ON THE TREATMENT OF POPLITEAL ANEURISM BY PRESSURE
W.K. Swettenham
1852
The Lancet
214 instrument of great power and value; and I should propose to apply it thus:—Our positive metal we may consider to be the lead in the nerves and muscles and tissues, and our negative metal, plates of copper, which we must attacli to the limb itself; a weak solution of acetic acid may form the oxidating and connecting link. I choose acetic acid, because the acetate of lead is soluble, and there is every ground for reasoning that the chemical and galvanic actions set up will cause the lead to
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... e withdrawn from the muscles. It is usual to give tonics, and in a safe form there can be no doubt of their general efficacy, but of the class of alkaloids, such as strychnia, we must admit that the danger of their use hardly excuses such experimental treatment without the greatest caution. My own recollection of the reputed success of the use of strychnia many years ago in France, coupled with my knowledge at the same time that these reports were unsupported by real evidence, makes me very dubious of later statements on this subject. If it were asked why not have experimented fully in after years, I should willingly reply, that I see no motive ever to justify the use of such remedies as we know to produce sinister consequences. Had the state of medical knowledge arrived at its highest degree of illumination, so that Disease, in its origin and nature, stood clearly revealed to our understanding, and it remained for us only to seek out yet unknown substances to perform the work which we fully comprehended, then might experiments of new compounds be a reasonable measure: but while we have so much yet to learn, and while the amount of our safe remedial substances exceeds our discernment as to their due application, it is surely a duty to extend our line of study in any direction rather than that which involves the possibility of injuring others while we gain our own experience. I venture on this remark, feeling th'lt the fashion of the day is setting rather too boldly towards perilous experiments, both in medicine and in surgery. The strychnia which is given in this disease is almost uncontrollable as a remedy as well as a violent poison, and is one of those things which the wise globulists give in the ten-millionth of a drop; and perhaps so to give it is one of the wisest things they do. The endermic method, however, is less objectionable, with the additional advantage of applying the remedy to the part itself. In concluding the subject of treatment, I may incidentally observe, that the early accession of lead disease is, like many other seemingly cruel visitations, often, in reality, a merciful arrangement, since the sufferer is rescued by it from severer evils, which would meet him in protracted exposure to the obnoxious cause. Removal to the hospital ensures the freedom from a poisoned atmosphere, whilst the system is by treatment once more purified from metallic saturation; and should the warning induce him to seek a different line of occupation, the acute attack would have proved a providential blessing. Having considered the case of the manufacturers of lead, and of those who use it in large quantities, it remains to be stated that the list of sources whence lead colic and paralysis are derived is not yet complete, since various manufactures, involving the use of lead in a very limited extent, yet furnish their quota of sufferers from the labourers employed. Here, again, I must regret the want of statistics, which would be valuable to ascertain the relative proportion of the numbers attacked with those who are exposed. Nothing would be more easy than to institute the formation of such tables ; in their absence we can merely state the fact, that frequent instances occur in those branches of industry which I shall enumerate. The compositor, who, in addition to other hardships, has often to labour through the night, and seek what rest he may during the hours of sunshine,is a frequent subject of paralysis, but he is rarely attacked by colic. The types, which are composed of a metal having lead for its basis, are obliged to be frequently washed, to free them from the ink, and are sometimes placed before a fire to dry. The ink is composed of linseedoil and lamp-black, thinned by turpentine. Lead is soluble in oil, and diffusible by turpentine, and heat assists the diffusion. The handling also favours the diffusion, and in a certain degree offers opportunity for absorption by contact with the sentient extremities of the fingers, a part which is perhaps as vulnerable as any external surface covered by epidermis. I am myself disposed to think that the reception of the poison is mainly attributable to respiration, else how can we account for the amaurosis which is not unfrequently found among compositors ? It is obvious that portions may be inhaled in the process of cleaning just alluded to. The compositor is too often also of intemperate habits, and the vapour from the lungs, being charged with spirit, diffuses the lead more easily, and favours the absorption. The plumber and the potter are both exposed to the influence of lead: the former, not only from handling the metal, but also from emanations during the process of soldering. The solder, composed of equal parts of tin and lead, is applied by heat, in combination with resin, which is the residue of the distillation of turpentine. This is another instance of the influence of turpentine assisting the action of lead on the human frame. Two processes involving lead are carried on by the potter: one consists in dipping the biscuitware into the glaze, which is a solution of litharge; and another is the burning in. They are performed by different workmen, and it is those who apply the heat who suffer. The glass-maker may be classed with the potter: lead, in the form of silicate, passes off with the heat used to favour the manipulations. The sealing-wax makers, who formerly suffered from mercurial tremblings only, from the use of cinnabar to colour the wax, now suffer, in addition, from the use of lead. The introduction of new colours, as white and yellow, has included the carbonate and the chromate of lead in the manufacture. A size containing litharge is used in glazing visiting-cards, from which the workmen occasionally suffer. The invention, at best, is but a clumsy one, as the cards lose their whiteness on exposure to hydrosulphuric acid. For the same reason I should argue that cosmetics never could have been composed of lead, notwithstanding that the French insist upon the fact, It seems hardly likely that it should retain its colour in the vitiated atmosphere of crowded rooms, abounding in hydrosulphuric acid. The same observation does not apply to the hair-dye, which is perhaps included in what they call cosmetics; for the more hydrosulphuric acid, the deeper the tint, which is the desideratum. Surgeon 44th Regt. I BEG to submit for insertion in THE LANCET the undermentioned case of popliteal aneurism, which has been successfully treated at Gibraltar Rock, under the pressure plan, affording an additional example of the triumph of art in surgery. The instruments employed were those invented by Mr. Read, of Dublin, and delineated in Dr. Ferrall's paper on Popliteal Aneurism, in the second volume of the Dublin Quarterly Journal, from which plates the pelvic instrument was constructed by a blacksmith on the station, for a case of the disease which occurred in a regiment some years previously. The lower instrument, or circular compressor, was made at the same time, consisting merely of a screw-shaft through the anterior ramus of the instrument, to which was attached a covered cork pad. My patient, Henry S-, aged thirty-two, able-bodied seaman of H.M. ship Phaeton, first applied, on the morning of the lOth of July, at sea, to Dr. White, surgeon of the ship. On examination he found a pulsating tumour in the left popliteal space, then about the size of a pigeon's egg, spheroidal in form; pulsation strong, and evident to the eye, having a distinct soufflet audible. He was sent to Gibraltar for treatment, from the squadron, in the Fury, with a tourniquet on, this being the only pressure attempted. He was admitted into the Naval Hospital at Gibraltar on the 12th of July, (the sick of the fleet being ttemporarily under my charge.) He is a fine, healthy-looking young man; states that he has served in several line-of-battle ships, and always enjoyed good health; was not aware of any swelling in the left ham until the forenoon of the 9th of July, but had aching pain in the left leg for four or five nights previously, which came on gradually when in his hammock, and which he attributed to rheumatism; is positive that he received no injury, and can assign no cause for the disease, except that the ship was exercised the two days previous. On admission, a tumour was visible in the left ham, about the size of a small orange, soft to the feel, and having a strong pulsation and loud bruit audible; the circulation through the sac was controlled by pressure of the finger on the artery in the upper third of the thigh. On the 15th of July, the instruments at hand above alluded to were attempted to be adjusted; but being found in many respects objectionable, and requiring some alterations, were not re-applied until the 21st, when both the pelvic, or upper instrument, and the lower, or circular, were put on at the same time, with the thigh kept slightly bent on the pelvis, and the leg on the thigh, resting on a pi How. The pressure was first commenced on the pubis. He was duly instructed as to the modus operandi of the cure, and directed that when the pain became severe he was to relax the
doi:10.1016/s0140-6736(02)60917-1
fatcat:7ia4kfp44neqfbodmtxgk42wm4