No. 1603.

MAY 20, 1854.

A Mirror.OF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

Nulla est alia pro certo noscendi via, nisi quam plurimas et morborumet dissectionum historias, tam aliorum proprias, collectas habere et interse comparare.—MORGAGNI. De Sed. et Caus. Morb. lib. 14. Proœmium.

ST. THOMAS’S HOSPITAL.

Femoral and Popliteal Aneurism on the Right Side, withDilatation of the left Femoral Artery; Deligation of theExternal Iliac; Recovery.

(Under the care of Mr. SOLLY.)WE related last week a case of popliteal aneurism in which

the prompt deligation of the femoral artery, without anyattempt at pressure, was followed by the most satisfactoryresults. Without leaving St. Thomas’s, we find another caseof the same affection, which exemplifies the advantages whichsometimes attend this line of practice, though it is plain thatno course but securing the external iliac artery can be thoughtof when the femoral is affected near the groin. Especialattention should be directed to the progress of the case, ofwhich we give a minute account, as it will show that patientsmay recover from a very precarious and almost desperate con-dition. We are indebted to Mr. Webster, house-surgeon tothe hospital, for the details.William G-, stonemason, aged thirty years, was admitted

into Abraham’s ward February 1, 1854. His family are

healthy; the patient himself has been subject to severe strainingin his employment, but he has never been ill, and his habitsare temperate.

History.—Three months before admission, he noticed onenight whilst getting into bed that there was a pulsating tumourof some size in his right groin, and at the same time felt abeating sensation in the popliteal space on the same side. Forthe space of a month the swelling in the groin made someslight advance in size, but for the last two months there hasbeen no increase. The patient suffered no pain during thisperiod, and has continued at his work without any otherinconvenience than a sensation of stiffness about the limb.Finding, however, the pulsation continuing, he applied to amedical man, who recommended him to come to the hospital.

State on admission.—Just below Poupart’s ligament of theright side, there is a prominent swelling, evidently an

aneurism, and apparently of the diffuse kind. It measuresthree inches and a half in length, by two inches and a half inbreadth, and pulsates synchronously with the ventricular con-traction. A bruit de soufflet can be heard at the lower partof the tumour, but it is less distinct over the central and upperportions. In the popliteal space of the same limb is an

aneurism somewhat smaller than the above; it pulsates forcibly,and has a rather harder character than the other; the bellowsmurmur is audible here also, but very faintly. Pressure onthe external iliac artery completely arrests the pulsation inboth tumours; the anterior and posterior tibial arteries pulsatesforcibly; th9 internal saphena vein is enlarged and turgid, andhas several varicose dilatations in the lower third of the thigh.The femoral artery of the opposite limb appears somewhat.dilated in the upper and more superficial part of its course; somelymphatic glands surrounding the artery are hardened andenlarged; and beneath the integument, just over the artery,a calcareous deposit has taken place, forming a thin plateabout half an inch in diameter. Heart’s action regular—sound.normal; pulse 72, full; tongue clean. Ordered a brisk pur-gative.Second day.-The aperients acted well yesterday; bowels

not opened to-day. Repeat the purgative.It was evident that no means of relief could in such a case

be thought of but the deligation of the external iliac artery;Mr. Solly therefore resolved not to lose any time, and pro-ceeded forthwith to perform the operation. On the 4th ofFebruary, third day after admission, the vessel was tied in theusual manner, whilst the patient was under the influence ofchloroform. During the steps of the operation a ligature hadto be put on the superficial epigastric artery. Both aneurismsat once ceased to pulsate, the popliteal becoming quite flaccid,

the femoral less so. The edges of the wound were brought to-gether by three sutures, and a pledget of lint, secured by stripsof plaster, was applied. The man was then removed to bed.-Three P.M.: Feels comfortable, but hungry; slight oozing fromthe wound ; pulse 96, full and soft,-Five P.M.: Slight vomitingwith eructations. Allowed some beef-tea. -Eight P. Thirsty;no discharge; pulse 100, full, but quite compressible; somepain in the right knee and foot, both of which are cold.Ordered, bottles of hot water.-Ten P.M.: Asleep; talkingabout the operation; face flushed; skin hot and moist; pulse100, firmer. Mr. Solly visited the patient, and ordered twograins of calomel and one of opium to be taken if necessary.Venesection was also to be performed if required.

First day after the operation.-Eight A.M.: Going on well;has slept; pulse 96, soft and full; no abdominal tenderness;tongue slightly furred; thirsty. Ordered barley-water.-TenP.M.: As before; bowels not yet relieved. Ordered, calomeland rhubarb immediately, and infusion of senna four hours after-wards.

Second day. -Eight A. M. : Slight uneasiness about the wound;pulse 106, full, firmer than yesterday; tongue furred; bowelsnot yet relieved. The femoral aneurism has much diminishedin size, and feels hard and firm, but the pulsation has Returnedto a trifling extent. Ordered, twelve leeches to the right groin,and five grains of calomel every fourth hour. The strappingwas cut off about two inches from the wound, and the leechesapplied.-One P.M.: Tenderness still continues. Mr. Sollyordered the strapping to be removed, and twenty leeches tobe applied; the wound looks well; the edges are in closecontact, though a thin, sero-purulent discharge oozes out;pulse 100, full, by no means hard.-Four P.M.: The leecheshave bled freely; the abdomen has been well fomented, andis now covered with a light poultice, which extends over thewound; there is less tenderness; still thirsty; sleeps at in-tervals ; pulse as before; bowels unrelieved at present.Effervescent draughts every four hours.-Ten P.M.: Bowelsopen once freely; the abdominal tenderness much lessened,and confined entirely to the vicinity of the wound; has someuneasiness when he coughs; the tumours are both diminishedin size, and become more solid; very slight pulsation in theupper one; pulse 88, full; tongue slightly furred. Ordered,two grains of calomel and half a grain of opium to be repeatedevery third hour.

Third day.-Eight A.M.: Has slept well, and is much re-freshed. The upper two-thirds of the wound have united bythe first intention, except at the point where the ligatureescapes. The lower third has not united, and a thin serousfluid escapes. Pulse 90, soft; skin moist; tongue cleaner;thirst diminished; appetite good. Omit the calomel. Infusionof senna immediately. -Two P.M.: Some local tendernessremains, but is going on well. Pulse 86, full and soft.

Fourth day. -Nine A.M.: Slept well at intervals. Pulse 86,less full and soft; tongue clean; bowels not yet opened;tenderness all but gone. -Two P. M. : The sutures were removed.A copious flow of sanious fluid escapes from the lowerrpart ofthe wound, which has been supported by strapping; bowelsconfined. Ordered the senna mixture as before.-Ten P.M.:Bowels have acted; motion dark, relaxed, and fœtid; feelsquite comfortable, and inclined to sleep; pulse 80, soft,moderately full; tongue white, moist; considerable oozing hasoccurred from the wound.

Fifth day.-Going on well; very cheerful, but feels weak;pulse 78; tongue cleaner; bowels relaxed three times to-day;wound looking well; less discharge.

Sixth day.-Nine A.M.: Some blood trickling from thewound; it escaped through the part which has not yet united—viz., along the ligature, and from a small opening at thelower part of the wound. The blood appears of a venous cha-racter. Mr. Solly ordered ice to be applied, the patient to beconstantly watched, and in case of a gush of arterial bloodpressure to be applied through the wound-dilating it, if needbe. The patient feels better; pulse 72, soft; tongue clean;bowels open.-Three P.M.: Still some oozing of blood. Theice has been discontinued, and he has taken three doses ofgallic acid, each ten grains, at intervals of three hours.-Six P.M.: As before; complains of right foot being cold.Ordered warm flannels and hot-water bottles.-Ten P.M.: Asbefore; still slight hxmorrhage ; feels comfortable.

Seventh day.-Nine A.M.: Haemorrhage still continuesslight; pulse 70, very soft; tongue clean. There is pulsationil2, both aneurisms, also in the femoral artery, but -tery feeble.-Two P. M.: The flow has been less during the last two hours,and is very slight now; it is also more of a purulent character;the integuments around the opening, for some extent, feel

534

boggy. Ordered meat; continue gallic acid.—Six P.M.:

Troubled with flatus, otherwise improving; tongue clean;pulse 70, soft.-Ten P.M.: Scarcely any discharge for the lasttwo hours; sleeping soundly.

Eighth day.-The discharge, which is trifling, is nowassuming the character of ordinary pus; bowels not relievedfor two days; pulse steady and soft; appetite good. To havea mutton chop every day; enema.From the eighth to the fifteenth day all the symptoms were

favourable, but a change took place on the eighteenth day,when the patient was found feverish and very thirsty; hevomited and complained of nausea. Ordered effervescent

draughts every four hours.-Eight P.M.: About two or threeounces of blood escaped from the site of the ligature; it flowedslowly, and not in a jet. Mr. Solly was sent for, but thehaemorrhage ceased before he arrived. He ordered the man tobe carefully watched. Pulse 110, soft. Ordered, extract ofaconite, one grain and a half, every sixth hour.

Nineteenth day.-About two drachms of blood were lostthis morning, but the flow was arrested by gentle pressure.-Eleven : There is still some oozing from beneath the bladder ofice which has been applied at intervals to the wound. Stillcomplains greatly of thirst. Omit the aconite. Effervescentdraughts, with spirit of mint, every four hours; calvesfootjelly; ice to drink; white wine, with soda water; strong beef-tea.-Fifty minutes past six r.M..About two drachms of bloodescaped from the lower wound, but was soon arrested; no pul-sation can be felt in the aneurism; the femoral is somewhat en-larged and tender; the whole limb seems somewhat oedematous,and he complains of heat and pain in the heel.Twentieth day.-Blood still oozing from the wound, mixed

with purulent matter; thirst still troublesome; bowels con-fined. Ordered, rhubarb and calomel.

Twenty-first day.-Bowels relieved yesterday; feels better;the wounds have become nearly closed with coagula; the in-teguments around the wound are more puffy, and pressure. gives some pain there; still thirsty; pulse 104; tongue white.

Twenty-second day.-Ligature not yet come away; oozingof sanguineo-purulent fluid continues; the integuments of thegroin are dusky-red, which colour extends inwards to thepubes; there is considerable tumefaction; but less tendernesson pressure around the wound and over the aneurism; bowelsconfined; thirsty and hot; pulse 110, soft, full. To take asmall dose of calomel and rhubarb.Twenty-third day.-Bowels still confined; some evidence of

fluctuation in the groin; thirst continues. Repeat the powder;small doses of dilute sulphuric acid.

Twenty-fourth day.-Somewhat improving; thirst diminish-ing; appetite improving; takes a chop every day; there is aslight discharge of purulent fluid going on from the side of theligature, which is more extended from the wound; the

neighbourhood of the latter has a boggy feel; in the grointhe fluctuation is most distinct and superficial; the fingerimpinges on the sac, which has a firm feel through the pus;the whole limb is swollen.-Same day, two P.M.: Mr. Sollyvisited the patient with Mr. Le Gros Clark. As he is sufferingfrom hectic, and the presence of pus is quite evident, Mr.Solly made a puncture with a bistoury into the sac, whereuponsome pus and blood escaped. The integuments were dividedon a director for about an inch, but the sac was not opened toAny extent. A little arterial haemorrhage occurred now andlater in the day, but on both occasions was arrested bypressure.

Twenty-fifth day.-Mr. Solly, finding the ligature still fur-ther extended, made steady traction on it, when it came away,followed by a considerable discharge of foetid, decomposedblood and pus. A poultice was afterwards applied throughthe day, during which about five ounces of pus escaped. Theincision over the sac discharges healthy purulent matter. Thegeneral health is improving. Mr. Solly now prescribed qui-nine, and allowed the patient six ounces of port wine and twoeggs daily.

Twenty-sixth day.-Hectic symptoms declining; tonguemoist; pulse less frequent and firmer; there is a free dischargeof grumous matter from the wounds.

Twenty-eighth day.-Improving; slight vesication of theheel where it has been resting; discharge very profuse, morehealthy.

Thirtieth day.-Much improved; pulse 98, soft; bowelsconfined; discharge considerable, especially upon makingpressure over the lumbar and iliac regions. Ordered to have ea compress applied to the last-named parts; rhubarb andcalomel; slice of meat; three eggs; air-cushion for the back.

Thirty-fifth day.-Progressing favourably; pulse 88, steady;

discharge diminished. An incision was made over the aneurism,as the pus was rather confined there. The blister on the heelis well. A small slough has formed over the sacrum. Theback to be dressed with zinc ointment; porter, one pint. Thepatient was desired to sit up a little.

Thirty-eighth day.-Sat up yesterday; found himself veryweak; health much improved; appetite voracious; dischargemuch less and thinner; the wound in the groin commencingto granulate. The aneurism in the femoral artery is firm,and greatly diminished in size. The vessel itself feels as

a thick, firm cord, without any trace of pulsation. The pop-liteal aneurism cannot be defined, but there seems to be athickening, as it were. of the tissues of the ham. The anteriorand posterior tibial arteries pulsate feebly. The limb is of thesame temperature as that of the opposite side, but it is stillcedematous.

Forty-fifth day.-Sits up daily. The wound has ceased to

discharge, and is granulating kindly. The sore on the sacrumis healing. The patient is improving in appearance, and con-siders himself well, except that he has a sore on the right heel.Allowed a pair of crutches, and to get about a little; stimu-lating lotion to the heel.

April 15th (ten weeks after admission).-Is in very goodhealth, and wishes to get into the country. The heel looksclean, and is granulating slowly. The man complains of afeeling of contraction in the right iliac region, and this,together with the soreness of the heel, causes him to allowonly the ball of the foot to touch the ground, the thigh andleg being slightly flexed. The femoral artery of the left sideappears to be somewhat more dilated than when he first camein, but not sufficient to induce Mr. Solly to advise any operativeinterference just at present.May 1st (twelve weeks after admission).-The man is still

in the hospital, and can nearly walk without his crutch. ’

ST. GEORGE’S HOSPITAL.

Chronic Mammary Tumour ; Death quickly following the Inha-lation of Chloroform.

(Under the care of Mr. CÆSAR HAWKINS.)WE regret to put on record two deaths following the inhala-

tion of chloroform, to which reference was made last week,page 531: one of these unfortunate occurrences took place atSt. George’s, and the other at the Lock Hospital. We beg todirect attention, in the first place, to the case at the formerinstitution; and merely premise, that it was one of a peculiarcharacter, where death supervened with fearful rapidity, andwhich teaches an excellent lesson as to the danger of adminis-tering chloroform to patients labouring under great nervous-ness and apprehension. From notes kindly furnished by Mr.Collison, one of Mr. Hawkins’s dressers, we beg to adduce afew details respecting the history of the patient.

Eliza H-, aged thirty-seven years, single, following theoccupation of bonnet-cleaner, was admitted into the Princess’sward, April 26, 1854, under the care of Mr. Hawkins. The

patient has had very bad health of late, and suffered muchfrom indigestion ; her fare has been restricted to a poor allow-ance within the last few months, but her appetite is good, hertongue clean, and pulse normal. The bowels are confined, thecatamenia irregular, and the face somewhat pale.About twelve months before her admission this woman ap-

plied to the hospital as an out-patient, and was treated for atumour of the breast, by iodine internally, and various externalapplications. She had noticed, a short time before that period,a lump in the left breast about the size of a nut, in which sheoccasionally felt a shooting pain; the tumour had graduallybecome larger, and the pain more severe.On examination, the tumour was found to have reached the

size of a walnut, the burning sensation extending down to theelbow ; the swelling was very movable on the subjacent struc-tures ; and, under these circumstances, Mr. Hawkins deter-mined to remove it.On Thursday, May 11, 1854, the patient was placed on the

operating-table, preparatory to the excision of the growth,when she was noticed to be very nervous and apprehensive;indeed, she had expressed herself in the ward as labouringunder some fear. Mr. Potter, the assistant-apothecary, whois appointed to administer chloroform in all the surgical ope-rations performed in this hospital, proceeded to place uponthe patient’s mouth Dr. Snow’s apparatus, and noticed, whiledoing so, that the woman breathed with a kind of spasmodiceffort, though the valve of the mouth-piece was full three-fourths open. She was thus inhaling a large proportion of