after which there was no recurrence of the pulsation; but secondary hæmorrhage occurring on the twelfth day, it was again necessary to secure the vessel.

Others repeated the operation on the human subject, with various modifications, but it was abandoned, as it seemed to be impossible to fix a determinate period when the ligature could be withdawn, with the assurance that obliteration of the artery would ensue.

Scarpa was the great advocate of this practice, with this improvement on those who preceded him. They divided the inner and middle coats, deeming this essential to the success of the operation. He endeavored to avoid this, merely bringing the walls in coaptation, by the interposition of a small cylinder of lint, spread with ointment, between the knot of the ligature and the artery. This, however, denuded the artery to a considerable extent, and was open to the serious objection of introducing, and allowing to remain in the wound, a considerable mass of foreign material.

A variety of metallic compressors have been contrived in times past, and applied to the exposed artery for the purpose of rendering it impervious. Among them may be named the serrenœud of Dubois, Assalini's compressor; the presse-artere of Deschamp, an instrument contrived by Mr. Crampton, and the pincers of Baron Percy. With these instruments they succeeded in producing obliteration of the artery without rupture of any of its coats. Notwithstanding the fact that entire success followed their use, by men greatly distinguished in surgery, the profession generally refused to accept their views, and clung to the old method by the single ligature.

The chief objection to most of these contrivances seems to be the necessity for great stripping and exposure of the artery in the operation.

The fact that temporary metallic pressure, by means of the needle and wire, does, with less exposure of the artery than by the ordinary ligature, obliterate its calibre, is now so well

established by the experience in acupressure, that the interest of surgeons in this subject is rekindled."

Within the past few months I have applied acupressure with entire success to the femoral artery for popliteal aneurism by a method which I shall describe. The case is one of such interest, apart from acupressure of the artery, that I hope to be pardoned for narrating it in extenso.

CASE 20TH. Temporary Ligature of Femoral Artery for Popliteal Aneurism.-Leopold Kah, Germany, aged twenty-nine, was admitted to New York Hospital October 20, 1868. A few weeks ago patient first noticed a swelling in popliteal region which was painful, and soon rendered him incapable of work. He was seen by three physicians, each of whom seem to have mistaken the nature of the tumor, as they opened it with the knife by small incisions three times in as many days. The openings made by the first two physicians were followed by a sharp spirt of blood, which seemed to surprise them, as they each stitched up the wound and left him to the tender mercies of a third, who, making a bolder dash than his predecessors, was appalled by the gush of about two quarts of blood; he hurriedly bandaged up the limb and abandoned his patient, who was then brought to the hospital. On admission he was almost pulseless and excessively prostrated from loss of blood. The lips of the wound made into the aneurismal sac were sloughy.

October 21, 1868.-I secured the common femoral artery by the following method, at the suggestion of Dr. Buck: The artery was exposed in Scarpa's triangle by the usual incisions. The sheath of the vessel was opened barely sufficient to allow a small aneurism needle, armed with a piece of strong, smooth, moderate sized hempen twine, to be passed round the artery; the ends of the ligature were threaded through a small silver double canula, about two inches in length, and the canula passed on through the wound down upon the artery. The ligature was then drawn tight enough to stop the circulation, but not with sufficient force to lacerate the coats of the vessel, and the ends

tied over the external extremity of the canula. The canula was then secured in a position at a right angle to the artery, against a roller-bandage placed on the thigh, and the roller in its turn was kept in place by adhesive straps. Wound was closed by silken sutures. Union by primary adhesion took place throughout the wound, except in the track of the instrument.

The ligature was removed with great ease forty-seven hours after the operation, and no blood followed it. The edge of the skin-flaps subsequently took on ulceration, but the union of the deeper parts was not disturbed. No pulsation could be detected below the point of acupressure, and the tumor was much diminished in size.

The threatened sloughing of the sac progressed until finally a cavity was left in the popliteal space in which a large fist could be buried. Owing to the great loss of blood which had occurred previous to his admission to the hospital, gangrene of the foot and leg supervened, necessitating amputation at the knee-joint, which was done November 13, 1868, by irregular flaps as sound skin could be found.

The patient eventually recovered, and was discharged, fat and hearty February 8, 1869, with a good stump.

On

CASE 21ST. Dr. Buck Applied a Temporary Ligature to the Femoral Artery, for Popliteal Aneurism, at St. Luke's Hospital September 23, 1868.-Patient a young man, aged twenty-four. Femoral artery was exposed in the usual manner, and a silver wire (No 26) placed under the artery; the ends were then crossed over it and secured by three half turns or twists. the third day the wire was removed, but it was found necessary to re-open the wound, in order to untwist the wire without endangering the artery. No hæmorrhage, except from the disturbed adhesions, followed the wire, and after a reasonable time the patient was discharged cured.

Dr. Buck also applied acupressure by this same method, with the twisted silver wire to the subclavian.

CASE 22D. Artery; for Axillary Aneurism.-This operation

was done at St. Luke's Hospital, but it was found impossible to remove the wire by untwisting without endangering the artery. It was therefore allowed to remain until it had cut through the vessel. Patient discharged cured.

CASE 23D.-Dr. Markoe used acupressure by this same method, at New York Hospital, September 29, 1868, on a man aged thirty-five, who was admitted with popliteal aneurism. He passed a fine iron wire around the femoral in Scarpa's triangle, and secured it by three twists; wire removed seventy-two hours after operation. In this case also it was found necessary to reopen the wound in order to untwist the wire. Gangrene of foot afterward set in, and the patient sank into a typhoid condition and died November 13, 1868. "The artery at the point of ligature was found slightly thickened, reddened, and its calibre but little diminished. The vessel was pervious, but a long thin clot, three inches in length, was found in it, extending on either side of the point of pressure."

The difficulties attending the removal of the wire, in the cases of Drs. Buck and Markoe, led me to prefer the textile ligature and the canula to the twisted wire, which is in itself without doubt more purely acupressure. If I were to use the same instrument again I should substituie a small lead wire for the hempen twine. The objection to iron or silver wire is, that in removing it on so short a turn round the artery I should fear injury to its coats.

Dr. Hutchison's modification, which I have described already, would, I think, answer admirably for application in the continuity of arteries.

In the application of acupressure to the continuity of a vessel for aneurism, it seems to me that the amount of pressure used should be sufficient to cut off the circulation at once, so that the consolidation shall be rapid, enabling us to remove the needle after the shortest time has elapsed consistent with safety; for, if the pressure be too long continued the artery will be cut through as by the ligature.

We have here twenty-three cases, never before reported, in which acupressure has been used-five times to the femoral artery after amputation of the thigh; three times to the femoral as a temporary ligature in the treatment of popliteal aneurism; once to the axillary artery after amputation at the shoulder-joint, and to many less important vessels.

In only one case was the use of the needle followed by secondary hæmorrhage, and in that case this accident was evidently due to its careless application.

As most of the above cases occurred in hospital practice, where primary union has been the rare exception when the ligature has been used, I think it may be fairly claimed for acupressure, that it greatly increases the chances for that most desirable result.

Before considering the special advantages of acupressure as a hæmostatic agent, it is desirable that we should determine the