From this date lie improved rapidly. The wound was washed with a weak solution of Condy's fluid and protected by antiseptic gauze. His temperature fell to 99 8? on the 18th, and. with few exceptions, maintained a normal standard. He suffered from slight bronchitis, which yielded to ipecacuanha. On the 25th
(10 days
after the
operation
and 8
days
after
withdrawal of the tube), air ceased to escape from the tracheal wound. On the 28th, he was removed from hospital, and it has
since been ascertained that he has completely recovered, the wound having cicatrized and bronchitis disappeared.
CASES TREATED IN THE 2nd SURGEON'S WARDS, MEDICAL COLLEGE HOSPITAL.
Fel., U.C., By Surgeou K. McLeod, and Clinical Surgery, Officiating Professor of Anatomy Second Surgeon, Medical C>llege Hospital.
-J
and
I.?FOREIGN BODY IX THE LARYNX ; EXTRACTION TRACHEOTOMY: RECOVERY.
:
As I was visiting my wards 011 the loth of January, a male child, 14 months old* was hurriedly brought to me, with a statement that he had, about an hour ago, swallowed an inch and h quarter screw nail with which he had been playing. The child was cold, pallid, somewhat livid, apparently insensible, and quite flaccid. A small quantity of bloody froth oozed out of each nostril, and he rather gasped than breathed?occasionally and with much effort and noise. Despatching my assistant for the tracheotomy instruments, I proceeded to explore the pharynx, and found the lima glottidis corked up by the head of a screw nail, the body of which had descended into the interior of the larynx. The slit on the head was plainly perceptible behind the epiglottis, and the nail itself could be felt by grasping the larynx between the finger and thumb. Death appearing imminent, I proceeded at once to extract the foreign body and succeeded in getting the nail of my right forefinger under the edge of its head. Dislodging it slightly I was enabled to grasp it between both forefingers, passed into the pharnyx, cne on each side, and thus to exercise firm traction. The larynx grasped the object spasmodically, and considerable force was required to extract it, the interior of the tube undergoing considerable laceration as the sharp edges of the screw were pulled through it. By the time the extraction was accomplished the child had ceased Artificial respiration was resorted to, and cold water to breathe. dashed at intervals on the face and trunk. After some little time this proved successful ; but the breathing was greatly embarrassed on account of the state of the larynx. The tracheotomy instruments had meantime arrived and the windpipe was at once opened below the isthmus of the thyroid. A large middle thyroid vein caused some trouble and delay, but the child did not seem to feel the operation and lay perfectly passive and iinrt-sisting. A tracheotomy tube was passed, and the relief to the breathing was immediate and complete. The extremities had however become very cold, and the surface was still pale and livid. Hot bottles were applied to the feet, beef tea and brandy eneraata given every four hours ; the patient was removed to a warm room and warm moist air was given him to breathe. The nail was found to be. as described, a new screw nail, an inch and a quarter long, the blade of the screw being almost as sharp as a knife. In about half an hour after the operation the skin had recovered its warmth and colour, the pulse its volume and regularity, the breathing had become free and quiet, and the features lost their pinched and distressed aspect. It was now observed that the child was in the seventh day of vaccination. Towards evening he had rather severe re-action; temperature 103* and pulse 120. Breathing was hurried and the tube got clogged up with viscid secretion occasionally, lie had swallowed a little milk and retained his enemata. On the morning of the lGth, the temperature had fallen to 102"S? and by evening to 100-8?. lie breathed more easily, swallowed milk readily, slept occasionally, and appeared, 011 the whole, to be doing well; no signs of pulmonary inflammation manifested themselves. On the 17th (4S hours after the operation), it was found that he was able to breathe without much difficulty through the larynx, and the tube was removed. His temperature was still about 3 degrees above normal, and slight indications of bronchitis, involving the larger tubes of the right luug, were
observed.
Remarks.?It is always a matter of satisfaction to be able to record a case in which life was undoubtedly saved by the timely and prompt adoption of suitable measures. The child who i3 the subject of the foregoing narrative was in articulo mortis when brought to hospital, and even after the foreign body had been removed some difficulty was experienced in resuscitating him. The case illustrates the facility with which foreign bodies can be removed from the pharynx by the use of the two forefingers. Not long ago I succeeded in removing a pin which had stuck into the laryngeal side of the epiglottis of a grownup person in this manner. The operation of tracheotomy fulfilled two important functions:?It facilitated the re-establishing of respiration, and gave the bruised and torn larynx a rest. The pyrexia which succeeded the operation was probably due in part to the vaccination which had been performed seven days previous to the accident. II.?COMPOUND FRACTURE OF MALLEOLI AND DISLOCATION OF ANKLE JOINT: AMPUTATION OF LEG: MANIA: RETRACTION OF FLAPS
;
PLASTIC OPEliATION
:
RECOVERY.
Lall, aged 25, a cooli, was admitted into the Second Surgeon's ward on the 17th of November 1874. The history of the case, which was elicited from the patient's friends, was that while engaged in arranging cargo in the hold of a ship, on the evening of the day of admission, a bag of mustard seed, weighing about 3 maunds, fell from the deck, a height of about 8 feet, on his right leg and broke it. On examination, a He was brought at once to the hospital. vertical, contused, and lacerated wound about 4 inches long was found on the outer side of his right leg above the ankle. Both bones had been broken across tlie malleoli, the fracture of the outer malleolus being oblique, and that of the inner transverse, Moti
and somewhat comminuted. The lower ends of the tibia and fibula protruded from the wound to the extent of about 3 inches, the detached malleoli being retained in position by the lateral ligaments of the ankle joint. The trochlear surface of the astragalus was exposed, and found to have been scraped by the rough ends of the bones of the leg. The periosteum wa3 stripped off the inner and back part oi the tibia to the extent of about 3? inches. Both tibial arteries were patent. Looking to the manner in which the injury had been sustained, the bruising and laceration of the soft parts, the involvment of the ankle joint, the comminution and the extensive stripping of periosteum, it was determined on consultation to amputate the limb. This was accordingly done below the knee. The bloodless method was successfully practised, long skin flaps were dissected, and the muscles divided from without inwards, a little below the level of section of the bonea, and the operation was performed under carbolic spray, the vessels secured by carbolized catgut, and stump dressed antiseptically. lie underwent some febrile re-action, the temperature rising to 103? on the 19th. The dressings were changed on this date. A little oozing had taken place, but the flaps looked sound and promised to adhere kindly. The fever subsided under salines and quinine, and the flaps remained healthy and seemed to be uniting, the discharge being scanty and free of putrid odour. On the night of the 23rd, however, he became delirious, and this proved to be the commencement of a prolonged attack of acute mania. He became extremely restless and knocked his stump about, so that the stitches gave away, the flaps separated, and the ends of the bones protruded between them. On the 25th a of both This condition swelling parotids became evident. full doses of bromide of gradually subsided. He was put on On were the 27th, the flaps potassium. subjected to traction by strips of sticking plaster, which were attached to a rope passed His extreme restlessness interover a pulley and weighted fered with the continuous and effective operation of this expedient, and though the flaps were kept down beyond the level of the ends of the bones, they gaped, and became somewhat
inverted. This treatment
was
maintained till the 30th of December.
*
March 1,
1875.]
A MIRROR OF HOSPITAL PRACTICE.
The patient continued very maniacal, but latterly had become quiet and rational. His general health was fairly good.
more
The ends of the bones had become entirely covered with granulations, and presented an oval rounded swelling about 3 inches long and 1? inch broad, protruding between the flaps, ?which had united only to the extent of about an inch, the margins throughout the rest of their extent being inverted and firmly adherent to the edge of the granulating space. It was determined to treat the stump on the principle of Syme's operation for hernia testis?to free the flaps, pare off the edge of the central ulcer, and bring the skin together over its surface. The patient was placed under the influence of chloroform. An incision was made at the line of junction of flaps and granulations, the former were fred by incisions until they met without traction, the cicatrising edge was shaved off, the surface of the ulcer carefully washed, and the edges of the skin brought together by harelip pins and iron wire sutures. All this was done under carbolic spray, and
the wound
was
dressed anti-
septically. The flaps
*
thus re-united healed by the first intention through the greater part of their extent, the rest granulating kindly and adhering rapidly. Patient had no pyrexia after this operation, and has continued to improve in mind and body. The stump now (12th February) presents a linear cicatrix with the exception of a minute sinus depending apparently on a small exfoliation. It is firm, rounded, and callous. Patient is now quite sane, and he will soon be able to get about with the aid of an artificial limb. Remarks.?The method of traction employed in this case would probably in a sane subject have obviated the necessity for the secondary operation ; but it is extremely difficult to succeed with maniacs in expedients which depend for their success on the rational co-operation of the patient. The traction was not without use, however, for it prevented the retraction, though not the inversion, of the flaps, and thus permitted the performance of an operation which was infinitely simpler in its nature and more satisfactory in its issue than a re-amputation? the only alternative?would have been. If a sufficiency of integument has, in the first instance, been left, it will probably be found possible in every case of gaping inverted flaps and protruding bones to Secure a good stump by resorting to the simple procedure adopted in the foregoing case. It is, of course, better to prevent amputations going wrong in this manner ; but misfortunes of the kind will some times occur in spite of the greatest caution and care. The foregoing record proves that the condition may bo very easily and effectively remedied. III.?NECROSIS OF TIBIA; THREE OPERATIONS; SUPPURATION OF KNEE JOINT; INCISION; RECOVERY.
(Reported by Assistant Surgeon Jogenduo Nath Giiose, L.M.S.) Rakhal Das Bannerjee, a student, aged 17 years, was admitted into the 2nd Surgeon's ward, on the 8th of May 1873, for necrosis of his left tibia. About three months previous to his admission he sprained his left ankle while walking. This produced pain and swelling of the limb, accompanied with fever. A short time after suppuration of the middle third of ihe leg took place, which was laid open by a medical practitioner; this healed up within a month, leaving behind a small ulcer from which a little sanious discharge escaped. About 2 months afterwards several other sinuses appeared spontaneously along the inner surface of the shaft of the tibia.which gave exit to a thin purulent discharge. On examination, dead pieces of bone were felt through each of these sinuses by means of a probe. The ankle and knee joints He was unable to walk without assistance were not involved. or rest his heel on the ground; could flex the knee joint, but could not extend it; phosphates were found in his urine. Codliver-oil, syrup of the iodide of iron and good nourishing diet were prescribed. The limb was adjusted on a Mcltityre's splint. Shortly after his admission he was operated on by the late Professor Cutcliffe, who removed several pieces of necrosed bone from almost the whole length of the shaft of the tibia. The wounds were carefully plugged and dressed. During this operation the patient was almost asphyxiated by chloroform, but was restored by artificial respiration. He did not suffer very much from fever after the operation. The wounds granulated and contracted after a few weeks. Within the period of about eight months several small pieces of dead bone came away and the wounds healed, leaving four small ulcers on the inner surface of the leg, through which dead bone was distinctly felt by means of a probe.
73
On the 11th of December 1S73, he was again put uuder the influence of chloroform, and several necrosed pieces of bone were extracted from almost the whole length of the tibia, by Professor Partridge, assisted by Dr. Crombie, then officiating 2nd surgeon, lie had very strong attacks of fever with rigors after the operation, and the limb became affected with erysipelatous inflammation, which speedily subsided through the local application of sulphate of iron lotion (gr. vi to 31) and large doses of quinia and iron internally. After this the ankle and knee joints became gradually anchylosed; the wounds situated at the upper part of the leg closed within the course of about four months, while dead bono could still be distinctly felt through the contracted orifices of Jie wounds sitnated on the lower part of the leg. On the 26th of April 1874, patient was placed under chloroform and operated on by Dr. McLeod, who removed all the redead bone from the lower part of the leg. maining portions Two days after this operation he had very strong attacks of fever with rigors and a very high range of temperature : (105" F.) His spleen became enlarged, and cutaneous erysipelas of the limb sot in with pain and swelling of the knee joint. The fever abated and the swelling of the leg subsided under treatment, but the knee remained swollen and painful and distinctly fluctuated above the patella, bulging a little on its outer pait. The wounds became flabby and discharged foetid pus. On the loth May the joint was tapped by means of Diculafoy's aspirator at its outer part above the level of the patella, and about 12 ounces of slightly foetid pus was let out. He felt much easier after this operation and the swelling of the joint partially subsided, but it soon filled up again, when, for the second time, the joint was similarly tapped on the 18th of May, and about 8 ounces of sanguinolent pus was removed; the cavity however soon refilled, and on the '21st of May it was tapped for the last time, and about 10 ounces of thick pus were taken off. Shortly afterwards it again filled, and on the 25th May a small incision was made on the outer side of the joint under carbclie spray, and about 1-1 ounces of pus let out; a drainage tube was inserted into the cavity, which was washed with weak carbolic acid lotion, and the wound was carefully dressed with antiseptie dressings. The joint then gradually collapsed, fever abated, discharge became less and less every day, and the wound completely healed within about five weeks of the date of the incision. The wounds on the leg gradually assumed a healthy appearcontracted slowlj'. The stiff knee joint became ance and angularly flexed, which was rectified by a cane splint (straight) adjusted on the flexor aspect of the limb. About the end of October 1874 he was again laid up with strong attacks of fever and rigors; the left inguinal glands wero swollen; his leg became erysipelatous ; spleen enlarged; wounds on the leg became sloughy and phagedamic, and discharged foul foetid pus. A small extent of bone also became exposed and carious. At this time the sanitary condition of the hospital wards was bad, and other patients were affected with erysipelas. The fever after some days subsided, sloughs and dead bona gradually separated by the application of dilute nitric acid lotion, and the wound took on reparative action and slowly contracted. IIi3 bent knee was straightened, so that he could rest his heel on the ground and walk with the help of a small stick; his general health improved very much, and he took his discharge from the hospital on the 8th February 1875, after a residence of very nearly two years. Remarks.?This case is interesting especially on account of the pysemic suppuration which took place in the knee joint of the affected limb, the failure of Dieulafoy's aspirator to cure this condition radically and the success of free incision into and drainage of the joint with antiseptic precautions. When ho left the hospital hi3 limb was serviceable for progression with a good prospect of further improvement. The case compares instructively with Dr. Mainfold's case reported on another page. The patient was peculiarly unfortunate in having on three separata occasions suffered from septic disease. This illustrates the difficulties and risks under which operative surgery is practiced in the Medical College Hospital, and points to the urgent need which exists for a new Surgical Hospital constructed upon ap-
of^
_
proved hygienic principles.
Rupture of the Spleen.?A lady aged 35, who had been subject to dyspepsia, and had suffered greatly from gastric pain due to an irritable stomach, died afcer a very short illness. The autopsy revealed an idiopathic rupture of the spleen, no symptoms of which had been detected during life,?British Medical Journal, Sept. 26, 1874.
(10 days
after the
operation
and 8
days
after
withdrawal of the tube), air ceased to escape from the tracheal wound. On the 28th, he was removed from hospital, and it has
since been ascertained that he has completely recovered, the wound having cicatrized and bronchitis disappeared.
CASES TREATED IN THE 2nd SURGEON'S WARDS, MEDICAL COLLEGE HOSPITAL.
Fel., U.C., By Surgeou K. McLeod, and Clinical Surgery, Officiating Professor of Anatomy Second Surgeon, Medical C>llege Hospital.
-J
and
I.?FOREIGN BODY IX THE LARYNX ; EXTRACTION TRACHEOTOMY: RECOVERY.
:
As I was visiting my wards 011 the loth of January, a male child, 14 months old* was hurriedly brought to me, with a statement that he had, about an hour ago, swallowed an inch and h quarter screw nail with which he had been playing. The child was cold, pallid, somewhat livid, apparently insensible, and quite flaccid. A small quantity of bloody froth oozed out of each nostril, and he rather gasped than breathed?occasionally and with much effort and noise. Despatching my assistant for the tracheotomy instruments, I proceeded to explore the pharynx, and found the lima glottidis corked up by the head of a screw nail, the body of which had descended into the interior of the larynx. The slit on the head was plainly perceptible behind the epiglottis, and the nail itself could be felt by grasping the larynx between the finger and thumb. Death appearing imminent, I proceeded at once to extract the foreign body and succeeded in getting the nail of my right forefinger under the edge of its head. Dislodging it slightly I was enabled to grasp it between both forefingers, passed into the pharnyx, cne on each side, and thus to exercise firm traction. The larynx grasped the object spasmodically, and considerable force was required to extract it, the interior of the tube undergoing considerable laceration as the sharp edges of the screw were pulled through it. By the time the extraction was accomplished the child had ceased Artificial respiration was resorted to, and cold water to breathe. dashed at intervals on the face and trunk. After some little time this proved successful ; but the breathing was greatly embarrassed on account of the state of the larynx. The tracheotomy instruments had meantime arrived and the windpipe was at once opened below the isthmus of the thyroid. A large middle thyroid vein caused some trouble and delay, but the child did not seem to feel the operation and lay perfectly passive and iinrt-sisting. A tracheotomy tube was passed, and the relief to the breathing was immediate and complete. The extremities had however become very cold, and the surface was still pale and livid. Hot bottles were applied to the feet, beef tea and brandy eneraata given every four hours ; the patient was removed to a warm room and warm moist air was given him to breathe. The nail was found to be. as described, a new screw nail, an inch and a quarter long, the blade of the screw being almost as sharp as a knife. In about half an hour after the operation the skin had recovered its warmth and colour, the pulse its volume and regularity, the breathing had become free and quiet, and the features lost their pinched and distressed aspect. It was now observed that the child was in the seventh day of vaccination. Towards evening he had rather severe re-action; temperature 103* and pulse 120. Breathing was hurried and the tube got clogged up with viscid secretion occasionally, lie had swallowed a little milk and retained his enemata. On the morning of the lGth, the temperature had fallen to 102"S? and by evening to 100-8?. lie breathed more easily, swallowed milk readily, slept occasionally, and appeared, 011 the whole, to be doing well; no signs of pulmonary inflammation manifested themselves. On the 17th (4S hours after the operation), it was found that he was able to breathe without much difficulty through the larynx, and the tube was removed. His temperature was still about 3 degrees above normal, and slight indications of bronchitis, involving the larger tubes of the right luug, were
observed.
Remarks.?It is always a matter of satisfaction to be able to record a case in which life was undoubtedly saved by the timely and prompt adoption of suitable measures. The child who i3 the subject of the foregoing narrative was in articulo mortis when brought to hospital, and even after the foreign body had been removed some difficulty was experienced in resuscitating him. The case illustrates the facility with which foreign bodies can be removed from the pharynx by the use of the two forefingers. Not long ago I succeeded in removing a pin which had stuck into the laryngeal side of the epiglottis of a grownup person in this manner. The operation of tracheotomy fulfilled two important functions:?It facilitated the re-establishing of respiration, and gave the bruised and torn larynx a rest. The pyrexia which succeeded the operation was probably due in part to the vaccination which had been performed seven days previous to the accident. II.?COMPOUND FRACTURE OF MALLEOLI AND DISLOCATION OF ANKLE JOINT: AMPUTATION OF LEG: MANIA: RETRACTION OF FLAPS
;
PLASTIC OPEliATION
:
RECOVERY.
Lall, aged 25, a cooli, was admitted into the Second Surgeon's ward on the 17th of November 1874. The history of the case, which was elicited from the patient's friends, was that while engaged in arranging cargo in the hold of a ship, on the evening of the day of admission, a bag of mustard seed, weighing about 3 maunds, fell from the deck, a height of about 8 feet, on his right leg and broke it. On examination, a He was brought at once to the hospital. vertical, contused, and lacerated wound about 4 inches long was found on the outer side of his right leg above the ankle. Both bones had been broken across tlie malleoli, the fracture of the outer malleolus being oblique, and that of the inner transverse, Moti
and somewhat comminuted. The lower ends of the tibia and fibula protruded from the wound to the extent of about 3 inches, the detached malleoli being retained in position by the lateral ligaments of the ankle joint. The trochlear surface of the astragalus was exposed, and found to have been scraped by the rough ends of the bones of the leg. The periosteum wa3 stripped off the inner and back part oi the tibia to the extent of about 3? inches. Both tibial arteries were patent. Looking to the manner in which the injury had been sustained, the bruising and laceration of the soft parts, the involvment of the ankle joint, the comminution and the extensive stripping of periosteum, it was determined on consultation to amputate the limb. This was accordingly done below the knee. The bloodless method was successfully practised, long skin flaps were dissected, and the muscles divided from without inwards, a little below the level of section of the bonea, and the operation was performed under carbolic spray, the vessels secured by carbolized catgut, and stump dressed antiseptically. lie underwent some febrile re-action, the temperature rising to 103? on the 19th. The dressings were changed on this date. A little oozing had taken place, but the flaps looked sound and promised to adhere kindly. The fever subsided under salines and quinine, and the flaps remained healthy and seemed to be uniting, the discharge being scanty and free of putrid odour. On the night of the 23rd, however, he became delirious, and this proved to be the commencement of a prolonged attack of acute mania. He became extremely restless and knocked his stump about, so that the stitches gave away, the flaps separated, and the ends of the bones protruded between them. On the 25th a of both This condition swelling parotids became evident. full doses of bromide of gradually subsided. He was put on On were the 27th, the flaps potassium. subjected to traction by strips of sticking plaster, which were attached to a rope passed His extreme restlessness interover a pulley and weighted fered with the continuous and effective operation of this expedient, and though the flaps were kept down beyond the level of the ends of the bones, they gaped, and became somewhat
inverted. This treatment
was
maintained till the 30th of December.
*
March 1,
1875.]
A MIRROR OF HOSPITAL PRACTICE.
The patient continued very maniacal, but latterly had become quiet and rational. His general health was fairly good.
more
The ends of the bones had become entirely covered with granulations, and presented an oval rounded swelling about 3 inches long and 1? inch broad, protruding between the flaps, ?which had united only to the extent of about an inch, the margins throughout the rest of their extent being inverted and firmly adherent to the edge of the granulating space. It was determined to treat the stump on the principle of Syme's operation for hernia testis?to free the flaps, pare off the edge of the central ulcer, and bring the skin together over its surface. The patient was placed under the influence of chloroform. An incision was made at the line of junction of flaps and granulations, the former were fred by incisions until they met without traction, the cicatrising edge was shaved off, the surface of the ulcer carefully washed, and the edges of the skin brought together by harelip pins and iron wire sutures. All this was done under carbolic spray, and
the wound
was
dressed anti-
septically. The flaps
*
thus re-united healed by the first intention through the greater part of their extent, the rest granulating kindly and adhering rapidly. Patient had no pyrexia after this operation, and has continued to improve in mind and body. The stump now (12th February) presents a linear cicatrix with the exception of a minute sinus depending apparently on a small exfoliation. It is firm, rounded, and callous. Patient is now quite sane, and he will soon be able to get about with the aid of an artificial limb. Remarks.?The method of traction employed in this case would probably in a sane subject have obviated the necessity for the secondary operation ; but it is extremely difficult to succeed with maniacs in expedients which depend for their success on the rational co-operation of the patient. The traction was not without use, however, for it prevented the retraction, though not the inversion, of the flaps, and thus permitted the performance of an operation which was infinitely simpler in its nature and more satisfactory in its issue than a re-amputation? the only alternative?would have been. If a sufficiency of integument has, in the first instance, been left, it will probably be found possible in every case of gaping inverted flaps and protruding bones to Secure a good stump by resorting to the simple procedure adopted in the foregoing case. It is, of course, better to prevent amputations going wrong in this manner ; but misfortunes of the kind will some times occur in spite of the greatest caution and care. The foregoing record proves that the condition may bo very easily and effectively remedied. III.?NECROSIS OF TIBIA; THREE OPERATIONS; SUPPURATION OF KNEE JOINT; INCISION; RECOVERY.
(Reported by Assistant Surgeon Jogenduo Nath Giiose, L.M.S.) Rakhal Das Bannerjee, a student, aged 17 years, was admitted into the 2nd Surgeon's ward, on the 8th of May 1873, for necrosis of his left tibia. About three months previous to his admission he sprained his left ankle while walking. This produced pain and swelling of the limb, accompanied with fever. A short time after suppuration of the middle third of ihe leg took place, which was laid open by a medical practitioner; this healed up within a month, leaving behind a small ulcer from which a little sanious discharge escaped. About 2 months afterwards several other sinuses appeared spontaneously along the inner surface of the shaft of the tibia.which gave exit to a thin purulent discharge. On examination, dead pieces of bone were felt through each of these sinuses by means of a probe. The ankle and knee joints He was unable to walk without assistance were not involved. or rest his heel on the ground; could flex the knee joint, but could not extend it; phosphates were found in his urine. Codliver-oil, syrup of the iodide of iron and good nourishing diet were prescribed. The limb was adjusted on a Mcltityre's splint. Shortly after his admission he was operated on by the late Professor Cutcliffe, who removed several pieces of necrosed bone from almost the whole length of the shaft of the tibia. The wounds were carefully plugged and dressed. During this operation the patient was almost asphyxiated by chloroform, but was restored by artificial respiration. He did not suffer very much from fever after the operation. The wounds granulated and contracted after a few weeks. Within the period of about eight months several small pieces of dead bone came away and the wounds healed, leaving four small ulcers on the inner surface of the leg, through which dead bone was distinctly felt by means of a probe.
73
On the 11th of December 1S73, he was again put uuder the influence of chloroform, and several necrosed pieces of bone were extracted from almost the whole length of the tibia, by Professor Partridge, assisted by Dr. Crombie, then officiating 2nd surgeon, lie had very strong attacks of fever with rigors after the operation, and the limb became affected with erysipelatous inflammation, which speedily subsided through the local application of sulphate of iron lotion (gr. vi to 31) and large doses of quinia and iron internally. After this the ankle and knee joints became gradually anchylosed; the wounds situated at the upper part of the leg closed within the course of about four months, while dead bono could still be distinctly felt through the contracted orifices of Jie wounds sitnated on the lower part of the leg. On the 26th of April 1874, patient was placed under chloroform and operated on by Dr. McLeod, who removed all the redead bone from the lower part of the leg. maining portions Two days after this operation he had very strong attacks of fever with rigors and a very high range of temperature : (105" F.) His spleen became enlarged, and cutaneous erysipelas of the limb sot in with pain and swelling of the knee joint. The fever abated and the swelling of the leg subsided under treatment, but the knee remained swollen and painful and distinctly fluctuated above the patella, bulging a little on its outer pait. The wounds became flabby and discharged foetid pus. On the loth May the joint was tapped by means of Diculafoy's aspirator at its outer part above the level of the patella, and about 12 ounces of slightly foetid pus was let out. He felt much easier after this operation and the swelling of the joint partially subsided, but it soon filled up again, when, for the second time, the joint was similarly tapped on the 18th of May, and about 8 ounces of sanguinolent pus was removed; the cavity however soon refilled, and on the '21st of May it was tapped for the last time, and about 10 ounces of thick pus were taken off. Shortly afterwards it again filled, and on the 25th May a small incision was made on the outer side of the joint under carbclie spray, and about 1-1 ounces of pus let out; a drainage tube was inserted into the cavity, which was washed with weak carbolic acid lotion, and the wound was carefully dressed with antiseptie dressings. The joint then gradually collapsed, fever abated, discharge became less and less every day, and the wound completely healed within about five weeks of the date of the incision. The wounds on the leg gradually assumed a healthy appearcontracted slowlj'. The stiff knee joint became ance and angularly flexed, which was rectified by a cane splint (straight) adjusted on the flexor aspect of the limb. About the end of October 1874 he was again laid up with strong attacks of fever and rigors; the left inguinal glands wero swollen; his leg became erysipelatous ; spleen enlarged; wounds on the leg became sloughy and phagedamic, and discharged foul foetid pus. A small extent of bone also became exposed and carious. At this time the sanitary condition of the hospital wards was bad, and other patients were affected with erysipelas. The fever after some days subsided, sloughs and dead bona gradually separated by the application of dilute nitric acid lotion, and the wound took on reparative action and slowly contracted. IIi3 bent knee was straightened, so that he could rest his heel on the ground and walk with the help of a small stick; his general health improved very much, and he took his discharge from the hospital on the 8th February 1875, after a residence of very nearly two years. Remarks.?This case is interesting especially on account of the pysemic suppuration which took place in the knee joint of the affected limb, the failure of Dieulafoy's aspirator to cure this condition radically and the success of free incision into and drainage of the joint with antiseptic precautions. When ho left the hospital hi3 limb was serviceable for progression with a good prospect of further improvement. The case compares instructively with Dr. Mainfold's case reported on another page. The patient was peculiarly unfortunate in having on three separata occasions suffered from septic disease. This illustrates the difficulties and risks under which operative surgery is practiced in the Medical College Hospital, and points to the urgent need which exists for a new Surgical Hospital constructed upon ap-
of^
_
proved hygienic principles.
Rupture of the Spleen.?A lady aged 35, who had been subject to dyspepsia, and had suffered greatly from gastric pain due to an irritable stomach, died afcer a very short illness. The autopsy revealed an idiopathic rupture of the spleen, no symptoms of which had been detected during life,?British Medical Journal, Sept. 26, 1874.
