GUY'S HOSPITAL.
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499 manner :-First, the patient bore the compression for thirty- nine hours; secondly, for twenty-four; thirdly, for twenty- four ; and fourthly, for forty-eight hours; after which period no pulsation recurred in the sac. No fall in the temperature of the limb took place, and the patient left the hospital, con- trary to Mr. Stanley’s wishes, a few days after the cessation of the pulsation. He was seen a week afterwards, and said that he had been walking much, and felt but slight pain in each ham; but no pulsations had occurred, and the tumours were the size of filberts. Mr. Stanley was kind enough to inform us that he saw this patient a short time ago, being almost ten years after the successful treatment by compression, his state being in every respect highly satisfactory. Let us now turn to the case of brachial aneurism at the Westminster Hospital; but before relating it, we would beg our readers to glance at a case of a somewhat similar nature, which was treated by Mr. Hilton at Guy’s Hospital, (THE LANCET, vol. i. 1851, p. 453.) WESTMINSTER HOSPITAL. Aneurism of the Radial Artery on the Right Side; Compression of the Brachial Artery; subsequent Deligation of the latter vessel; Recovery. (Under the care of Mr. HOLT.) THE details of this case were obtained from the notes of Mr. Cockril, house-surgeon to the hospital :- John Taylor, a drayman, of dark complexion, and intem- perate habits, aged thirty years, was admitted September 28, 1853, with a pulsating tumour at the bend of the right elbow. He stated that about a month before admission, whilst lifting a heavy weight over his head, he felt a sudden pain at the inner side of the bend of the right arm, and had the sensation as if something had given way in the limb. He was obliged sud- denly to let go his hold, and the forearm became rapidly so benumbed and painful as low as the wrist, that he was com- pelled to give up his work. The patient applied some leeches at the affected spot, and went on without using any direct treatment for a whole week, when the pain having constantly increased, he sought the advice of a surgeon. At this period a pulsating tumour had formed at the bend of the elbow, and the forearm was considerably swollen. A compress was now applied to the brachial artery, midway between the head of the humerus and the elbow-joint, but it fitted so imperfectly that it was constantly coming off, and gave rise to so much suffering, that two days before admission he left off the apparatus. The tumour and forearm went on increasing during this period, and one month after the accident, the man presented himself at the Westminster Hospital in the following condition :- The forearm is much swollen from the elbow to the wrist, and a hard pulsating tumour is observed extending from the division of the brachial artery about three inches downwards. Both arteries at the wrist pulsate strongly and synchronously with the tumour, which latter yields a strong bruit to the ear. By compressing the brachial artery with the finger, the eircu- lation through the tumour was arrested. Lead wash to the tumour. October 1. -The swelling is now reduced. This day pressure was commenced in the following manner :-A well-padded splint having been applied to the back of the upper arm, two circular steel tourniquets were attached to the splint, with a thumb-screw on the inner side to compress the vessel, and these were alternately tightened at intervals of about one hour. Sixth day. -Complains much of the pain; has not slept for the last two nights; the tumour is less and harder, and the bruit not so distinctly heard when pressure is removed from the brachial artery. Mr. Holt now thought that one of Signorini’s tourniquets might be used with advantage, it having a larger head, and being more easily regulated. This remained on without any alteration for twenty-four hours. Seventh day. -Nine A. -11. : Much pain; cannot bear pressure at all. The apparatus was removed. Ninth day.-Pressure again applied at ten P.M. Has had the tourniquet on all day; cannot endure the pain; and wishes it removed that he may sleep. Tenth day.-States that about five minutes after the pressure was removed, last night, he felt as if the blood was rushing all over his arm; the fingers are very numb; the arm hot, though not discoloured; bruit and pulsation very distinct. The tumour measured fifteen inches round the arm, and is so sore that he cannot bear pressure. Lead lotion. Tenth day. -A consultation has been held to-day, when it was agreed that the best plan to save the arm would now be to tie the artery. Mr. Holt accordingly put a ligature upon the brachial, in the middle third of the arm; all pulsation immediately ceased in the tumour, and the bruit became no longer audible; the patient (who was not under the influence of chloroform) stood the operation well. The edges of the incision were brought together with adhesive plaster, and no sutures used. Eleventh day.-No pulsation in the aneurism or bruit, but a slight pulsation in the radial at the wrist. Twelfth day. -Going on well. Pulsation in the radial artery was very indistinct; none in the tumour, which has decreased in circumference, one inch and a quarter, in forty- eight hours. Fourteenth day.-Yesterday, the pulsation in the radial artery was very indistinct; to-day, none can be detected in it at all, but very plainly in the ulnar artery, which circum- stance was not observed before. Nineteenth day.-Both arteries at the wrist pulsate; tempe- rature of both hands alike. The size of the aneurism slowly decreases. Twenty-seventh day.-The ligature has come away; the wound is almost healed; the tumour much softer; the cir- culation through the forearm is as strong as on the corre- sponding side, and the patient expresses himself entirely free from pain. Nov. llth, (one month after the deligation of the artery).- Patient going on well; nearly convalescent; gets up for an hour or two. Tumour rather flaccid, with one resisting portion ; it measures exactly twelve inches, having decreased one inch in about one month. Speaking of aneurisms at the bend of the elbow, we should mention that M. Malgaigne brought a traumatic case of this kind, a short time ago, before the Academy of Medicine of Paris, wherein he was obliged to tie the vessel after attempting to coagulate the blood in the sac, by an injection of six drops of a solution of perchloride of iron. The patient has done well, and we are bound to say, that M. Malgaigne’s paper was principally intended to show, by facts and arguments, that no reliance could be placed, for the cure of aneurism, on injections of the above-mentioned solution, which had lately been supposed to possess most wonderful properties. The coagulating powers of a galvanic current has also been much extolled of late, but the examples of success are ex. tremely few, and the method does not seem to be gaining ground. We may, therefore, congratulate the Irish surgeons upon the value of their treatment, which, unlike the two pre- ceding modes, is daily taking a firmer footing among us. But we must, nevertheless, from time to time, call attention to such cases in which compression was attempted and found in- effectual. The following, under the care of Mr. Hilton, at Guy’s Hospital, presented very unusual difficulties, and com- pression was, in fact, the only remedial means that could be used. GUY’S HOSPITAL. Two Aneurisms of the Femoral Artery on the right side; Com- pression; Negative Results. (Under the care of Mr. HILTON.) John K-, aged fifty-eight years, and a ship caulker by trade, was admitted into Luke ward Oct. 4th, 1852. The patient is a dark, tall, robust man, who has always enjoyed good health, and never drank to excess. He does not consider that, whilst at work, he strained the right side more than the left. One year before admission, he noticed a swelling, about the size of a marble, on the inner part of the thigh, just where the femoral artery enters Hunter’s canal; the tumour gave him no pain at that time, but it pulsated from the very first hour he perceived it. The,patient went on with his occupa- tion as usual, the swelling gradually increasing; when, six months afterwards, a second pulsating tumour made its ap- pearance in the groin; it was at first very small, but presented on admission the same dimensions as the first. These tumours produced so little inconvenience, that the man called at the hospital merely to learn their nature. Appeararace on adiytission.-The tumour formed first is of the size of a hen’s gg; the second a very little smaller. They both feel elastic, distinctly pulsate, and yield a bruit de souffle when the stethoscope is applied. The tumour situated on the thigh is fusiform in shape, and lies about midway between the hip and the knee-joint; the other is perceived about two inches below Poupart’s ligament, its greater diameter being transverse. Neither tumour projects much from under the skin, and it required the application of the hand to establish the diagnosis.
Transcript of GUY'S HOSPITAL.
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manner :-First, the patient bore the compression for thirty-nine hours; secondly, for twenty-four; thirdly, for twenty-four ; and fourthly, for forty-eight hours; after which periodno pulsation recurred in the sac. No fall in the temperatureof the limb took place, and the patient left the hospital, con-trary to Mr. Stanley’s wishes, a few days after the cessation ofthe pulsation. He was seen a week afterwards, and said thathe had been walking much, and felt but slight pain in eachham; but no pulsations had occurred, and the tumours werethe size of filberts. Mr. Stanley was kind enough to informus that he saw this patient a short time ago, being almost tenyears after the successful treatment by compression, his statebeing in every respect highly satisfactory.Let us now turn to the case of brachial aneurism at the
Westminster Hospital; but before relating it, we would begour readers to glance at a case of a somewhat similar nature,which was treated by Mr. Hilton at Guy’s Hospital, (THELANCET, vol. i. 1851, p. 453.)
WESTMINSTER HOSPITAL.
Aneurism of the Radial Artery on the Right Side; Compressionof the Brachial Artery; subsequent Deligation of the lattervessel; Recovery.
(Under the care of Mr. HOLT.)THE details of this case were obtained from the notes of Mr.
Cockril, house-surgeon to the hospital :-John Taylor, a drayman, of dark complexion, and intem-
perate habits, aged thirty years, was admitted September 28,1853, with a pulsating tumour at the bend of the right elbow.He stated that about a month before admission, whilst liftinga heavy weight over his head, he felt a sudden pain at the innerside of the bend of the right arm, and had the sensation as ifsomething had given way in the limb. He was obliged sud-denly to let go his hold, and the forearm became rapidly sobenumbed and painful as low as the wrist, that he was com-pelled to give up his work. The patient applied some leechesat the affected spot, and went on without using anydirect treatment for a whole week, when the pain havingconstantly increased, he sought the advice of a surgeon. Atthis period a pulsating tumour had formed at the bend of theelbow, and the forearm was considerably swollen.A compress was now applied to the brachial artery, midway
between the head of the humerus and the elbow-joint, but itfitted so imperfectly that it was constantly coming off, and gaverise to so much suffering, that two days before admission he leftoff the apparatus. The tumour and forearm went on increasingduring this period, and one month after the accident, the manpresented himself at the Westminster Hospital in the followingcondition :-The forearm is much swollen from the elbow to the wrist,
and a hard pulsating tumour is observed extending from thedivision of the brachial artery about three inches downwards.Both arteries at the wrist pulsate strongly and synchronouslywith the tumour, which latter yields a strong bruit to the ear.By compressing the brachial artery with the finger, the eircu-lation through the tumour was arrested. Lead wash to thetumour.
October 1. -The swelling is now reduced. This day pressurewas commenced in the following manner :-A well-paddedsplint having been applied to the back of the upper arm, twocircular steel tourniquets were attached to the splint, with athumb-screw on the inner side to compress the vessel, and thesewere alternately tightened at intervals of about one hour.Sixth day. -Complains much of the pain; has not slept for
the last two nights; the tumour is less and harder, and thebruit not so distinctly heard when pressure is removed fromthe brachial artery. Mr. Holt now thought that one of
Signorini’s tourniquets might be used with advantage, it havinga larger head, and being more easily regulated. This remainedon without any alteration for twenty-four hours.Seventh day. -Nine A. -11. : Much pain; cannot bear pressure
at all. The apparatus was removed.Ninth day.-Pressure again applied at ten P.M. Has had
the tourniquet on all day; cannot endure the pain; andwishes it removed that he may sleep.Tenth day.-States that about five minutes after the pressure
was removed, last night, he felt as if the blood was rushingall over his arm; the fingers are very numb; the arm hot,though not discoloured; bruit and pulsation very distinct.The tumour measured fifteen inches round the arm, and is sosore that he cannot bear pressure. Lead lotion.
Tenth day. -A consultation has been held to-day, when itwas agreed that the best plan to save the arm would now be
to tie the artery. Mr. Holt accordingly put a ligature uponthe brachial, in the middle third of the arm; all pulsationimmediately ceased in the tumour, and the bruit became nolonger audible; the patient (who was not under the influenceof chloroform) stood the operation well. The edges of theincision were brought together with adhesive plaster, and nosutures used.Eleventh day.-No pulsation in the aneurism or bruit, but
a slight pulsation in the radial at the wrist.Twelfth day. -Going on well. Pulsation in the radial
artery was very indistinct; none in the tumour, which hasdecreased in circumference, one inch and a quarter, in forty-eight hours.Fourteenth day.-Yesterday, the pulsation in the radial
artery was very indistinct; to-day, none can be detected init at all, but very plainly in the ulnar artery, which circum-stance was not observed before.Nineteenth day.-Both arteries at the wrist pulsate; tempe-
rature of both hands alike. The size of the aneurism slowlydecreases.
Twenty-seventh day.-The ligature has come away; thewound is almost healed; the tumour much softer; the cir-culation through the forearm is as strong as on the corre-sponding side, and the patient expresses himself entirely freefrom pain.Nov. llth, (one month after the deligation of the artery).-
Patient going on well; nearly convalescent; gets up for anhour or two. Tumour rather flaccid, with one resistingportion ; it measures exactly twelve inches, having decreasedone inch in about one month.
Speaking of aneurisms at the bend of the elbow, we shouldmention that M. Malgaigne brought a traumatic case of thiskind, a short time ago, before the Academy of Medicine ofParis, wherein he was obliged to tie the vessel after attemptingto coagulate the blood in the sac, by an injection of six dropsof a solution of perchloride of iron. The patient has donewell, and we are bound to say, that M. Malgaigne’s paperwas principally intended to show, by facts and arguments,that no reliance could be placed, for the cure of aneurism, oninjections of the above-mentioned solution, which had latelybeen supposed to possess most wonderful properties.The coagulating powers of a galvanic current has also been
much extolled of late, but the examples of success are ex.tremely few, and the method does not seem to be gainingground. We may, therefore, congratulate the Irish surgeonsupon the value of their treatment, which, unlike the two pre-ceding modes, is daily taking a firmer footing among us. Butwe must, nevertheless, from time to time, call attention tosuch cases in which compression was attempted and found in-effectual. The following, under the care of Mr. Hilton, atGuy’s Hospital, presented very unusual difficulties, and com-pression was, in fact, the only remedial means that could beused.
____
GUY’S HOSPITAL.Two Aneurisms of the Femoral Artery on the right side; Com-
pression; Negative Results.(Under the care of Mr. HILTON.)
John K-, aged fifty-eight years, and a ship caulker bytrade, was admitted into Luke ward Oct. 4th, 1852. The
patient is a dark, tall, robust man, who has always enjoyedgood health, and never drank to excess. He does not considerthat, whilst at work, he strained the right side more than theleft. One year before admission, he noticed a swelling, aboutthe size of a marble, on the inner part of the thigh, just wherethe femoral artery enters Hunter’s canal; the tumour gavehim no pain at that time, but it pulsated from the very firsthour he perceived it. The,patient went on with his occupa-tion as usual, the swelling gradually increasing; when, sixmonths afterwards, a second pulsating tumour made its ap-pearance in the groin; it was at first very small, but presentedon admission the same dimensions as the first. These tumours
produced so little inconvenience, that the man called at thehospital merely to learn their nature.
Appeararace on adiytission.-The tumour formed first is ofthe size of a hen’s gg; the second a very little smaller. Theyboth feel elastic, distinctly pulsate, and yield a bruit de soufflewhen the stethoscope is applied. The tumour situated on thethigh is fusiform in shape, and lies about midway between thehip and the knee-joint; the other is perceived about twoinches below Poupart’s ligament, its greater diameter beingtransverse. Neither tumour projects much from under theskin, and it required the application of the hand to establishthe diagnosis.
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From October 4th to the 1st of January, a bag of ice wasapplied to the upper tumour; this rendered the swellingharder, but enlarged the lower one. At this period, a compressinginstrument was applied a little above the lower tumour. Itconsists of a broad, well-padded belt, encircling the posteriorportion of the pelvis from one hip to the other. An ordinaryclamp is fixed to this resisting belt, and rises on the outer sideof the limb, at right angles with it, and then forms anotherright angle with a horizontal rod, to which are fixed twoplates firmly attached with a wire. The compressing screwpasses through the latter, and is held by a cup-and-ball joint,which is regulated by another screw at the side. The formeracts from above downwards; the clamp forms a vertical linerising from the bed, and by means of the two plates thedirection of the screws may be altered.The compression was begun on Jan. 1st, 1853, and continued
night and day for a week, the patient now and then givinghimself a little ease. At the expiration of this period, thetumour was certainly diminished in size, and felt somewhatharder; the compression was therefore continued, but thepatient soon began to complain of severe pain; the effects ofthe treatment were at the same time so slight as regarded thesize and consistence of the tumour, that it was thoughtadvisable not to subject the patient any longer to constraintand pain, especially as he was suffering from attacks of goutand from very obstinate bronchitis. He was therefore dis-charged, toward the end of January, with the hope that thetumours would remain in stcctzc quo.We saw this patient in the hospital a few weeks afterwards,
on the occasion of his paying a visit to his friends in the ward.He walked with great ease, and seemed in very good health;but we have since been informed that he died, after con-siderable pain and oedema of the limb.
We cannot leave the subject which we have treated in thisand the preceding " Mirror" without expressing a wish thatthe method illustrated by the cases which we have broughtforward may continue to be employed, with all the care andattention to details which it deserves, as surgeons possess, bythis mode of treatment, means of combating a very seriousdisease, without endangering the patient’s life. We ventureto conclude, from the cases which have come under our
cognizance, that one of the main points is the nice adaptationof the instruments, which should allow of being accuratelyfitted to the part. Next in importance come the advisabilityof using two screws, to be alternately tightened, the prepara-tion of the parts to be compressed, the arrangement of the bed,gentle depleting and sedative medicines addressed to the systemat large, and, finally, anxious and careful watching of thepatient, with very strict supervision if the slightest neglect orinattention be remarked.
ON
GALVANISM AS AN OBSTETRIC AGENT.
BY THOS. RADFORD, M.D., F.R.C.P. Ed., F.R.C.S. Eng.CONSULTING PHYSICIAN TO THE MANCHESTER AND SALFORD LYING-IN
HOSPITAL, ETC. ETC.
HAVING been the first to recommend. and practically to em-ploy galvanism as an obstetric agent in this country, and havingbeen the first who ever adapted its use to arrest uterinehaemorrhage, I confess I was highly gratified to read the veryexcellent remarks of Dr. Robert Barnes in the number of THELANCET for November 5th and 12th, which so fully agree withthe observations I had formerly made.I was first led to its use during and after parturition by thesuccessful treatment of a case of atony of the urinary bladder,which occurred after a difficult labour. - Vide ProvincialMedical and AS’urJicccl Journal, 1844, vol. viii., p. 604.
Those who are unacquainted with my opinions on this sub-ject might conclude from Dr. Barnes’s statement, (THE LANCET,p. 457, )-which I am sure he does not mean to be understood,- that I have only employed galvanism in cases of " post-partum haemorrhages." This, however, is not so. In my firstcase it was employed, during the first, second, and third stagesof the labour. I will now briefly state the kind of cases inwhich it has been successfully employed by me.
lst.-In cases of tedious labour arising from uterine inertia.2nd.-In cases of accidental haemorrhage, either before or
after the rupture of the membranes, and especially when ex-haustion from loss of blood exists.
3rd.-In- cases of " placenta prsvia,’’ in which the practice
of detaching the placenta is adopted, and the vital powers aregreatly depressed.4th.-In cases of internal flooding before or during labour.5th.-In cases of post-partum noodings.6th.-In cases of hour-glass or irregular contraction of the
uterus.7th.-To originate, de noro, uterine action, or in cases ia
which it is desired to induce premature labour.8th. -In cases of abortion, when the indications show the
necessity, or justify the expulsion of the ovum.9th.-In cases of asphyxia in infants.Galvanism is especially advantageous as a general stimulant
in all those cases in which the vital powers are extremelydepressed from loss of blood. Its beneficial effects are to beobserved in the change of the countenance, restoring an ani.mated expression; in its influence on the heart and arteries;in changing the character of respiration; and its warming in-fluence on the general surface. I have several times observed,in cases in which other powerful stimulants have failed to pro-duce any beneficial effects, the most decided advantage accrueafter its application.
I have never observed that the child, in utero, has been in-jured by its use, which gives it a great advantage over theadministration of secale cornutum, which, in many cases, isdestructive of it. " This drug is liable to great deterioration;its operation is not always certain, its failure depending some-times, perhaps, on its inert qualities, but frequently on a con-stitutional idiosyncrasy which resists its powers. There are
organic states which forbid its use : when the os uteri isundilated or undilatable, the child being still alive, it oughtnot to be administered. If in such a case it induces powerfultonic contraction of the uterus, it destroys the child. Wecannot control or confine its action, and therefore it is totallyunsuitable to cases in which we only want a limited effect.Again, if exhaustion is an element in the case, it is wholly in-applicable, as we ought not to adopt any means which tendfurther to depress the vital powers. The powerful and sanitaryinfluence of galvanism was most decidedly obtained in the pre-ceding case," (referring to a case to which these remarks wereappended,) ’’ and the great advantage of this agent is, that itseffects may be carried to any degree, from first only excitingthe uterus so to contract that its diameters are lessened,and that its tissue comes to be applied to the body of the child.These, however, may be at pleasure increased, so as to accom-plish the expulsion of the child and placenta. The gradualchanges produced upon the uterine tissue were admirably seenin the foregoing case, and also its great power developed by itscontinued application-to arrest the discharge, expel the childand the placenta, and leave the organ safe from the occurrenceof post-partum flooding. "-Extracted from a case detailed ir.the proceedings of the local branch of the Provincial Medical andSurgical Association, 1847.
In the above-named case I used the poles externally, andhave before this, and ever since adopted this mode of applica-tion.
CASES ILLUSTRATING THE EFFECTS ANDMANNER OF ACTION OF PARTICULARREMEDIES.
BY W. R. BASHAM, M.D.,PHYSICIAN TO THE WESTMINSTER HOSPITAL.
IODIDE OF POTASSIUM IN SOME FORMS OF CHRONIC PERIOSTEALRHEUMATISM.
(Concluded from p. 479.)THE third case is a very expressive example of the effects of
mercury in predisposing certain constitutions to a form ofrheumatism and periosteal subacute inflammation, identical incharacter with the syphilitic variety, and which the experienceof this and many similar cases has impressed me with the beliefthat they are specially amenable to the agency of the iodide ofpotassium.
.
William C-, aged forty-nine, a footman, was admittedOct. 3, 1849, suffering from severe rheumatic pains in all hislimbs, of near eight months’ duration, increasing slowly in in-tensity to the present time. The general aspect of the patientis unhealthy; there is no emaciation. The functions of ex-cretion appear pretty regular; tongue not unnatural; pulsemoderate in force and frequency; there is anorexia; no thirst;considerable bodily debility and exhaustion; the heart soundsnatural, somewhat feeble; no pulmonary disorder; the surfaceof the skin is everywhere natural; but on both tibia there are
