256 



FEMORAL ARTERY. 



separation of the artery from the vein : the best 

 method of effecting this, as it seems to the 

 author, will be, after having opened the sheath 

 directly over the centre of the artery either by 

 a touch of the knife or first nipping up a part 

 of it with the forceps ; making an aperture 

 into it with the blade of the knife held horizon- 

 tally, and extending the opening upon a di- 

 rector to the length of " three-quarters or an 

 inch," as recommended by Guthrie ; then with 

 the forceps to take hold of each portion of the 

 sheath in turn and drawing it to its own side, 

 outward or inward as the case may be, to de- 

 tach the artery from it with the extremity of a 

 director or of the aneurism-needle, moving the 

 extremity of the instrument gently upward and 

 downward at the same time that the vessel is 

 carried, by means of it, in the opposite direc- 

 tion from the side of the sheath which is in 

 the forceps ; by this proceeding the artery may 

 be easily and safely insulated almost, if not 

 quite, round, and with little if any disturbance 

 to it. That done, the needle and ligature may 

 be carried round the artery: the performance 

 of this, which is the most delicate step in the 

 operation, will be found much facilitated by 

 the separation of the artery as recommended ; 

 in fact, little more will then remain than to 

 pass the needle, the passage having been al- 

 ready opened. In doing so it will be well to 

 hold the inner portion of the sheath, with the 

 forceps, inward and backward, by which the 

 vein will be drawn away from the artery, and 

 at the same time to insinuate the blunt extre- 

 mity of the aneurism-needle round the artery 

 from within outward, because of the situation 

 of the vein, moving it, if any obstruction be 

 encountered, upward and downward, while it 

 is also carried forward, and bearing the artery 

 somewhat outward with it at the same time ; 

 when the extremity of the needle has appeared 

 on the outside of the artery it may be liberated, 

 if necessary, by a touch of the scalpel upon it. 

 In the execution of this manreuvre two acci- 

 dents are to be avoided, viz. injury of the 

 vein, and inclusion of the saphenus nerve : 

 the close juxta-position and attachment of the 

 former to the artery render much care neces- 

 sary to leave it uninjured ; but the proceeding 

 recommended will, if carefully executed, cer- 

 tainly preserve it from being wounded. The 

 saphenus nerve is here on the outside of the 

 artery, and might be included within the liga- 

 ture if the extremity of the needle were carried 

 too far outward ; the operator should therefore 

 assure himself, before tying the ligature, that 

 the nerve has not been included ; but the risk 

 of this accident ought not to be great at this 

 part of the artery's course, certainly not so 

 much so as at a lower point, inasmuch as the 

 nerve has as yet hardly entered the femoral 

 canal, and is therefore separated from the ar- 

 tery by more or less of its outer wall; and with 

 the precautions recommended in insulating the 

 vessel and passing the ligature it will almost 

 certainly be excluded at every part : the possi- 

 bility of the accident is, however, not to be 

 lost sight of. The needle having been carried 

 round the artery, the ligature is to be taken 



hold of with the forceps, and one end drawn 

 out, after which the needle is to be withdrawn. 

 The advantages of the part chosen by Scarpa 

 for this operation are numerous and obvious : 

 1. the artery is nearer to the surface and has 

 fewer coverings; there is therefore less to be 

 divided in order to bring it into view; 2. the 

 vessel being more superficial, its pulsations can 

 be more distinctly felt and its course ascer- 

 tained previous to operation, a guide wanting 

 in the lower parts of the thigh ; 3. " the ope- 

 ration is done/' as Guthrie observes, " on that 

 part of the artery which is not covered by 

 muscle, and all interference with the sartorius 

 is avoided : this method obviates all discussion 

 as to placing the ligature on the outside of the 

 muscle." The plan of cutting upon the out- 

 side of the sartorius in the upper stage of the 

 artery must be, if contemplated by any, a pro- 

 ceeding hardly defensible in the ordinary dis- 

 position of the muscle, for all the reasons ad- 

 vanced already against its use in the second 

 stage apply with much greater force to it in the 

 former case ; but it is at the same time to be 

 observed that the distance of the point at which 

 the muscle crosses the femoral artery is not ab- 

 solutely regular, and that great deviation in 

 this respect might render it necessary even to 

 cut upon the outer margin of the muscle in 

 order to expose the artery in the first third of 

 its course. The distance from Poupart's liga- 

 ment at which the muscle ordinarily crosses is, 

 according to the stature, from three and a half 

 to five inches, but it may in certain cases be 

 found to cross so much sooner that the artery 

 could not be exposed below the origin of the 

 profunda without displacing the muscle ; thus 

 Burns* mentions that he has seen, in conse- 

 quence of malformation of the pelvis, the artery 

 covered by the muscle, before it had reached 

 two inches below the ligament, and the author 

 has witnessed the same from retraction of the 

 thighs, consequent apparently upon long con- 

 finement to bed ; in the latter case it would 

 certainly have been more easy to expose the 

 vessel from the outer than from the inner side 

 of the muscle ; but such cases are to be re- 

 garded only as exceptions to be borne in mind, 

 but not to influence our general conduct. 



4. The performance of the last and most deli- 

 cate parts of the operation must be much more 

 easy and less embarrassed, the interference of 

 the sartorius being avoided; while, on the other 

 hand, all apprehension on account of the pro- 

 funda is removed, since that vessel seldom, if 

 ever, arises farther than two inches from Pou- 

 part's ligament, and the course of the case after 

 operation is more likely to be favourable and 

 exempt from untoward occurrences, since much 

 less violence must be done, and the superven- 

 tion of injurious inflammation or its conse- 

 quences thereby prevented. 



The operation for taking up the femoral ar- 

 tery above the origin of the profunda is not often 

 required, and, except in case of wound, may pro- 

 bably give place altogether to that of tying the 

 external iliac : it presents no advantage over 



* Op. cit. p. 321. 



