Extracted prom the 
TRANSACTIONS OF THE COLLEGE OF PHYSICIANS OF 
PHILADELPHIA. 
THIRD SERIES, VOLUME YI. REMARKABLE CASE 
OF 
SACCULATED OR OF CIRSOID ANEURISM OF THE 
SECOND INTEROSSEOUS BRANCH OF THE 
DEEP PALMAR ARCH TREATED 
BY EXCISION. 
WITH EXHIBITION OF THE SPECIMEN. 
By 
JOHN B. ROBERTS, M.D., 
LECTURER ON ANATOMY AND ON OPERATIVE SURGERY IN THE 
PHILADELPHIA SCHOOL OF ANATOMY. 
[Read May 3, 1882.] 
The specimen which I exhibit this evening and its 
accompanying history are interesting, I think, because 
of the extreme rarity of the condition. I know of no 
similar case reported; but I have not had an oppor- 
tunity to search for such in medical literature, because 
the operation was performed only a few hours ago. 
The specimen is fresh, and is exhibited now before 
the appearances have been changed by any preserva- 
tive fluid. 
Dr. Charles H. Thomas requested me a few days ago to 
assist him, at an early date, in operating upon a tumor of the 
hand in a boy aged sixteen years. From his earliest child- 
hood he had been under Dr. Thomas’s observation, and had 70 
ROBERTS, 
had a small elongated tumor upon the dorsal surface of the 
first phalanx of the left ring-finger, while in the 'palm, at the 
junction of the bases of the middle and ring-fingers, was a 
larger swelling. These were considered masses of dilated 
veins, as they had a spongy feel, and at times showed a 
bluish color. There was no very definite connecting band of 
swelling between the dorsal and palmar enlargements. 3STo 
special pain was experienced unless the parts were struck, 
and no marked growth occurred. Hence the child’s mother 
was advised to have nothing done. As the boy grew, the 
hand and tumor increased, hut held the same relative propor- 
tions. When the boy began work in a machine shop, the 
skin became thickened and soiled, and the bluish tint was 
no longer discernible. 
About two months or less ago, the growths seemed to en- 
large and to be accompanied by considerable pain, and Hr. 
Thomas advised the use of a compress in the palm and a 
bandage around the finger. This the boy wore at nights, 
and usually from Saturday to Monday morning when he 
returned to his work. Recently there was noticed pulsation 
in the palmar tumor and a lobulated feel; and Hr. Thomas 
feared that an arterial aneurism existed. 
When I examined the boy last evening, I found on the 
back of the third finger a hard fibrous-like tumor, as large 
as a watermelon seed, with the long diameter corresponding 
to the length of the phalanx. In the palm was an illy defined 
swelling covered with thick skin, very sensitive to pressure, 
and occupying about the area of a silver half-dollar. Ho 
swelling was evident connecting the two tumors. On the 
ulnar side of the palmar mass moderately distinct pulsation 
could be felt, which quickly stopped when the radial artery 
was compressed at the wrist, but merely decreased in force 
when the ulnar was pressed upon with the finger. Ho pul- 
sation was felt in the dorsal tumor. 
The boy had severe pain even when no pressure was made 
upon the growth in the palm. ANEURISM OF THE PALMAR ARCH. 
71 
I gave it as my opinion that the growth was an 
arterial angeioma connected with the second inter- 
osseous branch of the deep palmar arch, having anas- 
tomoses with the digital branches of the nlnar artery. 
Dr. Thomas considered it possibly this, but probably 
a sacculated aneurism. His diagnosis has proved to 
be the more correct. 
It was determined to employ the Esmarch elastic 
bandage, and to make a free incision over the tumor 
and dissect it out, whether it be angeioma or aneurism. 
As Dr. Thomas was disabled by a painful boil on his 
right hand, he requested me to operate. The boy was 
etherized and the elastic bandage applied. 
I made an incision from a point a little in front of the 
superficial palmar arch to the commissure of the fingers, and 
came upon a mass of fat and small vessels, in the centre of 
which was a bluish nodule, resembling larger vessels con- 
taining blood not driven out by the elastic bandage. Keep- 
ing close to the skin, and going down to the sheaths of the 
flexor tendons, I dissected the mass free. Lying alongside 
of the palmar interosseous muscle going to the ring-finger 
(2d interosseous) we saw a comparatively large vessel which 
seemed to be the main feeder of the mass. I then extended 
my incision, making a straight cut along the side of the ring- 
finger, dissected up the skin, and enucleated the hard nodule 
lying on the back of the first phalanx. This seemed con- 
nected with the other mass by some fibres or small vessels, 
and both were removed as one piece. The wound was then 
plugged with dry muslin to stop the general oozing that 
occurred after removal of the bandage, and a tight bandage 
applied. No ligatures were required, because my incisions 
were made at a distance from the tumor. 
Dissection of the palmar mass showed that I had re- 
moved a small body, about three-quarters of an inch in 72 
ROBERTS, 
diameter, containing clotted blood, and surrounded by 
adipose tissue and nerves. The tumor, when freed 
from other structures, as is seen on the table, consists 
of three lobules of rather unequal size, arranged some- 
what as a trefoil. The largest one of them, which 
has been punctured, allows the escape of soft clot; 
this sac is about one-half an inch in diameter. The 
three sacs seem to be separate, because the head of a 
pin introduced into one does not pass into the others. 
The two smaller sacs or lobules are hard, as if the 
clot was old. One has been laid open, and shows a 
white centre, or nucleus, of cartilaginous consistence, 
surrounded by a layer of red clot. On the surface of 
this three-lobed tumor runs a nerve, which probably 
was the seat of pain from pressure, and parallel to it a 
small artery. Both of these become lost in the mass, 
at the upper end of the tumor, which was thought to 
contain the main supply of the aneurism, and around 
which a string was tied and left for identification. 
The tumor from the back of the finger is hard, and 
on section shows an irregularly colored red surface. 
I believe the tumors, therefore, to be small sacculated 
aneurisms evidently allied to or identical with the 
variety called cirsoid aneurism. The one on the back 
of the finger and the two smaller lobules in the palm 
are undergoing cure by coagulation, induced in the 
dorsal one undoubtedly by the pressure from the 
bandage used at intervals during the last six weeks 
or two months. 
If the diagnosis had been more certain as to aneu- 
rism, I believe that digital compression of the radial 
and ulnar arteries, or the use of an Esmarch elastic ANEURISM OF THE PALMAR ARCH. 
73 
bandage to the forearm, would have been proper treat- 
ment before excision was attempted. 
The early period of life (about three years) at 
which the trouble was noticed primarily, renders it 
probable that the aneurisms were not originally trau- 
matic. 
The similarity to cirsoid aneurism is certainly very 
great, though there are some points which differ 
somewhat from the usual clinical history of these 
growths. 
Two weeks after the operation the wound was clos- 
ing satisfactorily by granulations. KEEN, ANEURISM OF THE PALMAR ARCH. 
75 
[After tlie reading of the preceding paper:—] 
Dr. W. W. Keen called attention to the danger of using coagu- 
lating agents in such cases, and spoke of a case of traumatic 
origin he had seen in consultation, in which a few drops of Mon- 
sell’s solution had been injected into the aneurismal sac, and gan- 
grene had followed, necessitating amputation of the hand. He 
thought compression of the radial and ulnar arteries would pro- 
bably have accomplished a cure, and the risks of an operation 
would have been avoided. With regard to the small tumor on 
the dorsal surface of the ring finger, he thought it unlikely to be 
an aneurism. Nothing short of a microscopical examination 
would determine its nature.