Sidney Coupland
1882 The Lancet  
9 as there was now only some venous oozinar from the wound, he applied a compress and bandage, by which all haemorrhage was arrested. The child was, however, nearly pulseless. On the fourth day the bandage was changed, but, as there was no bleeding and no reason for removing the compress, this was not disturbed. On the tenth day the wound was healed, but a pulsating tumour about the size of a filbert had formed. Another compress and bandage were applied, but during the ensuing night the child
more » ... came very excited and kicked about, causing a reopening of the wound and renewal of the bleeding. I was now called in consultation, and found the child very ansemic, with some oedema of the right leg and foot. There was a wound a little above the bend of the right knee, from which the blood was oozing, and a pulsating tumour occupying the upper three-fourths of the popliteal region. It was evident that the popliteal artery or some large branch of it had been wounded. The child having been anaesthetised by Mr. Corner, I made a vertical incision for about three inches through the skin and fasciæ, and then removed a considerable quantity of tough, firmly adherent clot. The popliteal artery now became visible, at the bottom of the wound for about two inches in length, partly overlapped by the internal popliteal nerve. There was no trace of the popliteal vein, which had probably been completely divided at the time of the accident. When the nerve had been drawn to the inner side the wound in the artery could be seen on the posterior wall of the vessel, circular in shape, about one-eighth of an inch in diameter, and filled with clot. The surface of the vessel for about threequarters of an inch below this was riddled with small holes, from which, even while the tourniquet was applied, some blood-stained fluid exuded. Two catgut ligatures were applied, so as to include between them about an inch of the artery. On the removal of the tourniquet there was still some fresh bleeding from the lower part of the wound. I therefore divided the vessel between the ligatures, dissected up the distal end, and again ligatured it about half an inch lower down. There being no more haemorrhage, the wound was closed with carbolised silk sutures, and was dressed antiseptically. A back splint was applied to keep the limb at rest. For a week the wound remained aseptic, but showed little disposition to heal. The subsequent history of the case has been kindly sent to me by Mr. Corner :-" The wound did not continue aseptic, nor did any part heal by first intention ; and when it was nearly healed a collection of pus was found high up on the front of the leg, which, on being opened, let out a lot of pus and a piece of muscle with a short tendinous attachment, the whole about an inch long. Now (Dec. 6th) the wounds, front and back, have been healed for several weeks." I did not understand at the time of the operation how the smaller holes in the wall of the artery could have been produced. A possible explanation may be that vascular communications had formed between the vasa vasorum and the organising clot, and that these, necessarily torn across in the removal of the adherent clot, did not contract in consequence of the previous application of an Esmarch's bandage, which seems to produce temporary paralysis of the walls of the smaller vessels. The abscess and sloughing of muscle on the front of the leg were probably due to the breaking down of a thrombus. The operation was done under carbolic spray, and presented no difficulty, owing to the able assistance of Messrs. Corner and Vernon. LONGEVITY IN IRELAND.-In the quarter ending the 30th of September last the deaths of eleven persons in Ireland were registered whose ages were stated to be 100 years or upwards. Of these aged persons seven were women. Their respective ages were as follows :-One 100 years; one 101 ; two 103; one 104; one 106; and one 115. The first, one of the third, and the two last-mentioned deaths occurred in the Donaghmore, Forkill, and Meigh districts, Newry union. Three died at 100 years ; six not mentioned ; and one man, who died in the Killaun district, Enniscorthy union, at 101, was, the registrar states, able to work on his farm up to within a week of his death. In reference to two of the women who died at 100 and 103 respectively, the registrar observes of the former that she was able to go about the day before her death ; her senses were perfect up to the last; and of the latter, the last eighty years of her life were spent in a cabin on the summit of the highest of the Burrew mountains. PHYSICIAN TO THE MIDDLESEX HOSPITAL. My contribution to this subject conshts in an analysis of eighty-four cases of acute and subacute rheumatism treated with more or less rigour by salicylate of soda. Statistics from the Middlesex Hospital bearing on this subject have been published by Dr. Finlay and Mr. Lucas in 1879,2 and by Dr. Greenhow in 1880.3 I decided to limit my survey to the cases which have occurred in my own wards during the two years I have been physician, in the hope that a closer scrutiny might thus be possible, than if one were dealing with a larger body of cases, and thus something more than a statistical inquiry be attempted. I may remark, however, that the number of cases exceeds that analysed by Dr, Greenhow, and as they came from the same hospital the two series may well be compared. But I have not, like Dr. Greenhow, excluded the mild cases, and with nine exceptions4 the administration of the salicylate was commenced upon the day of admission. In a few cases it was entirely abandoned from intolerance on the patient's part or apparent inefficacy on the part of the drug. I should also state that the doses which were administered were by no means heroic, the endeavour being to give as small an amount as possible consistent with the production of relief from pain and fever, for it had seemed that large and frequently repeated doses, rapidly efficacious though they are, have to be soon abandoned owing to the inconvenient, if not serious, toxic effects they produce. Only once, then, has as much as 160 grs, in the twenty-four hours been given, or 20 grs. every three hours-not often 120 grs., more frequently 90 grs. (or 15 grs. every four hours), and 60 grs. (or 15 grs. every six hours). Dr. Maclagan remarked at the last meeting that the rapid elimination of the drug required its frequent renewal and administration in large doses ; but although I have several notes of the rapid appearance of the salicyl reaction in the urine, as tested by the perchloride of iron, I have also notes where the reaction has been obtained two or three days after discontinuance of the drug, and Dr. Fagge quoted a case of Dr. Habershon's in the same sense. Moreover, the toxic effects are seldom produced after the first dose, but after two or three doses-have allowed the drug to act with cumulative eitect. I should argue, then, that the drug continues to exert an effect for some time after its administration has been discontinued. The point, however, is one which will be raised again in speaking of relapses. I may simply add now that throughout the principle has been recognised to prevent relapse, if possible, by continuing the administration long after the subsidence of the primary fever and articular manifestations ; and frequently the dose has been gradually reduced in the hope that the patient may be kept to a slight extent at least under its influence. With these preliminaries I may proceed to deal with the series of cases treated by salicylate of soda. I have said they were 84 in number; and the course of each case, especially with reference to the salicylate, is shown graphically in the accompanying chart. (This chart5 contained 86 cases; 4 of them-Nos. 6 to 9-were treated partly by salicin and partly by other methods; they were therefore excluded from the analytical summary. Of the remaining 82 two were readmitted, and were reckoned, for the sake of convenience, as new cases, thereby bringing the total to 84.) (Nos. lOA and 31A, readmitted, not included.) " 1
doi:10.1016/s0140-6736(02)21662-1 fatcat:o52v77xq7vgh5dey4zudzcler4