THERAPEUTICAL VALUE OF VENESECTION.

1428 THERAPEUTICAL VALUE OF VENESECTION. BY JOHN MACKENZIE, L.R.C.P., L R C S EDIN.

Clinical Notes : MEDICAL, SURGICAL, OBSTETRICAL,

AND

THE similarity between a case reported by Mr. Gay in THE LANCET of May 23rd tempts me to submit the following, the more so since both of us in our treatment appear to have been guided by the discussion on Dr. Ogle’s article CASES OF DISLOCATION OF THE LOWER END OF which appeared in THE LANCET of May 9th of the present THE ULNA AND SUBLUXATION OF TIBIA. year. Recently I was called to see an old lady aged sixtyBY WM. HORROCKS, M.B., F.R.C.S., eight, said to be suffering from a " weak heart and bronASSISTANT SURGEON, BRADFORD INFIRMARY; LATE ASSISTANT DEMONchitisOn examination, I found her actually suffering from STRATOR OF ANATOMY, UNIVERSITY COLLEGE, LONDON. chronic Bright’s disease, mitral regurgitation, and considerable oedema of the lungs. One evening 1 had an urgent CASE 1. Crzcahed furearm..Robert D-, a checker, message that the old lady had a "stroke," and was ding. arrival she was semi-comatose, face livid, On aged sixty-six, said two months ago his left forearm was irregular and slow; speech gone, eyes closed, pupils even, and caught between two heavy boxes when in a position similar sensitive to light. The right side of her face was flaccid and to that when examined-i.e., extreme pronation. The left motionless, the left side strongly contracted; the right arm forearm was much wasted, the hand being in a position of cold, clammy, and powerless ; temperature in the axilla extreme The elbow, wrist, and fingers were subnormal ; heart’s action feeble, but regular. She passed

THERAPEUTICAL.

my

pronation.

breathing

somewhat flexed, and could not be straightened without motions unconsciously while I was present. Fron-itho,-es3niparalysis of the face and arm—I diagnosed pain. The lower part of the forearm was much narrower ptoms-aphasia, of one of the branches of the middle cerebral artery, rupture than natural, and presented an oval, oblique prominence involving Broca’s convolution and the motor centres for the When this was examined it face and arm. My prognosis was very grave indeed ; but over the back of the radius. The styloid process Iwas constrained " to do something" to satisfy the was continuous above with the ulna. was separated some distance from the cuneiform bone. The anxious friends, and recollecting the remarks of Mr. Jonahead of the ulna was freely movable and quite separable from than Hutchinson, ab the Medical and Chirurgical Society on the radius, whose inner articular surface was easily mapped Jan. 27th, 1891, on Dr. Pye-Smith’s paper-" that a very out. Above the lower end of the radius was some simple measure gave all the advantages of venesection, and slight thickening and irregularity. Under chloroform the that was placing the patient’s feet up to the knees in a bath dislocation was reduced, but the deformity readily re- of very hot water for a considerable period : this local produced itself. Writers differ as to whether the deformity determination of blood appeared to act just as efficiently as should be called a dislocation of the radius or ulna. As venesection in cases of head and chest injury,"—I deterboth bones are equally distant from the spine, Mr. Hulke mined to use counter-irritation to the nape of the neck, suggests that the more movable bone-i. e., the radius- and ordered the feet up to the knees to be covered with should be said to be displaced. It seems more reasonable poultices, changed every two hours till morning. The to say that the bone is dislocated which is displaced most awkwardness of placing such a patient’s feet in hot water is from its normal position, and the head of the ulna is the obvious. To my surprise next morning she was able to speak part whose relations are most changed. Sir Astley Cooper, -though imperfectly- and complained of pain in the left side Malgaigne, and Hamilton so denominate this injury. The of her head. Gradually the face resumed its normal shape, cause of the dislocation is any twist or force with the and motion returned into the arm. In less than a week forearms in a position of extreme pronation. Lately a not a trace of either paralysis or aphasia was present. patient was seen with both forearms showing this con- In the words of Mr. Gay, " she made an excellent dition, the injury being caused by a fall on the palms recovery." Evidently I erred in my diagnosis. This was with both wrists pronated - an accident which usually another instance of how closely the apoplectic attack, due causes Colles’ fracture. Sir Astley Cooper mentions that to functional disturbance of the brain, may simulate that the radius is not usually broken, but Mr. Hulke says that due to haemorrhage. It seems to me that the advanfracture is not uncommon. In the case described it is tage of venesection in the aged is doubtful when the doubtful whether the radius had been broken, but in the abstraction of an ounce or two of venous blood relieves the I double dislocation there was certainly no fracture. A corresponding relief can be easily ob, congested area. CASE 2. Subluxation oactzvards of upper end of the tibia.- tained by changing the determination of blood as directed Edward H-, a labourer, aged thirty-eight, said that two by Mr. Hutchinson, who, by the way, confesses to have hours before being seen he was wheeling a barrow on a wet alternately denounced and recommended venesection. plank, eight feet above the ground. He slipped, his right Moreover, have we not a double advantage in his methodleg, which was slightly in-kneed, bending under him. On e g., congestion due to a torpid condition of the cerebral admission, the right knee was slightly flexed and the foot circulation ? (a) By the dilatation of capillaries there is an everted. On the outer part of the joint behind, the increased flow of blood to the part, thereby changing the tendon of the biceps made a prominent vertical ridge. In determination of the vascular engorgement; (b) by reflex front of this was a hollow bounded by the prominent outer action, stimulating to action not only the cerebral circulaedge of the patella, which reached beyond, and was firmly tion, but cerebral tissue as well. fixed against the outer edge of the trochlear surface of the Intake. femur. The outer condyle of the femur was not felt, but below this the upper border of the tibia, lying in an oblique BLOODLETTING ; SLOW PULSE. position, was felt with difficulty. Above this an oblique BY ARTHUR PERIGAL, M.D., C.M. ED. parallel to the upper surface of the tibia, the external semilunar cartilage, was readily made out and easily THE excellent paper by Dr. Seymour Taylor recalls pressed inwards. The under surface of the external femoral could be no of felt. There was oedema forcibly to my recollection the following case, illustrative condyle distinctly the foot; pulsation of the posterior tibials on the two sides both of the happy action of bloodletting and the (somewas about equal in force. Reduction was effected without nature of slow pulse. Some years ago I chloroform by fully flexing the knee, hooking the left fore- times) hereditary was asked to see a man who had been thrown from his arm under the knee, applying pressure inwards over the head of the tibia, while extension was made at the ankle. horse. He appeared about twenty years of age, was quite After a period of rest the patient recovered, with a perfectly insensible, pupils dilated, skin cold and moist, had vomited useful knee. The presence of genu valgum predisposed to and passed urine. There was a bruise of the vertex, but dislocation. The fixation of the limbs at the time of the no wound of scalp or any part of body, no bones broken, no injury, and the fact that the joint was not afterwards bleeding from nose or ears. He had been in this state some weakened, indicate that the crucial ligaments were not hours; and, as no consciousness returned after four hours, I torn. In a case given in Sir Astley Coopers work slight asked Dr. Stovin to see him, and we agreed to take a few ounces of blood from his arm. Before we had drawnfour ounces permanent lameness followed. he became quite conscious, expressing a wish to remount Bradford, York

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