THE BRITISH MEDICAL ASSOCIATION 189 



which afterwards healed hke an ordinary narrow ulcer. There was a remarkable 

 contrast in one particular in the treatment of this case compared with ordinary 

 cases. Instead of leaving the patient to lie with his limb constantly in one 

 position on a pillow until the time should have elapsed for the ligature to separate 

 by suppuration — there being no separation to take place, and as I believed, 

 no source of irritation present — I from the first began free movement of the 

 limb, and at a very early period got the knee extended, to the very great 

 advantage of the patient. I remember a precisely similar case in which I tied 

 the vessel with silk in the ordinary way some years ago, where the patient was not 

 able to straighten the knee for weeks after leaving the hospital ; and in fact 

 I do not know that he is able to do so now. 



The other case was much more remarkable. The patient, also aged forty- 

 seven, but looking more like sixty-seven, presented himself at the hospital last 

 summer with a diffuse popliteal aneurysm which had run an acute course, but 

 already extended some way up the thigh. I urged him to come at once into 

 the hospital. He said he had important business to attend to, and could not 

 do so. He came back a fortnight later with the aneurysm grown to enormous 

 dimensions laterally, and extending up to the junction of the middle and upper 

 thirds of the thigh. At the same time, partly from haemorrhage into its own 

 body, and partly from being worn out with the pain he endured, he was reduced 

 to an extreme degree, so that one of the surgeons of our hospital remarked, 

 * He is a dying man, at any rate.' In his case, also, the knee was flexed ; there was 

 much numbness and oedema in the foot, and no pulsation in either tibial artery. 

 Under such circumstances, what was to be done ? To open into this enormous 

 mass by the old operation would be most unpromising. To amputate would, 

 I felt sure, be to kill the man outright. The only alternative was to tie the 

 artery. Considering the extent to which the huge mass had already interfered 

 with the circulation, it seemed extremely probable that such a procedure would 

 be followed by gangrene. Still it seemed to afford the only chance. Then the 

 next question was, Where should it be tied ? The lower down, the further 

 from the heart, the better, if it could be safely done. But was there any choice ? 

 Was not the external iliac the only practicable site ? The only part remaining 

 in the thigh was what I believe is rightly regarded as a forbidden region, from 

 the vicinity of the profunda or other considerable branches. Yet having ascer- 

 tained, by experiment, that an antiseptic catgut ligature does not weaken the 

 artery at all, and does not make secondary haemorrhage likely to occur under 

 such circumstances, I felt justified in putting on the ligature in this forbidden 

 region. It is an extremely striking fact, if we think of it. that after a large 

 arterial trunk has been tied, we never have haemorrhae^e on the second or third 



