THE WESTERN JOURNAL OF MEDICINE,

(Formerly, "CINCINNATI JOURNAL OF MEDICINE.")

Thus it will be seen that if man has passions which impel him to the destruction of man, if he be the only animal who, despising his natural means of attack and defence, has devised new means of destruction, he is also the only animal who has the desire, or the power, to relieve the sufferings of his fellow citizens, and in whom the co-existence of reason and benevolence attests a moral as well as an intellectual superiority.-GRAVES' CLINICAL MEDICINE.

VOL. IV.

INDIANAPOLIS, JANUARY, 1869.

No. I.

*A CASE OF POPLITEAL ANEURISM RAPIDLY CURED BY MANIPULATION, FLEXION AND DIGITAL COMPRES

SION.

BY GEO. C. BLACKMAN, M. D.,

Professor of Surgery in the Medical College of Ohio; Surgeon to the Samaritan Hospital, Cincinnati, Ohio, etc.

We have recently treated a case of popliteal aneurism according to the above methods, which possesses at the present time, many points of interest, especially in connection with the cases lately reported by Dr. Mapother, of Dublin, Dr. Murray, of Newcastle-on-Tyne, Eng/land, and Sir Henry Thompson, of London. Before giving the details of our own case, we will present an abstract of Dr. Mapother's, as published in the British Medical Journal, October 5, 1867, and re-published in Braithwaite's Retrospect, part 56, page 157. The same journals also contain the particulars of Dr. Murray's views and treatment.

Dr. Mapother's first case was one of ilio-femoral aneurism. "Digital and partial instrumental pressure having failed, I tried to stop the common iliac with an elastic compressor, the patient being kept under chloroform for twelve hours. No clot formed. An anthracoid slough formed at the point of pressure. Five days afterward, another attempt

The term given to this paper means a particular manipulation of an aneurism, whereby the fibrin within may possibly be so displaced as either in part or in whole to block up the main artery on the distal side of the disease."-Commencement of Mr. Fergusson's paper, 1857.

was made, after the following preparatory steps: The abdomen was made lank by emptying the bowels and bladder; the limb was raised, bandaged and fixed to aid venous return, and to render increased flow of blood for muscular action unnecessary; and the sac was compressed by an elastic roller, so as to contract the space to be bled by the clot as much as possible. At Dr. O'Ferrall's suggestion, the superficial femoral was stopped, so as to keep the sac full. Signoroni's clamp was then fixed over the common iliac artery for four and a half hours, when the tumor was found solid and pulseless, the common and internal iliacs being still pulseless. Absorption and complete cure followed."

The Doctor's second case was one of popliteal aneurism. Pulsation was arrested by pressure maintained for five hours as firmly as could be done in a restless patient, but thirty-six hours afterwards the pulsation returned. "After three other attempts, unsuccessful because chloroform was refused, the femoral at Scarpa's triangle was compressed, and the flow of blood out of the sac was impeded by tight bandaging and elevation of the leg, distal pressure on the popliteal not being possible. The patient was kept apathetic, not insensible, with chloroform, for nine and a half hours, when the sac was found hard and pulseless. At the compressed point a superficial slough formed; but with this exception, the recovery was rapid and perfect."

Dr. Mapother suggests, that as distal pressure is impracticable in popliteal or "antecubital" cases, Mr. Hart's flexion plan may achieve the same result. Nearly seven years before he treated his case of popliteal aneurism just quoted, we tried the flexion method in a similar case, but the cure was delayed because we trusted to bandages and instrumental, rather than digital compression, until three hours before the pulsation of the tumor was arrested, at which time the digital compression was adopted. It is also to be taken into consideration that we had a restless patient to treat. But as bearing upon the history of this combination of methods in the treatment of aneurism, we re-produce here, from the Cincinnati Lancet and Observer, March, 1861, the report of a case treated by us in June, 1859, and in which we were ably assisted by Dr. John S. Billings and Dr. Charles Greenleaf, then medical students, but now accomplished surgeons of the regular army:

In June, 1859, I was consulted by Joseph Humbrick in reference to a large pulsating tumor in the left popliteal space. He was an American, and was twenty-seven years of age. For some years he had been engaged in carting lumber, and consequently was often compelled to sustain heavy weights. He was not aware, however, that he had ever received any injury upon the part affected. About thirteen months before I saw him he suffered

excruciating pain, which extended along the inner part of the thigh and calf of the leg as far as the heel. About three days afterwards he noticed a small pulsating tumor, about the size of a pigeon's egg, in the middle of the popliteal space. His case was regarded as acute rheumatism, and he was treated accordingly. The swelling continued to increase; and when I first saw him, on the 5th of June, it measured about four and a half inches in the axis of the limb, and five and a half in its transverse direction. It had a pyriform shape, the apex being above. For two months the pain had been severe; and at the time of his visit he was unable to extend his limb completely.

Having noticed the favorable reports of cases which had been treated by the London surgeons by flexion, I determined to unite this to the combined method of compression, manipulation, and the internal administration of veratrum viride, which I had successfully employed in a case of femoral aneurism of large size. On the 7th of June, after having given four drops of Norwood's tincture, I broke up and dislodged some of the layers of fibrin in the sac, by means of pressure with my thumbs and fingers (Fergusson's Manipulation); after this I applied a bandage, as recommended by Prof. Dudley, of Lexington, in 1818. The foot and leg were bandaged from the toes to the inferior margin of the aneurism, over which a compress was placed, and a still firmer one along the course of the femoral artery reaching to Poupart's ligament. These were covered by the bandage which extended to the groin. The leg was strongly flexed upon the thigh, and secured in that position. The only effect of the veratrum was to cause an intermission of the heart's action every thirteenth beat. For an hour after the manipulation the pain was intense; but morphia freely administered enabled him to pass a comfortable night. On the following day, however, the patient became exceedingly restless, and the compressor and bandage became deranged. After a week's trial, Dudley's dressing was abandoned and Petit's tourniquet substituted. At the expiration of another week this was changed for Skey's.* At this time the tumor had diminished somewhat, but still pulsated strongly. Under the use of digitalis the patient's pulse rose from eighty-five to one hundred and ten, and it was discontinued. Compression was continued for another week, by the alternate use of the tourniquets above mentioned. The patient now left for his home in Newport, Kentucky, the tumor having diminished about one-third in size, but the pulsation being quite distinct.

On the first of July, I requested my pupil, Mr. John Billings, and Mr. Charles Greenleaf, then medical students, to go to the patient's house and try digital compression at the groin. This was employed for three hours, when the pulsation entirely ceased. On Monday last, (February 14, 1861,) the patient came before the class of the Medical College of Ohio, and declared that his left leg was as good as the right. The contracted and indurated aneurismal tumor can still be felt, but pulsation has never returned. It is a question whether this indurated mass will ever disappear, for Mr. Paget has reported an examination of a case fifty years after the cure by ligature -John Hunter's fourth patient-and even after this long period, a hard, olive-shaped mass still occupied the popliteal space.

Shortly after the treatment of the above case, a patient came under our care, having an aneurism of the innominata of small size. Instead of ligating the subclavian and carotid on the distal side, I applied Bourgery's tourniquet, or compressor, for the subclavian, while a truss was adjusted to the neck to compress the carotid. Veratrum, in this case, had a happy effect in moderating the force of the circulation; and, with the compression above mentioned, I succeeded in producing a temporary consolidation of the aneur

For almost the exact counterpart of Skey's instrument, vid. the illustration of H. Searle's in Johnson's Med. Chir. Review, 1824. Mr. S. adds that "Sir Astley Cooper constructed an instrument on a similar principle, about twenty years ago, to compress a popliteal aneurism."

ism. In a few hours, however, pulsation returned, and in the course of a few days it became again consolidated. Thus alternating, matters progressed for several weeks, when, after trying digital compression for some hours, at several trials, it became evident that all our efforts were in vain. The patient left for the country, the tumor constantly increasing; and, in a few weeks more, after reaching an enormous size, it burst internally and suffocated the patient. A post mortem revealed an aneurism of the innominata; and the opening communicating with the sac was of large size.

In connection with this case. we have read with much interest, the report of a case published in the Dublin Quarterly Journal of Medical Science, November, 1867, in which Mr. George H. Porter treated a large aneurism of the right subclavian artery, by acupressure on the first stage of the axillary artery, and subsequently by direct compression on the arteria innominata. The consolidation of the tumor, however, was not complete, and only temporary. The disease at length terminated fatally.

We now give the details of our recent case, as reported by Dr. W. J. Murray, resident physician of the Samaritan Hospital:

Elliott Black, American, æt. 25, admitted October 21, 1868. He states that until two years before, he had always enjoyed good health. At that time, he suffered from an attack of asthma, which, however, was soon relieved. Ten weeks before his admission, he first noticed the swelling, and he had pain in the knee-joint. Three weeks previously, he had injured the leg by a fall sustained while he was engaged in rolling logs. To this fall and the accompanying twist of the leg, he attributes the origin of his difficulty. A swelling soon appeared in the popliteal space, which continued to increase until the time of his admission, when it had attained the size of a large orange. The aneurismal bruit was very distinct, and all the symptoms such as to leave no doubt of the character of the tumor. Prof. Blackman remarked to the class, that he would try, in this case, the obstruction of the artery on the distal side of the tumor as recently practiced by Dr. Mapother, of Dublin, and then he would combine, however, as he had done in other cases, manipulation of the tumor, with digital compression at the groin. He added, that as from the distribution of the arteries of the leg it would be impossible to shut off the current of blood completely by compression on the distal side, he would adopt Hart's method by flexion of the leg upon the thigh, by which the force of the current would be materially lessened. He hoped, also, to promote this object still further, by dislodging some of the layers of fibrine in the sac, through the manipulation of the tumor as first proposed and practiced by Sir Wm. Fergusson.

October 22.-The latter method having been carried out, Prof. B. flexed the leg strongly upon the thigh, and then requested Prof. Conner and Dr. S. C. Muscroft to keep up firm digital compression upon the femoral artery just below Poupart's ligament. At the end of thirty minutes, only a slight thrill could be detected. The digital compression was continued for sixty-eight minutes, when the leg was secured to the thigh by a strong band of adhesive plaster, and the patient was carried to his bed. Prof. B. remarked, that in all probability the digital compression had been sufficient to secure the formation of the clot which was to fill and consolidate the tumor, but to make the matter still more certain, he would continue the flexion treatment for a short time longer.