412

Illustrations of the Surgery of the Femoral Arte~:~l.

maxillary eellulitis when recovering from traumatic erysipelas of' the thigh. He was suddenly seized with a paroxysm of choking, and died before the house-surgeon could be summoned. On a post-mortem examination the epiglottis was found enormously enlarged from ~edematous infiltration, and there was also general infiltration among the muscles at the base of the tongue. The sixth case occurred in a girl aged nineteen. There was a diffuse, hard swelling under the jaw. Her life was saved by a free and deep incision in the middle line between the chin and hyoid bone. Mr. Bickersteth emphatically a d d s : - - " W e have learned by painful experience that deep-seated cellulitis cannot continue in this region without risk of oedema glottidis, and that delay in making

the proper incision for its relief may be fatal." I have myself endeavoured to lay much stress on this practical fact in the observations which I have submitted to the profession on the cases recorded in this communication, and it is extremely satisfactory to me to find that the experience of so skilful and able a surgeon as Mr. Bickersteth should thus fully corroborate the important points which I am desirous to inculcate.

ART. X.--[llustrations of the Surgery of the Femoral Artery. By JortN HAMILTON, Surgeon to the Richmond Hospital, and to Swift's Hospital tbr Lunatics. CASE I.--Popliteal Aneurism cured by Compression. ROBERT BUTLER,aged twenty-six, a ship carpenter, a strong, tall, active looking young man, admitted May 27th, 1863, with popliteM aneurism of the right side. It is about the size of a small orange, rather at the lower part of the popliteal space, the walls of the aneurism tolerably thick. The pulsation is very strong and diastolic, so strong as to lift the stethoscope and listening head at each pulsation. No bruit de sourer. Pulse 68--regular, but rather weak. Heart's action and sounds normal. There are evidences of syphilitic poisoning ; a bony node on the right tibia, at the lower third, slightly tender on pressure. A short time before it was painful, particularly at night, and tender. There are also two small, oval, yellow tertiary ulcers on the same leg. He feels only numbness in the leg, but no pain; nor is his usual activity impeded. For some time past he has suffered from numb

By MR. HAMILTON.

413

sensations in the llmb, but he discovered the pulsating tumour only a week since, his attention having been called to it by putting one leg across the other in bed. He would feel the pulsation when he lay in his hammock, with his clothes on and his legs over the edge of it. Four years ago had syphilis; the scar of a bad bubo is apparent in the right groin. Otherwise, he is healthy, and has apparently suffered under no other syphilitic symptom, except the node and the ulcers. The pulsation in the aneurism was readily controlled by moderate compression, on the femoral artery, both as it leaves 1%upart's ligament, and at the lower end of Scarpa's space. The man was at first very fidgetty, the upper compress could not be placed over the cicatrix of the bad bubo, which is just over the site of the femoral artery, as it crosses the ramus of the pubes, as the part became very red and tender, a portion of the instrument also got out of order, so that at the end of four days little way had been made. Read's truss-like compressor and Carte's double compressor, in perfect order, were settled on the limb, and by alternate pressure, which was well borne and never relaxed, in twenty-four hours the tumour was quite solid. The pressure was discontinued; to be re-applled if pulsation should return in the aneurism; but it never returned, and he left the hospital well, after a few weeks, having remained in after the cure of the aneurism, that the syphilitic symptoms might be removed by appropriate treatment. Two years after, March, 1865, he came to the hospital with paralysis of the right side of the face, from an affection of the portio dura. The popliteal aneurism had not left a trace, and the circulation through the two lower thirds of the femoral artery was perfect, CASh II.--Popliteal Aneurism cured by Pressure. Under the care of John Hamilton, Surgeon to the Richmond Hospital. By W. Thonson, A.B., M.D., Resident Surgeon, Demonstrator of Anatomy in the Carmichael School of Anatomy. John Nicholson, aged thirty, a sailor, presented himself at the dispensariT of the Richmond Hospital, on the 18th of January, complainng of a painful swelling in the left popliteal region. On making an examination, a tumour of considerable size was found in the p:ace indicated. There was well-marked pulsation of the distensik character peculiar to aneurism. He said that he first

414

Illustrations of the SurgerS of the Femoral Artery.

felt pain in the ham about the previous August. Shortly before, while pulling a hose along the deck, he became irritated because some of his comrades did not give him help, and he then suddenly jerked the tube. He immediately felt something give way behind the knee, and suffered some pain. He took no further notice of the occurrence, however, for some time; but, as he got a rheumatic affection of the other knee, he consulted a medical practitioner, and was treated for rheumatism. Two months previously to his admission to hospital he noticed the swelling of which he now complained, and as it pulsated strongly, he began to get alarmed, and at last sought advice. On further questioning him, he stated that he had served in the Royal [Navy, ' for ten years, chiefly in China, Japan, and the East Indies. S.me years ago, he contracted syphilis, and afterwards suffered from a skin eruption, but nothing more. tits countenance was sallow and wasted, and his general condition anaemic. The heart sounds were normal, but there was an unmistakable bruit along the course of the aorta. The pulse was regular, but not strong. W h e n the patient was in bed a closer examination of the turnout showed that it extended well up into the thigh, as well as latterly; that it was thin-walled; and a measurement round the knee gave fifteen inches as compared with thirteen on the other side. Pressure on the artery stopped all pulsation in the swelling. On the following day, the patient was seen by Professor R. W . Smith, under whom he was admitted, and who determined upon the trial of' pressure. He was subsequently scen by Mr. Adams and Mr. Hamilton, who concurred in the proposed treatment, although the latter expressed an unfavourable prognosis, grounded on the size of the aneurism, the thin walls, the fluid state of tile blood in it, and absence of fibrous deposit. M r . Smith, having taken ill, requested Mr. Hamilton to undertake the care of the case. The treatment began on Wednesday morning, at 1130. The leg was put up in a flannel roller, and a small Carte's tourniquet was applied to the femoral, so as considerably to diminish the flow of blood. He was placed upon full diet, and ordered to take an ounce of the following mixture every fourth hour :--

M

Tr. Ferri perchlor., Tr. Digitalis, A q u ~ ad.

Dviij. 3iv. ~viij.

By MR. HAMILTON.

415

At ].15 the patient declared he could not bear the pain any longer. He was very weak, and it was deemed advisable to remove the pressure altogether. O'Reilly's instrument was applied at 2.30 p.m, and was kept on, alternating the points of pressure, until 8 p.m., when Carte's was again applied at the patient's request. A t 12 o'clock p.m. he declared the pain to be intolerable, and the apparatus was removed. 2r roll of bandage was then put over the vessel, and weights were applied. He had great relief from the change. An opiate was administered, and the patient was soon asleep. Thursday, 23rd January.--He says the weights came off during the night, but since 4 o'clock he has held them on the vessel. The circulation is almost entirely controlled. A t 1 o'clock Carte's instrument was applied, and kept on until 3.15, when the weights were again resorted to, being suspended by strong elastic from a point above. He had another opiate. Friday, 24th January.--The patient slept well during the night. The tumour is to-day decidedly better. The puslation is less, and deeper than it has been. There is evidently a tendency to consolidation. The weights were kept on all day. When the parts became sore the patient kept up digital compression himself. Carte's tourniquet was applied at night, instead of the weights. The point of pressure was changed by Mr Hamilton to mid-way between Poupart's ligament and the lower part of Scarpa's space. Saturday, 25th January.--The instrument was borne well all night, the pressure giving less pain than when applied lower down. It was taken off during the day, and digital compression used for some hours, after which it was again applied. It was put on for the night at 11 o'clock, when the patient had 25 rain. tr. opii. He complained very much of pain to-night. In a couple of hours afterwards the opiate was repeated, as he could not sleep. The condition of the tumour still fi~vourable. Sunday, 26th.--The instrument was kept on all night, but the patient did not get much sleep. The weights and digital compression were employed during the day. Monday, 27th.--Carte's tourniquet was on all night. Throughout the day the patient was irritable, and had great pain in the tumour and in his leg. Digital compression was kept up for some hours, with an occasional return to the instrument, which was finally applied at 9 o'clock. The patient then got about 30 grains of chloral.

416

1-11ustratlons of the Surgery of the Femoral Artery.

Tuesday, 28th.--On visiting the patient this morning he said he had slept very little during the night. Tile paln was more than he could bear, and he was obliged to remove the instrument altogether. He had applied it again about an hour before he was visited, but he said he was quite sure there was no blood passing through the tumour when he took off the apparatus. Mr. Hamilton saw him at" 10 o'clock, when the pressure was removed, as there was no pulsation whatever in the tumour. Two articular arteries which had been observed enlarging for the past two days were throbbing strongly. The pain in the leg and tumour had considerably diminished. The tourniquet was not again applied. The patient ~as visited every hour, but there was no return of pulsation. Wednesday, 27th.--The tumour still remains pulseless. Ordered mutton chops and two glasses of Marsala wine for dinner. W h e n this man left the hospital a fortnight afterwards the tumour was hard and contracted, and the motion of the limb very free. The favourable termination in this case was largely due to the attention and skill bestowed on it by Mr. Thomson. CASE III.--Popliteal Aneurism, in which Compression failed, and

in which the Artery was tied, with success. A large, stout, healthy-looklng man, thirty-five years of age, was admitted January 22, 1868, under Mr. Adams, who transferred the case to me. He had a large aneurism of the popliteal artery, as big as an orange, pulsating very strongly. Six months previously he was making a strong exertion, during which he felt a snap at the back of the left knee, followed by uneasiness and by pulsation. Compression was tried carefully with the usual instruments, but failed. Whenever the instrument shifted, and allowed the blood to flow through the artery, or whenever it was taken off, and all pressure removed, the aneurism filled with fluid blood, and there was no indication of fibrine having been deposited. After the most watchful care for over a fortnight not only was no impression made on the aneurism, but it was evidently becoming larger. I felt, therefore, the time was come to tie the femoral artery, lest the aneurism should become diffused, and the man should have to suffer amputation to save his life. In consultation my colleagues agreed with this opinion, and I put a ligature on the vessel. In consequence of the long-continued pressure the operation was rendered more difficult and tedious than it generally is. There appeared more

By MR. HAMILTO/~'.

417

congestion of the parts about the vessels than usual, and there was general and free bleeding from the wound; a small artery which was divided required a ligature. The artery and vein seemed so matted together that they required cautious separation to enable me to pass the aneurism needle between them. The aneurism at once collapsed and became pulseless after the ligature. I t soon seemed to fill with blood again, though it never pulsated. The ligature came away at the right time, and the wound healed, but the aneurism continued for a long time nearly its primitive size, soft and fluctuating, and it was only two months after the operation that I thought him fit to leave hospital, the tumour having become hard and contracted. In this case the aneurism seemed to have been filled by collateral circulation, even after the main trunk was stopped. When compression fails we naturally look for the cause. In the previous case I have expressed my belief that the failure arose from the possibility of the aneurism being still supplied with blood by some free anastomosing branch between the point of pressure and the aneurism, to which may be added a want of good coagulating power in the blood itself. Even after the artery was tied the aneurism continued for some time large and with fluid contents. In the next case, which I shall only briefly relate, the want of success was not due either to any difficult local circumstance, improper instruments, imperfect application, or the attention of the attendants, but entirely to the indocility of the patient. A gentleman about thirty-eight years, whose character would have been most commendable but for the absence of temperance, was admitted into the hospital, as it was considered the only place to afford a chance of curing a popliteal aneurism by compression. The tumour was situated in the right popliteal space, which it filled, about the size of a goose egg, pulsating strongly, the walls thin, and no solidity about it. For some years he had drank very hard. He had the nervous manner of one who drinks. Pulse 96 ; tongue yellow, with red tips and edges. The liver was enlarged.The thigh fat, with large varicose veins. The fatness of the thigh prevented compression being properly applied over the lower part of Scarpa's space, but above it, nearer Poupart's ligament, it could be well applied, and commanded the aneurism completely. In adapting the compressor the varicose veins were much in the way. It will appear, therefore, that this was not a favourable case, and the fat thigh and varicose veins, the enlarged liver, and general bad 2F

418

Illustrations of the Surgery of the Femoral Artery.

habit of body, rendered it even more unsuitable for tying or amputation. The compression was tried for three months, from time to time only, for it had to be discontinued once for partial inflammation of the varicose veins, and at another time from an attack of acute pleurisy. Twice the aneurism was reduced to tbe size of a walnut, and became solid, nor did pulsation return till some minutes after the removal of compression. _A few hours more and a cure would have been certain, but these few hours were not granted. He continued to get stimulants through some of the attendants, and on one occasion was seen looking out of the window, with the compressor still on the llmb. When he left the hospital he was much better in health, and the liver nearly its normal size, but he would not consent to the artery being tied. The only effect of the compression was to delay the progress of the case, which before had been most rapid. It is now nearly two years since its use, and his medical adviser in the country informed me not long ago that he is still alive and going about. CASE IV.--Aneurlsmal Varlx following a t'unctured Wound of the Femoral Artery and Vein--Repeated Heernorrhage,and Ligature of the Artery. By Mr. Hamilton. Case taken by Mr. Vesey. James Farquhar, aged twenty-four, a shoemaker, admitted into No. 1 ward, Richmond Hospital, .-May25th, 1870, at 3.30 p.m., in Mr. Hamilton's absence from town. The man stated that a short time previous to admission he was cutting sand paper on a board which was resting on his knee, the knife slipped, and went with great force into his right thigh. Violent bleeding took place from the wound. He stopped it by pressure and linen wrapped round the thigh. He was then brought to the hospital. There was a small longitudinal wound in the right thigh, at the lower angle of Scarpa's space, and about half an inch in length. I t seemed deep, and the edge of the sartorius muscle was seen divided a t the bottom of the wound. There was swelling along the outline of this muscle, evidently from extravasated blood. A compress and bandage were applied, and he was removed to bed. An hour afterwards bleeding set in, and the patient lost about six ounces of blood. The wound was plugged from the bottom, and a compress and bandage applied by Mr. Henry, the resident pupil. 26th.--Spent a good night. Pulse 90. Mr. Fleming visited him, and removed the plug from the wound. He ordered an aperient,

By

MR. HA~tlLTOn.

419

with tartarlzed antimony. A pad of llnt over the wound and a many-tailed bandage applied. A bladder of ice over the pad. 5 o'clock p.m.--The nurse called Mr. Vesey, as the patient was bleeding. He was lying in a pool of blood. One of the patients was directed to make pressure on the femoral artery near the groin, which controlled the h~morrhage. The bandage and pad were then removed, and when the pressure was taken offthe artery the blood was seen welling up from the bottom of the wound. Mr. Vesey tried to catch the artery with a forceps, but failed ; the edges of the wound were then brought together, but this did not succeed in stopping the bleeding; the wound was, therefore, plugged from the bottom, and a compress and bandage applied. 27th.--No return of bleeding. Mr. Fleming removed the bandage, but left the compress and plug behind. 30th.--l~othlng particular since the last report ; he had got some aperient medicine, but he was anxious and rather feverish; the temperature higher in the wounded limb. There is ecchymosis extending to the groin above, and below to the popliteal space. In the evening dark pus was found to have saturated the bandage. The pad and the plug were loose, and the pus flowing freely from the wound; more was expressed by sponge and warm water. 5th June.--Nothing has occurred worth notice since the last report. But a symptom which has been observed for the last week is now very remarkable; in the diffuse swelling round the wound a very loud bruit is heard, very rough and distinct, and quite similar to that heard in aneurismal varix. A thrilling sensation is communicated to the hand. It is now nine days since there was any hzemorrhage, but in the evening, at 6.30 o'clock, violent bleeding began, to the extent of ten or twelve ounces, saturating the bed. Pressure on the femoral artery stopped the bleeding. Petit's tourniquet was applied. The patient was very pale and in an alarming state. Pulse scarcely to be felt, livid lips, and diarrhoea. Stimulants were adminlstered. A t 10.30 a consultation was held by Mr. Adams and M r . W. Colles (Mr. Hamilton being absent from town). It was considered the patient was in no state for operation. Mr. Carte's compressor was applied. 6th June.--Reaction has set in. Pulse 100, tolerably strong. t:Ie bore the compression well. The compressor was removed, and pads over the wound and in the course of the artery were applied and secured by broad strips of adhesive plaster and bandage,

420

Illustrations of the Surgery of tl~e Femoral Artery.

The tumour before this was more obvious, and the pulsation remarkable ; the bruit and thrill as before. He was troubled with tympany and uneasiness of the bowels. An enema relieved this. He has been taking muriated tincture of iron and digitalis for some days past. 9th.--In the evening about the usual hour, 6.15, bleeding set in, but not violently. Mr. Hamilton and Mr. Smith applied a fresh compress and bandage, and as the night was setting in when they saw the patient any operation was deferred till the next morning. He spent a restless night, little sleep, and a strong impression that the bleeding would return, the artery "thumping strongly," and a leaping sensation from the knee up. H~emorrhage recurred at 8.30 o'clock, the blood coming very freely from under the compress. The h~emorrhage was restrained by digital pressure till a horseshoe tourniquet was applied. A t 9.30 Mr. Hamilton, assisted by his colleagues, Messrs. Adams, Smith, and Stokes, proceeded to tie the artery. The man was put fully under the influence of chloroform. Mr. Hamilton made an incision over the femoral artery four inches in length, including the original wound in the centre ; firm pressure being made on the femoral artery by a pad in the handle of a door-key. In spite of this there was from time to time a little welling up of blood from the wound in the artery, to restrain which the pressure in the groin required to be very strong. A good deal of clotted blood had to be removed before the artery was visible ; it was then seen at the bottom of the wound, quite white, with a clean cut wound in the axis of the artery, about half an inch long. The wound in the soft parts was kept open by retractors, while a strong silk ligature was passed under the artery above and below the wound, and tightly tied. .All oozing of blood through the puncture entirely ceased. Some difficulty was experienced in carrying the aneurism needle between the vein and artery, amalgamated by the strong pressure that had been so long previously applied. The femoral vein, which had formed the aneurismal varix, was not apparent. The wound was dressed with sticking plaster and lint, and a flannel bandage roiled round the limb. On the 16th day both ligatures came away quite easily. There was a certain amount of contraction of the knee-joint remaining after the wound was healed, in consequence of the long-continued flexed position. This was remedied by keeping the limb in a double inclined splint, straightened by a screw, and he left the hospital in better health than before the accident.