NOTES OF CASES TREATED IN THE PILGRIM HOSPITAL. By Surgeon J.
H. TULL WALSH.
THREE CASES OF CONTRACTED
No. I.
PURI
KNEE-JOINT.
7 years of age, admitted 13th April 1889, is employed in leading her father, who is a beggar and blind. History of a fall, two months before, injuring the left knee-joint. When the patient came to the hospital she was unable to stand and progressed in a sitting posture, pushing herself along with her hands. Stated that she had not been able to stand since the accident, and had adopted the above method of progression since that time. The child, though not stout, was in fairly good health. The muscles of the legs were much wasted, especially the calf muscles of the left leg. The left kneejoint was contracted, so that the heel nearly touched the back of the thigh. The leg could not be extended, and any attempt to straighten the limb caused pain. There was no inflammation in or around the joint. The right knee-joint was freely moveable. 14th was
Besiki,
?
April, 1889.?Under chloroform
straightened, and
at the time
a
the limb
slight rupture
occurred in the skin at the back of the knee. The small wound was dressed and the limb fixed to a long back splint. After the operation there was no rise of temperature, very little pain, and only Cold ammonium slight swellino-of the knee-joint. 1*1 chloride lotion was applied to counteract any tendency to inflammation. ?
?
V/
CASES OF CONTRACTED KNEE-JOINT.
Dec., 1889.
18th April, 1889.?The splin t was removed and the small wound dressed with carbolic oil. The and well was rubbed the daily battery applied leg to the muscles of both legs for teu miuutes each
morning. 23rd April, 1889.?As
the child complained of little pain iu the joint, the splint was replaced on this day. 28th April 1889. Splint removed; patient walks without pain. She was discharged quite cured 22nd May 1889. No. II. Hindu, male, aged 40, admitted intohospital 4th August, 1889. History of a large abscess on the outer aspect of right ankle joint As about two months previous to admission. it caused him pain, when he placed his foot on the ground, he had kept the leg bent and when obliged to walk used a long pole. Patient stated that the inflammation had extended up the leg When admitted there as far as the knee joint. was induration and swelling, on the outer side of the right ankle-joint and several deep sinuses ' c discharging unhealthy pus. Moving the foot The knee was firmly or pressure caused pain. contracted at an obtuse angle ; but there were no signs of inflammation although the tissues round the joint were somewhat thickened. The sinuses were slit up freely and by 15th August, 1889, had completely healed. Patient placed under loth August, 1889. chloroform and the limb extended. The formation of tissue bands round the joint was marked and a great deal of force required to straighten the limb. There was a good deal ofpain in the joint after the operation, and on the evening of 16th August, 1889, the temperature rose to 100?; 17th August, 1889,morning temperature 99?; after this date the temperature remained normal. There was some effusion into the joint and some inflammation which disappeared uuder treatment, and the patient was discharged at his own request 14th September, 1889. The man could walk well and without pain ; a
?
?
but there the knee
was as
still
some
compared
slight enlargement
with the
joint
ot
of the
opposite side.
No. III.?Hindu, male, aged about 14, Admitted 26th September, 1889, states that about six weeks ago an abscess formed at the back of the left knee joint. Alter a time the abscess burst In order and had been discharging ever since. to relieve the pain caused by the abscess lie had kept the kuee flexed and now found that On admission lie was unable to extend it. there was a large cavity at the back of the kuee joiut and pus was also being discharged from a large sinus which ran upwards into the muscles of the thigh. 2ud October, 1889.?Placed under chloroform The hamand the limb forcibly straightened.
string muscles, softeued by inflammation, somewhat torn. When the limb
was
were
extended the
365
sinus was laid open and the large wound dressed with compound tincture of benzoin. I may here incidently remark that I find the compound tincture of benzoin a capital haemostatic for general bleeding from small vessels ; and also a good dressing for wounds generally. The limb was put up in two long side splints 3rd October, 1889. Dressing dirty ; side splints removed ; wound dressed and the limb placed ou a Mclutyre's splint. There was some slight paiu and swelling of the knee joint; evening temperature 101? ; 4th October, 1889, temperature 98?. After this date there was no rise of temperature and the abscess cavity filled rapidly with healthy
grauulations.
13th October, 1889.?The Assistaut Surgeon noticed a sinus which burrowed in among the muscles in the upper part of the thigh. A drainage tube was inserted. 26th October, 1889.?The sinus above referred to had closed, and the wound was looking well and covered with healthy granulations. At my suggestion, Assistant Surgeon Ananda Lai Bose planted 16 skin grafts on the surface of the wound: these were covered with a piece of plaintain leaf, and the dressing left undisturbed until 29thOctober, 1889, when several of the grafts had taken root and had a bluish appearance. The majority of the 16 grafts had died. 1st
November, 1889.?"Woundhealing rapidly:
Grafts in the
centre of the wound
growing. 13 round the edge of the ulcer. Two of these grafts took root and grew rapidly. 18th November, 1889.?Wouud almost healed. Splints removed. Patient can stand and walk a little without pain. There is a small superficial healthy ulcer, upon which more grafts will be grafts planted
placed. Remarks.?I have thought that these three might be of some interest to the readers of the Indian Medical Gazette as showing how useful the simple operation for such false anchyloses is, and how the same pathological condition may arise from various primary causes. The chief factor in all these cases is the unopposed action of the hamstring muscles, which become more or less permanently contracted. Tissue bands form round the joint, and a volunsoon betary contraction?cases II and III
cases
?
comes a
permanent contraction.
A CASE OF WANDERING FOREIGN BODY.
Hindu, male, aged
about 25,
day labourer,
states that about 3 years ago he was one
day
uuder a date-palm when a large leaf fell on him and the spike-like end pierced the front of his right shoulder. The long thorn broke off and remained in the substance ot the deltoid muscle. The thorn was not removed, but in course of time
sitting
48
THE INDIAN MEDICAL GAZETTE.
366
the wound healed. As bearing out the patient's statement, the contracted scar of the original "wound is visible in front of the shoulder over the deltoid. About a year after the healing of the first wound he noticed a lump at ths back of the shoulder : this burst after a time and had beeu discharging for many mouths when he attended the hospital as an outpatient, 24th August, 1889. The hospital assistant drew my attention to the case, as lie thought that the outer edge of The opening of the the scapula was necrosed. wound was in the posterior wall of the axilla, close to the edge of the scapula. The piobe passed into a sinus 1^- inches long, and then struck on a foreign body. The sensation communicated by the probe was quite unlike the of necrosed bone. I enlarged the roughness O sinus and dragged out of the substance of the infra spinatus muscle the end of the date-palm leaf. The piece removed was nearly 3 inches long and over \ inch in thickness at the base. I did not see the man again, but believe that after the removal of the foreign body the sinus closed rapidly. o
is true, and there does be any reason for doubting it, this case is a curious addition to tiie literature of wandering foreign bodies. The man does not seem to have been much troubled by the presence of the thorn in his tissues. If the
patient's story
not seem to
[Dec.,
1889.
H. TULL WALSH.
THREE CASES OF CONTRACTED
No. I.
PURI
KNEE-JOINT.
7 years of age, admitted 13th April 1889, is employed in leading her father, who is a beggar and blind. History of a fall, two months before, injuring the left knee-joint. When the patient came to the hospital she was unable to stand and progressed in a sitting posture, pushing herself along with her hands. Stated that she had not been able to stand since the accident, and had adopted the above method of progression since that time. The child, though not stout, was in fairly good health. The muscles of the legs were much wasted, especially the calf muscles of the left leg. The left kneejoint was contracted, so that the heel nearly touched the back of the thigh. The leg could not be extended, and any attempt to straighten the limb caused pain. There was no inflammation in or around the joint. The right knee-joint was freely moveable. 14th was
Besiki,
?
April, 1889.?Under chloroform
straightened, and
at the time
a
the limb
slight rupture
occurred in the skin at the back of the knee. The small wound was dressed and the limb fixed to a long back splint. After the operation there was no rise of temperature, very little pain, and only Cold ammonium slight swellino-of the knee-joint. 1*1 chloride lotion was applied to counteract any tendency to inflammation. ?
?
V/
CASES OF CONTRACTED KNEE-JOINT.
Dec., 1889.
18th April, 1889.?The splin t was removed and the small wound dressed with carbolic oil. The and well was rubbed the daily battery applied leg to the muscles of both legs for teu miuutes each
morning. 23rd April, 1889.?As
the child complained of little pain iu the joint, the splint was replaced on this day. 28th April 1889. Splint removed; patient walks without pain. She was discharged quite cured 22nd May 1889. No. II. Hindu, male, aged 40, admitted intohospital 4th August, 1889. History of a large abscess on the outer aspect of right ankle joint As about two months previous to admission. it caused him pain, when he placed his foot on the ground, he had kept the leg bent and when obliged to walk used a long pole. Patient stated that the inflammation had extended up the leg When admitted there as far as the knee joint. was induration and swelling, on the outer side of the right ankle-joint and several deep sinuses ' c discharging unhealthy pus. Moving the foot The knee was firmly or pressure caused pain. contracted at an obtuse angle ; but there were no signs of inflammation although the tissues round the joint were somewhat thickened. The sinuses were slit up freely and by 15th August, 1889, had completely healed. Patient placed under loth August, 1889. chloroform and the limb extended. The formation of tissue bands round the joint was marked and a great deal of force required to straighten the limb. There was a good deal ofpain in the joint after the operation, and on the evening of 16th August, 1889, the temperature rose to 100?; 17th August, 1889,morning temperature 99?; after this date the temperature remained normal. There was some effusion into the joint and some inflammation which disappeared uuder treatment, and the patient was discharged at his own request 14th September, 1889. The man could walk well and without pain ; a
?
?
but there the knee
was as
still
some
compared
slight enlargement
with the
joint
ot
of the
opposite side.
No. III.?Hindu, male, aged about 14, Admitted 26th September, 1889, states that about six weeks ago an abscess formed at the back of the left knee joint. Alter a time the abscess burst In order and had been discharging ever since. to relieve the pain caused by the abscess lie had kept the kuee flexed and now found that On admission lie was unable to extend it. there was a large cavity at the back of the kuee joiut and pus was also being discharged from a large sinus which ran upwards into the muscles of the thigh. 2ud October, 1889.?Placed under chloroform The hamand the limb forcibly straightened.
string muscles, softeued by inflammation, somewhat torn. When the limb
was
were
extended the
365
sinus was laid open and the large wound dressed with compound tincture of benzoin. I may here incidently remark that I find the compound tincture of benzoin a capital haemostatic for general bleeding from small vessels ; and also a good dressing for wounds generally. The limb was put up in two long side splints 3rd October, 1889. Dressing dirty ; side splints removed ; wound dressed and the limb placed ou a Mclutyre's splint. There was some slight paiu and swelling of the knee joint; evening temperature 101? ; 4th October, 1889, temperature 98?. After this date there was no rise of temperature and the abscess cavity filled rapidly with healthy
grauulations.
13th October, 1889.?The Assistaut Surgeon noticed a sinus which burrowed in among the muscles in the upper part of the thigh. A drainage tube was inserted. 26th October, 1889.?The sinus above referred to had closed, and the wound was looking well and covered with healthy granulations. At my suggestion, Assistant Surgeon Ananda Lai Bose planted 16 skin grafts on the surface of the wound: these were covered with a piece of plaintain leaf, and the dressing left undisturbed until 29thOctober, 1889, when several of the grafts had taken root and had a bluish appearance. The majority of the 16 grafts had died. 1st
November, 1889.?"Woundhealing rapidly:
Grafts in the
centre of the wound
growing. 13 round the edge of the ulcer. Two of these grafts took root and grew rapidly. 18th November, 1889.?Wouud almost healed. Splints removed. Patient can stand and walk a little without pain. There is a small superficial healthy ulcer, upon which more grafts will be grafts planted
placed. Remarks.?I have thought that these three might be of some interest to the readers of the Indian Medical Gazette as showing how useful the simple operation for such false anchyloses is, and how the same pathological condition may arise from various primary causes. The chief factor in all these cases is the unopposed action of the hamstring muscles, which become more or less permanently contracted. Tissue bands form round the joint, and a volunsoon betary contraction?cases II and III
cases
?
comes a
permanent contraction.
A CASE OF WANDERING FOREIGN BODY.
Hindu, male, aged
about 25,
day labourer,
states that about 3 years ago he was one
day
uuder a date-palm when a large leaf fell on him and the spike-like end pierced the front of his right shoulder. The long thorn broke off and remained in the substance ot the deltoid muscle. The thorn was not removed, but in course of time
sitting
48
THE INDIAN MEDICAL GAZETTE.
366
the wound healed. As bearing out the patient's statement, the contracted scar of the original "wound is visible in front of the shoulder over the deltoid. About a year after the healing of the first wound he noticed a lump at ths back of the shoulder : this burst after a time and had beeu discharging for many mouths when he attended the hospital as an outpatient, 24th August, 1889. The hospital assistant drew my attention to the case, as lie thought that the outer edge of The opening of the the scapula was necrosed. wound was in the posterior wall of the axilla, close to the edge of the scapula. The piobe passed into a sinus 1^- inches long, and then struck on a foreign body. The sensation communicated by the probe was quite unlike the of necrosed bone. I enlarged the roughness O sinus and dragged out of the substance of the infra spinatus muscle the end of the date-palm leaf. The piece removed was nearly 3 inches long and over \ inch in thickness at the base. I did not see the man again, but believe that after the removal of the foreign body the sinus closed rapidly. o
is true, and there does be any reason for doubting it, this case is a curious addition to tiie literature of wandering foreign bodies. The man does not seem to have been much troubled by the presence of the thorn in his tissues. If the
patient's story
not seem to
[Dec.,
1889.
