12

by leaving a portion of skin qutside the ligature. If a partial excision be thus performed, there seems no good reason why the operation should not be completed by excision altogether.

The whole growth, with the affected skin, ought to be included. The most convenient method is to cross two needles under the base of the tumour, and then tie firmly under them. If the nævus be large, it may be tied in halves or thirds. It is of importance that antiseptic precautions be taken. If the silk and needles be carefully carbolized, and they and the tumour covered completely with a layer of antiseptic wool and flexile collodion, the whole mass drops. off dry and shrivelled without suppuration, while the scar is much smaller and less conspicuous than if it be allowed to slough off in the usual way. To maintain this covering air-tight it is necessary, at least if the nævus be large, to apply fresh layers round the margin every few days.

Excision. When a nævus is purely subcutaneous, or when the cutaneous part bears a small proportion to the subcutaneous, and when it is situated on the covered portion of the body, it is best to excise it. Although the purely subcutaneous nævus is not common, it is very frequent, especially in large growths, to find the skin vascular over perhaps only a third or less of the surface. If it be a large and prominent tumour, it is probably best to remove the diseased skin along with it. If a very large portion of such skin be allowed to remain, it is not always certain to be cured. I have even seen cutaneous extension of the nævus after the subcutaneous part had been removed. Still that is rare. After the nævus has been excised, the vascular skin usually cicatrizes perfectly, and slowly assumes a normal hue, and this is always the case if only a small portion be left.

I prefer excision in these cases, because by it you have at least a great probability of healing by first intention. There is no slough to separate, as with ligature. There is no repetition of the operation, as with electrolysis. In these cases, moreover, you may rely with some certainty on the presence of a capsule, which greatly facilitates removal. But even when the capsule is adherent or absent, there is no risk of hæmorrhage if you cut well beyond the margin of the growth, as in most instances it is easy to do.

But it is only in these cases that it should be used. Some may extend its area of usefulness over a part of the ground which I have assigned to ligature, but it can never in any case be justifiable to produce a scar on the face or neck, and perform formidable operations on account of a disease which in itself is practically without risk, which frequently disappears spontaneously, and which by other methods and with a little patience may be cured without a mark and with perfect safety.

II. ON THE OPERATIVE TREATMENT OF POPLITEAL

ANEURISM.

By THOMAS ANNANDALE, F.R.C.S. Ed., Regius Professor of Clinical Surgery in the University of Edinburgh.

(Read before the Edinburgh Medico-Chirurgical Society, 2nd December 1885.)

THERE are now few surgeons who, when called upon to treat a case of uncomplicated and limited popliteal aneurism, do not first try the treatment of it by some form of compression. My own experience leads me to prefer either digital compression or a modification of Reid's method in these cases. My two last cases in private practice were treated successfully in the following way. An Esmarch's bandage was applied to a point immediately below the aneurism, and then pressure was made by means of a horseshoe tourniquet upon the femoral artery at the groin. From time to time this tourniquet was slackened slightly, so as to allow some blood to flow into the sac, and was again immediately tightened. This treatment was carried on for from two to three hours at a time, an elastic bandage being applied, but not so as to stop the circulation in the limb, after the tourniquet and Esmarch's bandage had been removed. An interesting point in both cases was that the patients were not confined wholly to bed during the treatment, but were allowed to lie on a sofa, and even to sit up with the limb resting upon a chair. Both cases were completely cured,-the one in two weeks, and the other in about three weeks. In the one case only one application of the tourniquet was employed, the patient having after the application an elastic bandage constantly round the limb, but not used so as to interfere with the circulation. In the second case two applications of the tourniquet, at an interval of a week, were required, and the use of the elastic bandage for two weeks after the second compression. It is a well-known fact that cases of popliteal aneurism are occasionally very easily cured, and it may be that my two cases belonged to this class; but, as they were both under treatment about the same time, I have thought a brief note of them might be interesting.

When compression fails to cure a popliteal aneurism, or when the case is one unsuitable for it, the treatment almost invariably suggested and practised is ligature of the femoral artery at the apex of Scarpa's triangle. Should ligature of the femoral artery fail to cure the disease, or should pulsation in the sac return and persist after this operation, the usual advice and practice is to try compression above the seat of ligature, or to try the flexion method; or, these failing, to tie the external iliac or common femoral arteries. Should these plans not succeed, there is, as Erichsen' (Science and

1 I quote Erichsen because he is a deservedly high authority upon the subject, and his work on Surgery has been quite recently carefully revised and brought up to date.

Art of Surgery, 8th edition, vol. ii., page 130) remarks, only the choice between "amputation and opening the sac." He further says:" Of these measures I should certainly prefer amputation, as offering the most favourable chance to the patient." Mr Erichsen continues: The operation of opening the sac, turning out its contents, and ligaturing the vessel supplying it, is in any circumstances a procedure fraught with the greatest danger to the patient, and full of difficulty to the surgeon, even when he knows in what situation to seek the feeding vessel."

There are certain local conditions of a popliteal aneurism which are recognised by all surgeons to render the case unsuitable for compression. Among the principal of these local conditions are:(1.) Large and rapidly growing aneurisms.

(2.) Diffused and ruptured aneurisms.

(3.) Aneurisms tending to involve or involving the knee-joint. (4.) Inflamed and suppurating aneurisms.

In addition to these local conditions may be mentioned an unhealthy state of the arterial system.

In the first three of these conditions the common rule followed is to try ligature of the femoral artery, but most authorities qualify this opinion by stating that the ligature of the artery is a very uncertain treatment in these cases, and that amputation will not unfrequently be required. In aggravated examples of these conditions immediate amputation is advised by some, as the ligature of the femoral artery frequently tends to produce gangrene of the limb.

In the fourth condition amputation has generally been resorted to, although laying open the sac has been performed under these circumstances. Erichsen (loc. cit.) observes:-" Though this plan has been several times tried, I am not aware that by it the surgeon has ever succeeded in arresting the bleeding from a suppurating aneurismal sac."

The present state of opinion in regard to the treatment of popliteal aneurism may therefore be summed up as follows:

(1.) Compression in favourable cases, and when it can be borne. (2.) Ligature of the femoral artery when compression fails, or is unsuitable.

(3.) Amputation when certain local conditions or complications exist.

The "old" operation, or laying open the sac and securing the artery at its point of communication with it, is occasionally referred to by authors, but it is certainly never advocated in the case of popliteal aneurism, and in the passage quoted from Mr Erichsen the general opinion in regard to this proceeding is, I think, correctly expressed.

While, then, I advocate the treatment of popliteal aneurism by some form of compression in suitable cases, and this failing, by

ligature of the femoral artery, my object in this paper is to express the opinion that the "old" operation has hitherto been too much ignored by surgeons, and that in certain cases of this disease it will prove to be a more safe proceeding than those methods which are usually adopted.

It may be well to remark here that, before the introduction of the Hunterian ligature, popliteal aneurisms were not unfrequently treated by laying open the sac, but the success then of such a proceeding was very slight, and this is not to be wondered at when we consider what this operation was. It consisted in freely laying open the sac, and then stuffing its cavity with some dressing, or in some cases pushing a hot cautery into its interior. If any attempt was made to ligature the artery at the site of the aneurism, it was simply a dive with a needle and thread in the position of the vessel, with the result that, when such a ligature was passed and tied, it usually included vein, artery, and other structures.

The "old" operation at the present time is a very different proceeding, and, in my experience of it, which has not been small, I have failed to meet with those difficulties so graphically related by Mr Erichsen. With the antiseptic ligature and dressing, I now look upon this operation as a very simple proceeding in properly selected cases, provided you can stay the circulation in the sac during the operation, and you can always do this in a case of popliteal aneurism.

In order to explain my method of operating, I have had this diagrammatic sketch prepared. It is supposed to represent the cavity of the aneurismal sac after it has been laid open and all the clots removed. a is the opening of communication with the artery,

into which a bougie, b, has been inserted, and passed along the canal of the vessel upon its cardiac aspect. c and d are the two small incisions made through the wall of the sac, immediately above the opening, and the aneurism needle, e, is shown after its point has been passed through these incisions and under the artery, with the contained bougie. By means of the aneurism needle the ligature is drawn through and tied round the vessel upon the bougie, the latter being gradually withdrawn as the ligature is tightened. Should there be only one opening, and this is the case in a very large majority of instances, the same proceeding is carried out upon the distal end of the artery, the bougie being inserted into the opening again and passed downwards. If two openings exist they must be treated separately. The employment of the bougie was first suggested to me several years ago by Sir Joseph Lister, when I was operating upon a case of femoral aneurism.

I will now relate a case in illustration. U. N., æt. 42, was sent to me in August of this year by Dr Hern, of Darlington, on account of a popliteal aneurism affecting the right leg. The patient had suffered from obscure pains, attributed to rheumatism, in this leg for one year and three months before his admission into my wards, but he only noticed a swelling in the popliteal region of this same leg about three months ago. Since first observed, the swelling, which pulsated strongly, has rapidly increased in size.

On examination, his condition of health was not very favourable. There was a slight systolic murmur over the mitral area, and the radial and temporal arteries were tortuous and affected with atheroma. The other organs were healthy. In the right popliteal space there was a large pulsating and expansile tumour, which filled the whole space, bulging out on each lateral aspect, but more particularly upon the inner side. A portion of the tumour felt firm and solid, but other portions were soft and fluctuating. A wellmarked bruit was heard when the ear was placed over the aneurism, and the pulsation was especially marked over its centre. The leg below the knee was slightly swollen and oedematous, and the pulsation in the tibials at the ankle was very feeble.

After consideration, I decided to treat the case by the "old" operation, and upon the 2nd of September I made a small incision into the aneurism, the circulation of the limb being controlled by a tourniquet applied round the upper third of the thigh. Having introduced my finger into the wound, and by means of it loosened the adherent clot in the sac, I laid the whole sac freely open, and removed all the clots contained in it, and I then found that there were two openings communicating with the sac,-one corresponding to the upper end of the popliteal artery, just at its junction with the femoral, and the other to the lower end of the popliteal artery. Both of these openings were pervious, and admitted a No. 10 bougie, which passed freely into the canal of the artery. The sac of the aneurism was entire, and its inner surface was lined with many