1868 The Lancet  
THE detachment of fibrinous deposits from the interior of the heart is now so thoroughly recognised as one of "the ills ( to which human flesh is heir" that it seems almost to require an apology from me in soliciting space for the following case. But although it contains nothing that has not already been brought before the notice of the profession in such a manner as to leave little for feeble efforts like mine, still I believe cases like the following are sufficiently rare to prove
more » ... o prove interesting, if only as an illustration of what we find stated by the late Dr. Kirkes in his admirable essay on Embolism,* and also in the works of Walshe and others. Lady H. M--, aged fifty-two, of delicate fibre, and the mother of twelve children, with a family history of gout on both sides. Until now she has not had any serious illness ; but has had slight fainting fits occasionally for some years past. Had a sharp attack of measles (printary), then prevalent in her parish, on the 18th of March, 1867, coupled with an unusual amount of bronchitis and catarrhal symptoms. On auscultation, a loud systolic murmur was heard all over the cardiac region. She did well, however; and was quite convalescent on the 25th, when, without permission, she unfortunately had a warm bath (to which she attributes her malady), instead of the cold one she was in the habit of having daily when well. She remained in the bath about three minutes; and after completing a hasty toilet, and walking into an adi joining room, she suddenly experienced the most acute pain in her left arm, extending from above the elbow to the wrist, came over faint and giddy, vomited several times, and "felt very bilious and unable to talk." 1 ordered stimulants and perfect rest, and saw her again in the evening, when I found the left arm pulseless, and much cooler than the right-in fact, it was an unmistakable case of embolism of the brachial artery at its bifurcation. She was placed in bed (as quietly as possible), and the arm encased in cotton-wool. She complained much of vertigo ; but slept soundly during the night. On the following morning the limb, although well wrapped up and in the horizontal position under the bedclothes, was quite blanched, almost cold, and somewhat shrunk. Dr. Walshe, of London, was then telegraphed for, and, on seeing the case with me, corroborated the diagnosis previously given. Perfect rest was enjoined, and an anodyne liniment was prescribed to relieve the very severe pain felt in the hand and arm. Ammonia and potash were given internally, with the view of their acting as solvents on any lesser portions of coagulated fibrin possibly then floating in the circulating fluid. Fortunately, the vitality of the limb was preserved through the anastomosing branches; and the progress, though slow, was on the whole satisfactory until the 13t,h of April, when gout showed itself in the same hand, and resisted for a time every effort to dislodge it. However, on the 7th of May she was much improved, and could use the hand a little. The arm was still pulseless, but of its natural size and temperature; and the patient felt well enough to start for a sojourn on the continent, where she remained six months, during which time she lost all the nails o2t the affected hand. On her return, much of the former strength and usefulness of the limb had been regained, almost the only difference being that the left hand and arm required more clothing than the sound limb. The pulse had now returned in the wrist, but, as might be expected, it was not so full as in the right arm. I am not aware that the intense pain complained of in this case is usual; it probably owed its origin to the situation of the clot, placed as it was in such close proximity to the principal nerves of the limb, and tightly compressed under the -tendinous expansion of the biceps muscle. That there was a Medico-Chirurgical Transactions, vol, xxxv. good deal of distension and perhaps partial laceration of the coats of the artery seems proved by the fact that there existed for some time discoloration of the integument immediately over the point of obstruction, but no tumour or other indication of aneurism presented itself. The vomiting is, I believe, a usual occurrence in these cases, but the mode of its origin is difficult to explain. The vertigo and head symptoms were probably the result of a suddenly increased current of blood sent to the brain, though at the time it was feared that a clot had probably found its way into some of the cerebral vessels; but as there were no permanent head symptoms, such could not have been the case. It is an interesting point in connexion with this case, as to whether the prostrating effects of the warm bath tended in any way either to produce coagulation, or to induce separation of a clot long since formed and connected to one of the cardiac valves. Or was the latter merely a coincidence? I am inclined to think it was; as had it been an immediate clot it would scarcely have formed so complete a barrier as to resist the full current of blood almost instantaneously, as it did. The happy termination of this case, which at one time presented a most serious aspect, fully illustrates the wonderful capabilities of the vis medicatrix naturce, even at the age of fifty-two, and in a delicate subject with longstanding cardiac disease. Staplehurst, Oct. 1868. ON the 26th of August last I was summoned at eleven P.M. to attend Mrs. A-in her first labour. On arriving at the house I found the pains very lingering and slight ; the os was dilated to the size of a sixpenny-piece. I could not detect the presentation. Finding I should not yet be wanted, I returned home, telling the nurse to send for me when the pains came on stronger. At six A.M. the following morning I was called np. The labour was progressing, and the breech presenting. It continued to do so until four P.M., when as soon as the'breech passed the os externum, the whole body of the child was expelled with some degree of force. It was dead, and from the peeling of the skin I conclude it had been so for some time. When I touched the cord it came away in my hand, leaving the placenta in utero, which I extracted after a little manipulation. It was a fine, full-grown male child, formed naturally as to its body, with the exception of the nails on the thumbs, which were like those of a rabbit. On examining the head I was surprised to find the parietal, frontal, and part of the occipital bones wanting; and at the space corresponding to, but larger than, the anterior fontanelle, was the brain, entirely denuded of skin or membrane, not even being covered with arachnoid. There was a little hair over the eyes, none elsewhere. The eyes, palate, and tongue were similar to those of a rabbit. At first I was inclined to think that in the absence of these bones the action of the uterus had squeezed the eyes into the shape I had found them, but on making inquiries as to any fright, and having heard the following story, I was induced to consider it a case of maternal impression. During the second month after conception the mother went to a penny show, in which she saw a trained horse pull the trigger of a pistol, pretending to shoot a rabbit. A dummy was then thrown out; the back of its head was bleeding, having to all appearances been shot off. This corresponded, as the mother-in-law declares, to the mark on the child's head. My patient seems never to have forgotten the circumstance during the remainder of her pregnancy, and was considerably frightened at the time. I was lucky in having to contend with a breech presentation ; if it had been a natural one should either have been puzzled to ascertain what it was, or, perhaps, have inadvertently pushed my fingers through the brain itself. The mother did well, and is now quite recovered. New Malden, Sept. 1868. LUNACY LEGISLATION.-An influential deputation of the Medico-Psychological Association had an interview with the Lord Advocate in Edinburgh last week, the object being to urge the Government to institute a thoroughly scientific inquiry into the best means of preventing the increase of lunacy and of incorrigible imbeciles. Promise was given that the matter should receive attention.
doi:10.1016/s0140-6736(02)72113-2 fatcat:ato7qfzqfbcqlhqbujl32eqbci