XLIX.

ROYAL INFIRMARY, GLAS

GOW.

REPORT OF CASES TREATED IN THE SURGICAL WARDS, FROM 1st Nov. 1827, To 1st MAY, 1828. BY J. COUPER, M. D., Senior Surgeon.*

During the above-mentioned period, 199 patients were under treatment, ten of whom died-eight were dismissed with advice--seventeen relieved-one was turned over to the care of the physician

one

was dismissed at his own desiretwenty-one still continued under treatment-and the rest were cured.

A table, displaying the nature of the cases, is appended, for which we refer to the original report.

1. ERYSIPELAS-EFFECT OF INCISIONS. -Erysipelas would appear the alpha and omega of surgical writings and surgical reports. It has ever been a subject of peculiar difficulty--it will ever be one of the keenest dispute, and no wonder, when we look to its varying forms-its dubious essence--and last, not least, epidemic character. A practitioner, from local circumstances, or other immaterial, perhaps unaccountable causes, sees much of a particular form of the disease. This form may be either the atonic or the tonic-the typhoid or inflammatory, in which case the surgeon very naturally becomes wedded to one mode of treatment, adapted, no doubt, to most of the cases he himself has seen, but totally misplaced in other situations, and at other times. The man who begins his professional career with the fixed determination to treat erysipelas by bark or by bleeding, will soon, if he carries his eyes in his head, discover what a narrow and fatal idea he has conceived. It may be that the nature of disease, like that of its subject-the human constitution, undergoes an inscrutable though still a decided alteration with the lapse of years; certain it is, that some modes of treatment once thought specific are at present pernicious in the gross. In the days of Dr. Fothergill, to take an illustra

* Glasgow Medical Journal, No. IV.

tion, bark was universally employed in erysipelas, apparently with better, infinitely better effects than would follow its general exhibition now. The taste of this day is rather for incisions, carried, at least in our humble opinion, to a very unnecessary if not an injurious extent. The disease is bad enough, but the remedy to bear is a thousand times worse. Incisions by the foot or by instalments are very pleasant subjects for a joke or a debate-the surgeon only makes them, but the patient has to feel them.

In making these remarks, we are far from underrating the value of the practice, we would merely protest against its indiscriminate employment. In far the greater number of cases it is totally uncalled for, and therefore, from the pain and suffering it produces, objectionable in the highest degree. In the acute and phlegmonous form of erysipelas none can be more favourable to incisions than ourselves, none more impressed with their absolute necessity. Another case exists, where early incisions are indispensably necessary for the safety of the limb or the life of the patient; where they act like a charm in arresting sloughing and procuring relief; and, in fact, where the favourable issue of the case hangs on their bold and judicious employment. A man receives an injury, we will say a compound fracture of the leg. In two or three days the limb, more especially in the neighbourhood of the wound, is observed to pit very slightly on pressure, and soon an emphysematous crackle is felt beneath the skin. The skin itself now assumes a dusky hue, which extends, and presents all the characters of the "brown erysipelas." If the surgeon is contented with bark and wine, the erysipelas, if such we may call it, extends, whilst the skin is extensively destroyed, and exposes beneath, vast putrid sloughs of bad and stinking cellular tissue. In this case, it is evident that the cellular membrane is affected first, the skin in only a secondary manner. then, incisions be freely made immediately the "emphysematous crackle" is felt, and before the integument is seriously affected, the latter will be sound, and the issue given to the putrid purulent matter and sloughs will prevent the extension of the disorganization of the cellular texture. To Mr. Brodie the profession are indebted for clearly pointing out the value of early and free incisions in cases of this description.

If,

The

Case. An officer of police, 43 years of age, was admitted on the 1st of December, 1827, with a sore ten inches in length and one in breadth, extending along the outside of the foot and around the outer ankle, its edges undermined, and its floor being a slough of yellow-coloured, dead cellular membrane. The whole of the integuments of the lower third of the leg were tense and greatly swollen, of a dull red colour, and boggy to the feeling, the back of the calf being covered with numerous vesicles. strength was much reduced-the pulse 120 and small-the tongue brown-thirst great -occasional delirium. It appeared that, eleven days previous to admission, the patient had severely sprained his ankle; on the following day he had frequent rigors, and these were succeeded by inflammation of the integuments around the injured joint, and especially over the dorsum of the foot. Emollient and fermenting poultices were used, but the inflammation extended to the calf of the leg, vesications were formed, the skin became destroyed, and the patient was admitted in the state above-described.

The practice on admission consisted in an incision three or four inches long, completely

through the inflamed integuments on the inside of the calf. The sore and wound were dressed with camphorated oil, and a bandage was lightly applied from the toes to the knee, that part of it covering the leg being constantly moistened with a lotion of spirits and lime-water. The patient was instantly relieved, and no sloughing whatever took place on the leg, the inflammation of which had ceased at the end of a week. The slough on the dorsum of the foot came away, but the sore which it left was not healed till after a residence of nearly three months in the house.

Does Dr. Couper bring forward the above as an instance of the value of incisions in phlegmonous erysipelas? The passage we have quoted is all that immediately bears on the subject, and in it the language is somewhat ambiguous. It is evident that here was one of those cases of sloughing of the cellular membrane, attended with a dusky brown colour of the skin, rather than the florid and phlegmonous variety. It was not a severe example of the disease, but yet it proves distinctly the power of incisions. In the first instance none was attempted, and the cellular membrane sloughed to the extent of nearly a foot; in the second, an incision in the calf prevented the sloughing in that situation in toto. By the bye, we conceive that a poultice would have been a more proper application than a roller to promote the separation of the slough.

II. BURNS AND SCALDS.-In the excellent report from this institution, published in this Journal some time ago by Mr. Plymsoll, allusion was made to the good effects of dry cotton wool immediately applied to the injured parts. Dr. Couper, from experience, is inclined to think in a favourable manner of the practice.

"When the injury, however extensive, is of such severity as to produce only vesica. tion, the cotton is by far the most advantageous application with which I am acquainted; and even in severer cases, when a portion of the integuments must slough, the patient may be saved from much of the debilitating discharge, which emollient and unctious applications always produce, by the application of dry cotton, and the careful renewal of it, as soon as it becomes soiled with pus."

III. HYDROCELE.-Since Sir James Earle introduced the practice of injecting for hydrocele, the modes which were formerly in vogue have been very nearly abandoned. Occasionally, though not very often, injection fails, and the surgeon is compelled to resort to other methods. In the case of an old man, in whom we saw the kali purum employed, a severe, and, indeed, if our memory serves us, a fatal attack of erysipelas succeeded. The practice is inferior to incision or excision of part of the tunica vaginalis. In a patient affected with hæmatocele, the tunica vaginalis was fully laid open by incision, and the cavity filled with lint. Abscesses formed in the scrotum, and smart constitutional disturbance ensued. In another case, that of a very large hydrocele, incision was performed, and the patient was many months in getting well. From these and other similar examples, our own impression is, that the above operations should never be performed in common hydrocele, unless the injection has totally failed, and that, after several trials.

At the Glasgow Infirmary, four cases of this affection were treated by excision of a very small portion of the tunic, after the fluid had been let out by puncture. The operation was successful, but the inflammation which ensued was extremely severe. In one patient, indeed, fully one half of the scrotum sloughed, and many weeks elapsed before the testes were covered with granulations, and cicatrization of the wound had taken place. This mode of operating, therefore, says Dr. C. should only be had recourse to after injection has failed, a sentiment with which we cordially agree.

IV. FATAL RESULTS OF EXTIRPATION OF THE BREAST.-In one of the clinical articles in our last Number, we stated that we had seen a patient die of inflammation of the thorax, after amputation of the breast. The immediate result of the operation was an attack of erysipelas, and this was succeeded by the fatal thoracic affection. A patient of Dr. Couper's has lately died of pleuritis, supervening after the operation, and another from sloughing of the wound and exhaustion. We lately saw the life of a young woman, whose breast was removed for an encysted abscess, placed in the most imminent jeopardy by the supervention of erysipelas. These cases, and a number of others that might be mentioned, prove that the re

moval of the mamma is not so unaccompanied with danger as many would seem to imagine.

We are sorry our limits compel us to close our notice of Dr. Couper's report for the present. Much intereresting matter remains behind, to which we shall return at another opportunity.

L.

ST. THOMAS'S HOSPITAL.

[Reporter, Mr. BURY.]

I. DISLOCATION OF THE THIGH-BONE INTO THE ISCHIATIC NOTCH.-Ben. Whittenburg, æt. 40, a very stout and rather tall countryman, was admitted, Nov. 4th, with a dislocation of the right hip, of twenty-two weeks' duration. The injury was occasioned, during the performance of his labour, by a large piece of timber striking against his shoulders, coming also in contact with the outside of the lower part of the thigh, whilst he was falling forwards to the ground from the force of the blow upon the upper part of his body. His right arm was also fractured at the same time. In this, there is much over-lapping of the fractured extremities, with shortening of the limb.

The following are the appearances and state of the lower extremity of the affected side. A considerable eminence is produced posteriorly below the crista ilii, by the displaced head of femur, which is situated higher than ordinarily in the dislocation backwards. It admits of an unusual degree of motion, can be distinctly felt resting a little above the ischiatic notch upon the glutæus medius muscle, and, when rotated, its movements are distinguishable beneath, or anteriorly to, some of the fibres of the glutæus maximus. The distance from the anterior superior spinous process of the ilium to the patella is found, by measurement, to be nearly two inches less on the right side than on the left. The right knee and foot are inverted, and the toes are approximated to the ball of the other foot. Flexion can be performed upwards to some extent, but scarcely at all backwards, independent of the move ments of the pelvis. The different motions of the leg, made either by the surgeons or the

patient himself produce but little pain. This has latterly been unimportant, but was severe for some time after the injury was first inflicted.

No attempts have ever been made to replace the bone; but, from the mobility of its head, and other circumstances of the case, it was considered advisable, even at this late period, to endeavour to reduce the dislocation.

Nov. 7th. Warm bath and venesection in the arm having been employed, the patient was brought into the operating theatre, well covered with blankets,&c. and was placed upon his back. The usual bandage and padded leather belt, to which the strings of the pullies are attached, were fixed just above the knee. The pelvis was secured by a girt, placed between the scrotum and thigh in the ordinary manner. Extension was made almost, if not quite, directly downwards, i.e. in the line of the body, and was gradually increased in force during forty-five minutes, the time employed in the operation. Rotation outwards and inwards was, at the same time, performed, both from knee and ankle. An antimonial solution was given at intervals, which shortly produced nausea and tendency to vomit. More blood was also taken from both arms pretty freely. An alteration in the situation of the head of the femur, and in the length of the limb likewise, slowly and gradually took place a short time after these means were used; and about forty minutes having elapsed since the extension was commenced, the head of the bone had moved immediately posterior to the acetabulum.

The upper extremity of the femur was now elevated by a towel placed under it, and drawn upwards and forwards; the extension and rotation were continued, and, the head of the bone being firmly pressed upwards and forwards by Mr. Travers, its return into the socket was effected and plainly heard. The patient himself was conscious of its replacement.

A curious circumstance was observable for nearly half an hour after the reduction ; namely, shortening of the thigh, with inversion of the leg, as previously to it. After the patient had been in bed, however, a short time, both patella were brought together, and the right was half an inch above the left; the toes of right foot turned inwards.

8th. Patient had little or no sleep during the night; says he feels weak from the loss of blood; is in no pain, except in the loins, which has existed since he left the operating table, and has no fever; there is some puffiness behind the trochanter major; he can rotate the foot outwards and inwards, which he has not been able to do before since the accident, but he does not move the knee at the same time. The limb certainly does not bear the appearance of dislocation, although the patellæ are uneven, and the inversion is the same. But, on measuring

the space, from spinous process to patella, on each side, that on the right is found shorter than that on the opposite by 14 dislocated; and, on inquiry, it is learned inches. This proves that the femur is now from the patient, that he moved in the night on his left side, from which cause, it may be supposed that the change of position in the bone took place, though quite unconsciously to the patient. The head of the bone atic notch. can be distinguished completely in the ischi

11th. Pain in the loins has been severe, but does not at present exist-pain across the bottom of abdomen during the last day or two, but no where near to the hip-tumefaction diminished-same appearance of the limb. Has had head-ach, and a quickened pulse, which are relieved by a calomel purge.

13th. The displaced bone was again tried dition to the means practised on the forto be reduced, but without success. In admer occasion, Mr. Travers made considerable efforts in rotating the femur outwards and inwards, whilst the extension was intermitted, by taking hold of the thigh, be low its middle, with both hands. A considerable time having expired in these ineffectual attempts, some change had obviously occurred, for the limb was perfectly moveable, and, in fact, had lost all features of dislocation; and, on further examination, a crepitus was discovered at the cervix femoris. Fracture having unfortunately ensued, the patient was placed upon Mr. Amesbury's bed, with the extremity on an inclined planc, and the pelvis fixed by the strap.

It appears probable that the head and neck of the bone had undergone absorption to some extent in their newly-formed situation, and thus the facility of fracture may be accounted for, since no more than ordinary force was made use of.

14th. The hip-joint has been very painful since yesterday, but he obtained some hours' sleep in the night-head in pain-is thirsty, and feels uncomfortable-bowels not open.

15th. In less pain, and feels much better --had some sleep-head easy-pulse firmbowels relieved by medicine. There is no tenderness of the hip. When left to the unrestrained action of its muscles, the thigh becomes shortened to nearly two inches, but by gentle extension with the hand at the ancle a difference of an inch and a half is produced, the whole limb being then only half an inch shorter than natural. The head is situated below the ischiatic notch. It seems doubtful whether the whole sphere of the head of the bone is detached from the cervix, as far as can be judged by manual examination. Mr. Travers and Mr. Amesbury, the circumstances of the case being new to them, and having no data from experience of similar cases on which to act, agreed upon bringing the upper end of the bone as near to the acetabulum as they could, and upon keeping it there by means of Mr. A.'s apparatus. With this view, extension of the extremity is persevered in upon the inclined plane, the foot being secured at the foot-board by bandage to maintain due extension of the leg. Extended in this manner, the thigh is abbreviated about of an inch. Mr. Travers conjectures that the fracture of the neck happened during the performance of rotation outwards. Some restorative process, it is reasonable to expect, will be set up by Nature, and by placing the fractured surface near to acetabulum, it is also reasonable to suppose that the best restoration, whether in the form of joint, or any other likely to be useful for the purposes of motion, will be effected in this the situation of the natural joint. Some months must necessarily elapse before the result can be known.

II. DISLOCATION OF THE RADIUS FORWARDS AND UPWARDS, AND FRACTURE OF THE ULNA, NEAR TO OLECRANON.-Timothy Carthy, æt. 40, whilst engaged at work, fell into a cellar from a height of some feet, Oct. 1st. and came upon his right shoulder, but whether or not his arm was bent under him, he does not recollect. The elbowjoint was a good deal swollen, and in great pain. The limb was placed horizontally

upon a pillow, and leeches and cold lotion were applied.

Oct. 4th. Great swelling of the jointpain felt particularly severe on pressure near the outer condyle, and on the posterior surface of fore-arm, not far from olecranon. The patient has no power of raising the limb, nor can any the slightest motion be performed without intense pain. The head of radius is resting upon the outer condyle anteriorly; the olecranon is drawn upwards, a sharp projection being formed at the back of the elbow, with a depression a little below, produced by the separation of the broken extremities of the ulna. Mr. Green exerted gentle extension from the hand for a few minutes, trying to replace the radius. He pointed out the singularity of the injury, and observed, that the indication now was, to reduce the inflammation of the part by ordinary means, before again attempting reduction. Patient complains only of his elbow; pulse rather quick; bowels opened by house medicine. Rep. hirud. et lotio.

Oct. 10th. Tumefaction subsiding, but patient complains greatly of pain-pulse natural-a thick paste-board splint is applied. Lotion continued.

15th. Swelling and inflammation are much reduced. Pretty forcible extension, ed, was again made from the carpus, or supination being at the same time employrather extremities of radius and ulna, but the head of radius was not apparently moved. The fracture of ulna prevented the use of any excessive degree of force.

20th. Parts kept at rest, with paste-board splint and lotion applied.

27th. Hitherto the joint has been easy. Reduction was once more attempted, by placing the fore-arm at an angle with the arm, making pressure with the knee against the lower part of the humerus, and by employing extension and supination from above the wrist, but without effect. The mode adopted before was also tried, but with no better result. Paste-board splints were used above and below the joint, which was kept at rest on a pillow. No inflammation ensued.

Nov. 13th. There is no pain in the limb, or joint, except on motion. The power of motion is at present very limited. The ulna, at its seat of fracture, we should suppose, must be nearly consolidated. Wooden splints are kept on the fore-arm.