ORIGINAL ARTICLES. "Qui Docet Discit." SIX CASES OF ANEURISM.* SELECT TOPICS As the title indicates, this paper is simply a casuistic report, which we desire to lay before the Society. The number of cases is so small, and their nature so different, that the subject of aneurisms in general cannot be considered here. No. 1. through the artery. No external hæmorrhage. Ligation of the popliteal artery in loco. Gangrene. Amputation at upper third of thigh. Death. J. M. A laborer, 35 years of age, was brought to Cook county Hospital July 5th, 1881, and placed under Dr. Fenger's care. On admission he gave the following history: July 4th, while walking across State street, he felt a sudden pain in the left popliteal region; simultaneously he heard the report of a revolver which had been fired from a group of boys on the sidewalk. He We do not need to state that while the was able to walk home, but pain and a general term, aneurism, is perfectly correct feeling of tension in the popliteal space anatomically, it is altogether too general soon rendered walking difficult and comwhen location, symptomatology, therapeu-pelled him to lie down. A small wound tics and cure are taken into consideration. could be seen at the lower extremity of the The necessity of individualization in this respect has been mentioned in only very few of even the more elaborate handbooks of surgery. Attention must be given to this important point in future. This individualization can be accomplished only by a large number of casuistic reports, and to this end Examination revealed a revolver bullet our paper of to-night is intended as a small wound, an inch above the head of the contribution. To counterbalance the fibula, close to the tendon of the biceps. necessary dryness of the bare casuistic Severe pain in the leg, which is slightly reports, we have added some remarks in-flexed at the knee, and the slightest movetended to point out some of the practical ment of which is painful. The capsule points of unusual interest, to which our at- contains no fluid and there is no swelling tention has been directed in some of the on the anterior side of the limb, but the popliteal space is swollen, tense and ten cases. outer hamstring tendon; from which, however, there was only very slight hæmorrhage. The pain and swelling increased during the night, and the next morning, as he was unable to walk, he was brought to the hospital. CASE I.-Traumatic popliteal aneurism der. The swelling extends downwards (Fenger, Chicago, 1881). through the upper third of the calf, and Synopsis.-Traumatic left popliteal aneur-upward through the lower third of the posism from revolver bullet, wound passing terior side of the thigh. *Read before the Chicago Biological Society, The hand applied over the popliteal February 1st, 1882. space feels distinct pulsation, and the ste 1 225447 thoscope reveals an unmistakable aneurismal flexed at the knee, and suspended in an bruit, most pronounced in the middle of elevated position. the popliteal space. July 6th.-Pulse 108; temperature 102.1°. Patient has been restless during the night. The crus and foot are somewhat swollen and painful, but warm, and have a slight yellowish discoloration. to submit to the operation, as he had no pain and was able to move the foot. July 8th.-Pulse 120, weak; temperature 102°. The discoloration along the vena saphena major now extends to the upper third of the thigh. The patient now consented to amputation, and consequently July 5th. In the afternoon the patient July 7th.-Pulse 110; temperature 102.5°. was anesthetized, turned on his face, and The swelling of the foot and crus has inEsmarch's bandage applied as high as the creased. The skin has a diffuse yellowishupper third of the femur where the elastic brown discoloration, and several brownishconstriction was made. A longitudinal in- red bullæ, from the size of a pea to that of cision, four inches in length, was made in a hazel-nut, are spread over its surface. the middle line of the popliteal space, The discoloration now extends from the through the skin, subcutaneous tissue and crus, up over the medial line of the kneefascia. Below the latter, in the adipose tis- joint, along the track of the vena saphena sue surrounding the large nerves and ves- major. Dr. Fenger proposed to the pasels, was a profuse extravasation of dark, tient immediate amputation in the middle clotted blood, extending above and below of the thigh, as a possible means of saving the ends of the incision. A probe intro- his life from the rapidly spreading moist duced through the entrance opening of gangrene, but the patient positively refused the bullet wound could be passed transversely through the popliteal space from the external to the median border, where it was stopped in the muscular mass of the internal head of the gastrocnemius. Leaving the probe in this position careful dissection was made with the dissecting forceps, so as to avoid injuring any vessels, amputation at the upper third of the and after the removal of several small clots it was found that the nerve and the popliteal vein were intact, but the artery was perforated twice, one opening being lateral and one median. Through these openings the probe passed transversely through the lumen of the artery. At the end of the July 9th.-Pulse 130; temperature 1019. wound, in the inner head of the gastroc- The patient rallied in due time after the nemius, a small revolver bullet, calibre 32, operation and slept well during the night. was found and extracted. The artery was With the exception of weakness he feels now easily isolated and ligated above and well. As some brownish discoloration of below the two perforations, the ligatures the skin was seen, in and above the inbeing at a distance of less than half an inch guinal region, the amputation wound was from each other. No signs of suppuration dressed, and showed gangrene spreading were to be seen in the tissues after the re- along the medial surface of the amputation moval of the clots. The constriction stump. around the femur was removed; a trifling July 10th. During yesterday afternoon hæmorrhage followed, which was checked the patient became weaker, collapsed and by irrigation; a drainage-tube inserted; the died at 9 pm. thigh was performed, with a large external and small internal flap, taken from apparently healthy tissue. The operation was accompanied by the usual amount of hæmorrhage. The stump was dressed antiseptically. wound united; Lister dressing applied; The autopsy demonstrated the usual the leg placed in a Bonnet splint, slightly signs of moist gangrene, namely, a little BaneJBRARY cloudy serum infiltrating h ha, Billroth, and Erichsen, in the tissue of the thigh andEonsideration of wounds of the popliteal arside of the abdomen fluid blood; heart tery, rathe recommend than condemn the flabby from cloudy welling; MAYby121902ature i loco, in suitable cases, which idneys; all the must, all the must,ourse, be a minority. cloudy spleen, liver other organs normal. didneys; ON,ooking over the literature for the last It was the conservative tendency of mod-fifteen years, we have been able to find ern surgery, relying upon the antiseptic only one case, besides the two above-menmethod, taken together with the rules laid tioned cases reported by Poland, in which down in modern works on surgery, that led the treatment of a wounded popliteal arteDr. Fenger to attempt to save the patient's limb in this case, by double ligature in loco. A discussion in the French Surgical Society in 1875 (Virchow-Horsch Jahresbericht, Band II, Abtheilung II, page 338, 1876,) concerning the treatment of wounds of the large arteries, showed that the opinion of the majority of those present was that immediate double ligature of the wounded artery should be made in cases uncomplicated by injuries to, or inflammations of the surrounding tissues. Two cases of gunshot wound of the femoral artery, one from pistol bullet and one from buckshot were reported from Volkmann's Klinik, by Kraske, at the Eighth Congress of German surgeons (VirchowHorsch Jahresbericht, Band II, Heft. II, page 307, 1880) in each of which perfect and speedy recovery, with conservation of the limb, followed immediate double ligature. These results seem to strengthen the advisability of conservative surgery in such cases. ry, by ligature in loco was successful in saving the limb. This case was reported by Annandale (Lancet, April 24, 1875). A boy ten years old suffered a punctured wound in the popliteal. Three months later a pulsating tumor was noticed, which, as was seen at the operation, was an arteriovenous aneurism. The operation of double ligature of both artery and vein in the popliteal space, under antiseptic precautions, was followed by recovery in four weeks. This case stands as an exception, and is not at all comparable to cases of acute diffuse traumatic aneurisms, from injuries, for which, as far as we know, amputation is still the only safe method of treatment. It has been advised in such cases to try to save the limb by ligature of the femoral artery. Rabe (Deutsche Zeitschrift fur Chirurgie, Band V, 1875, page 154), reports eleven cases, with only two deaths, ninė recoveries, no gangrene and no secondary amputation. The value of these favorable results of The popliteal artery has always had a bad the ligation of the femoral for rupture of reputation, on account of the dangerous the popliteal artery is seriously impaired character of its injuries, and Poland's opin- by the reports from the Franco-German ion, (Guy's Hospital Reports, 1860,) cor- war, in which two cases of gunthot wound roborated by Pollock (Guy's Hospital Re- of the popliteal artery are on record. One ports, 1866), after the treatment in all, of reported by Fischer (Deutsche Zeitschrift ten cases, was that amputation was prefer- fur Chirurgie, Band I, 1872, page 264), able to either double ligature in loco, or, ligature of the femoral artery, and that the amputation should be primary, as amputation after gangrene has commenced is always an uncertain operation. Only two of the cases cited by this author, in which immediate double ligature was made, recovered; in three cases gangrene followed. and one by MacCormac (Virchow-Hirsch Jahersbericht, 1872, Band II, Heft II), in which ligation of the femoral artery did not stop the hæmorrhage from the popliteal artery. A similar case is reported by Caspary (Virchow-Hirsch Jahresbericht, 1870, Band II, Heft II, page 348), of traumatic aneurism in the popliteal space, twen The larger standard hand-books on sur-ty-seven days after a gunshot wound |