class="smcap">Ligature of Gluteal.—This vessel, though one of the branches of the internal iliac, approaches the surface so nearly as to be occasionally wounded. It is also, though very rarely, the subject of spontaneous aneurism. The principle of treatment and the operation to be selected in any given case, depends upon its origin, whether traumatic or spontaneous. For if traumatic, the wound must almost necessarily be accessible from the outside; the neighbouring part of the artery is probably healthy, and hence the case can be treated by the old operation, slitting up the tumour, and tying the vessel above and below the wound. When the aneurism is spontaneous, there is no guide to tell us where the aneurism may have first originated; it may be that it is high up in the pelvis, and that the visible tumour is only its expansion in the direction of least resistance, or the coats of the vessel may be extensively diseased. The only chance is ligature of the internal iliac.
1. The old operation, or ligature of the gluteal artery in the hip.
Anatomical Note.—The gluteal is the largest branch of the internal iliac, and leaves the pelvis by the great sacro-sciatic notch just at the upper edge of the pyriformis muscle. After a very short course, it divides into superficial and deep branches opposite the posterior margin of the glutens minimus, between it and the pyriformis muscles.
Very precise rules have been given to enable the operator to hit on the exact spot where the artery leaves the pelvis. These, though perhaps interesting anatomically, are quite useless in a surgical point of view, for the only reasons which could possibly induce a surgeon to cut down upon the gluteal in the living body, are the existence either of a wound of the vessel or an aneurism. In the first the flow of blood, in the second the tumour, would give sufficient guidance.
In cases of traumatic aneurism the operation should be something like the following:—A free incision should be made into the tumour, dividing it in its long direction; the contents should be rapidly scooped out, and a finger placed on the bleeding point, just at the upper corner of the sciatic notch. This will at once stop the hæmorrhage till the vessel can be secured. This sounds easy enough, and has been done several times with success. Thus, John Bell, by an incision two feet long, as he tells us in his hyperbolical language, was enabled to tie the vessel in the case of the leech-gatherer who had punctured the artery by a pair of long scissors. Carmichael of Dublin used a smaller incision, removed one or two pounds of clots, and tied the vessel, in a case of wound by a penknife.
Now, though both of these cases were eventually successful, both patients lost during the operation a very large quantity of blood; John Bell's especially could not be removed from the operating-table for a considerable time after the operation. The period at which the great loss of blood took place was the interval after the incision was made, and before the artery was exposed to view, i.e. the interval in which the surgeon was busy dislodging the clots from the cellular membrane, the sac of the false aneurism. The procedure devised by Mr. Syme to obviate this difficulty, and which was put in practice by him in several very trying cases, is best given in his own terse description of an operation in a case of traumatic gluteal aneurism:—
"The patient having been rendered unconscious, and placed on his right side, I thrust a bistoury into the tumour, over the situation of the gluteal artery, and introduced my finger so as to prevent the blood from flowing, except by occasional gushes, which showed what would have been the effect of neglecting this precaution, while I searched for the vessel. Finding it impossible to accomplish the object in this way, I enlarged the wound by degrees sufficiently for the introduction of my fingers in succession, until the whole hand was admitted into the cavity, of which the orifice was still so small as to embrace the wrist with a tightness that prevented any continuous hæmorrhage. Being now able to explore the state of matters satisfactorily, I found that there was a large mass of dense fibrinous coagulum firmly impacted into the sciatic notch; and, not without using considerable force, succeeded in disengaging the whole of this obstacle to reaching the artery, which would have proved very serious if it had been allowed to exist after the sac was laid open. The compact mass, which was afterwards found to be not less than a pound in weight, having been thus detached, so that it moved freely in the fluid contents of the sac, and the gentleman who assisted me being prepared for the next step of the process, I ran my knife rapidly through the whole extent of the tumour, turned out all that was within it, and had the bleeding orifice instantly under subjection by the pressure of a finger. Nothing then remained but to pass a double thread under the vessel, and tie it on both sides of the aperture."
The bleeding in this case was thus rendered comparatively trifling, and the patient made a speedy and complete recovery. He returned home within six weeks after the operation.
2. In one case, at least, the gluteal artery has been tied with success (for traumatic aneurism) just where it leaves the pelvis, without the tumour being opened. This was in the practice of Professor Campbell of Montreal. The operation was a very difficult one, and while possible only in cases seen very early, and where the tumour is very small, does not appear to have any advantage over the old method.
Cases of spontaneous aneurism of the gluteal artery should be treated by ligature of the internal iliac. Steven's and Syme's cases of ligature of the internal iliac were of this nature.
Manuals of operative surgery occasionally devote pages to the description of special operations for the ligature of such arteries as the sciatic, epigastric, circumflex ilii, and pudic. They do not require ligature, except in cases of wound either of the vessels themselves or their branches; and, according to the modern principles of surgery in such cases, the ligature should be applied to the bleeding point, rather than to the vessel at a distance above it.
Ligature of Femoral.—Under this head we practically mean cases of ligature of the superficial femoral, for the common femoral, or (as called by some anatomists) the femoral, before the profunda is given off, very rarely requires to be tied. If it is wounded, of course the bleeding point must be sought, and the artery tied above and below it, but if an aneurism on the superficial femoral renders ligature of that trunk impossible, experience teaches that ligature of the external iliac gives better results than ligature of the common femoral. Erichsen asserts that out of twelve cases in which the common femoral has been tied, only three have succeeded, the others dying from secondary hæmorrhage. The experience of the Dublin surgeons, Porter, Smyly, and Macnamara, has been more satisfactory, as in eight cases of this operation six were successful. A ninth case was unsuccessful. Reasons to explain the danger are not far to seek, for the numerous small muscular