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A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

GUY’S HOSPITAL.CASE OF ERYSIPELAS, FOLLOWED BY GANGRENE; SLIGHT

NECROSIS OF FIBULA; EMBOLISM; SLOUGHINGOF LUNG.

(Under the care of Mr. BIRKETT.)

Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborumyet disseotionum historias, turn aliorum, tum proprias collectas habere, et interse eomparare.—MoMAaNi De Sed. et Caul. Morb., lib. iv. Proarmium.

THE following case is one of great interest as an example ofthe conveyance of gangrenous matter by tangible means. Dr.

Moxon, by whom the autopsy was made, and who has obligedus with an account of the case, thinks it cannot be held thatembolism was the cause of gangrene in the lungs. The mereocclusion of the artery would not of itself be a sufficient cause;but the cause of the gangrene must be sought in the existenceof gangrene in the leg. Examination of the vessels of thislimb showed it to be nearly certain that the clot had beenformed as usual in the region of the circumflex and profundafemoral veins, and then had projected into and been broken offin the chief femoral vein. Examination of the popliteal andother veins showed the absence of any considerable-sized plugsuch as could have stopped up the pulmonary artery in theway described. In this case, then, it is reasonable to believethat the general condition produced by the presence of gan-grene, and perhaps more particularly by the circulation of thejuices from the gangrene, so predisposed the lung and all elsethat the emboli excited the part it affected to complete gan-grene. It should not be overlooked that the vein in whichthe thrombosis occurred was permanently exposed to the blooddirect from the gangrenous part, so that the dead clot in itwould be very likely to take up to a disproportionate extent thebad juices from the sphacelus.The patient, a man affected with ulcer of the leg, had been

seized with pain in the limb, succeeded by erysipelas. Hisdresser, Mr. J. A. Sharp, gives the following report :-On the day of admission (Aug. 2nd) the man had been put

into Lazarus ward, but, as he was suffering from hospitalgangrene, which had attacked the ulcer of the leg, hewas at once transferred to Mark ward. On Aug. 9th, theulcer having assumed a more healthy appearance, he was re-transferred to Lazarus ward. The treatment while in Markward consisted in twenty drops of muriated tincture of iron inquinine mixture three times a day, with six ounces of wine,two pints of porter, and full diet. The ulcer was aboutthe middle of the leg on the outer side, seven or eight incheslong, and varied from half an inch to two inches wide ; itsedges were raised, indurated, and surrounded by a blush ofinflammation.Aug. 13th. -Ordered lead lotion, and twenty drops of

muriated tincture of iron three times a day.20th.-The edges continuing raised and indurated, they

were ordered to be scarified.Sept. 5th.-Edges more healthy, but still raised and indu-

rated ; rescarified.9th.-Since the second scarification the ulcer had again

taken on a sloughing action; the superficial area of the ulcerwas doubled, and the surface covered with a thick, tough,blackish, fetid slough, and the skin around, for the distance ofthree inches, was inflamed, swollen, and indurated. Patientwas feverish; pulse quick and full ; little inclination for food.Ordered the tincture of iron as before; also poultices to theleg, which was raised on a pillow.14th.-The sloughing progressing. The patient was re-

moved to Mark ward.2lst.-Sloughing progressing towards the back of the leg.Oct. 17th.-Since last report the sloughing has gone on un-

interruptedly. The muscles of the calf and outer side of theleg external to the tibia are laid bare from two inches belowthe knee to the ankle. This morning there was haemorrhagefrom the back of the leg, about a pint of blood being lost. A

tourniquet was placed on the femoral artery in the upper partof the thigh, which stopped further bleeding. A few hoursafter, when seen by Mr. Birkett, the tourniquet was removed ;no fresh bleeding ensued, and it was left off altogether. Mr.Birkett thought it probable that the posterior tibial artery hadsloughed through, and ordered that, if the bleeding recom-menced, the artery should be found and ligatured at the bleed-ing part. The patient was taking twelve ounces of brandy,and as much milk and beef-tea as possible.19th.-No further bleeding had occurred.29th.-During the last ten days he has remained in about

the same state, the sloughing progressing up the leg. Forthe last fortnight he seemed moribund. He was fed withas much brandy, milk, eggs, beef-tea, &c., as it is possibleto get him to take.Nov. llth.-Improving; takes more nourishment; surface

clear of sloughs and granulating, is now being dressed withcarbolic acid and linseed oil.l3th.-Although the diseased part was taking a healthy

action, the patient was so much exhausted that he diedto-day.On post-mortem inspection, the following appearances were

observed. The rigor mortis was moderate. The body wasabout middle height, slightly built, very spare, even to wast-ing. The complexion sallow and pale. No suffusion. Tracesof dropsy about the ankles. On the right leg was a great openspace, in which the fibula and deep-seated tissues were ex-posed, brown and sloughing. The tibia was nowhere de-nuded, but the fibula had, at one spot in particular, smallsuperficial sequestra. There were no nodes upon the head:thick membrane. The brain was only superficially examined;it appeared to be healthy. The right lung was attached byold adhesion at the hinder and lower part. The left lung wasin a state of acute pleurisy over the lower four-fifths, coatedwith plastic lymph, but no liquid present; the lymph wasscarcely removable. The left lung had its lower lobe in a stateof early inflammation, but it did not sink in water. At onespot in the lower lobe was a plum-sized patch of old sclerosis;the tubes in this were full of pus ; the pleura was depressedover this spot. The upper lobe was thus affected. An emboluswas on the principal bifurcation of the left pulmonary artery,but went so into the upper branch of this as to occlude itslower and greater division entirely. The part of lung whichthis artery supplies was gangrenous. The embolus was veryclosely adherent to the artery, and was quite decolorised.The mediastinum contained several large soft glands. Therewas not any hypertrophy or dilatation of the heart. Therewas one "milk patch" on the pericardium. The right side ofthe heart contained a little black blood, with a small fibrinousclot. The left side contained a little blackish blood. Themitral valve was somewhat thickened. The aortic valves wererather thick and stiff for some distance from their attach-ments. There was a moderate degree of superficial fattydegeneration of the great vessels. The right femoral veinhad an ante-mortem clot, invading the femoral vein from theinternal circumflex vein and the left profunda femoral vein.There were numerous ante-mortem clots in the prostatic plexus.The popliteal vein had a small clot behind a valve. The ante-rior and posterior tibial veins were free. The orifice of thebile-duct in the duodenum was quite free, though the eleva-tion on which it is seated was rather prominent. The jejunumwas thickened, and more prominent than usual ; yet, on sec-tion, nothing definite was observed to account for the uncom-mon distension of the gall-bladder. The large intestine wasfull of black tenacious faacal matter. The form of the liver wasnatural, except that there was a deep notch where the pressureof the distended gall-bladder had caused atrophy. This con-dition proved the distension of the cyst to be of very longstanding. The tissue was natural. The gall-bladder was sixinches long, by three in diameter, enormously distended bybright, clear, amber bile, which on pressure on the cyst wouldspirt freely into the duodenum ; this latter contained plentyof bile. The spleen weighed six ounces. In its substance,but not coming to the surface, was a circumscribed pale patch,with a dark margin, probably "embolic"; perhaps it hadcome from a pulmonary vein; these at least had thrombi in thegangrenous part. The kidney was of large size, and rathercoarse in appearance, but practically healthy. At the neck ofthe bladder were some small prostatic concretions. The rightulna had three considerable nodes on the cutaneous surface.

704

The skin was adherent over two of these, and had been ulcer-ated. No nodes were present on the tibia, and there was nosign of gout in. the joints.

KING’S COLLEGE HOSPITAL.

TRAUMATIC STRICTURE OF THE URETHRA; TREATMENTBY POTASSA FUSA.

(Under the care of Mr. HENRY SMITH.)A GOOD illustration of the advantages of the use of the

caustic potash in those somewhat rare and exceptional casesof stricture of the urethra which will not admit of dilatationis furnished by the following case, which has recently beenunder treatment at this hospital. The stricture was producedby an injury, and it is generally found that when thus pro-duced strictures are much more difficult to overcome thanwhen they are brought about by the more usual cause, and itis a customary thing for the surgeon to resort to perineal sec-tion in such cases.A fine healthy labouring man, aged twenty-five, was ad-

mitted August 28th for a very bad stricture of the urethra. Itappears that he had been injured by a cartwheel about twelvemonths previously, and had suffered a laceration of the urethra.On recovery from the immediate effects of this injury stric-ture in a bad form was found to exist. After having beenunder treatment in the country he applied to this hospital asan out-patient, under Mr. Smith, who on several occasions at-tempted to pass catheters, but he could not once succeed inintroducing an instrument, and the patient was therefore ad-mitted into the ward.On admission there was found to be very great thickening

all along the course of the urethra in the perineum, and thecatheter was arrested at a distance of four inches from theorifice. The patient could only pass urine in drops, and wasconstantly tormented by the desire to empty his bladder. He

was ordered to lie in bed, and to have relays of leeches on hisperineum.For the first week the man suffered very much-his bladder

became greatly distended, the urine only came away in drops,and he was in that condition which would have amply justifiedthe operation of puncture of the bladder. Mr. Smith made acareful attempt to introduce a small catheter through the stric-ture, but he could not succeed even in penetrating the front ofthe stricture ; and as there was so much induration he deter-mined upon perineal section at the point of a catheter, if anycutting proceeding were adopted, and in order to facilitatethis process he was anxious to destroy, if possible, the frontportion of the stricture. Accordingly, on Sept. 19th, he

applied caustic potash to the face of the stricture by means ofa small portion of the salt being inserted into a little cavitymade in the end of a No. 6 wax bougie. The patient did notsuffer from any distress, and Mr. Smith applied it again onthe 25th, on the 27th, and on the 30th, when the man statedthat he could pass his urine somewhat better. Encouraged by ithis, Mr. Smith applied it again on Oct. 2nd and 4th; and on ’Ithe 7th, finding that the patient could pass urine in a smallstream, and that the thickening in the perineum was less, heintroduced a No. 2 silver catheter; and discovering that hecould insert it into the stricture for about one inch, he madefurther attempts, and passed it into the bladder and drew offthe urine.On the 9th he passed the catheter again; on the llth a

No. 3 was introduced; on the 14th No. 4. The patient couldnow pass urine in a good stream. On the 22nd a No. 5 waseasily introduced, and the man was discharged, and desired tocome to the hospital once a week to have an instrument passed.

"DREADNOUGHT" HOSPITAL-SHIP.THORACIC ANEURISM, BURSTING INTO THE COATS OF

THE ŒSOPHAGUS.

(Under the care of Dr. WARD.)THE following case has lately occurred in the medical prac- I

tice of the above hospital, and Mr. Harry Leach, the residentmedical officer, has been kind enough to give us notes of it.

Many patients are admitted here suffering from aneurism,nearly all of whom furnish some definite history of injury as theexciting cause, and the majority proving fatal from secondarybronchitis. The case here given is noteworthy on accountof (1) the absence of auscultatory helps to diagnosis, (2) the

existence of intense emphysema, and (3) the peculiar directiontaken by the exuded blood.William S-, able seaman, aged forty-eight, was admitted

on the 15th of May, with pains in the lumbar region of threemonths’ duration, and stethoscopic signs indicative only ofslight bronchitis, the patient having suffered from cough withmucous expectoration two or three days previous to admission.The symptoms of active disease were altogether negative ; nodyspnoea or abnormal sounds other than bronchitic, nothing inthe urine to indicate renal complications, and no oedema, orascites. Emphysema with extreme dyspnoea commencedtwelve days after admission, with intense pain in the dorsalregion, difficult deglutition, and almost constant vomiting.After the lapse of forty-eight hours the emphysema diminished,but there was little, if any, intermission of the other symptoms.Slight haemoptysis subsequently occurred, and the man, afteralternating for two days longer between fits of agonising painand intervals of stupor, died on the 1st of June.

A uto]Jsy, thirty-six hours after death.-A large aneurism wasdiscovered attached to, and causing caries of, the fifth, sixth,and seventh dorsal vertebras. As there appeared to be somecommunication between the aneurism and the oesophagus, bothwere removed, in company with the heart, lungs, and stomach.The sac of the aneurism communicated with the aorta abouttwo inches below the junction of the left subclavian artery.A second opening was found towards the left and posteriorpart of the aneurismal sac, communicating with the muscularcoat of the cesophagus. Blood was extravasated between thestrias of this coat, and between the latter and the serous coat,so as to surround the cesophageal canal, and thus form a sortof double tube. This condition extended downwards as far asthe upper opening of the stomach, and blood was found tohave ramified along the anterior and posterior surfaces of thatviscus, separating its coats to some considerable extent aboutthe lesser curve. The blood found here, as also that in thecoats of the oesophagus, was, as its odour indicated, much de-composed. There were incipient atheromatous deposits alongthe first part Of the ascending aorta, and fibrinous clots in bothventricles. There was no valvular disease. The left lung wasemphysematous; the right bound by slight pleuritic adhesions,and in an almost rotten state of hepatisation. The liver wascirrhotic, and the other viscera normal.The point worthy of attention appears to be the absence,

. not so much of all diagnostic auscultatory signs, as of the generalsymptoms of aneurism-i. e., dyspncea, and that peculiar ex-

’

pression of anxiety so constantly associated with structural’

diseases of the heart and its larger vessels.

ROYAL FREE HOSPITAL.

SEQUEL OF A CASE OF STRANGULATED HERNIA.

(Under the care of Mr. GANT.)

IN the Mirror" for October 19th, we gave a short accountof a case of strangulated inguinal hernia, in which the wound,after operation, had healed with unusual rapidity. The

following report, for which we are indebted to Mr. C. F.

Jeaffreson, senior resident surgeon, is valuable as showing acontingency which may arise in a case of hernia apparentlyperfectly cured, and, though attended with comparativelylittle danger to life, protract the absolute recovery of the casefar beyond the usual period.On the 22nd September, Thomas B-- called attention to

the condition of his scrotum, into which he supposed thehernia had redescended. On examination a tumour is foundoccupying exactly the same site as the hernia did previously,and about the same size; it is exceedingly hard, tense, becomesnarrower as it approaches the external abdominal ring, is un--influenced by pressure or position, receives no impulse oncoughing, and has a deep though unmistakable feeling offluctuation. The patient’s general health is good, the bowelsbeing opened with regularity every day; and he states that theswelling is of exceedingly rapid growth, having made its ap-pearance during the course of sixteen or twenty hours.The fluid nature of the tumour having been determined, Mr.

Gant ordered it to be painted with iodine paint, in the hopethat absorption might take place ; but, in spite of the skincovering it being converted into one large blister, the swellingincreased in size and in hardness till it became like a stone.The iodine paint was therefore discontinued, and, the skin

’ having healed, on the 12th of October Mr. Gant made a punc-! ture with a small trocar on the anterior surface of the tumour.