ROYAL MEDICAL & CHIRURGICAL SOCIETY. TUESDAY, JAN. 28TH, 1862.

147 room by the help of a crutch. The forced flexion of the leg entirely arrested the pulsation of the tumour. Complete flexion caused, however, an inconvenient degree of pain, and after eight hours he relaxed the bandages so as to leave the leg in a semi flexed position. At night he ordered one grain of solid ROYAL MEDICAL & CHIRURGICAL SOCIETY. opium. The patient slept well. ]B"ext morning the tumour still pulsated distinctly. He again completely flexed the limb, TUESDAY, JAN. 28TH, 1862. and during the next two days it was retained in that position, DR. BABINGTON, PRESIDENT, IN THE CHAIR. being unmoved during the night. The patient moved about freely the whole time, by the help of a crutch and stick, and ON THE TREATMENT OF ANEURISM OF THE EXTREMITIES occasionally of a wooden pin leg roughly adjusted below the BY FLEXION OF THE LIMB. bent knee. He occupied himself in reading, writing, and BY ERNEST HART, ESQ., smoking. He complained of pains in the knee-cap, but after the first night he slept moderately well without opium. On SURGEON TO THE WEST LONDON HOSPITAL. the fourth day Mr. Hart somewhat relaxed the bandages, and IN a paper read before this Society in April, 1859, and examined the He had the satisfaction to find that it tumour. printed in the forty-second volume of the " Transactions," the was as nearly as possible solidified; a faint thrill, however, could author had brought to the notice of the Society a case of popli- be detected by placing the hand on the tumour. He again reteal aneurism which he had successfully treated by flexion of the leg in the position of forcible flexion, and retained placed the leg in 1858. Mr. A. Shaw kindly communicated at the it so until the end of the sixth day. He could not then find on same time a second case, which he had subsequently successexamination any trace of pulsation or thrill. The articular treated that method. fully by arteries beat perceptibly, and he concluded that the collateral Mr. Hart wished to ask the attention of the Society to some was satisfactorily established, and the aneurism confurther cases treated with success on this plan since the above circulation solidated by the deposition of laminated clots. As a desirable were made public through the medium of the " Transactions." measure of he retained the leg in the semi-flexed They were all cases of aneurism of the extremities-for the position for precaution, another week-a proceeding to which the patient, most part popliteal. Indeed, by the nature of this method of who fully understood the nature and object of the treatment, treatment, its application was confined to the extremities; offered The subsequent progress of the case was no objection. for here the general law of position of the great arteries to in Every way satisfactory; it offered no peculiarity worthy of some extent favoured it.

the

Medical Societies.

The author remarked that the effect of forcible flexion of the healthy arm or leg might be observed in the considerable retardation of the blood flowing through the main artery, and the almost entire extinction of its pulse. The application of this principle to the extreme flexion of the arterial trunks was obvious. Their structure favoured the effect described. Probably, also, the projecting bellies of the contracted muscles might cause some pressure on an artery which lay in contact with them; and in the case of an aneurismal swelling some direct pressure might be made upon the tumour ; but of the occurrence of this circumstance, or of its desirability, the author was doubtful. It was now pretty clearly established and generally accepted that the object in treating aneurism was not to cut off the supply of blood, or altogether at once to arrest circulation in it, but to cause such a retardation of the current as would lead to the gradual deposit of fibrinous laminm in the interior, and The former method was so effect its gradual consolidation. uncertain and dangerous; the latter safe and permanent in its results. In the case in which the author first applied the method of flexion to the treatment of popliteal aneurism, and in that in which Mr. Shaw subsequently tested it, they were completely successful in obtaining the latter result. Mr. Hart had met with similar success in the following case :-

note. It was three weeks from the conclusion of the treatment before the patient ceased to limp from the stiffness of the knee caused by its confinement. It seemed to the author that this case sufficiently established the simplicity and efficiency of the treatment of popliteal aneurism by flexion in certain cases. Here he was enabled to effect the cure practically in six days, without the use of any apparatus-without the intervention of any watchers or assistants-without risk or danger. This patient had been cured of popliteal aneurism-a disease formerly so formidable-without being confined for a day to bed. In order to afford the grounds of a judgment on the relative merits of the flexion treatment, it might be proper to add a brief resumé of the cases which had been successfully treated by other surgeons in this country who had employed the method since the author had the honour to introduce it to the notice of the Society. Some of these cases had been treated by flexion solely; in others, that method had been conjoined to the treatment by compression. CASE 4. Popliteal aneurism; recurrence after ligatlt1’e of

8upe?:ficíal anew’ism; tl’eatment by compression uns2sccessfuZ. Cure by flexion of the leg. By JAMES SPENCE, Esq., F. R. C. S. E.T. H-, a coal-carter, was admitted into the Royal Infirmary, Edinburgh, under the care of Mr. Spence, in August, 1658, with a pulsating aneurismal tumour, of the size of an orange. The superficial femoral had already previously been CASE 3.-In September, 1860, a healthy and robust-looking tied in May, 18a7, with the effect of producing solidification of man, aged thirty-five, was sent to him by Mr. Bridge for treat- the tumour. But the pulsation recurred a few days before ment of a popliteal aneurism of the left leg. It was of the size this second admission, and the tumour was then as large and and shape of a large lemon, projecting on the inner side of the pulsating as violently as before the artery was tied. Comham. It had a loud bruit and very perceptible thrill, but was pression was carefully employed over a period of upwards of not entirely reducible. The skin was somewhat discoloured five months, but the tumour was at the end of that time inThe patient creasing instead of diminishing. The patient left the house over the tumour as though from a recent bruise. had noticed the existence of this pulsating tumour for nearly for some weeks, but returned, desiring to submit to any operatwo years. It had increased somewhat in size during the first tion that might be thought necessary. The following is the sequel nine months that he had observed it, and he had several times of this very interesting case in the words of the surgeon :66 Un examining the aneurism at this time, its condition was thought of seeking advice, but as he had felt little pain from the disease, he had neglected its cure. About three weeks be- as follows: it was the size of a pretty large orange, and fore the author saw him he had received a blow in the region of pulsating strongly; the femoral artery could be felt to pulsate the tumour, and since then he had suffered pain in it, and the for about four inches below Poupart’s ligament, ceasing to beat swelling had increased. The arteries of the leg pulsated dis- about an inch or less above the point where the superficial tinctly, and there was no very marked dilatation of the veins femoral had been tied. Pressure on the common femoral combelow the knee. There was no history of gout or syphilis. A pletely and readily arrested pulsation in the sac. Compression week was allowed to elapse before commencing any treatment. of the superficial femoral above the point tied also did so, but The discoloration of the skin was then no longer visible, and required very firm pressure to be made directly backwards. the aneurism was pulsating distinctly as before. Mr. Hart Compression along the course of the superficial femoral below desired in this case to separate the effect of treatment by flexion the point tied produced no effect until it was made over the as clearly as he could from any collateral or adjuvant agencies. lowest part of Hunter’s canal, when the pulsation of the aneuHe did not, therefore, employ any form of medical treatment rism became thoroughly commanded by it. Under these cirwhatever; nor did he invalid the patient by enjoining the hori- cumstances, after weighing the comparative chances of success zontal position and confinement to bed. He rolled the leg in a ’, between ligature of the external ilnc, or the lower part of the flannel bandage from the foot upwards, stopping below the superficial femoral, the latter plan was decided on, and the tumour so as not to compress this in any way. He then bent patient willingly gave his consent. But as the case did not the leg on the thigh, and retained it in the flexed position by seem a very hopeful one, it was thought as well to try the plan means of three pieces of bandage attached to the ankle and of flexion of the leg upon the thigh recently proposed. On along the leg. The patient was allowed to rise and go about bending the limb fully, all pulsation was at once and com-

148

judgment. Compared with compression, it had the favourable advantage of requiring the constant and watchful attention

and the limb was bandaged in that position. patient could not bear such flexion to be kept up.. Accordingly, a slipper, with a slip of bandage sewed to the heel, was fastened to the foot, and the slip of bandage was then fastened to a loop connected with a broad bandage round his pelvis, and this gradually tightened, so as to increase daily the flexion of the leg on the thigh. This treatment was commenced on the 20th of May, 1859. On the 23rd, the pulsations were weaker, but returned when flexion of the limb was discontinued. On the 27th, the pulsation diminished; tumour smaller and firmer. There was still a tendency to increase of pulsation when the limb was allowed to remain straight for any length of time. On the 6th of June, the pulsation was scarcely

pletely arrested, But the

not

essential to the success of that method. No instruments were employed, and no assistants were needed. There was no risk of ulceration of the skin, of erysipelas, or of that other rare effect described by Mr. Oliver Pemberton-the production of aneurismal varix at the site of pressure. If not ultimately successful, it would still have had the effect of beneficially developing the collateral circulation. Of course, where practicable, it would always be preferred to the use of the knife. The interesting case of recurring popliteal aneurism under the care of Mr. Spence, affords an instance in which flexion effected a cure where the superficial femoral artery had already been tied, and to be felt in the aneurism, even when flexion was discontinued. compression during five months had failed; the undesirable The tumour felt solid and smaller, and enlarged anastomosing alternatives being the ligature of the femoral close to the sac vessels could be felt over it and around the knee. The patient or the external iliac, uuder unfavourable circumstances. Mr. was now allowed to walk about with crutches, the affected Spence states : " From what I saw of the plan of flexion of the limb being suspended in a flexed position. When in bed or limb in this case, I would have great hopes of its success as a sitting in the ward, he was desired to extend the leg occa- curativemeasure, far simpler and more efficacious than any sionally, and not to keep it constantly bent. On the 23rd of form of compression I have seen employed, devoid of all its June, there was not the slightest pulsation to be felt in the risks, and not interfering with, but rather beneficial as a preaneurism, which was firm and considerably diminished in bulk. paration for, ligature of the artery, should it fail in itself accomSeveral very large anastomosing vessels could be felt over the plishing the cure." The cases related show that flexion may be satisfactorily emtumour, the limb was of good heat, and there was no stiffness of the knee-joint. 1 kept the patient for about three weeks ployed as aiding compression where this is desired. Finally, longer in the hospital under observation, and he was dismissed Mr. Hart said that he did not now seek to define the position cured. Since then he has returned to his usual occupation of of the flexion treatment in relation to aneurism, or to establish coal-carter, which requires him to walk considerable distances, arbitrarily its superiority to other methods. He desired to but when I last saw him there was no tendency to return of leave this matter to the judgment and further experience of the surgical profession. His object in this communication had the disease." CASE 5. A nenrism of the popliteal artery successfully treated been to submit to this Society the further facts which had come knowledge since he had the honour first to bring the by flexion combined By OLIVER to their notice, and which furnish the grounds for a, treatment , Birmingham. Esq.,, Surgeon to the General Hospital, i. ’" more complete judgment of its merits and deficiencies. Mr. SOLLY said that the profession were greatly indebted to, CASE 6. Traumatic aneurism of the radial artery siccces.efislly treated byflexion and compression. By R. M. CRAVEN, Esq., Mr. Ernest Hart for again bringingunder their notice this Hull. simple plan of treating aneurism by flexion. This second paper CASE 7. Aneurism of the left popliteal artery, cured in sixty- presented a series of facts; and no one who heard those facts could hesitate to say that this was an ingenious and successful eight laours by the combination of flexion and compression. By an in the practice of surgery LEITH ADAMS,, M.B., Surgeon to the 22nd Regitnent. He (Mr. Solly) wished that he could say he had any practical ’.. CASE 8. Popliteal aneurism;compression;great inc2,ca-*e of experience of the plan, but he should employ it on future tumour;flexion of limb; cure. By WILLIAM COLLES,F.R.C.S., occasions. Mr. Hart, however, must be aware that some Surgeon to Steevens’ Hospital, Dublin. aneurisms would not yield to this plan, and that neither thisr CASE 9. Popliteal ane2criszn cured by forcible flexion. By nor indeed any other method was uniformly applicable. He AUGUSTIN PRICHARD Esq., Surgeon, Bristol. might mention to the Society a singular case of aneurism now under his care, which presented some features of interest. It The author was not unaware that the flexion treatment had was a case in which the patient had a pulsating tumour on the not always been successful. In cases under the care of Mr. arm; that arm had been paralysed. The skin over the tumour stained by a network of vessels, but this was superficial. Paget, Mr. C. H. Moore, and Mr. Birkett respectively, it had was been employed, and disused as ineffective. The first two were, His colleague, Mr. Simon, was disposed to connect the aneurismal however, cases in which the contents of the aneurismal sac condition with the paralysis of the coats of the artery; but the escaped by rupture or ulceration. These are severe forms of nature and origin of the disease were doubtful. Mr. Solly rethe disease in which extreme treatment is always likely to be ferred to the medical treatment of aortic aneurisms by restricted required. In all three compression also failed, and ligature was diet, rest, and occasional doses of aconite, in terms of praise, resorted to. In the hands of other surgeons the method had mentioning cases now under his observation in which it was been found painful, and apparently abandoned on that account. doing good. Dr. HARE also referred to a case in which it had been of On this head he would only remark, that other methods of benefit. are aneurism both more and tedious, commonly treating painful Mr. WiLUAM ADAMS said that Mr. Hart’s paper described as well as attended with greater risk. The first results of any method of treatment are likely to be, what was evidently a great step in advance in the treatment of that very interesting surgical affection, aneurism of the exas they always have been, less perfect and less uniformly successful than those which follow upon a larger experience and a tremities. It was to be regretted, in his opinion, that more more assured application. It is probable that attention to attention had not already been given to this valuable improvecertain points of detail may tend to prevent pain and incon- ment by competent surgeons, for he did not doubt that in the venience. By carefully bandaging the limb, support is given end a long list of successes would adorn this treatment, with to the superficial veins and rest to the contracted muscles. which Mr. Ernest Hart’s name was and must always be so Friction of the limb upwards may serve the same purpose. honourably associated. In the three years which had elapsed Inunction of the knee-cap with oil and chloroform diminishes since that gentleman’s paper on the flexion treatment appeared the sensation of stiffness and relieves pain. By allowing the in the " Transactions," there seemed to have been, however, patient to rise from his bed and dress himself, much of the nine cases illustrating the successful application of this method. tedium is obviated and coagulation of the fibrin aided. Sleep The treatment was founded and explained in the paper upon follows much earlier at night. Any favourite habit, such as an accurate view of the pathology of aneurism. It was an insmoking, may be usefully permitted, with the same object. genious and clever application of pathology to therapeutics, for It is desirable to bespeak the assistance of the patient himself, which the author deserved great credit. The case in which by explaining the nature of the malady and treatment. Flexion flexion was shown to have effected a rapid cure of a popliteal should be employed with care and graduated. The author’s aneurism, after the ligature of the femoral artery in the front of the thigh had been performed, and after a patient trial of reason for referring to these minutiae might be found in the past history of this method and of the cognate treatment by com- five months’ compression had failed, proved how especially this as a new and efficient surgical resource in pression, in which attention to minute details had been shown method might avail to produce a remarkable increase in the success obtained. For the treatment of aneurism. Here it had afforded a safe and effective substitute for ligature of the iliac under unfavourable success a watchful and intelligent interest was necessary. In reviewing the cases already successfully treated by flexion, circumstances, or of the femoral artery in its diseased part it seemed to the author that there were many elements for aI close to the sac. In Mr. Hart’s own case, for the first time a

with pressure.

PEMBERTON, his

procedure, constituting advance

.

149

patient had

been cured of popliteal aneurism without a day’s Cornwall,-we shall make such a list as would have appeared In any cases which came under his (Mr. to our forefathers to compass " a whole system of geography." Adams’s) care he should certainly employ this method, and it Now, be it remembered, each of these localities-these aspimight be expected that in a large number of cases it would rants for sanitary fame-has been talked and written about supersede any other hitherto employed. Mr. ERNEST HART, in reply, said he was gratified that his several times over. There is scarcely one from which has not paper had met with so favourable a reception. Hospital sur- issued many tables of meteorological observations, and about geons naturally acted with caution in adopting new methods their waters many volumes of analysis exist. Some have had of treatment in so formidable a disease, but he felt glad that their florv and their fauna brought to the door of the traveller’s Yet he so many surgeons had already essayed this plnn. whilst of all very minute information has been given lodgings; thought that the nine cases which he had collected might pro- as to what people should do when they get there-what they more and lead to a careful attract attention, bably general of the Failures method. had occurred trial mostly through should "eat, drink, and avoid." A professional man, with a employing the fl.-xion too forcibly at first, and not allowing numerous and well-to-do clientae, feels himself compelled to the patient enough liberty of general action. He thought that stand prepared with some amount of knowledge about the chief in the facts recorded it might he seen that in the cases to of these places. To hope to compass all that is written about which it was applicable flexion offerea a resource unsurpassed for its simplicity and safety. It removed many aneurisms them at present is impossible for him; to neglect all that is which at the beginning of this century were always fatal into current upon them is equally out of the question. What, the sphere of the most easily cured of diseases. He trusted to then, should be done ? We would say, select a single work see its application become generalized, and should feel percontaining the requisite information in a condensed and really sonally graitefal to any surgeon who would address to his care consultable form. hospital patients suffering with this disease, in order to permit As possessing this character, we can well recommend Dr. him to test the methodfurther; or who would acquaint him from time to time with the result of their experience, and Scoresby-Jackson’s "Medical Climatology" to the busy practitioner. In it will be found both good general information as allow him to witness the application of the method. to climatorial hygienics and useful descriptions of individual climates and their effects. The author has himself had abundant opp -.rtunities forjudgingfrom personal experience of the sanativeinfluence of the principal winter resorts in the south of Europe and in the north of Africa. He has made the Medical Climatology; or, a Topographical and Meteorological acquaintance also of the French, Swiss, and German spas. We Description of the Localities resorted to iw Winter and must allow that the work is written in a spirit of impartiality, Summer by Invalids of various Classes, both at Home and and with chiefly one end in view, that of furthering the conAbooad. By R. E. SCORESBY JACKSON, M.D., F.R.S.E., venience and interest of busy professional men. The author F.R.C.S., &c. pp. 509, with Map and Plate. London: observesChurchill. " I have no particular climate to eulogize above its fellows; Bradshaw’s I nvalirls’ Companion to the Continent;comprising no General and Medical Notices of the principal Places of personal interests to serve.......Ido not intend it, except Resort, with appended Observations on the Influence of Cli- perhaps in rare instances, to be used as a guide by the invalid. mate and Travelling, and Meteorological Tables. By EDWIN He will, if he rightly understand his own welfare, be subject Second Edition, with considerable Altera- only to his medical adviser.......In the chapter on diseases in LEE, M.D., &c. the alleviation of which change of climate may be usefully emtions and Additions. pp.416. London: Adams. 161. The Climate of Algiers in Rference to the Chronic Affections ployed, it will be at once perceived that little more than an of the C76est; being a PLeport of a Medical llission to Algeria enumeration of them has been designed. My reasons for presented to his Excellency the Minister of AlueriLt and the adding a chapter on Mineral Waters, as well as those for deCulonies. By PR sr r-x DE PIETRA SANTA, M.D., Physician scribing the qualifications of Summer Resorts, will be found in to his Majesty the Emperor of the French, &c. pp. 61. the body of the work. "-Preface. London : Baillière. Dr. Scoresby Jackson has added to his book an interesting WORKS upon different climates and their sanative relations chart of Medical Climatology, indicating the mean temperature have now become so multiplied that busy practitioners can of the principal places on the globe, together with small maps, scarcely be expected to have perused them all ; yet such per- showing the summer and winter and mean temperatures of the sons are exactly those who are more frequently obliged to give principal meteorological stations in central Europe and the an opinion to some of their numerous patients who are pre- British Isles. These havebeen adapted to the book by Mr. paring to reinvigorate, mentally and physically, exhausted sys I, Keith Johnson, of well known repute as a physical geographer. tems by a more agreeable method than that of taking drugs. The second work mentioned at the head of this notice may The number who now travel is so large, and the places re- be looked upon as a new edition of Dr. Lee’s " Memoranda of sorted to are so many, that not only is advice very constantly France, Italy, and Germany-" It can be recommended as demanded upon the propriety of a change of climate, but the answering to some extent the purposes of a general travelling difficulty of advising has become greater. In former days it guide, as well as those of medical climatology. ’!his book is for was easy to speak to an intending traveller of the advantages the traveller himself, whilst Dr. Scoresby-Jackson’s is for the of a trip to Madeira, to Rome, or Nice. The knowledge of medical adviser. The former may be regarded as a sort of these, with the results of perhaps some personal experience of Medical Murray." Dr. de Pietra-Santa’s memoir is a plain and straightforward Margate and the Isle of Wight, was all that the most inquisitive or undecided invalid could reasonably expect from his scientific report, and therefore entitled to very different conmedical attendant. But, latterly, things have greatly altered; sideration from that due to some of the numerous brochures of the climatorial bill of fare expected by the fastidious modern modern date upon places of fashionable or medical resort, and appetite to be laid before it is indeed a lengthy one, and no of which one or two have lately been exaggeratedly offensive. small amount of information is required to be able to undergo The Report is divided into three sections. One refers to Climate, a catechising upon its contents. Egypt, Syria, Algeria., Malaga, another to the condition of Phthisis, and the third to the inAustralia, the Cape, the Pyrenees; innumerable springs and fluences of the Climate of Algiers upon the malady in question. The summary of the first section may be thus expressed :spas in Germany; winter residences in the south of France and in Italy, the Ionian Islands, the West India Islands, and even The climate is marked by great atmospheric purity, with a blue cold northern, semi arctic climates are added now-a days to and cloudless sky, by a short twilight, by great variations in the dainty dish from which the traveller may select his mor- the temperature, but not much difference in seasons, and by If to these be added the numerous places of resort in having an average temperature of 66°5 Fahr. The atmosphere ceau. li our own country, - from the Shetland Isles to the coast of is tolerably moist, the diurnal and annual variations of the

confinement to bed.

Reviews and Notices of Books.

’