or the result of wound, is rare. When it does exist, its signs are
sufficiently distinct. The old operation—opening the tumour by direct
incision, and tying the vessel close to the cyst—has been performed
successfully in one remarkable case on record. But this is attended
with much risk, there being no means of commanding the bleeding during
the incisions, nor until the ligature is placed and secured. The
preferable proceeding is to tie the internal iliac near its origin,
as has been put in practice successfully in a few cases. The same
incisions are made as for reaching the common iliac, and then the
sacro-iliac junction is felt for; with the nail of the forefinger the
cellular tissue is cautiously and gently separated, and a needle and
ligature placed under the vessel. In a corpulent adult, a needle, with
a moveable point, may perhaps be useful, as also the copper spatulæ,
to keep the parts aside; and a serrenœud may assist in the securing of
the noose. It was the fashion once, and perhaps is so still, for every
young and aspiring surgeon, when he was about to attempt lithotomy
for the first time, to invent or alter some strange crooked tool, for
smoothing, as he thought, his way into the bladder. The rage now,
more especially on the other side of the Atlantic, is all for curious
aneurism needles and tonsil shavers. It ought never to be forgotten,
that the simplicity of any proceeding and of every machine is the
measure of their perfection. I have had by me a lot of needles, all
very ingenious, at the various operations for aneurism which I have
had occasion to perform—many of them of the most difficult nature—and
the simple needle has always been found to answer the purpose most
perfectly.
Aneurism in the groin is not uncommon, and is very easily recognised.
The old operation has been attempted, and unsuccessfully. Ligature
has been placed on the distal side of the tumour, with no favourable
result. One horrid example of the latter operation is on record, in
which the femoral artery had been completely obliterated spontaneously,
and nerves, vein, and portions of the muscles, were all included in
ligature, by one random thrust of a large sharp needle. The _external
iliac_ is to be tied—a proceeding now regarded as one of the regular
operations of surgery, and likely to insure a favourable result. It was
first undertaken in a case of secondary bleeding after ligature of the
femoral, and since, has often been performed for the cure of inguinal
aneurism, with almost uniform success. It has also been practised
successfully, on account of hemorrhage after amputation. I was under
the necessity lately of putting a ligature round the external iliac,
on account of profuse bleeding from an opening in the groin, made
five weeks previously, to secure the common femoral, on account of
hemorrhage from a stump of the thigh. This operation should have been
had recourse to in the first instance, the deligation of the common
femoral being an operation not likely to be followed by permanent
closure of the vessel, in consequence of its shortness, and the
branches given off from it both above and below. The patient ultimately
recovered from these three capital operations. The incisions are made
in the same direction as recommended for ligature of the common and
internal iliacs, but not nearly so extensive. This is preferable to
incision, either in the direction of the vessel, or of a semilunar form
with one of the corners pointing upwards; the abdominal muscles are
less weakened, less injury being inflicted on them, and no troublesome
bloodvessels are encountered. The artery is well circumstanced for the
application of ligature, affording a considerable extent without the
giving off of any branches. It is easily exposed by cautious separation
of the cellular tissue, and the ligature is secured either towards its
middle, or at its upper part, according to the size and situation of
the aneurism.
Popliteal aneurism is of more frequent occurrence than any of the
preceding; and in regard to it, also, the old operation has deservedly
fallen into disuse. It seems in most cases to be occasioned by partial
laceration of the coats of the vessel; a sudden pain, and a feeling as
of the receipt of an injury on the part, are generally felt, during
some violent or unusual exertion; the pain continues, and an unwonted
beating is soon perceived in the ham, along with inconsiderable
swelling; the tumour with pulsation increases, and may ultimately
attain a large size, causing pain, general uneasiness in the limb,
and lameness, sometimes œdema. In cases of long duration, and when
the patient is cachectic, the bones become diseased, absorption being
caused by the pressure of the tumour, and deep extensive abscess may
form in the soft parts.
The _superficial femoral_ is to be tied, and the preferable point is
where it is crossed by the sartorius muscle. This is always a better
practice than removal of the limb, which has not unfrequently been
resorted to in cases of large aneurism; there is great risk in such
a proceeding, the anastomosing vessels in the thigh are all much
enlarged, profuse hemorrhage takes place during the incisions, not
completely arrested by any pressure, and probably twenty arteries or
more require ligature, as I have witnessed; after all, the occurrence
of secondary bleeding is not unlikely. I have tied the femoral artery,
with a favourable result, in some cases of very large aneurismal
tumour, and in one instance after the cyst had been imprudently
punctured. An incision is made from three to four inches in length,
and in an oblique direction in regard to the thigh, tracing the inner
border of the sartorius muscle, and so placed that its middle may
correspond with that part of the artery on which the ligature is to
be put. In order to insure the wound being thus situated, there is no
need for measurements; these are but a clumsy substitute for anatomical
knowledge. The surgeon, well acquainted with the relative situation of
the parts, finds it sufficient to ascertain the exact course of the
muscle by manipulation, whilst the thigh is slightly bent, and then
guides his knife by the eye, unfettered with mathematical diagrams. The
muscle is exposed almost by the first incision; the dissection is then
continued through the cellular tissue on its inner border, until the
sheath of the bloodvessels is reached, the branches of the crural nerve
on the fore part being carefully placed aside uninjured; the sheath is
cautiously opened immediately above where the muscle conceals it, and
the artery separated from its connections to a very slight extent; the
needle is then passed, and the ligature applied. The operation, when
thus conducted, is exceedingly simple. But embarrassment and delay have
often been experienced from following an opposite method, cutting down
on the outside of the sartorius; the muscle must either be dissected
from its attachments and turned over, or cut across; or the artery
cannot be found, and an additional external wound is necessary.
The artery may require ligature at a higher point, either in
consequence of wound, or for the cure of femoral aneurism. This
disease, however, is very unfrequent. When it does exist, it is usually
so situated as not to admit of the favourable application of a ligature
below the origin of the profunda; and it may be considered necessary to
tie the _common femoral_. The course of this artery being superficial,
is easily ascertained; an incision of convenient extent is made in the
same line, penetrating the skin and fatty matter; the cellular tissue
is carefully separated, and the sheath exposed; a limited opening is
made, with corresponding detachment of the vessel, and the ligature
applied, close to the lower edge of the ligament of Poupart. But
ligature of the external iliac is in all cases to be preferred, for the
reasons already given. This has proved successful in more than one case
of double aneurism, one in the groin, the other in the ham.
In ligature of the common and of the superficial femoral, the vein is
in more danger than the nerve, and the utmost caution is required lest
it be punctured. It has been wounded—I witnessed one instance of it;
the opening was drawn together and closed by ligature, inflammation of
the vein supervened and proved fatal.
When secondary bleeding occurs, on the separation of the ligature,
either after this operation or after that for popliteal aneurism,
compression is not to be trusted to, nor should the vessel be tied
higher in the thigh. From imprudent reliance on the former method I
have known patients perish. An incision must be made in the same line
as the former, and a ligature placed on the vessel both above and below
the bleeding point, as may be necessary.
The arteries of the leg very seldom require ligature, except for
wound. In such cases, the source of the bleeding must be the guide to
the incisions, and these should be placed so as to interfere with the
muscles as little as possible, always in the direction of their fibres.
When the bleeding point is arrived at, the vessel is exposed to a short
distance, and tied above and below the wound. During the dissection,
it will in most cases be necessary to arrest the bleeding by pressure
in the ham, either by the fingers of an assistant, or by means of a
tourniquet.
The thigh may be the seat of _aneurismal varix_, the result of wound,
as in the following case. Fourteen years ago, a young man wounded the
lower part of his thigh deeply by the accidental thrust of a narrow
chisel. The puncture was in the direction of the femoral artery;
violent hemorrhage was the immediate consequence, and after he had
fainted the wound was stuffed and compression applied. In eight days
the parts had healed, and he returned to work as usual. But about
twelve months afterwards, troublesome pulsation was perceived in the
part, at the same time the veins of the leg became varicose, and a
succession of ulcers formed on the lower and anterior portion of the
limb. The affection attracted but little of his notice till about six
months since, when he observed a considerable swelling in the site of
the wound, beating strongly, and the pulsations accompanied with a
peculiar thrilling sound and feel—not confined to the tumour, though
strongest there, but extending to the groin along the course of the
femoral vein, which was evidently much dilated throughout its whole
course. At present the tumour is nearly equal to the fist in size,
of regular surface and globular form, pulsating very strongly, and
imparting to the hand the peculiar sensation of aneurismal varix,
remarkably distinct and powerful. The pulsation and thrilling are
continued, in a less degree, to Poupart’s ligament, and down to the
calf of the leg. On applying the ear close to the tumour, or listening
through the stethoscope, the peculiar noise is not only felt, but
heard of almost startling intensity—somewhat resembling the noise of
complicated and powerful machinery, softened and confused by distance.
By making firm pressure on the tumour, the thrill is lost, and the
regular pulsation alone perceived; at the same time, the turgescence of
the femoral vein disappears, and on compressing the femoral artery in
the middle of the thigh, both pulsation and thrilling are arrested, and
the swelling much diminished,—but only temporarily, for the collateral
circulation is free and complete. He feels little pain, but exercise
and exertion of every kind are seriously impeded; constant and firm
pressure on the swelling, with uniform compression of the whole limb,
has been employed, with the effect of relieving all the symptoms, and
rendering the limb much more useful, and by its continuance it is to be
hoped that the disease will at least be considerably palliated.
[Illustration]
In the lower extremity, as in the upper, the _bursæ_ become enlarged,
in consequence either of pressure or of external injury. The
affection may be acute, following a blow or squeeze, but is most
frequently chronic, enlarging gradually and with little or no pain,
and caused by habitual pressure on the part. From this, it will at
once be understood, why the bursa over the patella should be the one
most commonly affected. Its vulgar name, housemaid’s-knee, marks
its cause—the avocations of such persons requiring them to rest on
one or both knees, frequently, and often for a long time. It also
occurs in shop-keepers, and other persons accustomed to shut drawers
with their knee, or in other ways to make frequent pressure on that
part,—in gardeners, and those employed in similar pursuits. In the
acute swelling from injury, local depletion, fomentation, and rest
are required, and these are generally sufficient to arrest the
swelling, and promote its subsidence; but, in some cases, the fluid
is deteriorated and the surface inflames, free incision is required,
followed by poultice, and afterwards by simple dressing. In the
chronic collection of clear fluid, gentle and continued stimulation
of the surface, as by the gum and mercurial plaster, causes gradual
decrease by absorption; the causes of the affection being at the
same time studiously avoided. The tumour sometimes, as here shown,
attains a large size, and from repeated inflammatory attacks
becomes consolidated. The cyst is thickened, and lymph is effused
into the cavity so as to convert an encysted swelling into one of
solid consistence. In such cases as these, the tumour may cause such
inconvenience as to make the patient desirous to have it dissected
out. This is easily and safely effected; the incisions are made in the
direction of the limb, and it is kept at rest in the extended portion
for some time, so as to favour the healing of the wound.
Unyielding parts, habituated to pressure, defend themselves by the
interposition of a moveable bag containing fluid; betwixt them and the
surface the cellular tissue condenses into a cyst, its internal surface
assuming a serous appearance, and secreting a fluid resembling the
synovial. Such adventitious bursæ are not unfrequent on the ankles and
feet, as in tailors, or others usually sitting cross-legged. They may
attain a considerable size, and so produce deformity; but they should
not be interfered with unless they become inconvenient, as from excited
action.
When the extremity of the metatarsal bone of the great toe is large,
and consequently the seat of pressure, a bursal formation is produced
in the soft parts covering it; this from increase of pressure, or other
irritation, may inflame—forming the painful and troublesome disease
termed _Bunnion_. Sometimes unhealthy abscess occurs, with thickening,
infiltration, and condensation of the surrounding cellular tissue; in
such cases, incision and poultice are required, and occasionally it is
necessary to destroy the unsound cellular tissue and the degenerated
cyst by free application of the caustic potass. The cyst is thus got
rid of, healthy granulation takes place, and by afterwards avoiding
undue pressure upon the part, a permanent cure is obtained.
It has been elsewhere mentioned, that _cartilaginous bodies_ sometimes
form within articulating cavities, occasionally attached by a narrow
and slender connection with the secreting surface, but generally
loose, seldom numerous, and usually of no great size. They are most
commonly met with in the knee-joint, producing inconvenience by
impeding progression. Sometimes they are neither painful nor annoying,
being small, and seldom becoming interposed between the articulating
extremities of the bones during motion; such ought not to be interfered
with. But when large, they may be so troublesome as to warrant incision
and removal. The foreign body is made to project on one side, and,
having been made as superficial as possible at a favourable point, is
fixed by the fingers of an assistant. The integuments are then drawn
to one side, and an incision made over the body, the capsule is cut to
as limited an extent as possible, and removal effected by pressure—or
it may be laid hold of by a hook, and extracted; if the cartilaginous
substance be attached by a pedicle, this must be divided, but with
great caution. The integuments are immediately allowed to resume
their natural situation, and so to close the wound of the capsule by
overlapping it; the skin is then accurately approximated by adhesive
plasters. The limb is kept extended, and not the slightest motion
of the joint permitted. The patient is confined constantly to the
recumbent posture, purged, and kept on low diet; the utmost vigilance
is necessary to prevent inflammation of the synovial apparatus. In some
patients on whom I have performed this operation, the wound closed
by the first intention, and no untoward symptom threatened, motion
and the erect position being resumed in a few weeks. But in the last
case which came under my care, though the extirpation was performed
with the utmost care, most violent inflammation supervened; the wound
opened, synovial secretion flowed out in large quantity, profuse escape
of unhealthy matter followed, and exhausting discharge continued for
many weeks. At one time the constitutional disturbance was so great
as to endanger life; the limb was saved with difficulty, the joint
anchylosed. From the result of this case, I am disposed to dissuade
operative interference, unless the patient strenuously urge it, and be
willing to take the responsibility for the consequences on himself.
[The most common distortion to which the human body is liable is
_Club-foot_; an affection which has at all times attracted the notice
of the profession, but which has received unusual attention within the
last ten years on account of the novel operation suggested for its
cure by Dr. Stromeyer of Hanover, in Europe. The lesion is, for the
most part, congenital. It may, however, be developed after birth, and
even at an advanced period of life, from the foot being accidentally
placed in a constrained position, and so retained until the soft
structures—particularly the muscles and ligaments—are moulded into a
new shape, or until they become fixed in their new situation. Various
mechanical causes may give rise to this malady, such as splints and
bandages, by which the parts to which they are applied are injuriously
compressed, or thrown out of their natural relations. Similar results
are produced by convulsions, dentition, nervous irritation, contusions,
sprains, fractures, partial luxations, and preternatural laxity of the
ligaments. In some instances the defect is occasioned by the presence
of a corn, an ulcer, or some other disease which induces the person
to walk on one side of the foot, the tip, or the heel, to ward off
pressure from the tender parts. A vicious habit is thus established,
which, if it be kept up, as it often is, for any length of time, leads
to irregular action in the muscles, and to distortion of the bones into
which they are inserted.
The formation of congenital club-foot has never been satisfactorily
explained. By some—as Meckel, St. Hilaire, Serres, and Breschet—it has
been ascribed to an arrest of development. This theory, however, for
various reasons, is untenable, and has therefore not been generally
adopted by surgical men. Mons. Martin, a recent French writer, thinks
it is mainly occasioned by the pressure of the parietes of the uterus
on the feet of the infant during gestation, owing to a deficiency of
the amniotic fluid; an opinion in which he is joined by Professor
Cruveilhier. That the disease may proceed from this source in some
instances maybe readily supposed, but that this is the only cause, is
what few will believe. The most plausible hypothesis, in my opinion, is
that of Mons. Guerin of Paris. He supposes that the primary mischief is
in the nervous system, and that the spasmodic and permanent shortening
of the muscles of the affected limb is altogether consecutive. He
sums up the results of his numerous observations in the following
propositions:—1. Congenital club-foot is the effect of a convulsive
contraction of the muscles of the leg and foot. 2. In the absence of
general or direct traces of the convulsive affection we may almost
always discover some immediate characters which indicate the nature
of the exciting cause. 3. There are three constituent elements in the
retraction of the muscles of the part: namely, the immediate shortening
of their substance and tendons; a certain degree of paralysis; and,
lastly, a consecutive arrest in the development of their substance.
4. There are no other causes of genuine congenital club-foot than
convulsive muscular retraction. The pressure of the parietes of the
uterus on the fœtus appears, indeed, in some cases, to produce a
deformity of the limbs and feet, similar to but not identical with
club-foot. The views of Mons. Guerin are confirmed, in some degree,
by the history of those cases which occur after birth; but future
observation must determine whether they are correct or otherwise.
The congenital variety of this distortion often affects both feet
simultaneously, though rarely to the same extent. In one hundred and
sixty-seven cases reported by Dr. Detmold of New-York, the disease
was double in nine-three; in forty-one it occurred in the right foot
only, and in thirty-three only in the left. Of eighty cases collected
from various sources by Mons. Bouvier of Paris, or observed by
himself, two-fifths were double; one-third affected the left limb, and
one-fourth the right. Of sixty-one cases furnished by Martin, another
French writer, twenty-six were double and thirty-five simple: of the
latter, eighteen were of the right and seventeen of the left foot.
Mons. Helt has published the results of thirty-one cases, in nineteen
of which the disease was double; in two it was more distinctly marked
on one leg than on the other; and in one instance the calcaneal form of
the lesion was united with the inverted. In twenty-one cases observed
by Scoutetten, both feet were deformed in nine; and in the other twelve
the right limb was exclusively involved seven times; the left five
times.
The disease would appear to be more frequent in males than in females,
though the relative proportion has not been ascertained. The following
table, embracing three hundred and twenty-nine cases, will throw some
light on this subject:—
Authors. Number. Males. Females.
Detmold 167 98 69
Bouvier 80 48 32
Martin 61 45 16
Scoutetten 21 13 8
——- ——- ——-
329 204 125
There are certain facts which would seem to show that club-foot is
sometimes hereditary; or, at all events, that it may occur in several
members of the same family. Thus, Dr. Detmold states that he has been
able to trace the hereditary predisposition to this deformity in not
less than eighteen cases, and in all excepting one, to the father’s
side. Whether this was a mere coincidence, or obtains generally,
it is impossible to say. Mons. d’Ivernois relates an instance in
which four brothers were all born with the feet twisted inwards; and
another writer, Mons. Helt, speaks of a family, which consisted of six
children, all of whom were afflicted with congenital club-foot. In the
latter case the disease was probably hereditary, as one of the parents
was labouring under the same infirmity. It should be observed, however,
that club-footed parents do not always produce club-footed children.
[Illustration]