ill NATIONAL LIBRARY OF MEDICINE Washington Founded 1836 U. S. Department of Health, Education, and Welfare Public Health Service CASE ANEURISM OF THE FEMORAL ARTERY; COMMUNICATED 1* A LETTER TO JOHN ABERNETHY, Est* V R. f Assistant £ urgeon of St. Bartholomew's Hospital, London, &c. BY DAVID HOSACK, M. D. ?i-ofessor of the Theory and Practice of Physic and Clinical MHiriut in the University of New-York, NEW-YORK: rill-NTED BY C. S. VAN WINKLE, 122 Water-street 1312. WH M "; 'FP'? 'ff/i ■•" ■::-: ■ , ..■"■ '•■' ' ■'■■ ^-m* CASE OF ANEURISM OF THE FEMORAL ARTERY. Dear Sir, It is a remark of one of the most distinguished surgeons of the present day, Mr. John Bell, " that in the operation for aneurism of the thigh, more perhaps have died than have survived it." In the manner of conducting the operation, there, is also great difference of opinion, among the most ce- lebrated surgeons of Europe. These facts render it neces- sary and proper to record every case in which this impor- tant operation has been performed, the manner in which it has been conducted, and the result of the case. Influenced by these considerations, I enclose you the mi- nutes of a case which fell under my care, during my attend- ance as one of the surgeons of the alms-house of this city, and which I am happy to add has terminated successfully, John Spencer, amative of Germany, thirty years of age, came into the alms-house, about the twentieth of March, 1808, on account of a tumour of his right thigh, attended with pain and lameness, by which he was rendered incapable of pursuing his ordinary occupation, that of an oysterman. Upon inquiring into the history of his complaint, it ap- peared, that his disease came on spontaneously about the ( i ) first of February preceding; that he had sustained no previ- ous injury to which it could be ascribed, unless the circum- stance of a waggon having passed over his thigh, about four- teen years ago, could be supposed to have had any agency in giving origin to his disease. The first symptom which he discovered of his complaint, was a small hard tumour about the middle of the thigh, which he perceived upon rising out of bed in the morning ; in a few days, it evidently increased in size, and the pulsation became so considerable, that it was apparent to the bystanders. It then gave him no pain; but in about seven weeks from the time of its first appearance, the tumour became so large as to exU nd nearly to the knee, and almost as high as where the profunda leaves the femoral artery. It then produced a sense of numbness throughout the whole limb, and such a degree of pain in the part as deprived him of rest. The tumour also hud acquir- ed such magnitude, that, on the twenty-ninth of March, the pulsation was only to be perceived by the most atiemive examination, and then only by grasping the tumour with both hands. The tumour also, at that time, assumed a somewhat purple colour, and, in one part, was much more elevated and elastic, and in some degree appeared as if the aneurismal sac would soon be ruptured. From its diffusing itself entirely around the thigh, there could be little doubt of a rupture of the coats of the artery. His health had become much im- paired, his countenance pale, his pulse small and weak, and his extremities, excepting the part affected, much diminish- ed in size, and his whole body considerably emaciated. The nature of the disease being ascertained, and the tu- mour sensibly and daily increasing, a consultation was called the succeeding day, at which all present concurred in opin- ion, that the situation of the patient rendered it necessary that the operation should be performed as soon as possible. AecoiUir.£;y, the following day, the thirty-first, was appoint- (5) ed for the operation. The patient's bowels were directed to be emptied by an injection, and afterwards an anodyne of one hundred drops of laudanum to be given him an hour be- fore the time of operating. In conducting the operation, Dr. Post, the Professor of Anatomy and Surgery, in Columbia College, gave me his as- sistance, by compressing the artery as it passed under Pou- part's ligament; for the small space between the tumour and the groin did not allow of the application of the tourniquet. An incision was then made through the integuments, about six inches in length, in the direction of the sartorius muscle, at its inner edge, beginning about two inches from the groin. The sheath enclosing the muscle was then divided, and the muscle pressed aside. I then slowly divided the cellular membrane (scarcely to be called fascia) covering and enclos- ing the vessels; and with my fingers readily detached the artery from the vein and anterior crural nerve, and passed the needle probe with a strong double ligature beneath it. The iigatures were then tied, leaving about an inch between them, and the artery divided between the ligatures; but the division of it was made nearest the lower ligature, with a view to prevent the accident that has sometimes occurred, ot the ligature being thrown off by the force of the artery, On this account particular attention was given to the man ner of securing the artery. Great care was also taken not to separate it from its connexions, farther than was absolutely necessary to pass the probe beneath it, and to apply the liga- tures ; lest any unnecessary separation should lessen the chance of union of the sides of the vessel before the ligatures might separate. In the hands of the English surgeons it has, in several instances, occurred, especially in those cases where the artery was left undivided, that ulceration took place, and th« ligature separated before the sides of the vessel were-. ( 6 ) united, in which case the patient was destroyed by hae- morrhage. But by cutting the artery between the ligatures, as recom- mended by you and by Mr. John Bell, it retracts as after amputation; and its connexions being preserved, the union is as readily effected between the sides of the vessel in the one case as in the other. It may be proper here to remark, that the artery was secured about an inch above the tumour, which was left to be absorbed, and that the upper ligature was made so high that there was probably little more than half an inch between it and the profunda. Another circum- stance worthy of notice is, that the pulsations of the artery near the tumour were unusually feeble ; whereas the other vessels beat with their usual force, as also did the femoral artery, where it passes Poupart's ligament. The artery being secured, the sides of the wound were brought together and retained by strips of adhesive plaster, covered with lint and a light compress, and the whole sup- ported by a flannel roller; the patient was then conveyed to his bed, and his limb placed in an easy relaxed posture, with a pillow underneath his thigh to preserve it in that position. The next day a great increase of heat was perceived about the wound, but the lower part of the limb was much colder than natural, and not the least pulsation was perceivable in any of the arteries below the tumour. The limb was then bathed with spirits, and wrapped in warm dry flannels which were frequently renewed. On the fifth day from the operation, the wound became somewhat offensive; the dressings were removed, when it was found that an adhesion had taken place the whole extent of the wound, excepting the part immediately adjacent to the ligatures. The limb was also considerably warmer than on the second or third day after the operation, but had not yet acquired its natural temperature. Having cleansed the ( 1 ) parts first with soap and water, and afterwards bathed them with spirits, the plasters and compress were renewed, and the roller applied as before. The wound was from that time dressed daily, and the whole limb washed with spirits: as early as the ninth day, the diminution of the tumour was ap- parent. On the twelfth of April, i. e. the thirteenth since the operation, the ligatures came away ; and on the seven- teenth, a very feeble, pulsation was perceived in the poste- rior tibial artery, and the limb was restored to its natural temperature. He was then put upon the use of bark and a nutritious diet. In a short time his general health was so much improved, that he walked about the house without the least pain or inconvenience. The tumour continued to de- crease rapidly, and the wound healed without the least impe- diment of any sort. The limb was still washed with spirits, and the roller ap- plied as before, with the view to increase the tone of the parts, and to promote the absorption of the contents of the tumour. The twenty-second of June following, he called to see me, with a request to be discharged from the alms-house, and to return to his business. He had entirely recovered his strength, the circulation appeared perfectly restored in the limb, and the tumour so inconsiderable, that upon measuring the circumference of the thigh, at the part where the tumour had been most apparent, there was but one inch difference between it and the corresponding part of the other limb. He was accordingly discharged, with the direction to lay aside the bandage, and daily, for some time, to bathe the part affected with cold water. I am, dear Sir, with great respect and esteem, yours, DAVID HOSACK. C 8 ) [The man whose case is related above, again called upon me, a few months since, remaining in good health, and enjoy- . ing the perfect use of his limb. He informs me, that since the operation he has walked from this city to Philadelphia, and that his first day's journey was thirty-five miles.] ' New-York, June nth, 181& D. H. McJL. Hist, 110 c. I,