SURGERY.
Popliteal Aneurism; Tying of the Femoral Artery; Recovery. A
New Aneurism-Needle.—It is interesting to look back on the various
phases of the treatment of external aneurism, and modern surgery may
well be proud of the gigantic strides which have been made within the
last hundred years. Hunter’s and Scarpa’s share in these improve-
ments must ever give them a place (where this even their only merit)
among the benefactors of the human race. But great credit is likewise
due to surgeons of our own times for reviving the use of compression,
regulated so as to lessen the force of the circulation, and to promote the
solidification of the aneurismal tumour; and the Irish school has done
much to promote the improvements in the instruments used for that
purpose. Dr. Bellingham, who has worthily labored in the cause of
compression, has not yet succeeded in converting all his professional
brethren to his opinion, if we are to judge from the London practice,
and from the condemnations which have issued from North Britain.
As the question is still sub judice, it would be rash and presumptuous
to offer a decided opinion on the subject; but we will venture to say,
that it would be extremely useful if a competent surgeon would take
the trouble of partially examining the question, and give the profession
his opinion, not whether one of the two lines of practice (the ligature or
compression) is the best, but in which cases and under what circum-
stances, either is to be applied.
It will be perceived by the following case, that Mr. Le Gros Clark
is not wedded to any particular mode of treating such cases, for he
would have tried compression whilst his patient was in a favourable
condition for such treatment, but resorted to the ligature when delay had
put other means out of the question. We proceed to give an outline of
the case.
The patient is a man of forty-eight, robust, and of florid complexion,
accustomed to active exercise, being a woodman on a large estate. He
was admitted into St. Thomas’s Hospital, June 15th, under the care of
Mr. Le Gros Clark. About six months before the patient presented
himself at the hospital, his attention was attracted to the affected limb
by a pain extending from the hip to the ankle, and especially about the
knee. He applied to Mr. Curtis, of Harting, Sussex, who at once de-
tected a swelling in the ham, and ascertained its nature to be aneuris-
mal. There was some oedema of the leg at the time. The patient
was first seen by Mr. Clark, March 24th, who urged him to enter the
hospital at once, but the patient declined doing so. The tumor was
then about the size of'a duck’s egg, and occupied the upper and outer
part of the popliteal space ; it pulsated strongly, but the impulse could
be arrested by pressure on the femoral artery, and the sac partially
emptied. When admitted in June, however, nearly the whole ham was
occupied by the tumour, which was also much more solid than before,
from the increased deposit of fibrine, so that but little impression could
be made on the sac by pressure on the artery. The pain in the limb
was very great, and described as sometimes excessive; the thigh and
leg presenting a certain amount of cederaa and venous congestion. The
patient had been following his usual occupations up to this admission,
his health was good, and the viscera of the chest were found in a nor-
mal state.
After the man had been duly prepared, Mr. Le Gros Clark tied the
femoral artery, in the usual way, five days after admission. The
patient proved very excitable both during and after the operation. In
the evening the temperature of the operated limb was slightly below
that of the sound one; there was no pulsation either in the sac or arte-
ries ; and as the excitability continued, twenty minims of Battley’s so-
lution were ordered, and to be repeated if necessary. Two doses were
required to procure rest, and on the next day the wound looked healthy;
the pulse was 106, the skin hot and thirst great. Temperature of the
popliteal space on the operated side, 101°, on the sound side 991°. On
the second day, Mr. Clark, finding his patient rather weak, ordered two
ounces of gin, which had been the man’s accustomed beverage; and on
the third he expressed a desire for food. The wound looking rather
sluggish, the diet was gradually increased, and the patient improved ra-
pidly. On the fifteenth day the ligature came away in the dressings,
and the patient returned home (the wound being nearly healed) about
one month after the operation; there had been no pulsation either in
the sac or arteries, below the ligature, since the latter had been applied.
The patient was seen about three weeks after his discharge, and was
doing well.
Mr. Le Gros Clark remarked at the time of the operation, that when
he saw the patient at an earlier period he urged him to submit at once
to treatment for the cure of the disease; and he had intended trying
compression on the femoral artery at two different points, so as to keep up
a certain amount of resistance to the flow of blood without risk to the
superjacent soft parts. The progress of the disease, the increased size
of the tumor, now occupying the entire popliteal space; the oedema of
the limb, the suffering of the patient, and his extreme constitutional ex-
citability all concurred in forbidding that course. The application of a
ligature on the trunk of the artery, in the usual position, was, therefore
the only alternative which offered itself.
Mr. Clark used in this operation a new aneurism needle, manufac-
tured by Mr. Bigg, of St. Thomas’s-street.
This needle is composed of an oval silver stem, a portion of the
the extremity of which (about half an inch) is hollow, to receive the
point, which is bulbous, and takes off at will. This bulb has a thin
prolongation backwards, containing the eye, so that the ligature is con-
cealed within the cavity of the bend of the instrument, and hangs
loosely from its posterior aspect, a few lines below the beginning of
the curve. The thread being thus disposed, offers no obstruction whilst
the needle is passing under the artery ; and when the operator finds it
necessary to cut through any fascia that may resist the point of the in-
strument, he does not run the risk of dividing the silk. The needle is
furnished with an ivory handle, having two deep notches cut in the end,
for the purpose of winding the ligature round the extremity of the
handle, and rendering the instrument firm. Simplicity seems to be the
great quality of this needle; for in Mott’s the point is screwed off from
behind the curve ; in Kirby’s there is a loose pair of forceps resting
in a groove, which seizes the point of the needle, and withdraws it from
the sheath or handle ; and Le Strange has added a sliding canula to
Mott’s needle by which the screw is fixed, and the possibility of the
point shifting during the operation prevented. In fact, several aneurism
needles have been invented to accomplish the purposes above de-
scribed, but, from their complicated nature, have one after another been
laid aside,—London Lancet.