153 himself at the hospital complaining of pain in the region of the neck, of the shoulders, and in both upper extremities. This painful state was not produced by degrees, but had arisen suddenly without assignable cause. The pain was violent, and, according to the description of the patient, it seemed as if his arms were being twisted off. The slightest movement increased the pain. The seat of the pain was not localised, but it seemed to shoot down the arm. The neck was held quite rigid by the contractions of the muscles, so as to prevent any movement of the cervical vertebrae, and this part of the spinal column was bent backwards so as to constitute a slight opisthotonos. On examining the arm there was nothing seen to account for the pain. There was no redness or swelling, and the joints themselves were quite free from any suspicion of disease; but it was possible to discover that certain areas of the skin were devoid of sensibility; and, further, that these points were spontaneously painful-that is to say, the patient presented the phenomena of anesthésie douleureuse. When seen by Professor Jaccoud it was discovered that the region of the spine marked by the fifth, sixth, and seventh cervical vertebrae was very tender. Pressure over this region increased not only the local pain, but also the pain down the arms; and taking into consideration the character of the pain and the local tenderness, the professor came to the conclusion that the lesion was central, and, further, that it was rheumatic, because there was no history of a blow or other injury. There was no evidence of syphilis or tubercle; in fact, he considered it as a case of articular rheumatism of the upper part of the spinal column, involving the meninges; and, in accordance with this opinion, ordered a treatment of sodium salicylate. But to complete this diagnosis there was one point wanting, and that was the temperature. On the day of the examina- tion the patient’s temperature was normal, but in the evening it rose to 394° C., thus supplying the fact which was missing. The correctness of the diagnosis was well illustrated by the treatment, for the effect of the sodium salicylate was marked and immediate. The pain dimi- nished, and with it the rigidity ; and by the end of February the patient left the hospital practically cured, only a slight rigidity of the neck remaining, obviously due not to the muscular contraction, but to the articular lesion. But in the first fortnight of March he presented himself again at the hospital in exactly the same condition as before, with the addition that the lower limbs were also affected in a similar manner. Soon, however, another mani- festation showed itself, which is of great importance as adding another item of support to the diagnosis, and that was the tumefaction and redness in the left knee and ankle. The patient was now a hopeless cripple in bed, not daring to move a limb because of the pain, which, as before, was much exaggerated by any movement, though when en- couraged to make the requisite effort it was found that perfect power over the muscles was retained. This, how- ever, did not last long, for towards the end of March it was found that there was a loss of ability to move the limbs however much the patient tried; in fact, th ere was complete akinesia and anaesthesia of all four extremities. It is an interesting fact that this loss of motion appeared first in the arms and afterwards in the lower limbs. The treatment adopted at this time was iodide of potassium, but no marked benefit was noticed, and the patient continued in much the same state during April, with the exception that defecation and micturition became affected, and the patient passed his motions under him unconsciously. In the month of May mercurial inunctions night and morning were added to the previous medication, not with the idea of counteracting any syphilitic taint, but because of the well-known property of mercurials of removing plastic deposits, to which his troubles were attributed, and some slight improvement seemed to be gained. In the month of June the patient was again in much the same state, except that an ulcer over the sacrum was added to his other troubles. In September, during the absence of Prof. Jaccoud, the treat- ment was changed and strychnia was given, and soon after this a sign of improvement appeared, due probably not to the change of drug, but to the salutary influence of time, aided possibly by the previous medication. Whatever was the cause the power of movement began to return, first, in the upper limbs, and then in the lower, and at the same time the anaesthesia disappeared and gave place to a degree of hyper- æsthesia, and with these improvements the ulcer on the sacrum began to heal. The muscles were found to have preserved their electric reactions in a normal state, despite the time that they had remained useless. A Mirror OF HOSPITAL PRACTICE, BRITISH AND FOREIGN. LONDON HOSPITAL. TRANSVERSE FRACTURE OF THE PATELLA; ASPIRATION OF THE JOINT; SUPPURATION; ANTISEPTIC INCISIONS INTO THE JOINT, FOLLOWED A FEW DAYS LATER BY WIRING OF THE FRAGMENTS ; RECOVERY; REMARKS. (Under the care of Mr. RIVINGTON.) , Nulla autem est alia pro certo noscendi via, nisi quamplurimas at mor- I borum et dissectionum historias, tum aliorum tum proprias collectas habere, et inter se comparare.—MORGAGNI De Sed. et Caus. Morb. lib. iv. Proaemium. FRACTURE of the patella is an injury which requires both care and skill in its treatment, and the fact that there is still so much difference of opinion in the profession as to which is the best method to pursue in such cases is an additional proof of this. The methods employed are numerous, and Mr. Rivington’s case was one in which it was necessary to use more than one of these methods, and in which there is every prospect of a strong limb and useful joint being secured to the patient. Charles A-, aged fifty-eight, was admitted on the 29th December, 1883. He had fractured his left patella transversely a little below the middle, by falling on the- kerb. There was a great deal of effusion. A back splint and ice-bag were applied. Two days afterwards the house- surgeon made an attempt to bring the fragments together with strapping. On Jan. llth, there being still much swelling and effusion, Mr. Rivington aspirated the knee- joint, dipping the trocar and cannula in a strong solution of carbolic acid, and using the spray to make " assurance doubly sure." Only two drachms of mingled blood and serum could be obtained. Antiseptic dressing and an ice- bag were applied. On the 16th the house-surgeon tried to reduce the distance between the fragments with Malgaigne’s hooks inserted into strapping and gutta-percha, and the separation was diminished about a third of an inch. This procedure did no good, as it increased the effusion, and the hooks were accordingly removed. A week later, finding that pus was oozing from the puncture made by aspiration, Mr. Rivington had the steam spray turned on and an anaesthetic administered, and he opened the knee-joint freely, making an incision on each side of the patella,. removing a good deal of clot from the joint, washing it out, and inserting drainage-tubes. Finding at the end of the week that the case was doing well, he had the patient in the operating theatre, and cut down on the patella by means of a vertical incision in the middle line, removed all the vascular granulation tissue uniting the fragments, scraped the fractured surfaces, taking away pro- jecting edges with cutting pliers, and wired the fragments together. The wire was beaten down on to the patella, the lateral openings enlarged, and drainage-tubes inserted. The operation was performed with all antiseptic precautions, and a back splint applied on its completion. On the 5th the wounds were redressed; there was very little discharge. On the 12th the drainage-tubes were removed, and on the 22nd the openings into the joint had closed. On March 7th antiseptics were discontinued. On the 10th the wounds had healed. On the 22nd the limb was taken off the splint. There was considerable inflammatory thickening round the knee-joint, and it was slightly painful as well as stiff. On the 25th the patient was allowed to get up. Change from the horizontal to the vertical position produced oedema of the limb. The patient, naturally a spare, delicate-looking man, was in fairly good health, although weakened by his long illness. He could not bear any weight on the limb. By April 7th he was able to walk a little, but his feet swelled when he was up, and more especially the left foot. He was ordered an elastic bandage. He had very little movement in the joint, and no attempt was made to remove the stiffness for fear of breaking down the union of the fragments,.
Transcript
153
himself at the hospital complaining of pain in the region ofthe neck, of the shoulders, and in both upper extremities.This painful state was not produced by degrees, but hadarisen suddenly without assignable cause. The pain wasviolent, and, according to the description of the patient, itseemed as if his arms were being twisted off. The slightestmovement increased the pain. The seat of the pain was notlocalised, but it seemed to shoot down the arm. The neckwas held quite rigid by the contractions of the muscles, soas to prevent any movement of the cervical vertebrae, andthis part of the spinal column was bent backwards so as toconstitute a slight opisthotonos.On examining the arm there was nothing seen to account
for the pain. There was no redness or swelling, and thejoints themselves were quite free from any suspicion ofdisease; but it was possible to discover that certain areas ofthe skin were devoid of sensibility; and, further, that thesepoints were spontaneously painful-that is to say, thepatient presented the phenomena of anesthésie douleureuse.When seen by Professor Jaccoud it was discovered thatthe region of the spine marked by the fifth, sixth, andseventh cervical vertebrae was very tender. Pressure overthis region increased not only the local pain, but also thepain down the arms; and taking into consideration thecharacter of the pain and the local tenderness, the professorcame to the conclusion that the lesion was central, and,further, that it was rheumatic, because there was no historyof a blow or other injury. There was no evidence ofsyphilis or tubercle; in fact, he considered it as a caseof articular rheumatism of the upper part of the spinalcolumn, involving the meninges; and, in accordance withthis opinion, ordered a treatment of sodium salicylate.But to complete this diagnosis there was one point wanting,and that was the temperature. On the day of the examina-tion the patient’s temperature was normal, but in theevening it rose to 394° C., thus supplying the fact whichwas missing. The correctness of the diagnosis was wellillustrated by the treatment, for the effect of the sodiumsalicylate was marked and immediate. The pain dimi-nished, and with it the rigidity ; and by the end of Februarythe patient left the hospital practically cured, only a
slight rigidity of the neck remaining, obviously due notto the muscular contraction, but to the articular lesion. Butin the first fortnight of March he presented himself againat the hospital in exactly the same condition as before,with the addition that the lower limbs were also affectedin a similar manner. Soon, however, another mani-festation showed itself, which is of great importanceas adding another item of support to the diagnosis, andthat was the tumefaction and redness in the left knee andankle.The patient was now a hopeless cripple in bed, not daring
to move a limb because of the pain, which, as before, wasmuch exaggerated by any movement, though when en-couraged to make the requisite effort it was found thatperfect power over the muscles was retained. This, how-ever, did not last long, for towards the end of March it wasfound that there was a loss of ability to move the limbshowever much the patient tried; in fact, th ere was completeakinesia and anaesthesia of all four extremities. It is an
interesting fact that this loss of motion appeared first inthe arms and afterwards in the lower limbs. The treatmentadopted at this time was iodide of potassium, but no markedbenefit was noticed, and the patient continued in much thesame state during April, with the exception that defecationand micturition became affected, and the patient passed hismotions under him unconsciously.In the month of May mercurial inunctions night and
morning were added to the previous medication, not withthe idea of counteracting any syphilitic taint, but because ofthe well-known property of mercurials of removing plasticdeposits, to which his troubles were attributed, and someslight improvement seemed to be gained. In the monthof June the patient was again in much the same state, exceptthat an ulcer over the sacrum was added to his other troubles.In September, during the absence of Prof. Jaccoud, the treat-ment was changed and strychnia was given, and soon afterthis a sign of improvement appeared, due probably not tothe change of drug, but to the salutary influence of time, aidedpossibly by the previous medication. Whatever was thecause the power of movement began to return, first, in theupper limbs, and then in the lower, and at the same time theanaesthesia disappeared and gave place to a degree of hyper-æsthesia, and with these improvements the ulcer on the
sacrum began to heal. The muscles were found to have
preserved their electric reactions in a normal state, despitethe time that they had remained useless.
A MirrorOF
HOSPITAL PRACTICE,BRITISH AND FOREIGN.
LONDON HOSPITAL.TRANSVERSE FRACTURE OF THE PATELLA; ASPIRATION OF
THE JOINT; SUPPURATION; ANTISEPTIC INCISIONS INTOTHE JOINT, FOLLOWED A FEW DAYS LATER BY WIRINGOF THE FRAGMENTS ; RECOVERY; REMARKS.
(Under the care of Mr. RIVINGTON.)
, Nulla autem est alia pro certo noscendi via, nisi quamplurimas at mor-I borum et dissectionum historias, tum aliorum tum proprias collectashabere, et inter se comparare.—MORGAGNI De Sed. et Caus. Morb.lib. iv. Proaemium.
FRACTURE of the patella is an injury which requires bothcare and skill in its treatment, and the fact that there isstill so much difference of opinion in the profession as towhich is the best method to pursue in such cases is anadditional proof of this. The methods employed are
numerous, and Mr. Rivington’s case was one in which it wasnecessary to use more than one of these methods, and inwhich there is every prospect of a strong limb and usefuljoint being secured to the patient.
Charles A-, aged fifty-eight, was admitted on the29th December, 1883. He had fractured his left patellatransversely a little below the middle, by falling on the-kerb. There was a great deal of effusion. A back splintand ice-bag were applied. Two days afterwards the house-surgeon made an attempt to bring the fragments togetherwith strapping. On Jan. llth, there being still much
swelling and effusion, Mr. Rivington aspirated the knee-joint, dipping the trocar and cannula in a strong solutionof carbolic acid, and using the spray to make " assurancedoubly sure." Only two drachms of mingled blood andserum could be obtained. Antiseptic dressing and an ice-bag were applied. On the 16th the house-surgeon tried toreduce the distance between the fragments with Malgaigne’shooks inserted into strapping and gutta-percha, and theseparation was diminished about a third of an inch. Thisprocedure did no good, as it increased the effusion, and thehooks were accordingly removed. A week later, findingthat pus was oozing from the puncture made by aspiration,Mr. Rivington had the steam spray turned on and ananaesthetic administered, and he opened the knee-jointfreely, making an incision on each side of the patella,.removing a good deal of clot from the joint, washingit out, and inserting drainage-tubes. Finding at the endof the week that the case was doing well, he had thepatient in the operating theatre, and cut down on thepatella by means of a vertical incision in the middle line,removed all the vascular granulation tissue uniting thefragments, scraped the fractured surfaces, taking away pro-jecting edges with cutting pliers, and wired the fragmentstogether. The wire was beaten down on to the patella, thelateral openings enlarged, and drainage-tubes inserted. Theoperation was performed with all antiseptic precautions, anda back splint applied on its completion. On the 5th thewounds were redressed; there was very little discharge. Onthe 12th the drainage-tubes were removed, and on the 22ndthe openings into the joint had closed. On March 7thantiseptics were discontinued. On the 10th the wounds hadhealed. On the 22nd the limb was taken off the splint.There was considerable inflammatory thickening round theknee-joint, and it was slightly painful as well as stiff. Onthe 25th the patient was allowed to get up. Change fromthe horizontal to the vertical position produced oedema ofthe limb. The patient, naturally a spare, delicate-lookingman, was in fairly good health, although weakened by his longillness. He could not bear any weight on the limb. ByApril 7th he was able to walk a little, but his feet swelledwhen he was up, and more especially the left foot. He wasordered an elastic bandage. He had very little movementin the joint, and no attempt was made to remove thestiffness for fear of breaking down the union of the fragments,.
154
as nas Happened in otlier cases. The knee-joint acnect
occasionally, but there was no severe pain. There was bonyunion, and the patient was daily gaining power whendischarged.
’
Remarks by Mr. RIVINGTON.—Although it may not bedesirable to treat all cases of fracture of the patella bywiring, and although I should hesitate to undertake theoperation in an old case where there was much separation,and where division of the quadriceps was likely to berequired to bring the fragments into position, I think theprocedure is indicated in recent cases like the foregoing,where there is difficulty in drawing the fragments into goodposition. Hitherto the operation, considering that it is anew procedure, has been attended with very favourableresults, for though two deaths have taken place in morethan fifty cases, in one at least of the cases certainprecautions were omitted which experience would now sug-gest. There was no lateral incision made for drainage, andthe fragments were not brought nearly into apposition.When this is found to be impracticable it would be safer toabandon the operation, as I think was wisely done by mycolleague, Mr. Mansell Moullin, in his published case. Inthe second fatal case the operation was severe, and thepatient, being a hard drinker, was a most unfavourablesubject for its performance. The failure of the aspirationin the present case was doubtless due to the late period ofits use, the blood having coagulated in the joint, and Ithink the suppuration must be attributed to the attemptmade to bring the fragments together with Malgaigne’shooks. I should not myself have selected this procedurewhilst the effusion remained unabsorbed. The use of Mal- ’
gaigne’s hooks I have always avoided, except when employedby insertion into strapping or gutta-percha. Some years agoa case occurred in which the direct use of the hooks neces-sitated amputation of the limb. On the other hand, somevery good results have followed their employment in themediate method mentioned. Two cases in which bonyunion and good movement were obtained were shown atthe London Hospital Medical Society about a year ago.They had been under my colleague, Mr. Couper. I examinedthem carefully, and could not detect any mobility of thefragments, which were apparently united by bone. Time,however, sometimes proves the fallacy of supposed bonyunion. In a lecture published by Mr. Hutchinson inMarch, 1882, he states that he obtained bony union inabout half his cases treated with back splint, strapping,ice, and abstinence from examination of the fragments.1 have not myself been able to obtain anything likethis proportion of osseous union by the same method,and I must confess that I am sceptical as to the pro-portion given even by so deservedly high an authority.The future treatment of fracture of the patella must, Ithink, depend on whether bony union is to be obtained. Ifpossible or not, certainly limbs do not always appear to beso useful or satisfactory to the patients when bony unionhas been secured as in many cases of fibrous union; but, onthe other hand, there are a good many instances of fibrousunion in which life is rendered miserable by the conditionof the limb. If we are to be satisfied with fibrous union,Mr. Heath’s plan of immediate treatment by plaster-of-Paris,allowing the patient to walk about on crutches, is as goodas any other, and obviates the risk of atrophy of thequadriceps and the disagreeable confinement to bed. If weare to aim at bony union, some other method more reliablethan the ordinary modes of treatment must be adopted. InMr. Mitchell Banks’s valuable Clinical Notes mention is madeof a simple plan of bringing the fragments together bypassing a thick silver wire through the joint immediatelyunderneath the patella, and pressing the fragments togetherand retaining them in apposition by twisting the ends of thewire over pads placed in front of the bone. Antiseptic pre-cautions are adopted. I have not yet had an opportunity oftrying this method, but I hear it favourably spoken of bythose who have done so. The interval in the above case,between opening the joint to remove breaking-down blood-clot and wiring the patella, was allowed to elapse for thepurpose of avoiding any discredit to the operation in casethe foundation had already been laid for inflammatoryaction and blood contamination by the breaking down of thewound made in aspiration. The patient’s temperature hadrisen to 101°, and he did not seem so well as he had been.He improved after the joint was cleared, and his tempera-ture did not exceed 99° during the treatment after wiringthe patella.
BOURNEMOUTH COTTAGE HOSPITAL.SEQUEL TO THE CASE OF BULLET WOUND OF THE SKULL;
NECROPSY ; REMARKS.
OUR readers will recollect the case of bullet wound ofthe skull which was published in THE LANCET of Jan. 10th,and will read with interest the following notes of the case,for which we are also indebted to Mr. F. Gardner, whoappends remarks. The patient was under the care of Dr.Hartford during the latter part of the time. Cases of injuryto the brain are not uncommon. Bullet wounds are somewhatinfrequent in civil practice; when they do occur, they areusuallythe result of attempted suicide, and a fatal result gene-rally ensues early. At the present time, when the surgery ofthe brain has received a fresh impetus, tumours being not onlydiagnosed and localised by the physician, but removed bythe surgeon, the careful observation and record of cases ofwound or injury of that organ are specially important.The patient remained quite well from Dec. 13th until
Jan. 1st, 1885. The wound did not heal, however, a smallquantity of pus escaping daily.
Jan. 1st.—The patient complained of much pain in thehead. He had had no sleep. There was very little dischargefrom the wound; there was no paralysis; no fever; pulse 60.2nd.-Pain in head had increased; patient was more
restless. There was an increase in amount of discharge, from the wound. He complained of loss of vision of both
eyes. Temperature 97° ; pulse 40, and weaker.7th.-Vomiting came on and patient was more restless;
bowels constipated.9th.-Patient had constant nausea, also a convulsion.
Temperature 97° ; pulse only 20. Breathing was very slowand there was considerable accumulation of mucus in thethroat and chest. Bowels constipated in spite of purgatives.Patient was only semi-conscious.
11th.—Patient became more and more comatose, and died; at 4 P.M.. Autopsy, twenty-three hours after death.-Rigor mortis
well marked ; body well nourished. The wound in the left eyebrow presented the appearance of a depressed cicatrix,, the centre being adherent to the structure beneath. A small
sinus passed in some distance to some rough bone. On open-ing the skull the membranes presented no sign of recent ori old inflammation. On removing the dura mater the surface, of the brain presented a healthy appearance, except at the. anterior aspect of the left frontal lobe, which was blackened,
and from which a quantity of very fetid green-coloured pus, escaped through an opening inadvertently made into the- substance of the brain in removing the calvaria. On. removing the brain the cranial nerves were seen to be
healthy, and the dura mater lining the base of the skullE showed no trace of inflammation. The neighbourhood of3 the wound in the frontal bone was next examined. A massi of bone projected on the inner surface, the mass presentingi sharp bony points, to which the brain was firmly adherent.s This mass of bone appeared to have been pushed throughi the dura mater, and so pressed directly on the brain at a, spot corresponding to the blackened surface of the left!, frontal lobe. Some loose pieces of bone, with rough edges,1 were removed from the inner and upper aspect of this3 projecting mass. When removed, a cavity was opened,
in which lay the bullet flattened antero-posteriorly andseparated from the skin and depressed cicatrix in the wound
a by small pieces of bone similar to those removed from thee inner part of the projecting mass. The bullet lay immediatelyy beneath the level of the outer wound, resting on the orbitaly plate of the frontal bone. The cavity in which it rested hadr blackened walls and contained a little pus. The brain wase then examined. The whole of the left frontal lobe was- blackened on its anterior aspect, and its substance wasf occupied by a large abscess containing some three or foury ounces of very offensive-smelling, greenish-coloured pus.’, The smell was characteristically gangrenous. The rest of- the brain was healthy; there were no signs of inflammatione or other collections of pus. The other viscera were note examined.y Remarks by Mr. GARDNER.-The post-mortem examina-e tion confirms the opinion given that the bullet in this cased remained within the skull, although the patient to all intentsL. and purposes recovered from the injury. The man was shot- on Aug. 13th, 1884, and was discharged from hospital ong Oct. 1st, 1884, strong and well, with only a small granulating
wound at the seat of injury. He remained quite well
