603 posure to wet and cold as much as possible. I also told him that he might with advantage continue his tonic mixture for some time. After leaving Harrogate he went south, and I occasionally heard of him. He continued much in the same state as when I last saw him, until the end of November, when, after having been out shooting, he experienced a return of the pain in his great toe, for which he applied to Mr. Hussey, of Oxford, under whose judicious treatment he rapidly recovered. The finger was shown to more than one eminent surgeon in town, and on Jan. 28th the gangrenous portion was amputated by Mr. Walter J. Coulson, chloroform being administered. In a few days, the stump progressing favourably, Col. B-- re- turned to the country. About a month after the operation, Mr. Coulson tells me, a small abscess formed at the phalanx ; on opening this he found the bone exposed, and had no doubt that a small portion would exfoliate. He remarks in his letter, that " since the operation there has been less pain in the fingers and toes, and the patient has slept better." .RHKM’.—I have called this a case of anaemic sphacelus because I believe the death of the little finger and threatened mortification of the other fingers and toes arose chiefly, if not entirely, from their bloodless condition. I have found no similar case on record ; all the cases of spontaneous gangrene I have perused are attributed to mechanical obstruction of the circulation, by means of plugged arteries, osseous degeneration, atheroma, cold, &c., or are described as local manifestations of constitutional evils, such as purpura, ergotism, typhus, &c. The only case which is not assigned to one or other of these conditions is recorded in the Provincial Medical and Surgical Journal for 1S46, p. 302; but even here, "although many were the conjectures as to the pathology," the fact that morti- fication was preceded by 11 slight febrile symptoms with petechiae for four days" (bow many more?) points to toxsemia. of one kind or another as the exciting cause of gangrene. I am satisfied that none of the above-named conditions existed in Col. B-’s case. Mr. Hey suspected disease of the arterial coats; but he only saw the case twice. After many careful examinations, I came to the conclusion that the arteries were healthy ; and on Feb. 19th Mr. Coulson writes : "I am inclined to take much the same view of the case as you have done. Of one thing I am certain, and that is, that there is no disease in the arteries themselves. I believe with you that there has been a want of power in the vis a tergo of the blood, and, in addition, that there has been an excess of fibrin in the blood, favouring co- agulation. I speak confidently respecting the condition of the arterial coats, for I carefully examined the radials and other superficial vessels, and found them all alike of normal supple- ness. " I cannot express my views of the pathology of this case better than by copying the remarks I find in my case book :— After carefully considering the history of this case, I am satisfied that the whole symptoms arise from, and may be ex- plained by- lst. Feebleness of the circulation, from want of power in the vis a tergo. 2nd. Lowering of the vitality, from deficiency of nerve- force. There may have been a tendency to inflammation of the fibrous tissues, or an excess of fibrin in the blood, but we can- not say positively that there was ; whilst we can say that the heart’s action was extremely feeble, and consequently that the circulation, especially in the extremities, was languid and im. perfect. And, considering the constant haul upon Col. B-’s physical powers and nervous sensibilities, I think we need not wonder that he had nigh become bankrupt as regards that principle of life, nerve-force, which must imbue the whole man in order that he may not only enjoy perfect health, but be able to resist certain pernicious influences to which he is frequently exposed. The portion of the little finger which was lost was dead for some time before I saw it, and in my opinion might have been saved had it received in time similar treatment to its fellows. One word as regards treatment. Had I known when Col. B- was under my care the power digitalis possesses as a cardiac stimulant or tonic, I would have given it a trial. I had been in the habit of using it in heroic doses in delirium tremens, but then I only looked upon it as a counter-poison to alcohol. I have used it as a tonic lately in a case of cardiac debility with irregular action, consequent upon epilepsy, with great benefit; and, had I an opportunity, I would employ it in a case similar to that whose history I have now related. May, 1863. A Mirror OF THE PRACTICE OF MEDICINE AND SURGERY IN THE HOSPITALS OF LONDON. KING’S COLLEGE HOSPITAL. STRUMOUS DISEASE OF THE KNEE ; EXCISION , RECOVERY. (Under the care of Mr. FERGUSSON.) Nulla est alia pro certo noscendi via, nisi qnam plurimas et morborum et dissectionum historias, tam aliornm proprias, collectas habere et inter se com- parare.-MORGAGNI. De Sed. et Caus. Morb., lib. 14. Procemium. For the notes of the following cases we are indebted to Mr. W. J. Smith, house-surgeon to the hospital. Robert C-, aged six years, a pale delicate child, was ad- mitted into the female surgical ward on Jan. 9th, 1862, with strumous disease of the left knee-joint. Has lived in London, belongs to a healthy family, and had very good health until about a year and a half before admission, when he had scarlet fever, which was followed by dropsy. While convalescent he had a fall and injured his left knee; this swelled and became painful, but no notice was at first taken of it. Subsequently the child was brought to the hospital, and the knee was painted with tincture of iodine. Within the last three months a gutta- percha splint has been made for him, but the joint has been so tender that he could not bear it, and practically the joint has not been kept at rest at all, the boy having been allowed to move about as he wished. On admission the knee was found to be much swollen, mea- suring twelve inches round the thickest part. The swelling appeared to be more on the inner than the outer side of the ,joint, and it extends upwards for about four inches in front of the femur. Distinct fluctuation could be felt here and there, particularly on the inner side; and there was evidently a pulpy and thickened state of all the tissues surrounding the joint. The skin was tightly stretched over all this-pale, but healthy. The limb was slightly bent, and any attempt to straighten the knee gave great pain. He was ordered to be kept in bed, the knee to be painted with iodine, and a gutta- percha splint to be applied. April 5th.---The swelling has gone down very much since he has been in the hospital, and there is now very little pain in the joint. He was sent out, to be treated as an out-patient. 30th. --To-day he was readmitted. The knee is now very much worse, and more contracted. On the inner side of the joint is a large ulcer about the size of half-a-crown ; also one orifice of a sinus running into the joint. There is a copious and constant discharge of pus. The child is evidently suffering much from the disease. May 17th.-The patient having been put under the influence of chloroform, Mr. Fergusson excised the joint. A single trans- verse incision was first made, the patella removed, and the saw having been applied first to the lower end of the femur, and next to below the head of the tibia, a large wedge-shaped mass was removed, composed of the joint itself, where partial anchy- losis had already taken place ; and as the cancellous structure of the tibia, where exposed, was found to be diseased, another slice was removed. The parts having been then brought together, the lips of the wound were united by sutures, and the leg bandaged down to a straight excision splint. There was very little haemorrhage, and no ligatures were required. Upon examination of the excised joint, extensive disease was found to exist. The cartilage had almost entirely disappeared from both bones, and the exposed bone was soft, dark, and very vascular. The surrounding tissues were infiltrated with a thick gelatinous material. Very little constitutional disturbance occurred after the ope- ration. The patient complained not of pain except when the wound was dressed, and he rapidly gained strength. Union, however, was slow in taking place along the line of incision, and several small abscesses formed, which had a tendency to burrow high up among the muscles of the thigh, and which ro-
Transcript
603
posure to wet and cold as much as possible. I also told himthat he might with advantage continue his tonic mixture forsome time.
After leaving Harrogate he went south, and I occasionallyheard of him. He continued much in the same state as whenI last saw him, until the end of November, when, after havingbeen out shooting, he experienced a return of the pain in hisgreat toe, for which he applied to Mr. Hussey, of Oxford,under whose judicious treatment he rapidly recovered. The
finger was shown to more than one eminent surgeon in town,and on Jan. 28th the gangrenous portion was amputated byMr. Walter J. Coulson, chloroform being administered. In afew days, the stump progressing favourably, Col. B-- re-turned to the country. About a month after the operation,Mr. Coulson tells me, a small abscess formed at the phalanx ;on opening this he found the bone exposed, and had no doubtthat a small portion would exfoliate. He remarks in his letter,that " since the operation there has been less pain in thefingers and toes, and the patient has slept better."
.RHKM’.—I have called this a case of anaemic sphacelusbecause I believe the death of the little finger and threatenedmortification of the other fingers and toes arose chiefly, if notentirely, from their bloodless condition. I have found nosimilar case on record ; all the cases of spontaneous gangrene Ihave perused are attributed to mechanical obstruction of thecirculation, by means of plugged arteries, osseous degeneration,atheroma, cold, &c., or are described as local manifestations ofconstitutional evils, such as purpura, ergotism, typhus, &c.The only case which is not assigned to one or other of theseconditions is recorded in the Provincial Medical and SurgicalJournal for 1S46, p. 302; but even here, "although manywere the conjectures as to the pathology," the fact that morti-fication was preceded by 11 slight febrile symptoms withpetechiae for four days" (bow many more?) points to toxsemia.of one kind or another as the exciting cause of gangrene. I amsatisfied that none of the above-named conditions existed inCol. B-’s case.Mr. Hey suspected disease of the arterial coats; but he only
saw the case twice. After many careful examinations, I cameto the conclusion that the arteries were healthy ; and on Feb.19th Mr. Coulson writes : "I am inclined to take much thesame view of the case as you have done. Of one thing I amcertain, and that is, that there is no disease in the arteriesthemselves. I believe with you that there has been a want ofpower in the vis a tergo of the blood, and, in addition, thatthere has been an excess of fibrin in the blood, favouring co-agulation. I speak confidently respecting the condition of thearterial coats, for I carefully examined the radials and othersuperficial vessels, and found them all alike of normal supple-ness. "
I cannot express my views of the pathology of this casebetter than by copying the remarks I find in my case book :—
After carefully considering the history of this case, I amsatisfied that the whole symptoms arise from, and may be ex-plained by-
lst. Feebleness of the circulation, from want of power in thevis a tergo.
2nd. Lowering of the vitality, from deficiency of nerve-force.
There may have been a tendency to inflammation of thefibrous tissues, or an excess of fibrin in the blood, but we can-not say positively that there was ; whilst we can say that theheart’s action was extremely feeble, and consequently that thecirculation, especially in the extremities, was languid and im.perfect. And, considering the constant haul upon Col. B-’sphysical powers and nervous sensibilities, I think we need notwonder that he had nigh become bankrupt as regards thatprinciple of life, nerve-force, which must imbue the whole manin order that he may not only enjoy perfect health, but be ableto resist certain pernicious influences to which he is frequentlyexposed. The portion of the little finger which was lost wasdead for some time before I saw it, and in my opinion mighthave been saved had it received in time similar treatment toits fellows.One word as regards treatment. Had I known when Col.B- was under my care the power digitalis possesses as acardiac stimulant or tonic, I would have given it a trial. Ihad been in the habit of using it in heroic doses in deliriumtremens, but then I only looked upon it as a counter-poison toalcohol. I have used it as a tonic lately in a case of cardiacdebility with irregular action, consequent upon epilepsy, withgreat benefit; and, had I an opportunity, I would employ itin a case similar to that whose history I have now related.May, 1863.
A MirrorOF THE PRACTICE OF
MEDICINE AND SURGERYIN THE
HOSPITALS OF LONDON.
KING’S COLLEGE HOSPITAL.STRUMOUS DISEASE OF THE KNEE ; EXCISION ,
RECOVERY.
(Under the care of Mr. FERGUSSON.)
Nulla est alia pro certo noscendi via, nisi qnam plurimas et morborum etdissectionum historias, tam aliornm proprias, collectas habere et inter se com-parare.-MORGAGNI. De Sed. et Caus. Morb., lib. 14. Procemium.
For the notes of the following cases we are indebted to Mr.W. J. Smith, house-surgeon to the hospital.
Robert C-, aged six years, a pale delicate child, was ad-mitted into the female surgical ward on Jan. 9th, 1862, withstrumous disease of the left knee-joint. Has lived in London,belongs to a healthy family, and had very good health untilabout a year and a half before admission, when he had scarletfever, which was followed by dropsy. While convalescent he
had a fall and injured his left knee; this swelled and becamepainful, but no notice was at first taken of it. Subsequentlythe child was brought to the hospital, and the knee was paintedwith tincture of iodine. Within the last three months a gutta-percha splint has been made for him, but the joint has been sotender that he could not bear it, and practically the joint hasnot been kept at rest at all, the boy having been allowed tomove about as he wished.On admission the knee was found to be much swollen, mea-
suring twelve inches round the thickest part. The swellingappeared to be more on the inner than the outer side of the,joint, and it extends upwards for about four inches in front ofthe femur. Distinct fluctuation could be felt here and there,particularly on the inner side; and there was evidently apulpy and thickened state of all the tissues surrounding thejoint. The skin was tightly stretched over all this-pale, buthealthy. The limb was slightly bent, and any attempt tostraighten the knee gave great pain. He was ordered to bekept in bed, the knee to be painted with iodine, and a gutta-percha splint to be applied.
April 5th.---The swelling has gone down very much since hehas been in the hospital, and there is now very little pain inthe joint. He was sent out, to be treated as an out-patient.30th. --To-day he was readmitted. The knee is now very much
worse, and more contracted. On the inner side of the joint isa large ulcer about the size of half-a-crown ; also one orifice ofa sinus running into the joint. There is a copious and constantdischarge of pus. The child is evidently suffering much from thedisease.
May 17th.-The patient having been put under the influenceof chloroform, Mr. Fergusson excised the joint. A single trans-verse incision was first made, the patella removed, and the sawhaving been applied first to the lower end of the femur, andnext to below the head of the tibia, a large wedge-shaped masswas removed, composed of the joint itself, where partial anchy-losis had already taken place ; and as the cancellous structureof the tibia, where exposed, was found to be diseased, anotherslice was removed. The parts having been then broughttogether, the lips of the wound were united by sutures, andthe leg bandaged down to a straight excision splint. Therewas very little haemorrhage, and no ligatures were required.Upon examination of the excised joint, extensive disease was
found to exist. The cartilage had almost entirely disappearedfrom both bones, and the exposed bone was soft, dark, andvery vascular. The surrounding tissues were infiltrated with athick gelatinous material.Very little constitutional disturbance occurred after the ope-
ration. The patient complained not of pain except when thewound was dressed, and he rapidly gained strength. Union,however, was slow in taking place along the line of incision,and several small abscesses formed, which had a tendency toburrow high up among the muscles of the thigh, and which ro-
604
tarded his recovery for some time; but on Sept. 3rd he was somuch improved as to be able to leave the hospital for the infir-mary at Margate. Complete union had taken place, but theknee was pui%r and swollen, and there still remained both onthe inner and outer side of the joint several small ulceratedpatches, which were healing over. The shortening of the limbdid not exceed one inch.
April 18th, 1863.-To-day the boy came to the hospital.His health has very much improved, and he is able to walkabout all day. The left lower limb is quite straight, and aboutthree-quarters of an inch shorter than the sound one. Thereis no pain about the joint, and all the ulcers have healed up.
LONG-STANDING DISEASE OF THE KNEE-JOINT; EXCISION;FATAL RESPI/E.
(Under the care of Mr. FERGUSSON.)Jane D--, aged twenty-four, was admitted March 18th,
with long-standing disease of the knee. She was a corpulentand hysterical-looking young woman. Before her knee becameaffected she was in general service. All her relations are
healthy. Nine years ago she had some swelling about the leftknee, which subsided after the application of iodine paint.Three years afterwards a large abscess formed, and pointed onthe inner side of the joint, over the head of the tibia. The abscesswas opened, and discharged a quantity of pus. This was followedby very severe and constant pain in the joint, which graduallybecame stiff and contracted, so that when the abscess hadhealed, and she was able to get up, she found that she couldnot put her foot to the ground. A year ago she was a patientin the Northampton Infirmary, where an attempt was madeto straighten the limb, but with very little success. The kneehad increased in size during the last three months, and thepain had been so severe as to keep her in bed.Upon admission, the right knee was found to be much
swollen and slightly bent; there was partial anchylosis; thepatella was immovable, and thrown upon the outer condyle.At the upper part of the leg, below the head of the tibia, werethe orifices of three sinuses, which extended upwards into thejoint and communicated with bare bone. With the exceptionof these the skin was healthy, not red nor congested. Anyattempt to move the joint gave her great pain. The musclesof the left calf were very much wasted, and the whole limbwas somewhat smaller and less developed than the right one.The patient’s health seemed very fair; her appetite was good ;and she complained of very little save the occasional startingof the limb, which broke her rest at night. The limb wasordered to be kept at perfect rest, and to be fomented ; thepatient to take tincture of the sesquichloride of iron thrice aday, and cod-liver oil every morning.March 28th.-The pain daily getting more intolerable, and
exhausting her strength, Mr. Fergusson determined upon ex-cising the joint, as the long duration of the disease left little tobe hoped for from rest, or from any active treatment short ofan operation. To-day, having been put under the influence ofchloroform, she was brought from the ward into the theatre.Mr. Fergusson first made a single transverse incision over thepatella; the flaps of skin being then dissected back, and thelimb forcibly bent up at a very acute angle, the patella wasremoved, and the whole of the interior of the joint was exposed.About an inch and a half of the lower end of the femur wassawn off, and a thin slice from the head of the tibia. The softtissues were found to be infiltrated with a dark, thick, gelati-nous material, particularly at the posterior part of the joint,surrounding the popliteal vessels. The limb was then putstraight, and bandaged down upon an excision splint, the endsof the bones coming very well into apposition. The marginsof the incision were brought together by sutures, and waterdressing applied. Two small arteries required ligatures duringthe operation.The excised parts, when examined after the operation, were
found to be most extensively diseased. There was a thickened,pulpy state of the synovial membrane, and the cartilage hadnearly wholly disappeared from the femnr and head of thetibia, leaving a surface of carious bone. The cartilage of theinner surface of the patella was ulcerated here and there, andlarge patches of bone were exposed. From the lower end ofthe femur there had sprung two large outgrowths of bone-tissue.30th.-Was very restless after the operation, and suffered a
great deal from pain and starting of the limb. Yesterday shefelt very comfortable, and at night slept very well. This morn-ing she looks well; pulse 126; tongue clean. The knee wasdressed; the wound looking very healthy, and union taking
place along nearly the whole line of incision. To take six:ounces of brandy daily.
31st.-Passed a restless night, and had slight rigors. Feelbetter this morning. Wound looking well; water-dressing ap-plied.
April 2nd.-When seen to-day about noon was not so well..She is very restless, moaning in an hysterical manner, and com-plaining of great thirst; pulse 130; tongue red and dry. Aboutsix P.M. had a very severe attack of shivering, which was fol--lowed by constant vomiting. The knee when examined wasfound to be quite dry, and there was no discharge in the dress.ing. A large linseed-meal poultice was ordered to be applieddirectly, and to be changed every three hours. The patient to.suck ice, and to have dilute hydrocyanic acid, with chlcrieether, every four hours.3rd.-The vomiting continued the whole of the night, and-
nothing could be kept on the stomach. About six in the morn-ing the house-surgeon was called, and found her in a state ofcollapse. She rallied after some brandy had been administered,,and complained of great pain in the abdomen, which was tym-panitic. For the relief of this a large linseed-meal poultice wasapplied. In the evening she had slightly improved, but the-sickness still continued.4th.-Is better this morning; the sickness has nearly ceased,
and she is able to take beef-tea with her brandy. Is at times_delirious, and complains of severe pain in the left shoulder.joint. Tympanitis is much less, and there is some little dis-charge from the wound in the leg. Ordered to have ten ounces’of brandy daily.6th.-Much better. The knee at times is in great pain; there-
is no sickness, tympanitis, or pain in the abdomen.8th.-Going on well up to last night, when she was very-
restless and delirious. This morning she had an hysterical fit.Complains of great pain in the shoulder, and seems in a verylow condition.9th.-To day she is rapidly sinking; has a feeble, quick
pulse; complains of great pain in the head, and is at times deli..rious. About noon sickness and hiccough came on, with tym-panitis. She gradually sank, and died at ten P.M.
Autopsy, sixty-jive hou1’S after deat7t. -Putrefaction taking-place rapidly. The body well nourished, and on cutting throughthe abdomen the subcutaneous layers of fat exceed two inchesin thickness. The intestines, kidneys, and spleen were exa-mined, and found healthy. The liver was of the normal sizeand weight, but its structure was very pale and fatty; thelower half of the right lobe was softened down, and the tissueinfiltrated with a dark-coloured fluid. The uterus and ovaries.were very much congested. On opening the chest, old pleuriticadhesions were found on both sides. At the apex of the leftlung was an extensive deposit of tubercle, which in some partswas softening down. The heart was examined and foundhealthy. On the left shoulder-joint the synovial membrane wasfound congested, and about a tablespoonful of pus was let out.of the joint. The head was not opened.
ST. MARY’S HOSPITAL.
(OPHTHALMIC DEPARTMENT. )CASES OF MYDRIASIS TREATED BY THE SOLUTION OF OLD
CALABAR BEAN, A NEW OPHTHALMIC AGENT;WITH CLINICAL REMARKS.
(Under the care of Mr. ERNEST HART.)IN calling the attention of the students to this new agent for
obtaining contraction of the pupil, Mr. Hart said that the needfor such an agent had long been felt in ophthalmic surgery,and that he had been experimenting for some time with varioussubstances of which he had hoped that the local applicationmight produce contraction of the circular fibres of the iris.With this view he had employed solutions of various alkaloidsin glycerine, including morphine, strychnine, digitaline, andergotine; but the results were not satisfactory. Dr. ArgyllRobertson, of Edinburgh, however, had lately laid before the-profession an account of the operation of solutions of the Calabarbean on the pupil, which showed it to possess the desiredquality. Dr. Robertson’s paper on this subject had been read.before the Edinburgh Medico.Chirurgical Society on the 4th<of February, 1863. It had been published subsequently in theEdii2burgli Medical J oumal for March. The original inved=tigator of the properties of the bean was Dr. Christison, who.had read an account of those properties before the Royal Society
