ROYAL FREE HOSPITAL.
1
720 functions in maintaining the circulation of the blood that, be- cause impure, is unwelcome in the tissues,-these are ques- tions that do not admit of solution. But the state of the left heart and vessels in Bright’s disease must somehow be due to the impure blood ; and though in the case before us no Bright’s s disease existed, yet the blood may have been impure in other ways. It is not farfetching to suppose an imperfect digestion, for instance, which should cause to pass into the circulation a crude product, and so call for excess of action of the heart to urge the impure blood through the unsatisfied tissues. Violent action of the heart in indigestion is common enough; it is generally explained by reflected nervous impressions along the pneumogastrics; but such palpitation may be due to the ill- digested substances, unfitting the blood for its functions. Some such condition is indicated by the hypertrophy, &c., limited to the systemic heart; but an inherent or diathetic weakness may have helped the development of the fatal dis- ease. The case conveys an obvious caution against running to catch a train. ROYAL FREE HOSPITAL. RECENT DISPLACEMENT OF FALSE JOINT IN AN UNUNITED FRACTURE OF THE FEMUR; EXCISION OF JOINT, AND INSERTION OF IVORY PEGS; DEATH FROM PYÆMIA. (Under the care of Mr. JOHN D. HILL.) IN resuming his clinical observations on non-uniting frac- tures, Mr. Hill briefly remarked that false joints were rarely seen in surgical practice, and therefore he thought a report of the following case would prove interesting to the profession. An able description of the varieties of false joint had been given by Rokitansky, who had devoted considerable attention to the subject, and the case under discussion might be said to belong to the ball-and-socket class. Surrounding the joint was a capsular ligament, strengthened by bands of fibrous tissue, and within the joint was a secreting membrane lining the socket in the upper fragment, while the lower fragment which formed the ball was eburnated. The patient had fractured his femur many years ago, and the fragments had never united by bone. By some recent accident they had become so much displaced as to render the limb quite powerless. He was a most unfavourable subject to treat, being enfeebled by organic disease and habits of intem- perance ; nevertheless, it was evident that he had no chance (f f local repair without operative assistance, and as he was daily losing ground, it became a question whether excision of the false joint or amputation of the limb was more desirable. For good reasons the former operation was selected. Charles E. L——, aged forty-five, was admitted into the hospital on the 5th of April, 1868. He was by occupation a clerk; married, but without issue; badly nourished, and of exceedingly nervous temperament. Twenty-four years since, he was thrown out of a vehicle, and the right thigh- bone was broken in its upper third. After being under surgical treatment for several months, he got about on crutches, but had shortening of the limb and permanent lameness. He could give no satisfactory account of his present condition, but Mr. ’, Hill learned from a member of his family that he had been .intemperate in his habits, and had further injured the limb by a fall last Christmas, and it was very probable that another injury had occurred more recently, through which he lost all control over the limb. He had a cirrhotic aspect, and was troubled with a cough resulting from a chronic affection of the bronchial tubes, and the chest expansion was imperfect. He had also a stricture in the membranous part of the urethra. His appetite was not good, the pulse was small and weak, and he complained of pain at the seat of fracture, as though some inflammatory action were present in the bone. There was great thickening around the upper fragment, and tenderness on pressure. He had not the least control over the limb below the fracture, and any attempt at movement was attended with the greatest pain. The mobility of the limb was so great that, when Mr. Hill lifted it up, it could, like a flail, be put into any position ; but there was no rough crepitation. The frac- ture extended from without obliquely upwards and inwards, the upper fragment being projected outwards by the gluteal muscles, and forwards by the psoas and iliacus. It was sur- rounded by dense callus, and overlapping the lower fragment, which rested against the neck of the bone. Between these two points was a false joint. The right thigh was three inches shorter than the left, and the foot was everted. Extension and counter-extension having been made, the limb was brought down two inches, and fixed on a long external splint with a perineal strap. An endeavour was made to extend it further; but, in the first place, the patient could not bear the pressure, and, secondly, the obliquity of the fracture and the smooth surfaces of the fragments allowed it to slip back to its former position. It was therefore retained in the improved position until April 20th ; and in the meanwhile the stricture, which was not a very dense one, was dilated by gradual pres- sure. He was ordered full diet, two pints of stout and four ounces of wine daily, and a mixture containing twenty minims of the tincture of muriate of iron and an ounce of infusion of quassia, thrice a day. At the end of a fortnight, as the health was giving way, it was resolved to delay no longer, but to excise the false joint and peg the fragments together. On April 21st Mr. Hill performed the following operation whilst the patient was under the influence of chloroform :-An incision five inches in extent was carried over the outer surface of the thigh, dividing the skin, fat, and muscle, down to the fragments. The upper one was very prominent, and over- lapped the lower fragment; a small piece was therefore re- moved with a chain saw. The limb was then doubled upon itself and the scalpel passed between the fragments, severing the fibrous bands which held them together. Next, the extre- mity of each fragment was sawn off obliquely. Holes were drilled, and ivory pegs introduced and driven home with a mallet. Some difficulty was experienced in pinning the frag. ments together from the thickness of the bone and the conical shape of the pegs. This, however, was remedied by holding the fragments together while an assistant fixed the limb above and below to a long external splint having an interruption at the wound. An anterior splint was then fixed from the hip to the knee; and lastly, the edges of the wound were closed with suture, strapping, a good pad and bandage, and the patient was removed to bed. Three or four vessels were ligatured in the operation. ’ He passed a pretty good night, had a regular action of the bowels, and progressed tolerably well during the few following days, although the wound became sloughy. On the fourth day (25th) his cough began to trouble him, and the expectoration was slightly streaked with blood. On the fifth day he complained of feeling chilly, and his pulse rose from 96 to 118 in a few hours, and before morning to 140. A saccharine odour emanated from his breath and the body generally. The wound looked dry and glazed in those places where the slough had separated ; the tongue also became coated and dry, the superficial veins turgid and prominent, and the skin dry and harsh. Moreover, the urine was loaded with urates and purpurates, was of an amber colour, and presented a slight shade of albumen. Delirium set in during the night, followed by coma, and death supervened twenty-eight hours after the accession of the pyasmic symptoms. Unfortunately, an inspection could not be obtained. The latter part of the treatment consisted in directing--1Ùl efforts to support the patient, with beef-tea, milk, eggs, port. wine, &c., at frequent intervals; subsequently quinine was given internally in full doses, combined with opium, and, on the appearance of delirium, full doses of the latter drug; and when that failed, the subcutaneous injection of morphiawas employed. Examination of the false joint.-The fracture extended ob- liquely through the upper third of the femur, terminating about an inch below the trochanter minor. There was a dis- tinct capsular ligament and dense bands of fibrous tissue sur- rounding it. In the upper fragment was a partially cup- shaped cavity, covered with a secreting membrane. The lower fragment was smooth, rounded, and here and there polished like ivory, and when sawn through was so compact and dense that it doubled the weight of healthy bone, as shown by the piece removed. The capsule at the upper part had apparently given way, allowing the lower fragment to be drawn upon the cervix femoris. The cut surface of both fragments was ex- ceedingly hard, smooth, and compact throughout, and there was complete obliteration of the medullary canal. Provincial Hospital Reports. WEST RIDING PAUPER LUNATIC ASYLUM. CASE OF POISONING BY THE CHLORIDE OF AMMONIUM; RECOVERY. (Under the care of Dr. CRICHTON BROWNE.) I So few opportunities have occurred of studying the actions I of the chloride of ammonium when taken in poisonous doses,
Transcript of ROYAL FREE HOSPITAL.
720
functions in maintaining the circulation of the blood that, be-cause impure, is unwelcome in the tissues,-these are ques-tions that do not admit of solution. But the state of the leftheart and vessels in Bright’s disease must somehow be due tothe impure blood ; and though in the case before us no Bright’s sdisease existed, yet the blood may have been impure in otherways. It is not farfetching to suppose an imperfect digestion,for instance, which should cause to pass into the circulation acrude product, and so call for excess of action of the heart tourge the impure blood through the unsatisfied tissues. Violentaction of the heart in indigestion is common enough; it is
generally explained by reflected nervous impressions along thepneumogastrics; but such palpitation may be due to the ill-
digested substances, unfitting the blood for its functions.Some such condition is indicated by the hypertrophy, &c.,limited to the systemic heart; but an inherent or diatheticweakness may have helped the development of the fatal dis-ease. The case conveys an obvious caution against running tocatch a train.
ROYAL FREE HOSPITAL.RECENT DISPLACEMENT OF FALSE JOINT IN AN UNUNITED
FRACTURE OF THE FEMUR; EXCISION OF JOINT, ANDINSERTION OF IVORY PEGS; DEATH FROM PYÆMIA.
(Under the care of Mr. JOHN D. HILL.)IN resuming his clinical observations on non-uniting frac-
tures, Mr. Hill briefly remarked that false joints were rarelyseen in surgical practice, and therefore he thought a report ofthe following case would prove interesting to the profession.An able description of the varieties of false joint had beengiven by Rokitansky, who had devoted considerable attentionto the subject, and the case under discussion might be said tobelong to the ball-and-socket class. Surrounding the joint wasa capsular ligament, strengthened by bands of fibrous tissue,and within the joint was a secreting membrane lining thesocket in the upper fragment, while the lower fragment whichformed the ball was eburnated.The patient had fractured his femur many years ago, and
the fragments had never united by bone. By some recentaccident they had become so much displaced as to render thelimb quite powerless. He was a most unfavourable subject totreat, being enfeebled by organic disease and habits of intem-perance ; nevertheless, it was evident that he had no chance (f flocal repair without operative assistance, and as he was dailylosing ground, it became a question whether excision of thefalse joint or amputation of the limb was more desirable. Forgood reasons the former operation was selected.
Charles E. L——, aged forty-five, was admitted into thehospital on the 5th of April, 1868. He was by occupationa clerk; married, but without issue; badly nourished, andof exceedingly nervous temperament. Twenty-four yearssince, he was thrown out of a vehicle, and the right thigh-bone was broken in its upper third. After being under surgicaltreatment for several months, he got about on crutches, buthad shortening of the limb and permanent lameness. He couldgive no satisfactory account of his present condition, but Mr. ’,Hill learned from a member of his family that he had been.intemperate in his habits, and had further injured the limb bya fall last Christmas, and it was very probable that anotherinjury had occurred more recently, through which he lost allcontrol over the limb. He had a cirrhotic aspect, and wastroubled with a cough resulting from a chronic affection ofthe bronchial tubes, and the chest expansion was imperfect.He had also a stricture in the membranous part of the urethra.His appetite was not good, the pulse was small and weak, andhe complained of pain at the seat of fracture, as though someinflammatory action were present in the bone. There was
great thickening around the upper fragment, and tendernesson pressure. He had not the least control over the limb belowthe fracture, and any attempt at movement was attended withthe greatest pain. The mobility of the limb was so great that,when Mr. Hill lifted it up, it could, like a flail, be put intoany position ; but there was no rough crepitation. The frac-ture extended from without obliquely upwards and inwards,the upper fragment being projected outwards by the glutealmuscles, and forwards by the psoas and iliacus. It was sur-rounded by dense callus, and overlapping the lower fragment,which rested against the neck of the bone. Between thesetwo points was a false joint. The right thigh was three inchesshorter than the left, and the foot was everted. Extensionand counter-extension having been made, the limb wasbrought down two inches, and fixed on a long external splint
with a perineal strap. An endeavour was made to extend itfurther; but, in the first place, the patient could not bear thepressure, and, secondly, the obliquity of the fracture and thesmooth surfaces of the fragments allowed it to slip back to itsformer position. It was therefore retained in the improvedposition until April 20th ; and in the meanwhile the stricture,which was not a very dense one, was dilated by gradual pres-sure. He was ordered full diet, two pints of stout and fourounces of wine daily, and a mixture containing twenty minimsof the tincture of muriate of iron and an ounce of infusion ofquassia, thrice a day.At the end of a fortnight, as the health was giving way, it
was resolved to delay no longer, but to excise the false jointand peg the fragments together.On April 21st Mr. Hill performed the following operation
whilst the patient was under the influence of chloroform :-Anincision five inches in extent was carried over the outer surfaceof the thigh, dividing the skin, fat, and muscle, down to thefragments. The upper one was very prominent, and over-lapped the lower fragment; a small piece was therefore re-moved with a chain saw. The limb was then doubled uponitself and the scalpel passed between the fragments, severingthe fibrous bands which held them together. Next, the extre-mity of each fragment was sawn off obliquely. Holes weredrilled, and ivory pegs introduced and driven home with amallet. Some difficulty was experienced in pinning the frag.ments together from the thickness of the bone and the conicalshape of the pegs. This, however, was remedied by holdingthe fragments together while an assistant fixed the limb aboveand below to a long external splint having an interruption atthe wound. An anterior splint was then fixed from the hip tothe knee; and lastly, the edges of the wound were closed withsuture, strapping, a good pad and bandage, and the patientwas removed to bed. Three or four vessels were ligatured inthe operation.
’ He passed a pretty good night, had a regular action ofthe bowels, and progressed tolerably well during the fewfollowing days, although the wound became sloughy. Onthe fourth day (25th) his cough began to trouble him, andthe expectoration was slightly streaked with blood. On thefifth day he complained of feeling chilly, and his pulse rosefrom 96 to 118 in a few hours, and before morning to 140.A saccharine odour emanated from his breath and the bodygenerally. The wound looked dry and glazed in those placeswhere the slough had separated ; the tongue also became coatedand dry, the superficial veins turgid and prominent, and theskin dry and harsh. Moreover, the urine was loaded withurates and purpurates, was of an amber colour, and presenteda slight shade of albumen. Delirium set in during the night,followed by coma, and death supervened twenty-eight hoursafter the accession of the pyasmic symptoms. Unfortunately,an inspection could not be obtained.The latter part of the treatment consisted in directing--1Ùl
efforts to support the patient, with beef-tea, milk, eggs, port.wine, &c., at frequent intervals; subsequently quinine wasgiven internally in full doses, combined with opium, and, on theappearance of delirium, full doses of the latter drug; and whenthat failed, the subcutaneous injection of morphiawas employed.
Examination of the false joint.-The fracture extended ob-liquely through the upper third of the femur, terminatingabout an inch below the trochanter minor. There was a dis-tinct capsular ligament and dense bands of fibrous tissue sur-rounding it. In the upper fragment was a partially cup-shaped cavity, covered with a secreting membrane. The lowerfragment was smooth, rounded, and here and there polishedlike ivory, and when sawn through was so compact and densethat it doubled the weight of healthy bone, as shown by thepiece removed. The capsule at the upper part had apparentlygiven way, allowing the lower fragment to be drawn upon thecervix femoris. The cut surface of both fragments was ex-ceedingly hard, smooth, and compact throughout, and therewas complete obliteration of the medullary canal.
Provincial Hospital Reports.WEST RIDING PAUPER LUNATIC ASYLUM.
CASE OF POISONING BY THE CHLORIDE OF AMMONIUM;RECOVERY.
(Under the care of Dr. CRICHTON BROWNE.)
I So few opportunities have occurred of studying the actionsI of the chloride of ammonium when taken in poisonous doses,
