CASE OF RAPID COAGULATION OF THE CONTENTS OF AN ANEURISMAL SAC BY MEANS OF COMPRESSION

G.W.J. Sutherland
1876 The Lancet  
286 very alarming. For a time she lay in a semi-unconscious state, the pulse being quick, small, and compressible, the skin cool, and a feeling of nausea being very persistent. Her condition having assumed so serious a character, I was requested to sleep three nights in the house, in order to be at hand in the event of a return of the haemorrhage. Her general weakness being afterwards so exceedingly pronounced, her friends wished Sir William Gult to be sent for; he, however, not being at home,
more » ... not being at home, Dr. Habershon came in his stead. I had then given her both the gallic acid and doses of turpentine. When Dr. Habershon saw her, he thought the bleeding might not return, and advised the continuance of the remedies a little longer. He also recommended, if more blood should be vomited, the free use in large doses of the tincture of the perchloride of iron. The haemorrhage did not recur. This lady was an American, and subsequently to her first attack she had consulted some of the most eminent practitioners in New York, and the opinion had been given that her complaint was that of chronic gastric ulcer, in which Dr. Habershon fully coincided. For many weeks she remained in an extremely weak and fragile condition. She took quinine and iron, and from time to time other tonics; the bowels were kept open by mild laxatives, and very rigid rules were laid down in respect to her diet. I last heard of this patient through Dr. Habershon, who told me there had not been any more bsematemesie, and that she seemed to have greatly recovered her general health. During the first forty-eight hours of my attendance, I very much feared death by syncope. It must, however, be borne in mind that alarming quantities of blood may be vomited in haemorrhage from the stomach, and still recovery be the result. as I have reneatedlv witnessed. CASE 3.-The next example which I now give was one very typical of the slow but persistent progress of this complaint. On March 28th, 1870, I was requested to see Miss P. L. G-, a young lady twenty-six years of age, of whom I was told that she had been for several years an invalid. Her volume of flesh was good, nor was there any marked expression of disease in her countenance. I was also informed that about two years prior to the above date she had had for a long period persistent nausea and vomiting, and so continuous and distressing were these symptoms that her medical advisers then feared the consequent exhaustion would end fatally. She slowly recovered from that attack, and in the course of time could digest a prescribed diet. She, however, remained much of an invalid. She had consulted some of the leading men in London, and all whose advice she sought concurred in the opinion of gastric ulcer. She had repaired to various places for change of air and climate at home and on the Continent, and at length came to Tunbridge Wells. When I first saw her she was in bed, and she told me that during the previous three days she had had a return of sickness and vomiting. Her food could not be retained, and, immediately after taking any nourishment, it was ejected. On inspection of the abdomen, there was a rounded fulness ever the stomach, and on palpation moderate pressure produced epigastric pain. The line of hepatic dulness slightly exceeded the costal edge, but there was no splenic enlargement. The physical signs of the thorax gave no notable characteristics. The tongue was moist, but coated on the dorsum. Pulse 84, small, regular, and compressible. Bowels confined, and last evacuation was dark and biliary. She was ordered small doses of the bicarbonate of potash, morphia, and hydrocyanic acid. I was in constant atcendance on this young lady for some weeks, and the nausea and sickness, beyond very temporary alleviation, defied all remedies. Various medicines were prescribed, but with no satisfactory effects. She had morphia, herbane, conium, prussic acid, creasote, belladonna, and opium. Sedative suppositories, stimulating injections, counter-irritants, and ice to the spine, were tried, but without producing any marked relief. Concentrated soups, milk, and lime-water, jellies, and other bland nutrients, were ordered, but even these were as a rule rejected. Iced champagne was better retained than any other stimulant. When such a scanty amount of ingesta were kept in the stomach, it was not wondered at that she gradually lost flesh and strength. As time went on the wasting became more and more apparent, the lips became dry and parched, and the tongue covered with a silvery coat, the tip and edges looking red and irrit. able. The eyes assumed a sunken appearance, and seemed small in their foramina, and the facies hippocratica ere long was marked, and expressive of her slow but sure decline. With these ominous changes the pulse indicated the diminished column of blood passing through her heart; it was weak, thready, and irregular. Three days before her death the cerebral functions succumbed in the general loss of vital power; she looked around her with astonished gaze in hazy bewilderment. Utter unconsciousness supervened, and she tranquilly sank on May 7th, 1870. This instance of the disease well illustrated one mode of death which ushers in the final termination-that in which there is gradual and unarrested extinguishment. , aged twenty-nine, captain of the maintop, was received from the Boscawen on the lst July, with an aneurism, about the size of, a pigeon's egg, in the left popliteal space, the result of a strain when on duty aloft about a fortnight previously. Swelling and pain of the leg had been removed by former treatment. The pulsations in the sac were arrested, without diminution of its size and without stopping the circulation of the limb, by slight pressure with the thumb over the femoral artery where it leaves the pelvic cavity; but even this degree of force, when applied by means of a compressor, could be' borne only for a short time. Continuous pressure was therefore only employed so as to modify the strength of the pulsations in the sac. July 2nd.-Swelling painless and not enlarged. Genuflexion was tried to-day, but discontinued in consequence of pain behind the knee, and compression was resorted to as before. 3rd.-Sac increased in size, its -expansion being entirely lateral-i. e., across the axis of the vessel. One compressor was applied over the artery at the pelvic brim, and another at the apex of Scarpa's space, with sufficient force to render the sac all but pulseless. Considerable but not acute pain. was endured by the patient-an intelligent man who understood the nature of his case, but it was modified-by occasionally making each point of compression take its turn of duty, white the other was relieved. 4th.-Sac incompressible, but pulsates slightly without expanding. All pulsation ceases on pressing the tumour against the femur. Apparatus applied as before. 5th.—Tumour solid and pulseless. No pulsation can be felt in the main artery for two inches above the tumour, nor in the anterior and posterior tibials near the anklejoint. As a matter of precaution, one compressor was kept on the limb with a slight degree of force till the lOtb, when it was finally removed. In the meantime the tumour gradually diminished, and on the 21st was less than a. walnut, its ends becoming cord-like. Pulsation in the vessels at the ankle-joint was first observed on the 20th, but nothing abnormal was detected in the state of the leg during the period occupied in establishing collateral circulation, except that it was larger in circumference than the right leg by ! one inch. The apparatus mainly instrumental in completing within forty-eight hours the process of coagulation consisted of an aneurismal tourniquet or compressor, and an almost semicircular band of iron, which could be loosely applied-over the limb at the lower part of Scarpa's space. The posterior arm of this band, which was made by a blacksmith from a gutta-percha, model, was flattened out to twelve square inches, so as to afford a large area for counter-pressure on the back of the limb. Through a slit in the anterior arm could be passed the central rod (provided with a screw) of an ordinary tourniquet, the upper bar of which was fastened to the anterior arm, and a-pad attached to the lower bar could be pressed upon the femoral artery by merely turning
doi:10.1016/s0140-6736(02)49191-x fatcat:x22haiusujdmld2m27thc3o7cq