NOTES OK CASES 
ILLUSTRATING SURGICAL LESIONS 
OF THE 
VASCULAR SYSTEM. 
Hy RUDOLPH MATAS, M. D.. New Orleans. La.* 
Reprint from the October, j8()4, number of the Xew Orleans Medical and Surgical 'journal. 
L GRAHAM & SON, LTD., 44-46 BARONNE ST., NEW ORLEANS. NOTES OF CASES 
ILLUSTRATING SURGICAL LESIONS 
OF THE 
VASCULAR SYSTEM. 
Bv RUDOLPH MATAS, M. D., New Ok leans. La.* 
Reprint from the October, 181)4, number of the New Orleans Medical and Surgical ‘Journal. 
Observation i.—A large spontaneous (atheromatous) aneu- 
rism of the right common carotid involving the bifurca- 
tion and trunk, to a point two inches above the origin 
of the artery, in an old alcoholic subject. Ligation of 
artery low in the neck between sternal and clavicular 
attachments of the sterno-mastoid, under cocain anes- 
thesia. Recovery. 
The patient was admitted in Ward 2, Charity Hospital, 
in April, 1888. He is a tall, thin, but muscular, negro. Black- 
smith by occupation; age nearly eighty years. Peripheral 
arteries all markedly atheromatous ; “pipe-stem” radials; arcus 
senilis. Addicted all his life to alcoholic indulgence. The 
general bad condition of the arterial system, together with the 
age and the habits of the patient, decided that I should operate 
under cocaine anaesthesia. 
As the neck was long and thin and the interspace between 
the sternal and clavicular heads of the sterno-mastoid quite 
large and favorable, this space was selected for the application 
of the ligature (Sedillot’s method). No difficulty was experi- 
enced in creating a cocain atmosphere over the line of 
* Proceedings I.ouisiana State Medical Society, May, 18^. 2 
the artery with a 3 per cent. aq. sol. of cocaine hydrochlorate. 
The artery was exposed and ligated without difficulty as low in 
the neck as possible to avoid the neighborhood of the 
aneurismal region. The innominate bifurcated high in the 
neck and the bifurcation was recognized. An aseptic silk lig- 
ature was used and the wound closed without drainage. The 
wound healed without complications, per primam. Patient 
never complained of pain either during or after the operation. 
When the patient left the ward, twenty days after the 
operation, the aneurism had become quite hard and was much 
smaller. 
Observation 2.—Arterial varix (cirsoid aneurism) of the right 
common carotid extending from origin to a point one inch 
from bifurcation. Double ligature of the common carotid ; 
one below bifurcation of the carotid and one over the 
dilated trunk itself. Recovery with aseptic healing of 
wound and apparent improvement in aneurismal con- 
dition. 
The patient, James C., of Baton 
Rouge, La., negro laborer, aged sixty 
years. Was admitted to Ward 2, 1890. 
No hereditary history; no distinct his- 
tory of syphilis. Some alcoholism. On 
January 1, 1890, noticed a small tumor 
pulsating near root of neck immediately 
above sternal notch. It gradually in- 
creased in size, and last June cough, 
dysphagia and dysphonia annoyed him 
to an extent that decided him to go to 
the hospital for assistance. He was 
treated in one of the medical wards one 
month for thoracic aneurism before he 
was transferred to the surgical service. 
On examination patient appeared to enjoy a good general 
health. He is moderately stout, muscular, with a short, broad 
neck, covered with thin skin and little fat. Examination 
readily reveals a distinct tubular swelling starting under right 
sterno-clavicular articulation and sternal origin of right sterno- 
Diagram illustrating a cirsoid 
aneurism of right common car- 
otid, and points of ligation. 
(Dr, Matas’ collection.) 3 
mastoid muscles; the swelling fills tip the supra-sternal fossa 
and extends over trachea to anterior border of left sterno- 
mastoid muscle in an obliquely upward direction, from right to 
left, reaching apparently the lower level of the left lobe of thy- 
roid. A characteristic, expansile pulsation, thrill, and loud, 
systolic bruit confirm the aneurismal nature of the tumor. The 
abnormal vessel lies under the sterno-hyoid and sterno-thyroid 
muscles and it is difficult to determine its precise outline, but 
the direction would suggest that the tumor originates in the 
anterior mediastium and escapes upward into the neck as high 
as the lower thyroid level until it reaches the anterior border 
of sterno-mastoid overlapping the left carotid sheath. The left 
carotid is felt pulsating on a levrel with the upper border of 
thyroid, apparently perfectly normal at bifurcation. The right 
carotid pulsates more vigorously and is clearly recognized at 
level of normal bifurcation, though apparently closer to the 
median line and hugging the thyroid. 
The exact condition is difficult to determine. At first ex- 
amination concluded that it affected the arch of the aorta, which 
was congenitally displaced upward, but further examination 
discouraged this idea because the contour of the tumor could 
be made out, above the sternum, on the left side. I decided 
finally that it would be better to perform an exploratory opera- 
tion, and to expose the aneurismal vessel if possible, believing 
that owing to the absence of inflammatory adhesion, in the 
peri-vascular territory and the laxity and apparent soundness 
of the overlying tissues it would be possible, by careful manip- 
ulation, to determine the true condition and relations of the 
involved parts. 
Accordingly, on August 6, after very careful antiseptic 
preparation and with the valuable assistance of Dr. Michinard 
and other members of the staff, a free incision was made from 
the cricoid to the anterior sternal region. After dividing the 
fascia and carefully separating the muscles in the median line, 
I exposed a large tortuous trunk which evidently originated 
deeply in the chest, apparently at the point of bifurcation of 
the innominate under the right sterno-clavicular articulation and 
ascended obliquely upward until it touched the left carotid 
sheath under the edge of the left sterno-mastoid muscle. 4 
There the large dilated vessel became suddenly contracted, 
and forming a curve folded on itself and returned over the 
trachea, following the contour of the thyroid and returned to 
the right carotid region, where it terminated in an apparently 
normal common carotid that bifurcated at the usual level. The 
vessel in its first portion had the caliber of a large innominate 
trunk; its coats were very thick, and the impression conveyed 
was that it was a large artery that had undergone a uniform 
dilation with some thickening of its coats, but without any sac- 
ciform or fusiform dilation. The diagnosis was, therefore, 
arterial varix or cirsoid aneurism of the common carotid. 
This condition was so peculiar and novel to us that we hes- 
itated for a moment, but concluded that it would be safe to apply 
a distal ligature to the common carotid on the Brasdor princi- 
ple, just below the bifurcation. This was done without diffi- 
culty and a sterilized silk ligature was used. As the coats of 
the dilated artery over the trachea were thick but soft and 
apparently free from calcareous deposit, we decided to risk 
the application of another ligature over the middle of the varix 
itself. This was not done until an attempt had been made to 
trace the varix to its origin at the root of the neck. The fear 
of injuring the left innominate vein, which was separated with 
difficulty from the arterial trunk, compelled me to desist from 
satisfying myself as to the exact origin of the dilated trunk, 
but it appeared to me from its length and depth that it must 
have arisen from the arch of the aorta itself or from a very 
short innominate trunk. 
As stated previously, the condition of the abnormal artery 
was such that I felt justified in applying a ligature over the 
middle of the dilated portion, using a double heavy aseptic catgut 
ligature and employing just sufficient force to merely approxi- 
mate and keep in contact the arterial coats. No attempt was 
made to lacerate the intima, only simple approximation of the 
arterial surfaces was aimed at. The object of this second 
ligature was to produce sufficient irritation at the point of liga- 
ture to excite adhesive inflammation, and in conjunction with 
the distal ligature, below the bifurcation of the carotid, to oblit- 
erate the vessel. A marked diminution in the size of the ves- 5 
sel and the almost complete cessation of pulsation beyond 
it, attested its obstructive action. 
Dr. S. M. Fortier (one of the present Assistant House 
Surgeons, Charity Hospital), then interne of the service, writes 
in his notes: “Dressing, August 8 and io; sutures removed, 
union having taken place by first intention. A pulsation still 
exists (over supra-sternal fossa), but not as vigorously as be- 
fore. As the patient imagined himself cured he persisted in 
leaving, feeling very much improved/’ 
I received a letter from him one month after, stating that 
he was doing well and felt himself cured, as all his previous 
symptoms had been relieved. I have not heard from him since, 
and it has been impossible for me to ascertain his whereabouts. 
There may have been some temporary arrest in the prog- 
ress of the disease, but it is not at all probable that a perma- 
nent cure has been effected, as the first or proximal portion of 
the artery was too long and pulsating too actively to warrant the 
belief that it would undergo any retrogressive change. 
Observation 3.—Suspected aneurism of the right internal 
carotid, possibly of traumatic origin, projecting into the 
fauces and threatening life by suffocation, etc. Ligature 
of common carotid at point of election. Recovery. 
H. B., Englishman, hostler, aged 
35 years. Came to Eye, Ear, Nose 
and Throat Hospital of this city, 
complaining of a difficulty in swal- 
lowing and inability to speak and 
even breathe properly on account of 
a large tumor which nearly filled his 
throat. 
He stated that about six years ago, 
while working in Ontario, Canada, 
he was taken ill with an acute in- 
flammation of the throat, accompa- 
nied with swelling and huskiness of 
voice, which his medical attendant thought necessary to 
“ lance,” but without apparent result. From that time he no- 
Suppostd Aneurism of the internal 
carotid bulging into fauces. Showing 
displacement of palate and encroach- 
ment of tumor into pharyngeal isth- 
mus. (Dr. Matas’ Collection.) 6 
ticed that the swelling in his throat had continued and grad- 
ually increased to present size. 
On examination, externally, it is noticed that an irregular 
ovoidal tumor fills the submaxillary and parotid regions. The 
tumor appears, on careful palpation, to be indented by the 
digastric muscle, which gives it a bi-lobar contour. The sub- 
maxillary portion ot the tumor projects about \ ]/2 inches from 
the angle of the jaw. It extends from the tragus to the hyoid 
bone; from the angle of the jaw to the mastoid. The tumor 
feels very hard, but pulsates and, if it is aneuris- 
mal, must contain a great deal of hard, active clot in its outer 
walls. 
Intra-buccal examination.—A large bulging mass projects 
into the fauces almost filling the whole isthmus. It springs 
from a broad base of attachment in the right tonsillar region. 
Intra-buccal palpation confirms the marked pulsation of the 
whole mass; but the peculiar, tense, expansile feel of a typical 
aneurism is wanting. The mass feels unusually hard for an 
aneurism. There is only' a very narrow passage left for food 
and drink and the patient is compelled to subsist on semi-solid 
or liquid food. Uvula and palate displaced, to left; below, the 
mass extends to the epiglottis and hyoid. Compression of the 
common carotid at point of election causes complete arrest of 
all pulsation and some diminution in size of tumor. 
The patient is seen bv Drs. Logan and Souchon, consult- 
ing surgeons of the hospital, who pronounce the case one of 
aneurism of the internal carotid of traumatic origin and advise 
the ligature of the common carotid. 
I must confess to having entertained some doubts as to the 
aneurismal character of the swelling in spite of the history, and 
especially after one year’s observation of the case subsequent 
to the ligature of the artery; but the ligation was clearly indi- 
cated, if only as a denutrient factor. 
With the valuable assistance of Dr. de Roaldes and 
staff of the Eyre, Ear, Nose and Throat Hospital, the com- 
mon carotid was exposed and ligated at the point of elect- 
ion. The tumor was reduced in size, but not 
as much as was anticipated. The wound healed aseptically, 
and the patient left the hospital much improved, 7 
as the reduction of the intra-pharyngeal portion had facili- 
tated speech and deglutition. The effect on the size of 
the tumor was disappointing, however, as, even now, after two 
two years’ observation, I find that the tumor remains, only 
smaller in size, though it does not pulsate nor appear to grow. 
I am therefore inclined to believe that this is really a case of 
tonsillar fibro-adenoma, which has been reduced and kept 
dwarfed through arterial fasting. 
Observation 4.—Enormous traumatic aneurism of the com- 
mon femoral, simulating an aneurism of the external iliac. 
Sac filled the thigh and the whole iliac fossa, pushing up 
the external iliac and femoral, almost causing spontaneous 
cure through upward pressure of the iliac 
artery. Laparotomy ; ligation of the external iliac mid- 
way between Poupart’s ligament and origin ; aseptic heal- 
ing. Death from anemia and exhaustion one week after 
operation. Autopsy reveals a cavity containing fully one 
gallon of clot. 
This patient, a young mulatto, aged 23, was admitted in 
Ward 2, June, 1892, presenting an exceedingly wasted and 
anemic appearance. He had a tumor which filled the right 
iliac fossa, the inguinal and upper femoral and obturator re- 
gions. The swelling was semi-elastic, tense, full, covered by a 
glazed skin; there was no sense of fluctuation except at inner 
half of base of Scarpa’s triangle, where a soft spot existed, in 
which a slight thrill and murmur could be perceived. The 
first impression caused by the appearance of this tumor was 
that of a tubercular abscess. But the history of traumatism 
(a gunshot injury sustained several months before), carefullv 
elicited by Mr. Brady (Dr. C. Milo Brady, of Gretna), in- 
terne of the service, convinced us that we were dealing with a 
large traumatic aneurism. The solid, elastic feel indicated 
that the sac had filled with a large mass of clot and that the 
circulation within it was quite sluggish. 
The exact point of communication of the sac with the 
artery of supply could not be ascertained, but owing to the ex- 
tension of the tumor above Poupart’s ligament we concluded that 
the common femoral was injured on a level with the ligament 8 
and that a higher exposure of the iliac artery or even of the 
common iliac would be required to apply a safe ligature. 
Accordingly, after careful preparation of the patient, median 
laparotomy was performed and the artery was exposed. It 
was noticed then that the tumor which filled the entire iliac 
fossa extended deeply down into the pelvis in the direction of 
the obturator foramen. An aseptic silk ligature was applied 
without difficulty at the point of election midway between 
Poupart’s ligament and the bifurcation of the common iliac. 
The artery was flattened against the tumor, but pulsated vigor- 
ously down to Poupart’s ligament, where it was lost in the 
tumor. The Tredelenburg posture permitted of a ready ex- 
posure of the affected area and exhibited the pelvic relations 
of the aneurism. 
The patient rallied slowly from the anesthetic, ether. No 
marked difference in the size of the tumor was observed, but 
the purring thrill and murmur over Scarpa’s triangle disap- 
peared. The patient was not seriously affected by the opera- 
tion. There never was a sign of peritonitis, but hiccough set 
in; the abdomen retracted more and more every day, the pulse 
gradually grew weaker and finally the patient succumbed on 
the seventh dav, apparently from exhaustion. 
Report of Autopsy. 
Subject injected about twelve hours after death with 
chloride of zinc and glycerine, followed by plaster of Paris. 
The injection was made through the abdominal and thoracic 
aorta (this was on Thursday, 14th). 
Autopsy on Sunday, 17th. The subject remarkably 
emaciated. Abdominal wall retracted, presenting a wound 
in the linea alba about 4y? inches in length, extending 
from a point about 1 y2 inches above the pubes to a point just a 
little above the umbilicus. This incision had to be torn apart, 
and its edges throughout the entire thickness, including the 
peritoneum, show evidences of recent plastic exudation as if 
primary union had taken place along the whole extent of the 
wound. Inspection of the peritoneal cavity revealed a total 
absence of adhesion or exudation in the peritoneal cavity. 9 
There were no evidences of vascular injection anywhere. The 
intestines were collapsed and empty, and everything pointed 
to a perfectly normal condition of its cavity and total absence 
of peritonitis. After enlarging the wound and cutting down to 
Poupart’s ligament a perfect view was obtained of the whole 
extent of the common iliac and external iliac arteries from, 
the bifurcation of the abdominal aorta to Poupart’s ligament. 
It was then seen that about 2]/2 inches above Poupart’s liga- 
ment the external iliac artery had been ligated and that the 
ligature (silk) was imbedded in a mass of exudation, which 
covered also a slight perforation in the peritoneum through 
which the ligature had been applied. The artery above the 
ligature was distended with plaster, while below it, all the way 
down to the sac, the vessel was empty and collapsed. 
By continuing the abdominal incision into the thigh down 
to a point about eight inches below Poupart’s ligament, a com- 
plete view of a large semi-fluctuating tumor was obtained. This 
tumor filled up the whole of the right iliac fossa up to the iliac 
crest posteriorly and bulged into the pelvis below the iliac 
vessels. It was apparently constricted at Poupart’s ligament 
and then appeared to fill up the whole of the thigh down to 
about the level of Hunter’s canal. At a point midway between 
the anterior superior spine of the ilium and the spine of the pubes 
the fascia lata which covered the tumor appeared to be very thin 
and threatened to burst. By carefully exposing the artery from 
the point of ligation down to Poupart’s ligament, it was easily 
seen that it had not been injured in any way until Poupart’s liga- 
ment was reached, when it was found to have become very ad- 
herent to the surrounding fascia and that it communicated 
with the tumor directly by an opening which nearly measured 
one inch in its longest diameter. Below this point the artery 
was easily separated from the surrounding parts and was 
traced down about four inches below Poupart’s ligament where 
the profunda was given off. Upon laying open the artery it 
was found filled with a thin thrombus from the point of ligation 
to the opening which led to the aneurismal pouch. 
The sac was now laid open by a free incision and enormous 
quantities of clot were removed, which measured at least a gal- 
lon. The clots were of the passive, grumous variety, indicat- 10 
ing recent coagulation, while masses of adherent active clot 
were found attached to the distal walls of the sac and especially 
to the parts neighboring the foramen, which communicated with 
the artery. After washing out the aneurismal cavity it was found 
that the anterior walls were formed entirely of very thin atro- 
phied cutaneo-musculo-peritoneal layers, and the posterior walls 
were formed mainly by the denuded skeleton of the iliac fossa 
and thigh. The ilio-psoas muscle had been entirely disin- 
tegrated and absorbed, leaving the venter ilii entirely exposed. 
A rudimentary tendon attached to the lesser trochanter of the 
femur, which was exposed in the cavity, was the only vestige 
of the psoas-iliacus. The femur down to about three inches 
below its surgical neck was entirely exposed and only covered 
by periosteum. All the anterior femoral and the adductor 
group of muscles had been amalgamated with the fascia lata 
and were reduced to an exceedingly thin musculo-membranous 
sheet, which included the femoral sheath, the vein, artery and 
nerve. It was found that the capsule of the hip joint had been 
entirely eroded in its anterior portion, exposing the head of the 
femur in the acetabulum. The femoral vein was found unin- 
jured. 
Further examination of the lower extremity shows that 
the injection did not reach these parts, while on the opposite 
side the soft parts were saturated with the preservative fluid. 
The position of the limb was that of complete abduction 
and outward rotation. 
Conclusions.—ist. There was no peritonitis. 2d. The 
abdominal wound was healing by primary union. The ligature 
which was placed on the external iliac between Poupart’s liga- 
ment and the bifurcation of the common iliac was being rapidly 
encysted. 3d. The cause of death appears to have been ex- 
haustion and anemia, due to the enormous internal drain upon 
the vascular system by this vast aneurismal cavity, which con- 
tained fully a gallon of coagulated blood. 4th. Coagulation of 
the contents appeared to have been almost completed before 
death. 5th. The aneurism was evidently caused by a gunshot 
injury involving the artery about the level of Poupart’s liga- 
ment. 11 
Observation 5.—Contusion of the upper lip in an infant 9- 
months old. Laceration of the frcenulum lab it; hemo- 
philia, bleeding. Failure of hemostatics and suture. Ar- 
rest of hemorrhage by direct elastic compression. 
In August, 1894, I was called to attend a little Italian baby, 
aged 9 months, nursing at the breast. It accidentally fell on 
its face and contused the upper lip and lacerated the mucous 
membrane at the gingivo-labial 
commissure, corresponding to the 
bridle of the upper lip. Little im- 
portance had been attached to the 
accident at the time, but the con- 
tinuous bleeding which took place 
from the laceration in the lip de- 
cided the parents to call the family 
physician, who upon examination 
regarded the injury as trivial in 
view of the small extent of the 
laceration, which did not exceed 
one-quarter of an inch and was 
very superficial. Washes with 
arnica tincture were'ordered, but as these failed the tincture of 
chloride of iron was applied. This only served to blacken 
the mouth, but had no effect in arresting the steady, continuous 
oozing that constantly filled the mouth with blood, especially 
when the baby took the breast. The child had bled in this- 
manner about four days, and was exceedingly weak and paie.. 
At this stage I was called, and recognized that the condition was 
of the utmost gravity in view of the feebleness of the little pa- 
tient and the extreme anemia, which caused almost cadaveric 
pallor. It was evident that so trifling an injury could not have 
caused this rebellious bleeding without the aid of some consti- 
tutional condition which interfered with coagulation and 
physiological hemostasis. It was also plain that the suc- 
tion movement of the lip, while nursing, greatly fa- 
vored the tendency to bleed. The first indication was 
to stop nursing and to substitute the spoon for the 
breast or the bottle; then the wound itself was closed by a 
single suture with a small round milliner’s needle and fine 
Obs. 5.—Diagram illustrating applica- 
tion of elastic compression of upper lip 
for arrest of haemorrhage in haimo- 
philic subject. (Dr. Matas’ Collection.) 12 
thread; the tissues were grasped deeply and for the moment 
the hemostasis was complete. The next morning I was again 
notified that bleeding had returned and that the child was grow- 
ing weaker. I called, and noticed that some slight but con- 
tinuous oozing still came from the wound, so that I again ap- 
plied two more deep sutures with a view of compressing all the 
tissues at a distance from the trauma. The sutures now com- 
pletely concealed the little laceration. This for the moment 
seemed to accomplish the desired result until the next day, 
when I was again summoned, with the explanation that there 
was still some oozing from the wound. I could scarcely be- 
lieve this statement, as the wound had been practically buried 
by the sutures, but upon careful examination I discovered that 
the oozing came from the foints of suture. This discovery 
was certainly discouraging, but after thinking of the situation 
for some time it occurred to me that simple elastic compres- 
sion applied externally to the lip would be effectual in arresting 
the flow. I therefore applied an elastic band, such as is sold 
by all stationers for holding papers together, and which I hap- 
pened to have at the moment around my pocketbook, and se- 
cured this snugly over the lip and occiput, after protecting 
these parts with pads of gauze. The elastic was prevented from 
slipping upward or downward by the attachments shown 
in the accompanying figure. The band exercised just the 
pressure that was required and effectually stopped the bleed- 
ing. It was worn continuously during three days after con- 
firming the permanent arrest of all bleeding. Feeding was not 
interfered with by this simple hemostatic contrivance, and the 
child soon recovered from the extreme weakness and anemia 
that threatened its life. 
There were several petechial and ecchymotic spots over 
the chest and limbs which indicated a purpuric condition, but 
these have since disappeared and the child is now apparently 
in the best of health. 
This is instructive, in so much that it illustrates the great 
danger attending even the most trivial injuries in hemophilic 
subjects and suggests a method of relief which may be of ser- 
vice to those who may be confronted by a similar perplexing 
.and troublesome experience. 13 
Observation 6.—Prophylactic ligation of the external carotid 
artery as a preliminary to the resection of the second and 
third divisions of the trigeminus for tic douloureux on a 
level with the basal foramina, viz.: f. rotundum and ovale, 
by Mixter’s modification of Salzer’s- operation. Unex- 
pected death forty hours after, notwithstanding apparent 
complete recovery from operation, with symptoms of sud- 
den respiratory and cardiac failure, due possibly to the 
formation of cardiac or medullar}’ thrombus. 
The patient, a white male, type-setter, get. 36, had suffered 
for eight years prior to operation with a progressively aggra- 
vated neuralgia of the trigeminus, for which all classical reme- 
dies, including galvanism and large doses of morphia hypo- 
dermically administered, had absolutely no effect. The super- 
ficial as well as deep branches of the superior and inferior 
maxillary divisions were involved, the gustatory branch being 
the seat of the most intolerable pain. As the patient’s general 
condition was otherwise excellent, I decided to resort to the 
modification of Salzer’s operation described and successfully 
practised by Mixter, of Boston (vide Boston Medical and 
Surgical Journal for August 13, 1894). 
The operation was performed January, 1893* with the val- 
uable assistance of my friends Drs. F. W. Parham, L. F. 
Reynaud, and other gentlemen of the Charity Hospital staff. 
To protect the patient against the dangers of excessive 
bleeding from the temporal, meningeal and terminal branches 
in the spheno-palatine fossa of the maxillary artery, I began by 
a preliminary ligation of the external carotid at the point of 
election. The ligature was applied without notable diffi- 
culty. 
A temporal flap consisting of all the soft parts down to the 
bone was raised from the skull; the zygomatic arch divided 
with a saw and the pterygoids lifted with a periostotome from 
the zygomatic and spheno-palatine fossrn. The superior max- 
illary trunk was divided in the spheno-palatine fossa on a level 
with the foramen rotundum, and after clearing the fossa with a 
blunt curette and insuring the destruction of Meckel’s gan- 
glion, the terminal portion of the nerve was exposed in the 
infra-orbital foramen and the whole nerve extracted entire from 14 
the infra-orbital canal. The terminal, nasal, labial and pal- 
pebral filaments were also dissected and removed. 
After exposing the external pterygoid plate the inferior 
maxillary trunk was recognized in the space between the 
spinous process and posterior border of the pterygoid; fully 
one inch of the inferior maxillary was resected from the level 
of the foramen downward. There was no arterial bleeding, 
the venous flow from the pterygoid plexus was consider- 
able, but was finally completely controlled by an iodoform 
gauze pack, which was left in the pterygoid fossa. The zygo- 
matic arch was restored by drilling through the malar bone and 
zygoma and wiring with silver. The control of the venous 
hemorrhage consumed considerable time and the patient was 
kept under chloroform for fully two hours. Nevertheless, the 
general condition was excellent and never gave a moment’s 
concern. The patient recovered perfectly from the anesthetic 
and examination of the tongue and face corresponding to the 
affected regions demonstrated an absolute anesthesia, showing 
that the section of the superior and inferior maxillary nerves 
had been complete. 
The patient’s mind was perfectly lucid after the operation ; 
nothing peculiar was observed in the pulse, which fell to no 
after the patient was removed to his bed and the respirations 
were normal. 
All went along smoothly until the second night after the 
operation, when the patient complained of weakness and pain 
deep in the neck on a level with the carotid ligature. The 
pulse at the same time rose rapidly in frequency, running up to 
140, 150, and soon became so rapid and compressible that it 
could not be counted. The respirations, on the other hand, 
progressively diminished in frequency and finally were so re- 
tarded that no voluntary breathing could be observed except 
wrhen artificial stimulation and respiration were resorted to. 
The pupils were contracted. The mental state simulated 
somnolence and stupor, but the patient could be roused and 
gave intelligent but monosyllabic answers when repeatedly and 
loudly questioned. 
A quarter of a grain of morphia had been given hypoder- 15 
matically early in the evening when the patient had first com- 
plained of pain in the neck, and as the condition imitated 
opium narcosis completely he was treated on an antidotal basis, 
with repeated injections of atropia, caffeine, strychnia, am- 
monia and digitalis, which were administered with a liberal 
hand by Dr. Parham and myself. But all this seemed to be 
of no avail and the patient gradually sank into total uncon- 
sciousness, coma, and death about eight hours after the initial 
disturbance began. The temperature, which had been 99° 
in the evening, gradually became sub-normal. The wound 
looked healthy; slight oozing had occurred through the drain- 
age tube; there was no hasmorrhage, but the iodoform pack 
which had been left in the pterygoid fossa was removed shortly 
after the pain and cardio-respiratory disturbance began, for 
fear that the bad symptoms were due to excessive pressure up- 
on the pneumogastric. 
There was no paralytic symptoms. The urine, which had 
been carefully examined before and after the operation, showed 
no trace of sugar or albumen. 
What was the cause of death in this case? It was surely 
not opium narcosis, because the patient had taken large doses 
of morphia prior to the operation, one and two grains hypo- 
dermically, without any untoward effect. Yet the symptoms 
were nearer those of opium poisoning than those of any other 
condition. An injury to the pneumogastric during the opera- 
tion would have caused a disturbance in the respiration and 
circulation at the time of the injury and would not have waited 
nearly a day to manifest itself. I can not account for this 
unfortunate complication and termination in a manner satisfac- 
tory to myself. It has occurred to me that a small embolus 
which would have lodged in a branch of the vertebral controlling 
the circulation of the fourth ventricle and the pneumogastric 
nuclei would have accounted for this condition; but this is not 
at all probable, as there were no paralytic or other nervous 
manifestations than those mentioned. 
The cause of death in this case will ever remain a mystery, 
as no autopsy was held. 16 
Observation 7.—Secondary diffuse lympho-sarcoma of the 
axilla involving the axillary vein in the middle and lower 
thirds recurring nearty one year after amputation of the 
breast for primary growth. Resection of the diseased 
axillary vein and prophylactic ligature of the axillary artery 
below the subscapular to prevent venous choking of the 
limb. Uneventful recovery from operation, but recurrence 
of disease almost immediately after cicatrization. Enor- 
mous lymphatic edema and neuralgia from pressure, four 
months after last operation. Death. 
Mrs. H. A., ast. 38, white, apparently in perfect health 
apart from the existence of a painless tumor which involves 
the right mamma and is slightly adherent to its upper and outer 
quadrant. No glands in axilla can be felt. Tumor discovered 
three months previously, when it was detected as a small nodule 
in the breast. Growth has been rapid during the last month. 
In November, 1891, the breast and axillary contents were re- 
moved by Gross’ method. No diseased gland could be detected 
in the axillary fat. Microscopical examination revealed the 
tumor to be round-celled sarcoma. The wound healed fer 
jprimam, and outside of a slight impediment in raising the arm 
the recovery of the patient was complete. Nearly twelve 
months after, a slight edema of the hand made its appearance. 
Neuralgic pain in the arm became annoying. A characteristic 
infiltration in the axilla, along the outer boundary and over the 
vascular sheath, easily accounted for the symptoms and an- 
nounced the recurrence of the growth. 
A secondary operation was decided upon and the axilla 
was freely exposed. A large nodular, diffusely infiltrated mass 
was discovered surrounding the axillary sheath. Much diffi- 
culty was experienced in making the dissection, as the vein—a 
short large trunk—had been partially incorporated in the 
growth. In order to gain free access to the diseased mass the 
.pectoralis major was divided, and, finally, after much patient 
work the artery and nerves were isolated. The vein was 
ligated above and below the diseased portions and resected 
with part of the adherent mass attached. Adopting a precau- 
tion (Braun, Pilcher, Souchon) which I now believe to be 
unnecessary in dealing with wounds of the large venous trunks 17 
of the neck and upper extremity, I ligated the axillary artery 
below the sub-scapular to prevent venous choking of the limb. 
The hand and arm were cold for a few days, but no notable 
circulatory phenomena followed this operation. The axillary 
wound healed partially by first intention and by granulation. 
The rapidity with which the axillary gap was closed was ex- 
traordinary and was only accounted for by the unusually vig- 
orous physique of the patient. Cicatrization had barely taken 
place, however, when the scar became hard, brawny and mani- 
festly diseased. The movements of the arm were seriously 
crippled, and in two weeks after convalescence lymphatic 
edema of the arm and of the whole extremity soon gave it an 
elephantine appearance. Neuralgic pains, which followed the 
course of the median and musculo-spiral branches, added 
greatly to the distress of the patient. The scar assumed a 
fungous appearance ; emaciation and cachexia supervened and 
multiple nodules of malignant infiltration appeared on the chest 
and neck. 
Morphia in enormous doses was the only agent that mo- 
mentarily relieved the patient, who continued to live through 
this constantly increasing torture until nearly four months after 
the second operation, when death closed a scene that I have 
never seen paralleled by its horrors as well as by the heroic 
fortitude of the patient in all my surgical experience. 
I have selected this unfortunate case from a list of thirteen 
cases of malignant diseases of the breast which have been treated 
by modern operative methods simply to call the attention of the 
members of this society to the propriety of advising disarticu- 
lation at the shoulder in this especially unfortunate class of 
patients who, being still young, vigorous and robust, are pre- 
pared to offer a long resistance when attacked by axillary 
growths which involve the vascular sheath and nerve plexus 
and in whom lymphatic edema and neuralgia are sure to fol- 
low attempts at radical extirpation. 
These cases are practically incurable, but they are often 
operable, and there is no doubt in my mind that a more satis- 
factory effort at radical extirpation can be attempted if the 
useless preservation of a worthless limb is left out of considera- 
tion. If disarticulation is performed, as advocated by Watson 18 
Cheyne, not only will the operation be more thorough and the 
chances of recurrence diminished, but the patient will be re- 
lieved of an enormous burden. The lymphatic edema in 
these cases is progressive. The arm assumes gigantic propor- 
tions; it is rigid and absolutely immovable; even the fingers 
become so swollen that they are inflexible. As the arm swells 
it becomes flexed and its weight upon the abdomen or chest 
interferes with rest in any.position. The sitting or recumbent 
postures are nevertheless the only positions that the poor 
sufferer can tolerate, because the weight of the huge swollen 
limb drags and chains the patient down, like an anchor, to 
his bed. The neuralgia of the arm is also a terrible cause of 
suffering and compels the use of morphia in excessive doses. 
By resorting to disarticulation at the shoulder early, recurrence 
will not necessarily be prevented, but life will be prolonged 
without the martyrdom that otherwise characterizes these terri- 
ble cases. 
\ 
Observation 8.—Large cavernous angioma of nevoid origin,, 
involving palm of hand; the whole thenar region, entire 
thumb, index and part of medius, involved in the tumor. 
Attempt at conservatism by resection of diseased soft 
parts, leaving a purely tegumentary flap. Ligation of 
radial artery in first inter-space with other digital branches. 
Sloughing of all diseased area, with great and nearly fatal 
shock ; secondary amputation of all but the fourth and 
fifth fingers and metacarpals. The remnants of the 
medius utilized to fill the gap caused by the loss of the 
index and its metacarpal. 
In July, 1892, a little mulatto boy, F. V., ast. 6 years, was 
brought to me for the relief of a swelling which had developed 
shortly after birth in his right hand. The child was born with 
a spot in the hand like a “mother’s mark,” which at first 
attracted little attention, as it was insignificant in size and ap- 
pearance. Gradually as the baby developed, the spot enlarged 
and became thicker. As the functions of the hands were 
brought into greater play by the increasing activity of the 
child, the palmar spot began to swell, and finally a distinct, 
prominent deformity of the hand aroused the anxiety of 19 
the parents, who sought the advice of a physician. The 
doctor recognized the nevoid character of the growth and ad- 
vised that the child be at once subjected to surgical treatment. 
Nothing was done, however, until several months after, when 
the boy was brought to me for treatment. When first seen by 
me the little patient appeared to be a healthy, vigorous child, 
possibly a little pale and underweight for his size, but yet 
showing no abnormality outside of the deformity of the hand, 
which at once commanded attention. As shown by the ac- 
companying illustration, the whole thenar eminence, including 
the thumb and part of the proximal portion of the index, was 
abnormally blue in color, and swollen. The swelling was 
equally visible on the dorsal surface over the metacarpal bone of 
the thumb to the styloid process of the radius, and as far as 
the middle metacarpal. If the hand was [allowed to hang 
down the swelling markedly increased; if elevated above 
the head the tumor diminished, so that the hand had an almost 
normal appearance. If an elastic string was applied above the 
wrist, as is shown in Fig. 2, the swelling remained and ap- 
peared to be more turgid than ever. 
Upon careful palpation the vascular and erectile nature of 
the tumor was easily determined. By systematic pressure, the 
tumor could be easily emptied of its fluid contents. The meta- 
carpal bone of the thumb could be easily outlined in the centre 
of the swelling and appeared to be entirely denuded of all the 
soft parts, as if the palmar muscles had been entirely atrophied 
by the growth. It felt like a skeleton finger in a rubber bag. 
The second metacarpal gave much the same sensation to pal- 
pation. There was no distinct pulsation, but the affected area 
felt unusually warm. The skin covering the parts was very 
thin, and when the elastic band was applied so as to interfere 
with the venous circulation the tension was so great over the 
thenar eminence that it appeared as if the skin would burst. It 
was plainly a case of angioma cavernosum with a preponder- 
ance of venous ectasis. What to do in the way of treatment 
was a question which could not be answered easily. Amputa- 
tion of the hand or a part of it appeared to be the easiest and 
safest way out of the difficulty. Injections of carbolic acid or 
other irritating coagulants appeared dangerous from both the 20 
standpoints of embolism and sloughing. Electrolysis has been 
exceedingly unsatisfactory in my experience and was especially 
difficult of application, because of the long duration of the treat- 
ment and the restlessness of an active child under restraint. 
I concluded that I would carefully lay open the diseased 
area and dissect away as much of the erectile tissue as possi- 
ble after ligating all visible vessels of supply. Chloroform 
was administered and the Esmarch bandage was applied. 
An immediate collapse of the erectile tissues followed, and the 
hand assumed a perfectly natural appearance. An incision 
was now made from the base of the first phalanx of the thumb 
to the middle of the palm, which completely bisected the 
thenar eminence and exposed the interior of the most 
prominent part of the tumor. It was now easily ascertained 
that the flexor muscles of the thenar eminence had entirely dis- 
appeared and that a loose cribriform connective tissue—evi- 
dently erectile—had taken their place. The bone was only 
covered by this tissue and periosteum. Another incision was 
now made on the dorsal surface of the-hand which extended 
from the second phalanx of the index, along the line of the 
second metacarpal up to the styloid process of the radius. This 
was connected with the thenar incision by another incision 
over the edge of the first interdigital web, thus leaving a flap 
attached to the extensor surface of the thumb. The first 
interosseous muscle was brought to view, but it had evidently 
participated in the abnormal process, as it was riddled with 
vascular cavities through its whole extent. The second inter- 
osseous was likewise affected. The skin itself appeared to be 
essentially diseased. This was very discouraging but had been 
expected, and an attempt was now made to excise as much 
of the diseased muscle and erectile tissue as possible. The 
whole area of the skin was trimmed, and made so thin by con- 
stant shaving on its under surface that it resembled a large 
Thiersch graft consisting only of epidermis; the first interosse- 
ous muscle was excised in toto, and the vascular mass which 
represented the thenar group of muscles was likewise excised 
with scissors and knife. 
While clearing the field in this way the radial artery was 
purposely exposed as it enters the palm in the first interosseous 
space. After securing this vessel we decided to relax the con- Fig. 2. Palmar Aspect 
Observation S.—Cavernous Angioma of the Hand. (Dr. Matas collection.) 
Fig i. Dorsal Aspect. 21 
strictor and observe the restoration of the circulation in the 
parts. We were prepared for a change, but the spectacle 
offered by the sudden exhibition of the extraordinary vascular- 
ity of the tissues was astonishing. The skin, which appeared 
to be thinned to a mere epidermal parchment, was now swol- 
len, angry, turgid, and blue as if nothing had been done to it. 
The whole wound swelled up and it was almost impossible to 
understand the enormous capacity for distention that was ex- 
hibited by the merest shred of connective tissue. With all 
this, however, there was no spurting of arterial blood ; there 
was simply a general and copious oozing, which came from 
every quarter and flooded the whole held of the operation. 
All attempt at further extirpation was given up and our efforts 
were simply directed to hemostasis, which fortunately was 
readily secured by returning the dissected flaps to their places 
and compressing the whole thenar, region with packs of 
iodoform gauze, cotton, and firm bandaging over a splint that 
extended to the elbow. The child recovered perfectly from 
the anesthetic (chloroform) and was removed to his home 
from the hospital that evening. 
Early the next morning, I was summoned by the parents 
to see the boy. There had been no hemorrhage, but I was 
told that a severe and long chill had come on during the night, 
and that very high fever accompanied by intense pain in the 
hand had followed. When I saw the child it was unconscious 
and in convulsions. The temperature had risen to 105 
F., and the pulse was so rapid that it could not be counted. It 
was evident that serious mischief had been caused, but I could 
not believe that it was due to septic infection. The hand was 
hurriedly unbandaged and I discovered that the whole diseased 
area was cold, dark and completely anesthetic. This meant 
sloughing. The hand was bathed in very hot water and a 
loose dressing, consisting of lintine saturated in a weak car- 
bolized solution, arid loosely bandaged, was kept constantly ap- 
plied. An ice bag to the head, general sponging of the body 
with cold water and the internal administration of digitalis, 
potassium bromide, and minute doses of phenacetin in whiskey 
toddy constituted the basis of the treatment for that day. The 
unconscious state continued with elevated temperature all that 
day and following night—but finally the temperature slowly fell 22 
to 103° and continued at this height with slight remissions 
forty-eight hours longer. The hand in the meantime did not 
improve. The vitality of the affected area had been per- 
manently destroyed and a line of demarcation began to show 
itself before the third day. This line mapped out with ab- 
solute precision the whole erectile area on both the palmar and 
dorsal surfaces. The sloughing process did not extend one 
line’s breadth beyond the diseased area, but when the sloughs 
were removed, it was found that only half of the palm had been 
left, together with the third, fourth and fifth metacarpals and 
their corresponding fingers. The medius was so much denuded 
on the radial side that I decided, some time later, to turn it 
down after the extirpation of the ungual phalanx, and utilize 
it to fill the gap caused by the removal of the second metacar- 
pal and index finger. The hand is now reduced to part of the 
palm and two last fingers, which are very useful to the patient. 
The remarkable feature of this case is the limitation of the 
slough to the diseased tissues, which were differentiated from 
the normal elements with extraordinary accuracy and in a man- 
ner that could not have been approached by the surgeon with 
the help of the naked eye. At the same time it teaches the lesson 
that conservatism in these cases is dangerous and that radical 
measures should be preferred from the start. The sloughing was 
evidently due to three unavoidable causes, viz.: (1) impaired 
vitality from arrested arterial supply; (2) prolonged ischemia 
caused by Esmarch bandage; (3) interference with a weak- 
ened circulation by firm and prolonged compression, with a 
view of maintaining hemostasis after the operation. 
The conclusion is finally forced upon us that in advanced 
cavernous angioma of the hand which involves the deeper 
structures and the true derm as well, it is best to amputate, as 
conservatively as possible, as an initial procedure. 
Observation 9.—Gunshot injury causing a large traumatic 
aneurism in the lower and inner femoral region. Incision 
of the whole sac along the line of the femoral vessels ten 
days after injury. Exposure of the femoral artery and 
vein completely divided at the bottom of the sac in Hun- 
ter’s canal. Ligation of both trunks. Packing and iodo- 
form gauze. Recovery without notable complications, 23 
This case is selected out of a group of four traumatisms 
involving the ligation of the femoral because of the special 
severity of the injury, which included both the artery and vein 
in their passage through Hunter’s canal. The patient, N. D., 
a white laborer, aet. 21, was admitted to Ward 8, Charity Hos- 
pital, in the summer of 1892. He stated that he had been shot 
accidentally by a friend. The revolver carried a 38-caliber 
bullet, which appeared to enter the middle of the thigh, near 
the apex of Scarpa’s triangle, and then took a downward and 
inward course, to escape finally in the popliteal space, near the 
inner border of the inner hamstring tendons. The injury 
had been received the day before, and the patient had been 
admitted shortly after and put to bed, as it was evident 
that one of the femoral vessels had been injured. Much 
blood flowed through the anterior opening; a firm com- 
press over this controlled the external bleeding, but the rapid 
swelling of the thigh indicated that a large hematoma was 
forming. 
A firm bandage was applied and ice bags were kept over 
the wounded area, but the tumor continued to increase in size 
and soon developed a characteristic heaving pulsation, purring 
thrill and murmur which indicated the advent of the aneuris- 
mal state. On the 10th day after the injury, the patient was 
placed under the influence of chloroform, and after the appli- 
cation of the Esmarch, the sac was opened freely throughout 
its whole length. 
The aponeurotic covering of Hunter’s canal was divided, 
and a complete transverse section of the artery and vein was 
discovered. The artery had retracted, the divided ends being 
only held together by a portion of the sheath. The ends of 
the injured vessels were secured with sterilized silk ligatures, 
and the whole cavity packed with iodoform gauze after 
thorough preliminary irrigation with hot sterilized water. 
The recovery of the patient was uneventful. A slight 
flexor contraction of the leg upon the thigh remained for several 
months, but I have recently examined the patient and he has 
now no trace of the injury in his walk. The scars alone 
indicate the site of the injury. 24 
Observation io.—Punctured and incised wound of the super- 
ficial and deep palmar arches. Wound soiled by cob- 
webs and perchloride of iron. Great prostration and acute 
anemia from excessive bleeding. Anesthesia, careful 
washing of the wound ; bleeding points secured with hemos- 
tatic clamps; iodoform tampon in wound. The limb im- 
mobilized by long extensor and flexor splints and aseptic 
dressing. Removal of the hemostats in three days fol- 
lowed by complete healing by granulation. 
In November, 1892, the patient, a robust male, aet. 36, 
while clumsily opening an oyster with an unusually sharp knife 
transfixed the left palm through and through, so that the rounded 
end of the knife appeared on the dorsum between the third and 
fourth metacarpals. Profuse bleeding followed, which indi- 
cated that an important vessel had been injured. He was 
brought to a neighboring drug store for assistance, but a hand- 
ful of cob-webs had been applied in the meantime over both 
bleeding orifices. The druggist applied a compress of lint 
soaked in perchloride of iron and then bandaged the hand. 
This temporarily checked the bleeding, but in a few hours the 
hemorrhage recurred, soaking through the bandage, the 
blood soon dripping to the floor. When I saw the patient 
late at night, I found him exceedingly weak, with a small, 
rapid pulse. There was great pallor, nausea and inability to 
sit up. After the administration'of aromatic spirits of ammo- 
nia, digitalis and brandy, I unbandaged the hand and applied 
an Esmarch bandage. A mixture of equal parts of chloroform 
and ether was administered and well taken by the patient. 
The whole hand was dipped into a bowl of hot carbolized 
water and scrubbed until the hard perchloride clots and cob- 
webs had been washed away. 
The palmar wound was then freely enlarged on a line cor- 
responding to the long axis of the medius and its metacarpal 
until the deep tendons were exposed. It was evident that both 
the superficial and deep arches had been injured, and that it 
would not be an easy matter to discover the bleeding points in 
the midst of the stained tissues. Nevertheless, after freely ex- 
posing the whole depth of the wound, the constrictor was re- 
laxed and the point from which the blood spurted at the bottom 25 
of the wound was promptly secured with a Tait’s clamp, which 
was left in situ. The wound in the superficial arch gave no 
trouble and all further oozing was readily controlled by a firm 
iodoform gauze pack. A long extensor splint reaching to the 
elbow was then applied and the arm was thus immobilized. 
Three days after, the splint was removed and the hemostat un- 
damped. The wound had a healthy• appearance and finally 
healed without accidental complications. 
This case is presented to illustrate a simple method of 
treatment for an injury which is not rare and which is likely to 
cause no small amount of worry to the inexperienced prac- 
titioner. 
It is well known and admitted that the ligature of the arteries 
in the forearm for a bleeding palmar arch is untrustworthy, 
and that nothing short of the ligation of the brachial at the 
bend of the elbow above the bifurcation, as recommended by 
Thiriar, of Brussels, can give security against secondary 
hemorrhage. But the ligation of the brachial at the] bend of 
the elbow, simple as it may appear to the surgeon of experience, 
is nevertheless an anatomicul operation which many practition- 
ers will hesitate to attempt. Furthermore, it is always unsur- 
gical to ligate a parent trunk when it is possible to control the 
bleeding vessel at the bleeding point. The danger of septic 
teno-synovitis has been the chief drawback in the past against 
the ligation of the deep palmar vessels. The difficulty of 
securing a bleeding vessel in the depths of the palm has also 
discouraged the application of the ligature in the wound, and 
favored ligation at a distance, but the modern methods of anti- 
sepsis and hemostasis have greatly cleared the field of these 
objections. 
The practitioner of the present day should find no more 
difficulty in controlling a palmar haemorrhage in loco than he 
would in dealing with bleeding in wounds of other localities.