THE LANCET. A Journal of British and Foreign Medicine, Physiology, Surgery, Chemistry, MDCCC LIV. IN TWO VOLUMES ANNUALLY. VOLUME I. EDITED BY THOMAS WAKLEY, SURGEON, M.P. DURING] EIGHTEEN YEARS FOR THE METROPOLITAN BOROUGH OF FINSBURY, AND CORONER FOR THE COUNTY OF MIDDLESEX. LONDON: PRINTED FOR THE EDITOR, AND PUBLISHED BY GEORGE CHURCHILL, 423, STRAND. THE LANCET, JANUARY 7, 1854. Clinical Lectures ON showing how quietly serious disorganization will creep on, in a strumous subject, without much warning. In this case there is decidedly some displacement of the anterior extremity of the ISEASES AND INJURIES OF astragalus and navicular bone, resulting, as I believe, from the JOINTS. Delivered at St. Thomas's Hospital. BY SAMUEL SOLLY, Esq., F.R.S., SURGEON TO THE HOSPITAL. GENTLEMEN,-I am glad to have the opportunity afforded by my last taking in, of showing you a case of disease of th alcano- and naviculo-astragaloid joints in its very early stage. To appreciate the features of this disease you must, as I Jave advised in reference to the knee-joints, bare both at the ame time, and thus compare the sound joint with the diseased. f you do not do so you will not perceive so clearly the amount of deformity which really exists in these cases. In the sound ot you observe the beautiful hollow on the inner side of the Jot, bounded above by the internal malleolus, anteriorly by he ball of the great toe, and posteriorly by the heel. There is very slight projection of the point of navicular bone into this epression. Now look at the diseased foot. Here you find ais hollow partially obliterated from effusion. The cellular sue here is soft and quaggy; there is no fluctuation, but it feels as if it were infiltrated. The patient cannot bear any firm pressure, it is painful. Motion of the ankle-joint alone does distress him, but not so if you take the foot in both hands, fixing the ankle with the left hand, and taking hold of the front of the foot with the right, you twist the foot, gently moving the inferior astragaloid joint, you then put him to pain. If the disease has advanced to ulceration of the cartilages or caries, then the pain is very severe. I will now proceed to the details of the case as given by my dresser, Mr. Chiperfield :— “Inflammation of the Calcano-Astragaloid Articulation. "John D, aged eighteen years, admitted into Abraham's ward, under the care of Mr. Solly, on the 22nd November, 1853. “History.—Three months ago he felt a pain in the left foot and ankle, which became slightly swollen. He kept about his work, but found himself getting lame. When walking, the foot seemed to slip outwards, so that he trod upon the inner side of the foot. He had no surgical advice; the pain increased so that walking became excessively irksome, and this induced him to apply for admission here. He states that the swelling has not always continued to the same extent, but has sometimes so much subsided as to be scarcely visible. "Present state. He is a pale, strumous-looking lad, with a dead white skin, dark hair and eyes, long eye-lashes, and other marks of a cachectic habit. The left ankle is considerably altered in shape. There is a projection on the inner side of the foot, just below the malleolus, by which the hollow of the foot on this side is quite lost, and there is also a slight, but by no means corresponding, depression below the outer malleolus. The centre of the swelling is of stony hardness, slightly painful upon pressing, the pain being aggravated by a jar upon the heel. Upon a cursory examination it looks like a displaced astragalus. The integuments are unaffected; there is no redness of the part, but the temperature is rather above that of the other foot, of which he makes no complaint, and it appears quite healthy, its contour presenting a marked contrast to that of the left. Motion of the joint produces pain, which is greater apon extension of the foot than upon flexion. The swelling of the foot is so great, that lateral motion is scarcely permitted of. "Nov. 23rd.-Mr. Solly desired him to keep his bed, and ordered a mixture of iodide and gentian twice a day. Two grains of mercury with chalk every night. Twelve leeches to be applied, and afterwards a linseed-meal poultice. "24th-The leeches bled well, and relieved the pain. The swelling also has considerably subsided. He is suffering slightly from catarrhal symptoms, most probably due to the iodine he has taken. “25th, (third day.)—The foot is less swollen, but still painful upon pressure. Has no pain when lying quite still, but the least motion brings it on. The catarrhal symptoms are subsiding; sleeps very well; pulse 80, moderate power; tongue clean; bowels open." In this case the disease has come on insidiously; he is not aware of having sprained it; and this very fact is instructive, No. 1584. yielding of the interosseous ligament. I am afraid that this boy has been admitted too late to prevent caries, but we must try our best, and you will have the opportunity of watching the progress of the case. In our treatment, I have felt it necessary to subdue by leeches the existing inflammation as evidenced by heat and tenderness. You must, however, avoid, as a general rule, bloodletting in these strumous subjects, and give tonics at the same time, of which there are none that I prefer, in such cases, to the various preparations of iodine. In the next case, there is no question as to the existence of caries. Its interest arises especially from the long continuance of the disease, and the fact of its having been under the care of three hospital surgeons in succession who preferred the expectant plan of treatment. "Caries of the Astragalus. "J. O. L Four aged twelve years, admitted into Abraham's ward, Nov. 22nd, 1853, under the care of Mr. Solly, years ago, whilst endeavouring to raise a bar of iron he let it fall upon his right foot, which was slightly bruised. The pain was not very severe, and he made no complaint to his parents, as he had been desired not to meddle with the iron. Three Mr. weeks afterwards the foot and ankle became much inflamed, red, and swollen, and his mother took him to a London hospital, where he continued for a month, under the care of He states that whilst there nothing was done to the foot, and he was allowed to be up and walking about. the hospital, as he thought, well. In about eighteen months, The inflammation subsided, and the swelling also, and he left the ankle became swollen and tender, and he was admitted into another hospital, under the care of Mr. --, but he states and became an inmate of the Welsh school, in Gray's-inn-lane, that he was not submitted to any treatment. He went out not suffering at all from his foot, though it continued slightly swollen. Soon afterwards, he received a kick on the same ankle, and it became inflamed, but the inflammation was not very violent, neither did he suffer much pain. The nurse of the school strapped up his foot, but it still continued enlarged about the ankle; and, a twelvemonth ago, an abscess formed over the inner malleolus and opening spontaneously, gave exit to some purulent fluid, the discharge of which continued for some months. "On the 21st of June last, he was admitted into another hospital, under Mr. who ordered poultices to be applied. Was in the hospital for ten weeks, and went out much the same as he came in, except that the swelling was somewhat diminished. The foot has continued in the same condition up to this date, when Dr. Griffiths, who had seen the case, requested that he might be admitted here. "Present state (Nov. 22nd.)-The tarsus of the right foot is evidently diseased; the shape of the foot is altered; there is a depression greater than natural, under the outer malleolus, whilst a considerable hard prominence exists just in front of, and below the inner malleolus, looking somewhat like a displacement of the head of the astralagus inwards. The hollow in the inside of the foot is thus destroyed. The integuments around the part are congested-evidently the result of previous inflammation. There is a fungous protrusion just over the inner malleolus, in which two papillæ, the orifices of two sinuses exist. A small quantity of thin pus exudes, and the upper sinus allows of the passing of the probe downwards, for about an inch, when it strikes upon carious bone. He makes no complaint of pain, and can bear manipulation without any severe suffering. He walks about without difficulty, having scarcely an appreciable halt. Ordered full diet." Nov. 26th. I cut down on the astragalus and removed some carious bone with the gouge, and he has been going on well ever since. The os calcis is not unfrequently the sole seat of carious disease, and Mr. Thomas Wakley, of the Free Hospital, has shown that it may be successfully removed from the rest of the tarsus, and a very useful, comely foot eventually remain. The os calcis may also be the seat of necrosis. In my last lecture I called your attention to numerous cases of scrofulous carious disease of the tarsus, the result of sprains. Necrosis of the os calcis, however, more frequently results from exposure to cold. The bony tissue inflames, the interstices are infiltrated, the periosteum detached, and the channel of the bloodvessels going to the interior is interrupted, the supply of blood cut off, and a portion of the bone dies. The dead piece 2 MR. SOLLY ON DISEASES AND INJURIES OF JOINTS. is a sequestrum a slough which ought to be cast off; but as it is in the substance of the bone, it cannot get out. The surgeon is called upon to interfere, to release the prisoner, and relieve the rest of the sound bone. There are no class of cases which are more satisfactory. The only thing is to diagnose the case accurately, and the treatment follows as a matter of course. Generally speaking, in hospitals we do not have the opportunity of tracing these cases from the beginning; they come to us after the sequestrum has formed. The following case I had the opportunity of observing from the onset : Hannah S- aged thirty-two, married, was admitted into Queen's ward, under my care, May 30th, 1851. I first saw her about two months previously at Poplar, in conjunction with my friend Dr. Bain, by whom I was called in. She was suffering the most excruciating pain in the heel, but more especially at the under part; there was no appearance of inflammation on the surface. From the history of it, and the general symptoms, I was induced to regard it as a case of inflammation of the surface of the os calcis, brought on by standing in the wet, and I thought that there might be some pent-up matter. The pain was agonizing. I made a free incision over the tuberosity of the os calcis, through the origin of the plantar fascia, right down to the bone. No pus followed the knife, nor was there any relief to the pain for two days; after that she became easier, and I did not see her again till her admission into the hospital. She then stated that about a fortnight after I saw her an abscess formed on the outer side of the foot; this broke, and discharged a thin purulent fluid up to the time of her admission into the hospital. On looking at her foot, I found the heel swollen from infiltration of the soft parts over the os calcis. On the outer side there was a sinus leading down (as the probe testified) to a portion of necrosed bone. Now I dare say some of you are considering how the probe bore witness to the fact that this was a case of necrosis, not caries. Where you have a distinct sequestrum in a cavity, you can rattle it with the probe, you can shake it in its den, you move it, and feel it move. The walls of the cavity in which it rests are often quite hard, instead of being soft and crumbling, as in caries. On the 31st of May I made an incision on the outer side of the bone, about two inches in length, down to the surface, and then without difficulty I removed a sequestrum about the size of a horse-bean. June 4th.-The wound is clean, and beginning to granulate. The soft parts around have already lost a good deal of their puffiness and tumefied appearance. She suffers no pain, and there is no constitutional disturbance; in fact, the foot was so well that she was anxious to return home, so I allowed her to do so. The wound healed, and she recovered perfectly. I must not dismiss the subject of diseases and injuries of the foot, without a few words on some of the injuries to which it is liable from railway accidents. We are oftener now called upon to treat a crushed foot than we used to be, and the question of amputation of the leg, or partial amputation of the foot, oftener comes before us. I feel convinced that many a foot is amputated which ought to be spared. More than once I have seen a foot saved by the obstinacy of the patient which had been condemned by the surgeon. I remember on one occasion being consulted as to the situation in the leg where the amputation should be performed. When I saw the foot, I advised that the amputation should be abandoned, and that the foot should be preserved. This plan succeeded, and the patient has now got a very useful foot. In many of these cases of railway accidents the soft parts are most seriously injured; the skin separated; the muscles and tendons lacerated, but still do not consider that therefore you must remove all the injured portion. It is true that if you do not do so, you may have most extensive sloughs to contend with; nevertheless it is such a great gain if you can save any portion of the metatarsal bones or phalanges that it is worth running some risk to do so. They are cases which require great care and attention, and constant watching; but if you succeed they amply repay you all the trouble and time you may bestow upon them. You may sometimes be baffled by causes over which you can have no control. I remember on one occasion attempting to save a foot which had been crushed in a thrashing machine. The patient was a country boy about fifteen years of age. He appeared to be in good health, though he was thin and ill-nourished. I will not detain you with the daily notes of the case, but just quote that portion of the history which illustrates what I mean when I refer to hidden causes sometimes interfering unexpectedly in the progress of the case. "Sept. 17th (the nineteenth day since the receipt of the injury).-The sloughing has extended into the tarsal articulations; the bones are quite exposed to the fourth and fifth toes, as are also the tendons of the common extensors. The boy wanders in his mind. The thigh and leg are of the natural colour and size, and the incisions in the upper two thirds of the latter are slowly healing; rests at night, and also dozes during the day; hectic symptoms still manifest themselves; the bowels are still very much relaxed; if he takes any nourishment it almost directly passes through him; he passes his motions almost unconsciously beneath him. Ordered two ounces of brandy. "18th.-As there appeared to be no possibility of saving the limb, and the boy's health suffering so severely from the sympathetic symptoms, and his vital powers manifestly sinking rapidly beneath the hectic under which he was suffering, it was determined by Mr. Solly, after consultation with Mr. Green, to amputate, as being the only chance to save the boy's life. The limb was accordingly removed in the upper third of the leg, and a good flap was formed. There was considerable bleeding from the surales, and ligatures had to be applied. The parts were brought together by sutures and strapped with the isinglass plaster. The lad did not appear to suffer much during the operation, and after its performance at once went to sleep; and after being put to bed (for he was so weak as to necessitate the operation being done in the ward), dozed for the rest of the afternoon and appeared much refreshed, and his pulse slightly improved. There was not the slightest hæmorrhage from the stump; his bowels are much relieved, and the motions run from him. Took twenty minims of opium at night. "19th. The lad slept more or less all night; his pulse is better, and he takes his food and nourishment with an appetite; his diarrhoea is very obstinate, and will not yield to remedies. A starch and opium enema was administered, which brought away eventually two acarides lumbricordes, and which the boy says (now) he has been subject to, and which always make him very ill prior to passing them. He dozes the whole time, but sleeps lightly; calls for his food and stimulus, which he appears to take with much satisfaction. About eight o'clock in the evening there was a manifest change in his appearance, though he made no complaint, and did not appear to suffer much pain. At half-past ten he gave several gasps, and died without a struggle; in fact, so rapid was the transit from life to death that those around were hardly aware that all was finished. He evidently sank under the severe diarrhoea which caused so great a prostration of the vital powers as precluded the possibility of rallying." From the above short details, I think you will agree with me in considering that his life was sacrificed to his ignorance in concealing the fact of his suffering from worms. If I had known this at the outset of the case, I should have adopted measures for immediately getting rid of the ascarides; a dose of turpentine or a few injections of salt and water would soon have affected this object, and after that I have no doubt that the diarrhoea would have ceased. The local symptoms frequently improved, showing that the local injury was not the sole cause of depression and constitutional irritation. The erysipelas, which had ascended up the thigh on the ninth day, had entirely sudsided on the sixteenth day; the incisions in the leg were healing. It was, in fact, the sickness and diarrhoea which carried him off. 66 In the following case the injury was quite as severe, but the result was favourable. There was no internal disturbing cause to interfere with nutrition, and excite constitutional irritation. Thos. B, aged twenty-two, labourer, was admitted into George's ward, under Mr. Solly, with a crushed foot. The patient says, that while employed at the Waterloo-bridge station of the South-Western Railway, a wagon-wheel of a luggage-train passed over his left foot, which happened to be resting on a rail. The wagon was laden, and must have weighed altogether two or three tons. He was immediately carried to the hospital. On admission (May 24th, ten P.M.) he was seen by Mr. Richardson, one of Mr. Solly's dressers. "No constitutional disturbance; no hæmorrhage. The wheel had passed over the inside of the tarsus, over the metatarsus, and the third, fourth, and fifth toes of the left foot. The tarsus and metatarsus, from their figure and elasticity, had escaped fracture and laceration of muscles and ligaments; but the second and third phalanges of the third, fourth, and fifth toes were crushed, and the first phalanges of those toes were broken in the middle, and the fractured ends appeared through the lacerated soft parts of the dorsum of the toes. There was a rent of the skin extending from an inch anterior to the inner DR. R. BARNES ON SARCINA VENTRICULI. malleolus to the inner side of the first phalange of the great toe, and the skin, and the subcutaneous areolar tissue, and granular it were separated from their attachments around the foot, except at its outer border, so that a little finger could be passed over the plantar fascia, from its origin at the os calcis to its mertions at the metatarso-phalangeal articulations, and over the whole dorsal fascia of the foot, from the anterior annular higament of the foot until it made its appearance at the compound fractures of the first phalanges of the third, fourth, and if toes, and at a continuation of the laceration over the dorsum of the first phalange of the second toe, where the exor digitorum longns appeared like the string of a bent bow. The man was aged twenty-two years, florid complexion, pare make, and very healthy. The fourth and fifth toes were amputated at the metatarso-phalangeal articulation, (leaving the heads of the metatarsal bones,) and the projecting tendon of the extensor-digitorum divided. Flaps were obtained from the skin above and below the heads of the metatarsal bones, two digital arteries were tied, three sutures used, and strips of strapping applied all round the foot, with cold water over those. A cradle was placed over the foot and leg, which was flexed on the thigh, and laid on the outside on a pillow, so ranged that the toes were on a plane below the steel. He refused chloroform, and behaved as a stoic.-Ten P.M.: Pulse quiet; tongue clean. Has slept. May 25th, Ten A. M.-Ditto, ditto; no inflammation above the foot. Appetite good. 26th-Pus issuing from between the sutures, which were removed; and it being manifest there was much pus in the ole of the foot, the plaster was removed, and the foot enveloped in a poultice of linseed-meal. There is no constitutional disturbance. 27th. The skin sloughing; granulations appearing every where underneath, covered with healthy pus. The head of the fifth metatarsal bone may be seen bare; poultice continued; no symptomatic fever. th-As yesterday. Took some skin (dead) away with the scissors. Granulations covering heads of metatarsal bones; paise weaker. To take two ounces of brandy daily, in addition to the house-dict. 30th-Wound healthy; removed more skin; tongue furred; bowels confined. Ordered calomel pill and black draught. 31st-Removed more granulations; healthy. General good health. From this date the skin ceased to slough, and contracted adhesions beneath, so that from the tarso-metatarso joints to the first phalanges of the first and second toes all and the foot, new skin had to form before the foot would be sand. Small islands of skin formed, increasing in size till the 21st. There is no spot uncovered by skin, and he walks with a stick. The foot is sound, and very little impaired as to beauty or activity. age The details of this case speak for themselves; they show what nature will do for a young man twenty-two years of age, healthy and temperate. If this man had been fifty-two, and his constitution injured by intemperance, he must have lost his leg, or he would have sunk under the reparative process. In pursuing this line of conservative surgery, you must of course do so with great care and caution, and remember that the and previous habits of your patient must mainly guide you in your decision. There are, of course, two classes of Cases in which there is no difficulty in deciding; in the one where the injury is so severe that no part of the foot remains uninjured, and the other where the injury is so slight that no honest man can doubt the propriety of withholding the knife. It is to the intermediate class of cases that I refer, and of the importance attached to the study of such cases when at the hospital I need not further insist. ON A CASE OF SARCINA MEMBER OF THE ROYAL COLLEGE OF PHYSICIANS. SINCE the first observation of the sarcina ventriculi in vomited matter, it has been an object of great pathological and practical interest to determine the relations of this parasite to disease, and to ascertain how far its presence ought to be regarded as an essential morbid condition, or as a complication mcidental to other affections, organic or functional. It is obvious that these questions can only be answered satisfactorily, 3 when a considerable number of cases shall have been accumulated. Pending the deductions which the analysis of a sufficient number of observations can alone render authoritative, it is not, however, useless to indulge in such speculations as to the causes of this parasite appearing in the stomach, as may be suggested by the consideration of individual cases. Such speculations are frequently useful in directing inquiry into new paths; and any ill-founded assumptions are sure to disappear under the corrections of a more enlarged experience. But the addition of new cases is the most important step; and it will not be disputed that those cases are of the greatest value, in which the opportunity has been afforded of observing the condition of the body by anatomical investigation. The case I have to relate is one of this kind: I believe it exhibits the sarcina in a new relation. CASE-A lady of about sixty years of age had been addicted for many years to the free use of opium in different forms. For a long time together she consumed daily half an ounce of Battley's solution, and probably often more. She was stout, and of adipose disposition, but accustomed to exercise in the open air. Her anxiety for fresh air sometimes amounted to an uncontrollable longing; her appetite was usually good; her diet consisted generally of well-seasoned dishes at night, of bread and milk. She suffered at intervals from "bilious attacks," which were relieved by vomiting. Of late years she had had one or two attacks in the year of an alarming character: spasms, attended by great pain in the stomach, prostration, numbness, and approach to paralysis of the right side of the body. At these times the power of speech was commonly impaired. These attacks-so severe as apparently to threaten a speedy fatal termination-gave way under the use of large doses of opium and ether. I have ordered her sometimes three grains of morphia at a dose. This was usually followed by warmth of surface, remission of pain, a rising of the pulse, a general sensation of improvement, and sleep. After this action the symptoms would abate, and under bitter stimulating tonics she would recover her usual strength. In the autumn of 1852 this lady went to Jersey, where she had a severe illness, marked by pain in the right side, for which leeches and blisters were resorted to. The cause of her illness was represented to be inflammation of the liver. My acquaintance with her previous history, and subsequent opportunities lead me to doubt the correctness of this view of the case. At any rate this illness would appear to have been much more protracted and grave than any she had previously suffered. It left her weak, with her appetite impaired: she never recovered her ordinary health. Throughout March, 1853, she underwent excessive anxiety and fatigue owing to the illness of her husband, which terminated fatally. On the 8th of April she complained of spasms, pain in the stomach, and loss of appetite. These symptoms increased, and on the 14th the cramps and pain were intensely aggravated, and violent vomiting set in, with great mental depression. Hydrocyanic acid, ice, soda-water, blisters to the pit of the stomach, dressed with morphia, had no alleviating effect. No sleep; pulse not quick, but full; tongue white, furred; bowels not costive; urine high-coloured. The vomited matter was at first light-coloured, containing milk, and such similar bland articles of food as she could still take. It gradually became greener; and no food but an occasional spoonful of beef-tea could be swallowed. When the vomited matter was allowed to stand, a green matter subsided forming a thick stratum. On examination this green matter was found to consist almost entirely of sarcina. Sulphite of soda was now administered in scruple doses every four hours. After thirty-six hours' use, the vomiting had abated, the last vomitings exhibiting less of the green sediment. The pain remained of the most agonizing intensity. The expression of suffering exhibited in the countenance was afflicting to witness. She begged for chloroform as an escape from her torture. The quantity of sulphite was diminished, and a mixture of infusion of quassia, bi-carbonate of potassa, and tincture of orange was added. The Breathing was distressing; she could not fill the chest, but symptoms remitted somewhat, but the prostration increased. respiration was heard in every part; the pulse was intermitting, especially after any exertion, such as sitting up in bed. Pressure below right ribs gave pain. There was no swelling of the feet or abdomen. A blister was applied to the right hypochondrium; ten grains of calomel, followed by an enema. the 18th, Dr. Hassall saw the case with me. The symptoms were as detailed. The treatment was persisted in. On the 19th the quassia mixture seemed to compose and give relief, so much so, that it was supposed by the patient and her attendants to contain a narcotic. The appetite was somewhat improved; she took a little beef-tea. Some urine passed, and the bowels acted freely. On the 20th the distress of breathing On |