FEMORAL ARTERY. 



255 



arch downward, and when he comes to the 

 place where he does not feel any more, or very 

 confusedly, the vibration of the artery, he will 

 there fix with his eye the inferior angle or ex- 

 tremity of the incision which he proposes to 

 make "for bringing the artery into view. This 

 lower angle of the incision will fall nearly on 

 the internal margin of the sartorius muscle, 

 just where this muscle crosses the course of the 

 femoral artery. A little more than three inches 

 above the place pointed out, the surgeon will 

 begin his incision and carry it along the thigh 

 in a slightly oblique line from without inwards, 

 following the course of the femoral artery as 

 far as the point fixed with the eye." By this 

 incision the skin and cellular substance are to 

 be divided, and the fascia lata exposed, " then 

 with another stroke of the bistoury, with his 

 hand free and unsupported, or upon a furrowed 

 probe, he will divide along the thigh, and in the 

 same direction as the external wound the fascia, 

 and introducing the fore-finger of his left hand 

 into the bottom of the incision, he will imme- 

 diately feel the strong beating of the artery, and 

 this without the necessity of removing the in- 

 ternal margin of the sartorius from its position, 

 or at least very little. With the point of the 

 fore-finger of the left hand already touching the 

 artery, the surgeon will separate it from its 

 lateral connexions and from the vein;" after 

 which the ligature is to be carried round it by 

 means of a blunt aneurism-needle. The author 

 has introduced the preceding account in order 

 to fix the precise situation of the operation as 

 performed by Scarpa, because it appears to him 

 that it has been to a certain degree lost sight of, 

 and also to direct attention more strongly 

 to the advantage proposed by that distin- 

 guished surgeon in the adoption of the method 

 which he has recommended. A very brief 

 consideration of the descriptions given by se- 

 veral writers* of the proceedings to be adopted 

 in the operation of taking up the artery in the 

 upper part of the thigh will suffice to shew 

 either that Scarpa's method has been con- 

 founded more or less with the operation at a 

 lower point, or that its advantages have been 

 disregarded: thus, while it is stated that the 

 part of the limb in which the femoral artery 

 can be tied with the greatest facility is between 

 four and five inches below Poupart's ligament, 

 and which is Scarpa's point,-)- the displacement 

 of the sartorius is accounted a part of the ope- 

 ration, and it has even been debated whether 

 the incision should not be made on the outer 

 edge of the sartorius, and the artery exposed 

 by drawing the muscle inward ; but the dis- 

 placement of the sartorius is not only not a 

 necessary part of Scarpa's plan, but is that 

 particular the avoidance of which he proposed 

 to himself by the method he selected ; from 

 whence it will appear that the operation, as 

 described in the accounts alluded to, refers, 

 strictly speaking, to the second and not to the 

 first third of the vessel's course, within the 

 latter of which it must be performed in order 



* Hodgson, &c. 



t The distance at which the sartorius crosses the 

 artery varies according to the stature. 



to avoid the sartorius. The structures to be 

 divided in this operation are, 1. the skin, 2. 

 the subcutaneous cellular structure, 3. the 

 fascia lata, forming the anterior wall of the 

 femoral canal. The extent of the superficial 

 incisions need not exceed three inches, com- 

 mencing above either according to the rule of 

 Scarpa or about two inches below Poupart's 

 ligament : the direction in which they should 

 be made ought to correspond as nearly as pos- 

 sible with the course of the artery. The extent 

 to which the fascia lata is to be divided is 

 stated differently by different writers : by some 

 it is directed to be divided to the extent of 

 about an inch : the direction of Scarpa is not 

 precise upon the point in the text, though it is 

 plain that he intended it should be divided to 

 a much greater length than an inch, but in a 

 note it is strongly insisted that the division of 

 the fascia should correspond in extent to that 

 of the external wound. Two reasons present 

 for this : 1. greater facility in the performance 

 of the operation, and less disturbance in con- 

 sequence to the artery; 2. the avoiding the 

 injurious effects which must be produced by 

 the confinement consequent upon too limited 

 a division of the fascia in the event of the 

 supervention of inflammation. It cannot be 

 doubted that a division of an inch is altogether 

 too short to meet those considerations, and that 

 the fascia ought to be divided to a greater ex- 

 tent ; on the other hand it does not appear that 

 advantage would be gained by so free a divi- 

 sion as that recommended by Scarpa ; and the 

 rule of Guthrie seems the best calculated to ac- 

 complish the ends in view : he advises the fascia 

 to be divided for the space of two inches. The 

 division may be effected either with or without 

 the assistance of the director. It will be well 

 to recollect here that, at the point at which the 

 sartorius is about to overlap the artery, a du- 

 plicature of the fascia takes place in order to 

 enclose the muscle, and hence that, if the 

 opening of the canal be attempted at the lower 

 extremity of the stage, and close to the muscle, 

 two layers of the fascia may require to be di- 

 vided before this purpose can be accomplished. 

 The femoral canal having been opened by the 

 division of the fascia lata, the next step in the 

 operation is the division of the proper sheath 

 of the vessels and the insulation of the artery. 

 Previous to this, should the internal genicular 

 nerve be found to cross the canal superficial to 

 the artery at the part, at which the vessel is 

 to be detached from the contiguous parts, it 

 should be separated and drawn outward. The 

 insulation of the artery Scarpa recommends to 

 be effected with the finger, raising the vessel 

 from the wound even along with the vein if 

 necessary; such a proceeding, however, must 

 be very objectionable, as inflicting great dis- 

 turbance and violence upon the artery. It is 

 to be recollected that in order to insulate the 

 artery it is necessary to divide or lacerate the 

 investment, which immediately encloses the 

 two vessels and connects them to each other, 

 and which has been elsewhere denominated 

 the femoral sheath ; this, though thin, is dense, 

 and is to be expected to offer resistance to the 



