The femoral artery was ligated. Three size until it was as large as a hen's egg, and days later secondary hæmorrhage set caused him so much pain that he was unin from the popliteal wound, necessitating able to walk. After he had been in this amputation. condition for about six weeks, he was seen The absurdity of attempting to compare by Drs. Lee and Fenger, who found on the ligation of the popliteal artery in cases examination, an aneurism in the left popof spontaneous aneurism, with the same liteal space of about the size of a hen's egg, treatment in cases of traumatic aneurism is with marked pulsation and bruit. Dr. Lee shown by one of Rabe's statistical tables, tied the left femoral artery in the middle of in which ten cases of Antyllus' operation, the thigh, and the patient was sent to namely, double ligation of the artery in loco Cook County Hospital for after treatment. and extirpation of the sac, are reported, The pulsation and bruit ceased; the wound with six recoveries, and the appearance of healed by first intention and an elastic gangrene in the other four cases. bandage was kept on the left knee. The There is one point in regard to the liga- patient gradually became able to walk with-tion of the large vessels, of which very lit-out pain, and was discharged from the tle notice has as yet been taken, but which hospital June 5. may in the future be adopted as a means Shortly afterwards he went to work, the of avoiding the gangrene subsequent to swelling in the popliteal space returned, ligation. An extended series of experi- accompanied by pain in walking, and he ments on rabbits, published by Meyer consequently re-entered the hospital June (Bayousches Artzliches Intelligenz Blatt, No. 16, and was placed under the care of Dr. 4, Jan. 24, 1868), shows the remarkable Fenger. fact that the simultaneous ligature of the large vein and artery in the same place was never followed by gangrene, nor by any other grave symptoms, such as inflammation or secondary hæmorrhage. The case

of Annandale, mentioned above, is in conformity with these facts. More extended experiments on the large animals are, however, desirable for the elucidation of this important question.

On examination, a small fluctuating. tumor was found at the upper margin of the left popliteal space. There was no bruit and no pulsation. The skin covering the apex of the tumor was brownish in color and thin, so that a perforation might be expected at this point. By the use of an exploring needle, a little thick, slimy darkred fluid was evacuated, which, on microscopical examination was found to contain

CASE II. Spontaneous Popliteal Aneur- numerous red blood corpuscles, but no pus ism. Fenger, Chicago, 1880.

cells. An elastic bandage was applied, the leg placed in an elevated position, and absolute rest in bed ordered.

June 29th. ished in size.

The tumor has not dimin

Synopsis. Spontaneous left popliteal aneurism-ligation of left femoral artery in middle of thigh-apparent recovery. Two months and a half later, rapidly increasing, fluctuating, nonpulsating tumor in popliteal space-aspiration of thin viscid blood, no effect. Two weeks later, radical operation, July 8th. The tumor was aspirated and accompanied by uncontrollable venous about six ounces of dark-red, bloody serum hæmorrhage-double ligation of popliteal withdrawn, and the elastic bandage reapvein, complete recovery in two months.

July 6th. The tumor is considerably enlarged and very painful.

plied.

July 11th. The cavity of the tumor has filled again.

John Smith, a Scotch bricklayer, fifty years of age, noticed in March, 1880, a tumor in the left popliteal space, commencing in a small sub-cutaneous lump which was movable. This gradually increased in space, to an extent of about seven inches.

July 20th.--The tumor is considerably enlarged, occupying the whole of the popliteal

in length and extending on either side beyond the hamstring tendons. Fluctuation. can be felt both external and internal to these tendons, these lesser cavities communicating with the main cavity. As the tumor was steadily enlarging and dissecting through the loose connective tissue between the muscles and tendons of the popliteal space, and at the same time threatening to break through the skin, Dr. Fenger resolved upon the radical operation as the only resort for recovery, the patient having positively refused amputation.

No hæmorrhage.

July 24th. July 27th. No hæmorrhage. In several places along the edges of the incision wound, small pieces of skin have sloughed off and are separating.

August 4th.-Drainage tube removed. August 11th.-the entire cavity is closed and the wound presents a solid, healthy granulating surface.

September 20th.—The wound is entirely healed. The dressing was removed, a roller bandage applied and the patient out of bed and around on crutches.

October 19th-The patient was discharged from the hospital. At this time he could walk on crutches, but was able to bear very little weight on the foot.

scar is a superficial excoriation about half an inch in diameter, which causes the patient no pain. There is some oedema around the ankles at night, after he has been walking about all day long, but it disappears before morning. The foot feels somewhat numb, but otherwise the limb is in its normal condition.

July 22nd.--The patient was anesthetized with ether. A longitudinal incision ten inches in length was made in the median line of the popliteal space, though the skin and the wall of the cavity, a quantity of March 25th, 1881. The patient came to the above described dark-red, viscid bloody Dr. Fenger's office for examination. He fluid was evacuated, and it was then seen can walk without a cane. The movements that the walls of the cavity consisted of the of the knee-joint are free, but he cannot structures constituting the popliteal space; exercise the utmost extension on account arteries, veins, muscles and tendons. These of the contraction of the cicatricial tissue were all covered with a layer of gelatinous, in the popliteal space. In the popliteal soft and friable substance, one to three space is seen a large reddish cicatrix about millimeters in thickness. This membrane five inches long, and from quarter to half was removed from the main and lesser an inch in breadth. In the center of this cavities with the sharp spoon and a considerable hæmorrhage followed. The blood was venous, and poured out rapidly from even the smallest openings, which it was impossible to take up and ligate. Irrigation with a warm five per cent. solution of carbolic acid had no influence over the hæmorrhage. As the bleeding was most profuse in the middle of the popliteal space, where The interesting feature of this case, was the blood rushed out through some larger the constantly enlarging cavity, filled with openings, the popliteal vein was isolated thin, viscid blood. The exact pathological and ligated in two places, about three nature of this cavity was not shown even inches apart, whereupon the greater part by the operation, which occurred two of the hæmorrhage ceased. There was still months and a half after the ligation of the however a considerable oozing of blood femoral artery. It was not a common from the periphery of the cavity, which varix, because the blood was considerably was overcome by irrigation with a thinner, that is, mixed with serous or synostrong solution of chloride of zinc. A vial fluid; but it was evident that the poplarge drainage tube was then inserted liteal vein was involved, as the severe though the entire length of the cavity, the hæmorrhage during the operation could not wound united, and Lister dressing applied. be checked until a double ligature had been July 23d. Very little hæmorrhage. The passed around the vein. wound was washed out and dressed.

From an excellent article by Dr. S. W.

Gross (American Journal of the Medical On June 20th, Dr. G. W. Tucker was Sciences, January, page 19; April, page called in, and found a pulsating tumor in 305, 1867), we learn that gangrene very the left inguinal region, covered by Pouseldom follows ligature of the large veins. part's ligament, extending from three quarSecondary hæmorrhage or phlebitis are ters of an inch above the latter to two inchmore common sequelæ of this operation. es below it. The tumor was oval in form, and about three inches in its longest diameter, in the track of the external iliac and femoral arteries, and about two inches in its transverse diameter. There was a distinct aneurismal bruit, and pressure on the

It is more than probable that the secondary hæmorrhage is due to the same cause as the phlebitis; namely, suppuration in the wound leading to the ligated vein.

As antiseptic precautions in operations and after-treatment will overcome both of external iliac above the tumor diminished these complications, the surgery of the future should allow us, unhesitatingly to perform ligation of the large veins whenever indicated.

the size of the latter, and caused the cessation of the pulsations.

July 10th.-Dr. Fenger was called in consultation. He found the aneurism as above

CASE III.-Aneurism of the External described; no swelling of the limb, but dry Iliac (Fenger, 1881).

gangrene of the little toe, and dark discolorations around the nails of the third and fourth toes. An operation was decided upon, and approved by the patient.

July 12th.-Dr. Fenger, assisted by Dr. E.

Synopsis.-Left inguinal aneurism of three month's standing.-Dry gangrene of little toe. Ligation of external iliac.-Progress of gangrene.-Secondary hæmorrhage, after thirteen days.-Ligation of common iliac.-W. Lee, Dr. S. D. Jacobson and the House Death five days later. Staff of Cook County Hospital, ligated the external iliac, half an inch above the aneurism, and in apparently healthy tissue of the arterial wall. The limb was elevated, and hot cans applied.

E. A. B., aged fifty-five, a speculator on the Board of Trade, came under Dr. Fenger's care July 11, 1881. The patient had never suffered from any serious disease except syphilis, contracted seven years ago. About a year ago, without any perceptible cause, he suffered from neuralgic pains in the toes of the left foot, accompanied by slight swelling, which, with the pain, subsided after a time, but reappeared thereafter at irregular intervals. These symptoms, July 14th.-Pulse.100; temperature 100°. however, were not so severe as to prevent The bluish discoloration has extended him from walking around and attending to around both malleoli and the posterior side his business as usual. of the calf of the leg.

July 13th.-Pulse 100; temperature 100o. The patient did not sleep well last night on account of pain in the limb. There is slight bluish discoloration of the whole foot. No pulsation can be felt in either of the tibial arteries.

July 17th.-Pulse 90; temperature 100°. The discoloration has extended over the lower half of the crus. The patient feels

weak.

About three months ago, April 20th, when pulling on his boots, he was attacked by pain in the region of the left Poupart's ligament, which was so severe as to oblige him to return to bed. After the use of cold applications, the pain subsided, and he was again able to walk around. A month later a tumor appeared in the left groin. This coloration is slowly advancing toward the gradually increased in size, and commenced knee, but has no defined limits. to pulsate, and at the same time stiffness

July 20th.-No pus in the dressings. Drainage tube removed. The wound was apparently healed by first intention. The dis

July 25th. This morning it was discover

and pain along the entire left limb render-ed that some blood had soaked through the ed walking impossible.

dressings, on the removal of which the hole

of the drainage opening was found to be the secondary hæmorrhage took place, and filled by a fresh clot. There was no pulsa- the cavity of which was filled with bloody tion in the tumor. Ergot and elixir acidum pus. Excepting at the place of the rupHalleri were administered, and a close watch kept over the patient.

July 26th.-Early this morning the hæmorrhage recurred, and Dr. Fenger, having the same assistants as in the former operation, ligated the common iliac in the usual man ner, quarter of an inch above the bifurcation.

ture, where it was thin, the wall of the artery was healthy. Half an inch below the ligature, the artery suddenly dilated into an ovate diffuse aneurism, three inches long and two broad. Below the aneurism the wall of the femoral artery, showed masses of products of endarteritis deformans, but without calcareous deposits, the diameter of July 27th.-Pulse 120; temperature 101°. the vessel being about normal. In the Last night the patient suffered from pain profunda femoris, about half an inch below in the left foot, ankle and groin. He has its origin, the vessel was narrowed, and the not vomited and slept a little during the thickened wall entirely encrusted with calnight. He has taken milk, beef tea and careous matter. The popliteal artery was brandy. No pain in the abdomen. He filled with fluid blood, and signs of comfeels weak, but talks naturally. The people mencing endarteritis were noticeable only in the house state that at times he has been in isolated spots. The femoral vein was a little delirious. open above Poupart's ligament, but at this

July 28th.-Pulse 130, weak; temperature point, commenced an adherent thrombosis 101.5. Has had diarrhoea all night. The which extended down as far as the poplitebluish discoloration now extends four inches al vein, caused by compression of the walls above the knee. He has a slight cough, of the aneurism. and expectorates mucus streaked with blood. July 29th. The patient grew gradually weaker yesterday afternoon and died at 9 commenced before the first ligation, and p. m.

In this case complete recovery was not to be expected, as the gangrene had already

the plan of treatment was necessarily limited to: First The stoppage of pulsation in the aneurism by ligature, and second: amputation, when the progressing gangrene showed a sufficient line of demarcation, to permit us to determine how high up the operation should be made.

Autopsy. Twelve hours after death. In the abdominal aorta were found diffused yellowish white spots of fatty degeneration, in the deeper layers of the intima; but no calcareous deposits were to be seen, showing that the endarteritis deformans was in its first stage. The left common iliac was During the whole time from the first filled by a recent clot from the bifurcation ligature, until the secondary hæmorrhage of the aorta down to the ligature. From occurred no such demarcation of the slowly the bifurcation of the common iliac a firm progressing gangrene took place, but at the clot extended an inch down into the inter- same time, no marked constitutional sympnal iliac. The upper part of the external toms made a speedy amputation imperailiac was filled with a firm but fresh red tive.

clot, which was adherent, in some places to It is possible that this was caused by the the wall. The lower part of the external very careful disinfection and antiseptic iliac down to the ligature contained no dressing of the whole of the gangrenous clot. The catgut ligature had all become portion of the limb. But if this be erroneabsorbed except the knot, which lay loose, ous, the antiseptic dressing had this effect, on the anterior surface of the vessel. Above that at no period, even at the patient's this was found an irregular perforation two death, were the slightest traces of gangrenmillimeters in diameter, which leads into ous odor perceptible on the removal of the the bottom of the wound, through which dressings.

The occurrence of the secondary hem- as large as a walnut. It then became sore orrhage in a part of the eternal iliac where and painful, in three weeks ruptured, bled the wall was healthy, confirms the opinion profusely for a time, and then kindly healed. of Rabé, that secondary hemorrhage at the He underwent a short course of treatment point of ligature is due, not so much to a by compression with a rubber ring, but depathological condition of the intima and rived only temporary benefit therefrom. media, or to the distance from the point of From this time the tumor increased in size ligature to the first branch of the artery more rapidly. When the patient was twenty above it, that is to the length of the clot years of age, it was as large as a man's above the ligature, as to the suppurative hand, and elevated about an inch above its destruction of the external coat of the origin, and gradually decreasing toward its artery, since in this case the ligation wound margin. A new tumor now began to dedid not heal by first intention. velop on the forehead, just between the

The autopsy further shows that the eyebrows. During the succeeding six years secondary hemorrhage was not due to too the tumor increased in size very slowly, early absorption of the catgut ligature, as and caused the patient no especial inconthe perforation in the arterial wall, through venience. Six weeks previous to his admiswhich the hemorrhage took place, was situ- sion to the hospital, a small white spot apated above the point of ligature. peared at the apex of the tumor; on July 2d. CASE IV. Cirsoid Aneurism of the 1879, this was accidentally punctured by the head. (Lee, Chicago, 1879.)

Synopsis.-Large cirsoid aneurism of the entire frontal region, of eighteen. years standing; rupture of aneurism; ligation of right common carotid with no effect; fifteen days later, ligation of left common carotid; aphasia, and right sided hemiplegia; cessasation of hæmorrhage; three days later, extirpation of the entire tumor; extreme anæmia; transfusion of ten ounces of blood; complete cessation of hæmorrhage; four days later, erysipelas; death five days after the operation.

W. H. D., aged twenty-six; American; shingle sawyer; was admitted to Cook County Hospital July 28th, 1879, placed under the care of Dr. Lee, and gave the following history:

tooth of a comb and bled very profusely. The hæmorrhage was not per saltum, and was controlled by a compress. During each dressing, the hæmorrhage recurred with a like severity. The patient was kept in the recumbent posture for three weeks, a firm compress being applied at the bleeding point. The ulcer still continued to increase in size, notwithstanding this compress, and on July 28th, he applied at the hospital for treatment.

On examination, the scalp and underlying tissues were found to be the site of an elastic, racemose tumor, elevated at its apex, about an inch and a half from the bone, extending longitudinally from the bridge of the nose to the occipito-parietal suture, and laterally from an inch and a When about eight years of age he sus- half above one ear to the same distance tained a contusion in the region of the an- above the other. The tumor presented an terior fontanelle, by running against the end irregular ulcer three inches long by two and of a fence rail. The force of the blow pros- a half in width, which bled on the slightest trated him but he did not lose conscious- provocation. It was found to be supplied After a few hours, a tumor of about by the supraorbital, temporal, and occipital the size of a hazel nut appeared, which was arteries, as the hæmorrhage could be conat first tender to the touch and painful, but trolled by an elastic band applied just above later on became painless and remained in the ears. The diagnosis was cirsoid aneurstatu quo for eighteen months. From that ism, and the following plan of treatment time it slowly increased in size, so that proposed: First, ligation of the right comwhen he was fourteen years of age it was mon carotid. Second, ligation of the left

ness.