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rapid improvement noted in all cases after evacuation of theblood and serum supports Mr. Owen’s view that this is due tothe relief of tension ; but, on the other hand, much greatertension is often present in the abdominal cavity withoutcausing any discomfort. The employment of a trocar andcannula, or, better still, of an aspirator, may sometimes besufficient, as in Case 2 ; but in Mr. Owen’s case the presenceof blood-clot and in Case 1 the presence of a septumrendered laparotomy necessary for complete success. In theabove cases the progressive anasmia was a marked symptom,and suggested that the effusion of blood continued for sometime after the original injury. In Case 1-which presumablyin the absence of any history of other lesion was due to thetapping of the hydrocele-the amount of blood found seemedout of all proportion to the extent of the injury.Carlton-hill, N.W.

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A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

ST. THOMAS’S HOSPITAL.INGUINAL ANEURYSM TREATED BY LIGATURE OF THE

EXTERNAL ILIAC ARTERY BY THE INTRA-PERITONEALMETHOD.

(Under the care of Mr. MAKINS.)

NuHa autem est alia pro certo noscendi via, nisi quamplurimas et mor.borum et dissectionum historias, tum aliorum tum proprias collectashabere, et inter se compare.-MORGAGNI De Sed. et Caus. Morb.,lib. iv. Procemium.

CASES in which it is necessary to ligature one of the iliacarteries for aneurysm are very rarely met with in surgicalpractice, and the fact that the ligature was applied in thisinstance through the peritoneum makes this account of

especial interest. There are few instances on record where

a ligature has been applied to the external iliac by themethod described below, and it is worthy of remark that onthe same day that Mr. Makins performed his operation Mr.Mitchell Banks operated on a similar case at the LiverpoolRoyal Infirmary, also with success. His patient, aged sixty-three, was of spare frame ; the aneurysm was situated onthe right side, was as large as a fist and of some weeks’duration. Catgut was used to ligature the vessel, andthe coats were not divided. The patient left the hospitalon the forty-first day after the operation. Mr. Makinsdraws attention in his remarks to the anatomical diffi-culties which may be met with, and also directs attentionto the possibility of greater risk of hernia after thismethod. Mr. W. H. Brown, who appears to have also per-formed the ligation of this vessel through the peritoneum,found it very difficult to reach ; but details of the case arewanting. We hope that the publication of this case will leadto the record of others, for the intra-peritoneal method (or,as we prefer to call it, the "transperitoneal") will doubtlessbe favoured by operators in the future. The records of

ligation of the common iliac artery are more numerous thanthose of the artery which we are considering; but we onlywish to direct attention to the latter, though it is quite pos-sible that the operations on the common iliac of Dennis inAmerica and of Rivington and Lucas in this country haveled to the fuller consideration of this subject.The patient was a carpenter aged thirty. Family history

good ; father, three brothers and two sisters alive and in goodhealth. Mother died at fifty-four ; cause of death unknown.He has, on the whole, enjoyed good health, except an uncom-plicated attack of acute rheumatism three years and a halfago, gonorrhoea in youth and four years ago he acquiredsyphilis, which does not seem to have been thoroughly treated.At present there are no evidences of tertiary syphilis beyondthe presence of the aneurysm. His occupation at times giveshim heavy work and exposes him to the liability of strain.

Sept. 16th, 1892.-For the past twelve months he hasnoticed that when he slept on his left side he awoke in a coldperspiration and experienced considerable pain in the leftgroin and neighbourhood. Four months ago he thinks he

strained himself lifting a heavy wardrobe. Three months

ago he noted pain and pulsation in the groin, and during thepast six weeks swelling and pain down the front of the thighto the knee. No pain referred to the testicle. Thesesymptoms have been gradually becoming more severe, and onSept. 15th he was sent to the hospital by Mr. Winterburn.On admission the patient was a stoutish man of ruddy com-

plexion, due to dilated capillaries and considerable develop-ment of subcutaneous fat. The limb was much swollen andcedematous. In the left groin there was a large oval pulsatingtumour in the course of the external iliac and common’

femoral arteries. It extended upwards about two-fifths ofthe distance between the middle of Poupart’s ligament andthe umbilicus and for about two inches below the ligament ;it was about two inches in breadth. The tumour was hard,the pulsation expansile and synchronous with the heart beat ;there was a rough double bruit. Pulsation in the posteriortibial artery was weaker than on the sound side. The areaof cardiac dulness was not increased, the first sound wassomewhat indistinct at the apex, and the second sound)accentuated over the aortic area, but there was no distinctmurmur. Pulse 70-80, rather irritable ; there was no markedevidence of general arterial disease ; no evidence of any othervisceral disease ; urine, sp. gr. 1018, clear, no albumen,deposit of phosphates ; bowels regular ; temperature 988°He remained quiet in bed during the next four days, duringwhich time the pulse subsided and the heart’s sounds and’action became normal.On Sept. 20th, the patient being under the influence of an

anaesthetic of mixed chloroform and ether, an incisionfour inches in length, commencing one inch below the levelof the umbilicus, was made in the left linea semilunaris.The incision was carried through the abdominal wall into theperitoneal cavity and was slightly enlarged downwards, andthe deep epigastric artery, which originated in the tumour,doubly ligatured and divided. The small intestines were heldover to the right with Messrs. Ballance and Edmunds’ broadabdominal retractor, the sigmoid flexure was pushed upwardsand an incision was made through the lower part of its

mesentery and the peritoneum at the margin of the pelvis inthe course of the artery. The wound was deep, there

being about an inch and a half of subcutaneous fatand abundance of fat in the subperitoneal tissue bothbeneath the anterior abdominal wall and around thevessels. This, together with some retching on the part ofthe patient, rendered the freeing of the artery and the passageof the ligature a process of some difficulty. The spermaticvessels also were exposed and swelled up considerably in the-wound. The artery was secured about three-quarters of aninch below the bifurcation of the common iliac and an inchand a half above the aneurysmal sac, and lay somewhatdeeply at the inner margin of the psoas muscle ; two threadsof stout flossy sterilised silk were tied separately, but in closeapposition, with sufficient firmness to rupture the internaland middle coats. The posterior peritoneum was suturedover the artery, and the abdominal wound closed with silk-worm gut sutures. Bicyanide dressings were then appliedand a flannel roller. Pulsation in the aneurysm ceased entirelywith the application of the ligatures.The after progress of the case was in all respects satis-

factory ; the patient complained of some pain in the limbfor the first few days, and the front of the thigh wasmarkedly cold in contrast with the buttock. The circulationin the foot was throughout satisfactory, quick return ofblood being noted after pressure upon the toe-nail on the:second day. The general bodily temperature rose to 994° onthe first two evenings, and afterwards remained uninter-

ruptedly normal. There was never any abdominal pain,tenderness or distension.On the seventh day pulsation was palpable in the anterior

tibial artery. The bowels were opened by an enema, the woundwas dressed for the first time, and the stitches removed,as it was found completely united. A week later the patientcomplained of some discomfort, and on examination it wasfound that the subcutaneous section of the wound had gapedin its central part, windowed strapping was applied, and inten days complete union again took place. On the twenty-fourth day an abdominal belt was fitted to support thecicatrix, and on the thirtieth day he was allowed to sit upin a wheel chair. The aneurysm remained hard and firm,with no trace of pulsation throughout, and graduallydiminished in size. On the forty-fourth day he was allowedto walk, and on the forty-seventh he left the hospital. The

aneurysm now occupied about two-thirds the area it did before

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treatment; it was hard and painless. The limb was warm,the tibial arteries both palpably pulsating, and except forslight numbness in the foot he felt well. Three weeks laterhe was still improving.

Re1narns by Mr. MAnrns.-The reason for selection of theintra-peritoneal method in this case was the high position ofthe aneurysm. Before operation the pulsation in the iliac.fossa was so forcible and extensive that it seemed probablethat it might prove necessary to ligature the common iliac,and it was thought that this would be more readily performedby the intra-peritoneal method. Beyond this the intra-peri-toneal method seemed to offer the great advantage of not inthe least interfering with the coverings of the sac, which bythe ordinary method might have been disturbed by the.stripping of the peritoneum. The experience gained by theoperation showed that the usual method might have beensafely adopted, but this could not be definitely determined’beforehand. An advantage was gained in ready access to the.deep epigastric artery, which, as directly feeding the sacitself, needed ligature, but of course might readily have beensecured by an extension of the ordinary wound. As to the com-parative difficulty of the two operations, I think there is little tochoose, and on the whole the incision for the extra-peritonealmethod is perhaps to be preferred in the matter of cicatrix ;in the vertical incision the advantage of suturing the fibrousstructures in the linea semilunaris is gained ; but, on theother hand, the resulting cicatrix passes directly throughfrom skin to peritoneum. In the oblique incision the decus.-sation of the various muscular layers leads to a certainintricacy and irregularity in the line of the cicatrix which mayrender it the stronger, since pressure is less readily brought tobear directly upon it. The choice of the iliac vessels obtaineds, I think, a real advantage, since the incision needs neitherextension nor modification ; but in saying this it should be’pointed out that this is a much stronger argument on theright than on the left side of the body. Ligature ofthe right common iliac artery by the intra-peritonealmethod is probably the easiest of all the operations on

the great arteries, since the vessel lies directly beneaththe peritoneum of the posterior abdominal wall uncoveredby any structures of importance. On the left side, on

the other hand, the inferior mesenteric vessels as theyenter the sigmoid mesocolon and pass down to the meso-rectum cover practically the whole of the artery, and to reachthe common iliac comfortably and safely the peritoneumwould need to be divided close to the left of the median lineof the sacrum and then displaced outwards. This manoeuvrehas the disadvantage of exposing the vein freely, but thiswould probably give far less trouble than the numerousmesenteric vessels would when swollen by reason of the lossof their peritoneal support. In the case recorded above thedistension of the spermatic vessels when set free by thedivision of the peritoneum was much greater than would havebeen expected.

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ANCOATS HOSPITAL, MANCHESTER.THREE CASES OF COMPOUND DEPRESSED FRACTURE OF THE

SKULL TREATED BY ELEVATION AND REIMPLANTATION

OF FRAGMENTS, AND WITHOUT THE USE OFTHE DRAINAGE-TUBE.1

(Under the care of Dr. P. TYTLER.)THE treatment of compound depressed fractures of the

skull has of late received considerable attention in our

columns,2 and we would only direct our readers to some ofthe more important points which bear out our former state-ments with regard to such cases. These are the reimplanta-tion of bone, whether removed with the trephine or brokenby the violence of the injury, and the closure of the woundwithout drainage. In these three cases the treatment wassimilar, the wounds were made thoroughly aseptic, per-chloride of mercury was the antiseptic used, and fragmentswere replaced. Under these circumstances it is interesting tonote that the only patient who had any necrosis of replacedfragments was the one aged thirty-eight, in whom the bonewas hardest and least vascular. The youth of the patients’and the healthy state of the bone have been the con-

ditions most evident in the cases where full success has beenattained, like Cases 1 and 3.

1 The cases were shown to the members of the Clinical Society,Manchester.

2 THE LANCET, vol. i. 1892, p. 1186. Ibid., vol. ii., p. 992.

CASE 1. -A boy aged six years was on May 5th, 1892,admitted with a compound depressed fracture on the rightside of the skull, immediately above the ear, caused by ablow from a swing-boat. The patient had suffered fromsymptoms of shock when first admitted, but these had dis-appeared when Dr. Tytler saw him about three hours afterthe accident. The wound was washed with antiseptic lotionand the scalp was shaved for three inches round, and thenthoroughly cleansed. After the patient was under chloro-form the wound in the scalp was found to be at the posteriorend of a marked depression of bone. The wound wasenlarged upwards by a vertical incision for about an inch ;this incision was then extended forwards and down-wards in a semilunar form to half an inch below thelevel of the fracture, passing in front of its anteriorend. The flap thus outlined was reflected, displayinga gutter-like depression about an inch and a half long,formed by two long narrow fragments of bone bent intowards each other, gradually sloping and deepeningtowards the posterior end, where the groove was abruptlyterminated by one large and several minute pieces turnednearly vertically inwards. The depression would be aboutthree-quarters of an inch deep at its posterior end, and rosegradually to the surface at its anterior extremity. The pieces ofbone were firmly wedged together, and left no opening for theelevator or sequestrum forceps. By means of a sharp chisel anotch was gently made in the sound bone at the upper aspect, soas to allow force to be brought against the upper fragment. Onintroducing the elevator it was easily dislodged, and the otherpieces were then carefully removed without much difficulty. (Allthe fragments were on removal immersed in warm perchloridelotion.) After removing the end-pieces a small hole wasfound in the dura mater at the posterior end of the opening,where the end-pieces had been turned in vertically. Therewas a flow of blood and cerebro-spinal fluid from the opening.(Mr. Williamson, the house surgeon, had reported the dis-charge of cerebral fluid. from the wound on the patient’sadmission.) After some small blood-clots were removedcerebral pulsation appeared. The whole field of operationwas then deluged with warm perchloride lotion andcleared of all clots and debris, after which there was no

bleeding which required attention. The largest fragmentof bone was then placed on the dura mater and twoor three small chips to fill up the vacant corners.

As much periosteum was spread over the pieces as

could be got. After removing the artery forceps, no vesselrequiring ligature, the scalp was replaced and secured withsilver sutures, applied chiefly at the points where the arteryforceps had been. No drainage-tube was employed, but thewound opposite the fracture was left unsutured for an inch,so that any effusion could easily make its way out. Iodo-form was then sprinkled thickly over the external wound,after that iodoform gauze and then a wood wool pad. Thesewere secured by a gauze bandage and several long strips ofstrongly adhesive plaster applied as a bandage over all. Thepatient was then put to bed and kept on low diet for a fort-night. Happily for the patient the wound has no furtherhistory except the removal of the dressing four weeks later,when sound healing was found all round ; the sutures werein situ, as harmless as earrings, without a trace of inflam-mation or ulceration. The patient was discharged well onJune 6tb.CASE 2.-A woman aged thirty-eight was admitted on

May 6th, 1892. She had sixteen wounds on the head, inflictedwith an axe, varying in severity from superficial abrasions togashes several inches long reaching down to the dura mater.The patient having rallied from the shock and hsemorrhage,the scalp was shaved and washed with 1 in 40 carboliclotion. Under chloroform the following compound fractureswere made out : (1) the front portion of the right parietalbone had been cut through with the axe down to the duramater; (2) another fracture of the same kind was foundin the posterior portion of the parietal ; (3) anotherof the same kind, but not quite through the bone, appearedin the upper part of the occipital bone ; (4) a fissure in theleft parietal running parallel to and about an inch from thesagittal suture. The scalp was thoroughly washed with per-chloride lotion. A flap was reflected from the middle line,passing through the two wounds anterior and posterior soas to completely expose the gashes in the parietal bone. Thefracture in the anterior part extended to the dura mater anda fissure passed upwards from it to the sagittal suture. Fear-ing that the inner plate might be splintered or inverted inspicules a portion of bone, after reflecting off the periosteum,