516 Practical ATotes from Kilkenny County Infirmary.

is now rapidly disappearing. The following are some of the diseases in which I have given iodoform a trial, and that an extensive one. At the Belfast General Hospital I have ordered it in several cases of phthisis in the following way :--Iodoform sixteen grains, essence of aniseed one drachm, cod-liver oil eight ounces, mix; dose, a tablespoonful twice daily one hour after food. Also in neuralgia given with iron, in chronic rheumatism, chlorosis, anmmia, and

a s a suppository in the vagina in cystitis in the female. At the Belfast Hospital for Diseases of the Skin iodoform has been prescribed locally in prurigo, in pruritus ani, in cancerous ulceration and painful ulcers of limbs. In phthisis the remedy in second stage of the disease checks the night sweats, and relieves the hacking cough. Moreover, the cod-liver oil agrees better with the stomach when thus combined. In neuralgia it is often curative when other remedies have failed, and I can specially call to mind the case of Serjeant D , Royal Irish Constabulary, as a case in point. I t acts better when combined with reduced iron.

Although not to the point, it may be interesting to conclude this brief notice by remarking that Dr. Dupre, of the Westminster Hospital, found in the course of his experiments on elimination of alcohol, that after six weeks of total deprivation from alcoholic drinks, and even in one individual who completely abstained from alcohol, the urine contains sometimes a substance which is not alcohol, but which presents the characters by which we generally recognize alcohol. This body passes over among the earliest pro- ducts of distillation, gives acetic acid on being oxydized, reduces blchromate of potash when dilute sulphurlc acid is present, and its aqueous solution has a lower density than water. I t furnishes iodo]brm, and exists in the urine in a very small quantity.

ART. XVI.--P~'actical Notes from Kilkenny County Infirmary. By DR. EACH. JOHNSON, A.M., T.C.D., F.R.C.S.I.; Licentiate, King and Queen's College of Physicians, &c., &c.

P O P L I T E A L A N E U R I S M S U C C E S S F U L L Y T R E A T E D B Y

C O M P R E S S I O N .

THE treatment of aneurism by compression is a subject of ~uch great importance that the publication of each successful case seems to be a matter of duty. On these grounds the following details arc now made public. Although it forms but a unit in the statistics

By MR. JOHNSON. 517

Of aneurismal compression, even one successful case is of importance in determining the value of this plan of treatment; and although those cases already recorded are so numerous as to have set the question nearly at rest, the addition of another cannot be amiss, if only to strengthen the evidence already accumulated; while the circumstances and successful issue of that under consider- ation are useful, not alone in aiding toward the arriving at a just conclusion, but in teaching the important lesson that we should not be discouraged by dimculties, or abandon the prosecution of any useful or promising expedient, because our first efforts are not crowned with immediate or complete success.

Michael Murphy, an agricultural tabourer, aged about thirty-four, and of medium size and healthy aspect, was admitted into Kilkenny County Infirmary in February, 187"2, on account of a popliteal aneurism of the left leg, which gave him great pain, and was increasing rapidly in size. He could not assign any cause for its formation. His occupations were only those common to his class, and he was not aware of any accident, injury, or exertion which could have conduced directly to its formation. Moreover, he was a man of temperate habits.

His attention was first drawn to it by dull persistent pain, stiffness of the knee, and inability to accomplish the ordinary motions of the joint. He applied for advice to the late Dr. Leech, of the Gowran Dispensary, who at once appreciated the true nature of the disease, and recommended him to apply for admission into the County Infirmary.

On admission a strongly pulsating tumour was distinctly observ- able in the left popliteal space. That it was not merely pulsation communicated by the underlying artery was plain from the expansile character of the pulsation, an d by its total disappearance on obliterating the current of the femoral artery by pressure on the ramus of the pubis.

The nature of the ease being sufficiently plain, it was at once decided to give a fair trial to the method of compression. Accordingly, the patient was confined to bed. Two clamps wei'e applied, so as to enable him to relieve the pain arising from continued pressure by their alternate use. By means of the ordinary large pelvic instrument, with combined movements, and ball and socket joint, pressure either above or below Poupart's ligament was provided for, while Lister's more simple instrument, embracing the thigh, effected alternate pressure in the triangular

518 Practical Notes from Killcenny County Infirmary.

space comprised between the sartorius, adductor longus, and Poupart's ligament.

These instruments were fully capable of arresting the arterial current, and stopping pulsation in the tumour, if only the patient could have been prevailed on to endure their alternate use. "But he proved extremely intolerant of all pressure, and did not carry out the directions given him; it has been since ascertained that he invariably relaxed the instruments as soon as his attendants turned their backs. The tumour increased with great rapidity, and the paln became more and more intolerable. In a short time the appearances became very formidable and alarming. Tile swelling was no longer confined to the popliteal space, which was now greatly enlarged, and the entire knee became distended by synovitls, which supervened gradually. The pulsation became daily more violent and more widely diffused, the tumour encroached rapidly on the inner side of the joint, a dusky shade overspread the greater part, and over the inner condyle of the femur a patch became conspicuous, dark and well-defined, about the size of a florin, with well-marked line of demarcation, indicating unmistakably that a slough was on the point of forming, and that in a few days, perhaps hours, the tumour would burst, and the patient perish, unless prompt and effectual means were taken to arrest the progress of the disease.

However, previous to resorting to the operation of tying the femoral artery, a measure attended with some danger, and, at the best, uncertain in its result, it was determined to give one final trial to compression by means of continued digital pressure.

The measurements at this time, March, 1872, were as follows : - Sound leg, girth round patella and popliteal space twelve inches; diseased leg, corresponding measurement seventeen inches: sound leg, girth of thigh immediately above patella eleven inches; diseased leg, corresponding mcasurement sixteen inches: longi- tudinal measurement of tumour four inches.

These measurements indicate a very considerable enlargement, but the critical position of the case was more forcibly shown by the suggestive dusky complexion of the tumour, the defined spot of impending sphacelus, the violent pulsation, which was hourly acquiring greater force, and the pain, which had become intolerable, and for the relief of which anodynes had now become ineffectual.

Arrangements were made accordingly, and a day fixed for the final trial of compression by persistent digital pressure, applied by

By Mrs. Jor~soN. 519

a succession of skilled assistants, who undertook to give an hour or more each in turn until some decided result might be obtained. From 8 sharp a.m. till 10.30 p.m., 7th March, 1872, effectual pressure was never allowed to relax for a moment, being applied alternately above and below Poupart's ligament, but principally on the ramus of the pubis, where the patient bore it. best, and where a smaller amount of' pressure bad a more decided effect on the arterial current. About 1 o'clock p.m. the patient became almost uncon- trollable from intense pain in the tumour, and struggled hard to break away, but was with difficulty restrained, partly by force, and partly by the earnest remonstrances of those present. And here material advantage was obtained by the interposition and personal influence of Sir John Blunden, Bart., one of the governors of the hospital, but for whose encouraging interference as an amateur, and reassuring remonstrances with the patient, the best efforts of the medical staff were in danger of being baffled.

]?or some time the patient struggled violently to break away, and it was with difficulty he could be kept in bed and pressure continued. However, by judicious restraint his struggles were overcome, and the pressure, which had never been permitted to relax, successfully continued. A full opiate was promptly adminis- tered, and preparations made for bringing him under the influence of chlorofbrm, but befbre they were completed the opiate appeared to have taken effect, the intense pain abated, and the patient once more became amenable to treatment.

By the kind assistance of my colleague, Dr. Kinchela, aided by Drs. Lyster and Fitzsimons, and Mr. White, of Kilkenny Dispen- sary, each undertaldng the maintenance of digital pressure by turns, effectual compression was unremittingly sustained from 8 o'clock a.m. until 10.30 at night, when it was gradually withdrawn, and it was then found, to the great satisfaction of those interested, that there was not a vestige of pulsation in the tumour.

The pain in it had never returned since 1 o'clock p.m., and the patient had borne the digital pressure throughout without incon- venience. The intolerable pain complained of at mid-day was in the tumour itself. He now got a full anodyne. He had been given aliment at intervals during the day while pressure was going o n .

He had a good night, and from this out the progress of the case was most satisfactory. The dusky hue gradually left the tumour. The defined semi-sphacelated spot soon recovered its natural colour.

520 Practical Notes from Kilkenny County l~rmary.

From day to day the tumour slowly diminished in size. No trace of pulsation ever reappeared. Health and general aspect rapidly improved. On the 10th Ju ly the measurement round patella was the same as that round thigh just above it, and had been reduced from seventeen and sixteen inches to fourteen and a-half. On the 27th August it had been further reduced to fourteen. He had now been for some time walking about, the only inconvenience remaining being inability to perfectly straighten the leg, and pain and stiffness in the instep.

He has since presented himself at the hospital able to straighten the knee perfectly; it has now attained its natural size. The tumour has been ahnost altogether absorbed, and only a small firm kernel is to be found in the popliteal space. Fie has been able to resume his ordinary duties as a field labourer, and is in excellent health.

So far as the circumstances of a single case are of value nothing could speak more favourably for compression than the one under consideration. I t proves, at least, that before resorting to an operation which cannot be divested of danger and uncertainty by the most consummate skill, the surgeon is bound to give a fair and patient trial to compression. That it is not suitable to all cases, and that it will notsucceed in all must be admitted; but that it ought to be fairly tried in all, when at all applicable, the past history of compression goes far to prove, and the preceding details are now offered as a contribution to the statistics already accumu- lated on this important question.