writer, 

 therefore, it seems that the method by the 

 outer margin of the sartorius, which appears 

 to have been suggested by Hutchison, is the 

 more eligible in the operation for taking up 

 the femoral in its third stage. 2. The great 

 thickness and strength of the anterior wall 

 of the femoral canal both increase the dif- 

 ficulty of opening the canal, and render it 

 desirable that that structure should be freely 

 divided for the double purpose of facilitating 

 the taking up of the artery, and preventing 

 the injurious effect which must be produced 

 by the confinement caused by the structure in 

 question in the event of inflammation extend- 

 ing along the vessel. 3. The relation of the 

 vein to the artery at this part, viz. posterior 

 and external, will make it more safe to pass 

 the needle round the latter from without than 

 from the outside ; this, however, is a rule 

 which cannot be strictly adhered to, for the 

 direction in which the instrument shall be 

 passed must be varied according to circum- 

 stances; it would be difficult to pass it from 

 the outside in case the artery were exposed 

 from the inside of the sartorius ; but attention 

 to the caution demanded by the position of 

 the vein is, for this reason, only the more 

 necessary. 4. The saphenus nerve being here 

 within the femoral canal is to be carefully 

 avoided ; it will be so with certainty, if the 

 needle be earned from the outside. 5. The 

 mistake of confounding the superficial supe- 

 rior internal articular artery with the femoral 

 must be also avoided.* This mistake, which 

 has occurred, ought not however to occur 

 again in the hands of a well-informed surgeon, 

 for the possibility of it ought not to be lost 

 sight of in operations at the lower part of the 

 thigh ; and it may be easily avoided by re- 

 collecting, first, that the femoral itself is 

 within the femoral canal, and therefore that 

 any vessel, which presents before the division 

 of the anterior wall of the canal, which is so 

 remarkably thick in this situation that it can 

 hardly be overlooked, cannot be the one which 

 is sought for; and, secondly, that the course of 

 the branch within the canal, after its origin, is 

 very short, and therefore that in case of doubt 

 the vessel which presents, must, if the arti- 

 cular, conduct us directly to the trunk itself, 



* See that vessel. 



