Part I., p. 539. (Part 7)

a curved incision, with its concavity towards the malleolus, will be over the artery. The relations of the veins on either side, and of the i)osterior tihial nerve behind, are among the least variable features of the anatomy of this region. In two cases I have seen the artery immediately behind the inner malleolus. When the posterior tibial is small, the peroneal branches undergo compensatory enlargement. P. S, — Since closing these notes, some weeks ago, the writer has made seven additional dissections of this region, with the following result: — In 4 out of 7 cases, calcanean branches originated from the poste- rior tibial artery — 1, one inch ; 1, one-half inch, and 2, one eighth of an inch above the bifurcation. In 7 cases, 2 calcanean branches were derived opposite the bifur- cation. In 7 cases, 19 calcanean branches were derived from the external plantar, within one inch of its origin; 3, within one-sixteenth; 2, within one-eighth; 1, within one-fourth; 4, within one-half; 4, within three-fourths, and 5 within one inch of the bifurcation. Articular branches were, as usual, from posterior tibial and internal plantar. The posterior tibial bifurcated in every case, as usual. {See dia- gram.) NOTES UPON THE SURGICAL ANATOMY OF THE OBTURATOR ARTERY/ THE DIFFERENCE OP ITS RELATIONS IN THE MALE AND FEMALE, WITH A CONSID- ERATION OF ITS IMPORTANCE IN THE OPERATION FOR RELIEF OF FEMORAL HERNIA — DEDUCED FROM TWENTY-SEVEN CONSECUTIVE DISSECTIONS OF THE ARTERIES IN THE MALE, AND TWENTY-SIX IN THE FEMALE PELVIS. In its distribution the obturator artery is simple and constant ; in its origin and relations ttere is no artery in the human body which presents so many vagaries. In support of this last statement it will suffice to quote from some of the standard text-books the different opinions of different anatomists upon this artery. Quain gives its origin as ** usually from i\iQ posterior trunk of the internal iliac, not unfrequently from the epigastric." Sappey takes a different view, and says ** from the hypogastric (anterior trunk of internal iliac), sometimes from the external iliac, rarely from the femoral^ Leidy is of the opinion that it *' is a branch of the posterior trunk, and often a branch of the anterior trunk of the internal iliac^ Wilson gives it ** from. the anterior trunk; frequently from the posterior trunk of the internal iliac J^ Gray agrees with Wilson verbatim, adding that "in 2 of 3 cases the obturator arises from the internal iliac, in 1 of 3J from the epigas- tric, in 1 of 72 by two roots from both vessels." Luschka, " from anterior trunk of internal iliac; occasionally, from external iliac, epigastric, or femoral^ Velpeau writes: "An examination of several thousand cadavers does not permit me to say that the obturator artery comes from the epigastric in 1 of 3, nor 5, nor 10, but only 1 in 20." (!) Tiedemann says, on the other hand, that *you may expect to find » New York Medical Record, October, 1877. 17 ( 257 ) 2o8 PRIZE K83AY. the obturator from the epigastric in 1 of 3 cases, this variety being more common in the female than in the male."^ In the two following tables I have given the analysis of 53 dis- sections, made in order to contribute something of certainty to the analomj of this artery. Thirteen subjects of each sex were chosen, and both sides noted as they were dissected. BBMALB8. HA LBS. ll 5i 1 1 ll 1 i^ & s- i& £| ■cS 1 ' ^1 Is ■3 1 ■^z ■s 1^ J ^ . J « = B S i s ll sS ||! S 1 fs i. 1^ {I R L \ ' {1 R L T] ::: ~ {I R L ::: ::. & R L 1} ::: {I R ill R L 1} 1 7 R 33 i34 R 1} 1 8 L t^taloT urciii ovoMhB L J » R mi>iioer,ihal,h>d/«R^- (35 R n (lO L ral hernia eilsHd, Ihe 136 L if ill (IS R L R "i i :;: jr /37 (39 R L R 1} '.'.'. U4 L 1 140 L |1B R "i (41 R 1} I" L 1 142 L ,17 ilB R 1 {ll R 11 L 1 L i} (19 tao R 1 145 R ... i L 1 ,\46 L 1 (21 1 22 R 1 147 i48 E 1} L 1 L {11 E '.'.'. 1 J 49 (so R 1 L "i L "i r R ■■; ::: One origin (quite (51 152 B i (26 L ... 1 1 uutlBd in otturslot cb- 53 L 1 ... 11 jter 1 22 ~r 4 ' The writeris ludebted to Dr. I. Miuia Haja for valnable reference in regard to this artery: to "Lawrence on RnptnreB," one of tbe moat lalaable books on this aabjeot pnblisbed ; and to Dr. W. L. Wardwell for asaUtanoe in talcing notee of the ' Tlie — ~- to the left indirsles the dissections to have been made npon both fiides of the same subject ; that to the right, Ihnt the origin waa the same on both sides of the aaine subject. Note. — In 8 other dissectiona in which the sex was not noted, this artery came from the anlerior liuiik in 5, from the posterior in 1, from the deep epigastric in OBTURATOR ARTERY. 259 It will be seen that in females, of 26 cases, the obturator was from the deep epigastric in 13|- instances; from the posterior trunk of the internal iliac in IJ; from the anterior trunk in 11 instances. In males, of 27 cases, it was from the epigastric in only 5; from \\Q posterior trunk in 1 ; while from the anterior trunk of ttie inter^ial iliac it was derived in 22 instances. In these cases it is seen that, \n females we may expect to find the obturator to be derived from the deep epigastric in 1 of 2 cases; in males, in 1 of 4 J cases. And, in a total of 61 cases, regardless of sex, the proportion is 20, or 1 in 8. Tiedemann is the only one of these anatomists who notices the difference between the origin oF this vessel in males Sitid females. In 160 cases in which Cloquet noted the obturator as coming from the internal iliac, 87 were in males, 73 in females, showing, as in my cases, the greater tendency of this vessel to come from the internal iliac in men. In 56 cases this same author noted from the epigastric, 21 were in males, 35 in females; agreeing, also, with the dissections embodied in this article, that the tendency of the obturator to come from the deep epigastric was much greater in women than in men. So great is this difference, that the estimates made from both sexes should not be considered, in view of the probable contact with this vessel in femoral hernia. An examination of the foregoing tables will show that, in 19 of 26 subjects, this artery was derived from the same point on the two sides, showing, in this respect, a symmetry of arrangement I have not noticed in any other artery of the body. Femoral hernia being comparatively a rare accident in the male, and the obturator artery having a dangerous relation to the femoral ring in the male sex in only a small proportion of cases, the surgi- cal interest of this vessel belongs to the opposite sex. When derived from the epigastric, it usually comes off from this artery from | to f of an inch from the origin of the epigastric from the external iliac. It then turns abruptly down on the outer side of .\Q femoral ring, being in intimate relation with the sheath of the external iliac vein, and thus makes its way to the obturator foramen in such a manner that it would be exceedingly difficult for the in- testine, descending to form a femoral hernia, to insinuate itself between tlie iliac vein and the obturator artery, so as to loop this latter vessel around the hernia. This danger will be greater as the 260 PRIZE ESSAY. obturator is distant at its origin from the external iliac. However rare this double' accident may be (femoral hernia, with the ohturator artery looped around it), yet, as it can and has occurred in several instances, the surgeon should proceed in every case as if he supposed this accidental arrangement existed. In the American Journal of the Medical Sciences^ J^lyj 1878, p. 269, is a notice of a case in which death resulted from division of the obturator artery in an operation for femoral hernia in a woman. The vessel was from the epigastric, J an inch from its origin. Mr. Barker had collected 12 cases of this accident ; in six of these the vessel was secured either by ligature, or with a hook. Of this group 2 died. In 6 nothing was done, and only one died (his own case, which is reported as dying of peritonitis). ' At the autopsy, 3 or 4 ounces of Hood were found effused under the peritoneum, in the pelvis." This extravasation may have caused peritonitis and death. It is lo be regretted that Mr. Barker does not say what proportion of these twelve cases were females, I do not doubt that most of them were of this latter sex. "When the stricture is so situated that Gimbernat's ligament re- quires division, the point of the probe pointed bistoury should be kept hard pressed against the surface of the os pubis to which this ligament is attached, and as is advised by one of the most eminent American surgeons, ** the ligament should be divided without any sawing motion."^ It is evident that, if the cutting edge of the knife is not pushed beyond the ligament into the pelvis, the artery will not be divided. I have noticed that the ohturator vein is in relation to the femoral ring in a much larger proportion of cases than the artery, it being often double, one going to the internal iliac, the other to the exter- nal iliac vein, when the artery was from the anterior trunk of the internal iliac alone. Deductions: 1st. That anatomists giving the origin of the obtu- rator artery from the posterior trunk of the internal iliac are positively wronrj, the vessel not originating from this point in more than 10 per cent. 2d. That in females it will be derived from the deep epigasti^ic in one of two or two and one-half cases. 3d. That in males it will be from the deep epigastric in one oi'four or six cases. ^ Hamilton's System of Surgery, p. 743. OBTURATOR ARTERY. 261 4th. That the obturator vein is found to empty into the external iliac or epigastric vein in a much greater proportion of cases than the artery is found to orignate from the epigastric or external iliac, 5th. That the advice to **feel for the pulsation of this artery be- fore cutting Gimbernat's ligament"^ (as is frequently given), seems unnecessary, since the insertion of the finger through the constricted canal, completely filled by the intestine, that has for this reason he-, come strangulated^ is impossible until after the section is made. 6th. That, although the conditions in which the obturator artery is found to the inner side of a femoral hernia rarely exist, the ope- ration should be made with every regard to this abnormal arrange- ment. Note. — In one instance I have seen the obturator a branch of the epigastric^ and this latter a branch of the profunda femoris. This speciuien is the property of the VlTood Museum of BeUevue Hospital, and is not included in these notes, on account of its being so unusual. * Holmes's Surgery, vol. iv. p. 779. 262 PRIZE ESSAY. NOTES ON THE SURGICAL ANATOMY OF THE HIP-JOINT/ The comparatively trifling amount of blood lost in an operation of such magnitude as the excision of the hip-joint, when there is no means of stopping the supply of blood to the part, has doubtless added very much to the remarkable success which has attended this operation in the hands of its author. The following synopsis of twenty dissections of the hip-joint made with regard to the arterial distribution to this region, may serve to show the extreme nicety of execution requisite, in order to avoid hemorrhage, tliat would always be annoying, and in some instances dangerous. The arteries found distributing branches to this region were the gluteal^ sciatic^ obturator^ external and internal circumflex^ and the superior perforating by anastomoses. None of these approached the line of incision given by Prof. Say re near enough to be divided, before they broke up into branches of distribution too small to give rise to any notice- able hemorrhage, except one of the terminal branches of the internal circumflex, sometimes mentioned as the trochanteric branch, but never described in connection with the surgical anatomy of this ope- ration, to my knowledge. In 20 dissections this artery was present in every case. In 18 of these it came from the internal circumflex^ passed between ttiequadratus femoris behind, and the obturator ex- ternus in front, and turning toward the digital fossa, broke up into its terminal branches within from one-eighth to one-fourth of an inch of the insertion of the tendon of the obturator externus into that fossa, anastomosing with the sciatic^ gluteal^ and external circumflex arteries. In 2 cases in which it failed to come from the internal circumflex^ it was derived from the sciatic^ and ran in the depression between tlie quadratus femoris and obturator externus muscles, near the digital fossa. This vessel varied in size from a crow's-quill, down, oftener small than large, but in all cases of sufficient size, at the distance from the fossa above given, to interfere with the success of the operation, if carelessly divided. As it is only at this point that the knife is used in the deeper structures (in cutting the tendon of the obturator ex- ternus out of this fossa), it behooves the surgeon to guard against this danger by keeping the point of the knife *well against the bone," as advised in the operation, and never to attempt to divide this tendon out of the fossa. (The obturator externus muscle was occasionally observed to be inserted into the great trochanter, and not into the digital fossa.) ' From Orthopedic Surgery and Diseases of tlie Joints. By Prof. Lewis A. Satrb. II LANE MEDICAL LIBRARY To avoid fine, this book should be returned on or before the date last stamped below. n i 2f ^SR DRIVE nLO ALTO, CAL/F. M47 T»yeth, J, A. Essays in Vv'97 surgical anatomy 1879 17699 NAME .;^?'::-4,c:,«.....4^L'^ __. jBIA.10.I9M DATE DUE