IMAGE EVALUATION TEST TARGET (MT-3) 1.0 I.I ^128 |2.5 1^ i2.2 ^ ... I m Hi I 2.0 E 1 25 1 1.4 1.6 « 6" ► r. vl ''/ '/ M ? Photographic Sciences Corporation 33 WIST MAIN iTMIT WilVlit.N.Y. Msao (716) ir^usoa r o 4<3 CIHM/ICMH CIHM/ICMH Microfiche Collection de Series. microfiches. : ' ■ • [■ _ . ; r _ ■ ' Canadian Instituta for Historical IVIicroraproductions / Inatitut Canadian da microraproductiona historiquas Technical and Bibliographic Notes/Notes techniques et bibliographiques The Institute has attempted to obtain the best original copy available for filming. Features of this copy which may be bibliographically unique, which may alter any of the imager in the reproduction, or which may significantly change the usual method of filming, are checked below. n n D n D n Coloured covers/ Couverture de couleur I I Covers damaged/ Couverture endommagte Covers restored and/or laminated/ Couverture restaur^ et/ou pelliculAe I I Cover title missing/ Le titre de couverture manque I I Coloured maps/ Cartes g^ographiques en couleur Coloured ink (i.e. other than blue or black)/ Encre de couleur (i.e. autre que bleue ou noire) r I Coloured plates and/or illustrations/ Planches et/ou illustrations en couleur Bound with other material/ Relii avec d'autres documents Tight binding may causa shadows or distortion along interior margin/ Lareliure serrie peut causer de I'ombre ou de la distortion le long de la marge intArieure Blank leaves added during restoration may appear within the text. Whenever possible, these have been omitted from filming/ II se peut que certaines pages blanches ajouties lors d'une restauration apparaissent dans le texte. mais, lorsque cela Atait possible, ces pages n'ont pas 6ti film^es. Additional comments:/ Commentaires supplAmentaires; L'Institut a microfilm^ le meilleur exemplaire qu'il lui a 6t6 possible de se procurer. Les details de cet exemplaire qui sont peut-dtre uniques du point de vue bibliographique, qui peuvent modifier une image reproduite, ou qui peuvent exiger une modification dans la methods normale de filmage sont indiquAs ci-dessous. I I Coloured pages/ Pages de couleur Pages damaged/ Pages endommagdes Pages restored and/oi Pages restaur^es et/ou pelliculdes I I Pages damaged/ I I Pages restored and/or laminated/ 1/ □ Pages discoloured, stained or foxed/ Pages d6color6es, tacheties ou piqudes □Pages detached/ Pages ditachies EShowthrough/ Transparence I I Quality of print varies/ Quality inAgale de ('impression Includes supplementary material/ Comprend du materiel supplimentaire Only edition available/ Seule Edition disponible Pages wholly or partially obscured by errata slips, tissues, etc., have been refllmed to ensure the best possible image/ Les pages totalement ou partiellement obscurcies par un feuillet d'errata, une pelure, etc., ont M filmies A nouveau de facon A obtenir la meilleure image possible. This item is filmed at the reduction ratio checked below/ Ce document est filmi au taux de reduction indiquA ci-dessous. 10X 14X 18X 22X 26X 30X y 12X 16X 20X 24X 28X 32X Th« copy film«d her* hat b««n raproducad thanks to tha ganarosity of: Medical Library IMcGill University IVIontreai Tha imagas appearing hara ara tha baat quality possibia considaring tha condition and iagibiiity of tha original copy and in icaaping with tha filming contract spacificationa. Original copiaa in printed paper covers are filmed beginning with the front cover and ending on the laat page with a printed or illustrated impres* sion, or the back cover when appropriate. All other original copies are filmed beginning on the first page with e printed or iliuatrated impree- sion, and ending on the laat page with e printed or illustrated impreeiion. L'exemplaire filmi fut reproduit grice h la g^nArositi de: Medical Library McGill University Montreal Lee imeges suivantae ont AtA reproduites avac la piua grand soin, compta tenu de la condition at de la nettet* de I'exemplaire fiimA, et en conformitA avac las conditions du contrat da filmage. Lee exempleiree origineux dont la couvarture en papier eat imprimia sont filmis an commen9ant par la premier plat et en terminant soit par la darnlAre pege qui comporte une empreinte d'impression ou d'illustration, soit par la second plat, salon la caa. Tous lea autras exempiaires origineux sont filmte en commenpant par la pramiAre page qui comporte une empreinte d'Impreeaion ou d'illustration et en terminant par la dernlAre pege qui comporte une telle empreinte. The laat recorded frame on each microfiche shall contain tha symbol ^^> (meaning "CON- TINUED "), or the symbol ▼ (meaning "END"), whichever applies. Un dee symboiee suivants apparattra sur la darnlAre image de cheque microfiche, selon le cae: le symbols — *> signifie "A SUIVRE", le symbols ▼ signifie "FIN". Meps, plates, cherts, etc.. may be filmed at different reduction ratios. Thoae too large to be entirely included in one exposure are filmed beginning in the upper left hand corner, left to right and top to bottom, ae many frames as required. The following diegrams illuatrate the method: Lee cartea, planches, tableeux, etc., peuvent Atre filmie i dee taux de rMuction diff Arents. Lorsque le document est trop grand pour Atre reproduit en un seul clichA, ii est filmA A psrtir de I'angle supArieur gauche, de geuche h droite, et de haut en bee, en prenent le nombre d'Imeges nAceesaire. Lea diagrammes suivants illustrent la mithode. 1 2 9 1 2 3 4 5 6 m Extracted from the American Journal of the Medical Sciences for Januarj, 1885. AN OBSCURE CASE OF tOPLITEAL ANEURISM WHICH SIMULATED SARCOMA. By FRANCIS J. SHEPHERD, M.D., CM., Professor of Anatomy McGill University ; Surgeon to the Montreal General Hospital.* r. t Mo W. H., aged 46, carpenter, entered the Montreal General Hospital Dec. 31, 18H3, suffering from a large ulcer of the right leg, and a tumor of tlie lower and back part of the right thigh. Previous to 1875, his health had been always good, no history of syphilis or rheumatism, but has had frequent attacks of gonorrhoea. Has been intemperate since boy- hood. For three years was a soldier in the British army. In the autumn of 1875, was treated in the Montreal General Hospital for double popli- teal aneurism.* The aneurism of the left popliteal was treated by digital compression, and that of the right by Carte's compressors. After remain- ing in hospital two months, he was discharged cured. He says that he kept well for two years, then the small hard lump which had remained in his rigiit popliteal space began to enlarge and pulsate, and was again cured by compression. For the next four or five years he was not troubled with his aneurisms, but about a year and a half ago noticed a small tumor in the right popliteal space; this tumor was hard, firm, and did not pul- sate ; it gradually increased in size, and when he was in hospital a year ago for treatment of the ulcer on his right leg it was noted as being about the size of a man's fist, fixed, hard, and without pulsation. From this time the tumor increased more rapidly. The following is the surgical reporter's account of his condition on entrance : " On examining the affected leg a huge indolent ulcer is seen on the lower and outer side ; there is also a large tumor, nearly the size of a man's head, on the back of the thigh ; it extends from the popliteal space to the middle of the ham, and is somewhat egg-shaped. The measurement of the thigh a little above the knee, the point where the > Read before the Canada Medical Association, Aug. 1884. * An account of his case is published in tiie Canada Med. and Surg. Journ., vol. i. p. 898. 2 circumference is greatest, is twenty-three and a half inches.^ The left limb at the same point measures twelve and a half inches. • The tumor is immovable, smooth, and inelastic ; it gives on palpation no sense of fluctuation, neither is tliere any pulsation in it, nor is any thrill felt or bruit heard. Pressure on the artery above does not influence the tumor. It is not tender, and there has never been any pain, either in the leg or the tumor, excefjt after long standing; in fact, the patient thinks very little about the tumor, and comes into hospital for the purpose of having the ulcer in his leg treated. The leg, owioi; to the size ofthe tui^pr and the stretching of tlie tissues over it, can^t be straightened perfectKy or fl^exed completely ; he lies with it in 4liji>'8ewfflexed position. Coursing over thfe^^ tumor are numbers of enlarged veins. The leg is not swollen or oedema--*! tons. The glands in the groin are enlarged, and can be felt extending under Poupart's ligament into the abdomen." Not feeling sure as w the diagnosis, and hesitating from the history to pronounce it a sarconn*^ I decided to watch the case for some time before undertaking operative procedures. After the patient had been under observation some three weeks, he complained of severe pain in the tumor and down the back of the leg, and it was found that the measurement at the point of greatest circum- ference had reached tw«nty-foiir and a half inches. He now began to develop febrile symptoml^ and for several weeks his temperature was a couple of degrees above normal, his tongue was coated with a white fur. w and there was some tenddness on the right iliac fossa. When he re- covered from this slight fever, which lasted about three weeks, and which I in no way connected with the tumor of the leg, a consultation of my col- leagues was called. The tumor had all this time been slowly increasing in size, the man could How only very slightly either flex or extend his leg, and he suflfered severely from pain. Although fully alive to the possibility of the case being one of aneurism, still, from the total absence of aneurismal symptoms, and after repeated and careful stethoscopic and manual examinations, I was becoming, from week to week, more convinced that the evidence pointed to sarcoma, either of the periosteum or the parts about the old aneurism. My col- leagues agreed with me in this conviction, and amputation was decided on. The man having readily consented, amputation was performed on February 24, 1884, at the junction of the upper with the middle third of the thigh and well above the tumor. The circular method was employed, and the stump Was dressed with iodoform, gauze, and borated cotton. The wound healed rapidly, and at the end of two weeks, with two dressings, was all united by iirst intention, except where the drainage tubes had been. Examination of the 2'umor. — On cutting into the tumor it had to the naked eye all the appearances of a neoplasm, but on examining it microscopically it turned out to be composed simply of fibrin. The fibrin was not deposited in layers as is commonly the case, but solidified " en masse," so to speak. There was no cavity in the tumor, but it was solid througiiout. The femoral artery ended above the tumor in a blind sac (see A in accompanying Fig.). Upon slitting up the popliteal arteiy, at the lower end of the tumor, the external coat of this vessel was found con- 6°» ■)een. d to igit brin "en solid sac r, at ■con- tinuous with the capsule of the tumor, and here no doubt was the orifice of the aneurism ; about this point the clot was in a softer condi- tion than in other parts of the mass. The sciatic nerve was tightly stretched over the tumor and con- siderably flattened. JLftTge collate- ral branclnes joffiied the popliteal artery near where it was connectec with the tumor (see accompanying" Fig-). The diagnosis of popliteal aneur- ism is not generally a matter of great difficulty, still some of the cases of aneurism simulate other diseases so closely that mistakes are occasionally made. Many able surgeons have opened aneurisms supposing them to be abscesses,^ and others again have tied the femoral artery for malignant growths, mis- taking: them for aneurisms. There are not a few cases recorded where an old consolidated aneurism htis been mistaken for a sarcomatous tumor. Dr. Henry B. Sands re- ported such a case to tlie New York Patliological Society {Med- ical Record, vol. xxv., 1877. p. 188), where amputation was perfonned for supposed sarcoma of the ham, and which turned out to be a co < ■•>>i- dated aneurism. The case is as follows: — "A man aged 4G entered the Roosevelt Hospitrtl, suffering from a tumor of the right lep. He had been the round of other hospitals, and the opinion arrived at was that the patient suffered from a sarcomatous tumor. Treatment by com- pression had been practised fourteen years previously, for 8uj)posed popliteal aneurism. This was continued for nine weeks, and subsequently another tumor developed below the site of the original one. This increased from year to year, by an annual increment of an inch and a half in the circumference of the limb. len days before adniission to the Roosevelt Hospital he was seized with a rigor, and, on entering, a painful tumor on the leg was noticed, which extende«l down from the popliteal region. A careful examination was deferred for four days, on account of the depressed state of the patient. It was then found that the tumor was situated on the posterior and upper two-thirds of the leg. The measure- ments were as follows : Five inches above the ankle tlie circumference was five inches, six and a half inches above the ankle, the girth was nineteen inches ; at A. Femoral artery ending above the tnmor. P. Popliteal attery coDtinuous with the sac of the tumor. C. Large collateral branch. N. Sciatic nerve. > See Dr. S. Smith's " Diagnoeis of Abscess from Aneurism," Ambb. Journ. Mbd. Sci., April, 1873. the upper third of the le«r the measurement was twenty-three and a half inches. The size diminished gi-adnidiv in the u|)wurd direction. The tumor was firm, smooth, and nodulated. Tliat jjortion of the tumor which was at the lower part of the thijih was found to give evidence of fluctuation and pulsation ; there waa alsoabrurt heard with a stethoscope. On December 18th. the mass broke in two places, and discharged a large amount of grumous blood together witli solid masses of bloodclots. Following this, there was a subsidence of fiuctuution and pulsation. Amputation of the thisrh war performed, and thirteen days after the patient died. At the autopsy it was found that the tumor was an aneurism. At its upper i)art there was a solid mass which was at first thought to be a neoplasm, but, on more thorough examination, j»roved to be a blood-clot. The popliteal artery above the sac was obliterated, and it was a mystery how pulsation could be accounted for without communication being made out with arterial branches, and, moreover, without the mass being superimposed on the artery." The desci'iption of the appearances of the tumor is not very full ; no doubt it was fed, as in my case, by anastomotic brandies, which joined the popliteal immediately below the tumor. The existence of pulsation and a bruit, with fluctuation, made the case more like an ordinary aneurism than my own. Its points of resemblance are the consolidated tumor ^ which increased in size the former cure of the aneurism by compression, and the obliteration of the artery above the tumor. Mr. Erichsen {System of Surgery, vol. ii. p. 22, ed. 1869) figures a somewhat similar case wliich was mistaken for a painful solid tumor. The leg was amputated, and the tumor proved on dissection to be a con- solidated aneurism pressing on the popliteal nerve. From the plate of the aneurism wliich is given, there appears to be a large cavity near the surface of the tumor which contained a recent coagulum, and which must, during life, have been filled with fluid blood. Mr. Holmes, in his article on aneurism (^Holmes's System of Surgery^ vol. iii. p. 43, ed. 1883), says : — "I can refer to at least three cases, one a preparation in the St. George's Hospital Museum, another in the jSluseum of the Royal College of Surgeons, and a third in private, in wliich the limb was amputated for a large tumor in the popliteal space, believed to be mnlignant, and which turned out to be cured aneurism, and I know that this has occurred in several other instances. In some of the cases, however, the pressure of the tumor had produced gangrene, so the operation was necessary." Mr. Prescott Hewitt {Medico-Chirurg. Trans., vol. xxix. p. 75) relates an interesting case of aneurism of the femoral artery, which was cured by ligature of the external iliac, and where, after all pulsation and sound had ceased in it, the tumor gradually increased till it reached the size of the head of a full-grown foetus, and was thought by many of the surgeons to be a tumor of a malignant character. The man died of phthisis, and the post-mortem examination revealed a consolidated aneurism and oblite- ration of the femoral above the tumor. Mr. Morrant Baker, in an article on "Aneurisms which do not Pulsate" (^St. Bartholomew's Hospital Rep., vol. xv. p. 79), mentions three cases where the leg was amputated for supposed malignant tumors, which turned out to be consolidated popliteal aneurisms. Two of these cases were referred to Mr. Maunder at a discussion of the Clinical Society (Lancet, Marcli 16, 1878). Dr. Dunning (iWedical Record, August 5, 187G) reports a case of popliteal aneurism mistaken for semi-malignant growth, in which the surgeon attempted to remove the tumor, tiie case terminating fatally from hemorrhage a few liours after the operation. In this case the tumor was hard, inelastic, having no pulsation or bruit, and was slowly increasing in size. The tumor, as examined after removal, was found filled with con- centric layers of fibrin occupying its entire space, save a small cavity in the course of the artery. Mr. Oliver Pemberton {Lancet, vol. ii. p. 120, 1877) reports a case of femoral aneurism, for the cure of which he tied the external iliac. The tt;mor disappeared, and for two and a half years the man remained per- fectly well, Avhen suddenly he found the seat of the aneurism enlarging to the size of a man's fist. It continued to grow slowly till, wlien the case was reported, it measured five inches in length and breadth, and three in depth. It was free from pulsation and pain. He looked upon the case " as an instance of the production within the walls of an apparently cured aneurism of deposits of fibrin, continually increasing in amount, always feeling solid, and never giving rise to pulsation or sound." He mentions, shortly, two other somewhat similar oases. These cases which I have quoted will give some idea how difficult may be the diagnosis between a consolidated aneurism and a sarcomatous tumor. PirogofF says :' — "If I were asked what signs I hold most decisive of the existence of an aneu- rism which does not pulsate, I must confess tluit, if there is no bruit to be iieard at any part of the tumor, I know of no other than these two: (1), collapse of tlie swelling, sometimes only to a slight extent, when the main artery is com- pressed between the iieart and the tumor ; and ('2), if the pulsation of tiie artery can be felt upon the surface of the tumor, an unnatural extension of its impulse, for example, over twice tlie usual breadth of the vessel. But, in order to satisfy myself of these two plienomena, it is, of course, necessary to examine the case repeatedly, and with the greatest attention. Tlie diagnosis must not be founded on a single examination." Barwell {Liter national Encyclopeeiia of Surgery, vol. iii. p. 398) " does not know of any positive signs by which to distinguish between a solidified aneurism and other hard tumors." He savs, " the jjreat aid to diagnosis will be the more or less globular form of the tumor, its isolation from adjoining structures, and the fact that it does not increase (if really solid) but rather decreases." Now in my case all the signs by which a diagnosis is usually made were wanting, there was no fiuctuation, pulsa- tion, bruit, or increased arterial impulse, and the tumor steadily increased in size. The history of the case certainly pointed to aneurism, but the clinical signs did not ; in fact, there was not a single symptom which • Klin. Chir., quoted by Holmes, St. George's Hosp. Rep., vol. vif. 187!. Ii 6 pointed to aneurism, so that an accurate diagnosis was, in ray opinion, impossible. Had a diagnosis of consolidated aneurism been made out, could any other means besides amputation have been adopted for relief? I think not. Ligature of the superficial femoral above the tumor would not have availed, owing to the obliteration of that vessel. Compression of tiie common femoral on the pubis would have been equally useless, as cutting off the blood from this source had been practised before, and the circulation was carried on, probably, by branches of the internal iliac artery anastomosing with the perfawrting arteries of the profunda and articular branches of the popliteal. Removal of an aneurismal tumor by dissection has recently been successfully practised by Mr. Wm. Rose, Surweon to King's College Hospital, London. In this case the aneurism was a femoral one, and Mr. Rose had failed to cure it by digital com- pression, ligature of thefexternal iliac, or rest and iodide of potassium, so he determined to dissect out the tumor, tying all the communicating vessels as lie met with them. The aneurism being a small one, only the size of a lemon, the operation was successfully performed, hemorrhage being prevented by Esmarch's bandage and Davy's hiver {Lancet, Dec. 22, 1883). In my case this ^method of treatment would have offered little chance of success, owing tO'lthe immense size of the tumor and the already badly nourished condition of the limb, as evidenced by the large indolent ulcer of il;? leg So, had the nature of the tumor been certainly diag- nosed, it seems to me that amputation would have been the most suitable, and probably the only means, by which the patient could have been relieved from his sufferings and cured of his disease. There are several interesting and important points connected with the tumor itself. Tiie fibrin was not arranged in layers but was simply one uniform mass,* and, to the naked eye, looked exactly like a new growth. The orifice of the aneurism was at the distal end of the tumor, and the blood therefore flowed from below up, with, of course, a lessened stream ; the circulation owing to the obliteration of the femoral above the tumor being carried on by collateral branches. As there was no cavity in the tumor the absence of pulsation and bruit is explained. It is, however, difficult to understand in what manner the tumor increased in size, and how the new fibrin was deposited ; probably the mass was in a spongy condition so that the blood could easily permeate it, and thus fibrin could be slowly deposited. ' Mr. WagetafTe (Path. Soc. Trans., vol. xxlx, p. 73), reports a case of popliteal aneurism cured by Esmarch's bandage, in which, after death, he found the clot con- tained within it solidified throughout aud well organized. w * t % :f' m^': 1 I * V -I.J • ■m, I If < •'?,<'' , * -, ./rV' •%i -,^f. -«u ^fi' «" * jf^iifei' ^. ■ §#«^33i*> &^^iMmr- .^SmXm^BsSMUt "■J"- 4^*;»"i,j»if %.-t<- *"/ ii*^"f >?!ilWf «,^if«?vjf.. vmu.