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which generally took place in from twenty-four to forty-eighthours. The purging generally ceased within one or twohours at furthest after the first dose. The vomiting alsoceased after a short time, but this, I apprehend, was due moreto the large draughts of water being prohibited, which thepatient constantly craved after. Urine was made in largequantity several hours after reaction. Some of the patients,after several hours, vomited large quantities of dark-green,bilious matter, of the consistence of gruel. Although themixture was taken very well at first, yet after its administra-tion for some time it became so loathsome to the taste of allthat it required much persuasion to cause it to be taken. Thecolduess and lividity of the extremities persisted until the
period of full reaction, and the shrunken features generallyremained for a week or ten days after. In all, mild typhoidfever supervened, with delirium only in two.
In several cases of rice-water purging, before the superventionof collapse, in which sugar was administered, the purging ceasedin a very short time, and the patients, with the assistance ofwine and beef-tea afterwards, invariably recovered very rapidly.I should mention, that of the four fatal cases, one was thesubject of organic disease of the heart, for which he had been,antecedent to the attack of cholera, repeatedly under my carefor dropsy and other concomitant affections. A nother had beenin the habit of getting frequently drunk, and had returnedhome late on the night previous to the attack in a state of deepinebriation.The sugar was administered in the form of mixture. Two
ounces of refined sugar, dissolved in six ounces of camphormixture, with a few drops of rectified spirit. One tablespoonfulwas given every ten minutes. Wine was also generally givenin frequent quantities, and beef-tea. It must be observed thatvisible improvement up to the period of reaction was not veryencouraging, and such, I apprehend, must always be the casein deep collapse from remedies intended to operate through thealimentary canal. I should have mentioned that the first curetreated with sugar, occurred November 1, 1853, and the laston December 14, a period corresponding with the subsidence ofthe epidemic in this locality. It is very possible from what isknown of the amenability of cholera to treatment during itsdecline, that other modes of treatment might have provedequally successful.Saint Olav2’s Infirmary, Southwark, March, 1854.
A CASE OF INCISION INTO THE KNEE-JOINT,AND RECOVERY WITHOUT ANCHYLOSIS.
BY ROBERT B. JORDISON, ESQ., M.R.C.S., L.S.A.AN observation made by one of your late contemporaries-viz.,
The P1’ovi nciullfI ed iCCtl and Surgical Jonr7aal, in the number forOctober 21, 1853, p. 925, where he says-" vVe have often hadoccasion to regret that country surgeons, who might add fromtheir note-books so many records of successful cases illustrativeof the curative powers of Nature, should, from a false fear ofostentatious display, add so little to the medical literature ofthe day. They are thus equally unjust to themselves as indi-viduals, to the Association, of which they form a part, and tothe true and rightful interests of medical science, which cannever assume its place until it has accumulated from suchsources stores of information upon many points on which weare still far from certain proof," has induced me to forwardyou for insertion in THE LANCET an interesting case of incisioninto the knee-joint, which came under my observation lastsummer, and which terminated favourably without anchylosis,thus illustrating the curative powers of Nature, in a moreforcible degree than the instructive case reported by Mr. Webb,from the Staffordshire General Infirmary, in THE LANCET ofAug. 6, 1853, p. 117, which terminated in partial anchylosis.
George G-, aged twenty years, an agricultural labourer,of strumous habit, whilst in the act of mowing, came in contactwith the scythe of his fellow-labourer. Immediately after theaccident, he was conveyed in a cart to my surgery, when, onexamination, I found an incised wound of about five inches inlength, extending transversely across the anterior part of thethigh immediately above the superior edge of the patella. The
haemorrhage, which had been considerable, had in a greatmeasure subsided. On introducing my finger into the woundto ascertain its course, I could readily pass it into the cavityof the joint, the aperture into which was to the extent of aboutan inch. I lost no time in closing the wound, which I did bya number of sutures covering the entire wound with numerous
strips of adhesive plaster, and encasing the whole in oil skin,so as to exclude the air as much as possible. I then placed theleg and thigh upon a long, straight splint; and had him con-veyed home. In the course of two hours reaction commenced,and for about six hours he suffered excruciating pain, which Isuccessfully combated with large doses of opium, combinedwith small doses of calomel. I allowed the dressings to remainundisturbed for several days, and for a fortnight there was notthe least constitutional disturbance, but at the expiration ofthat time, (he being still under the most rigid antiphlogisticdiscipline,) the pulse suddenly rose to 135, the tongue becameloaded, and the countenance anxious ; the knee was very muchenlarged, exquisitely tender, and discharged large quantitiesof synovia. I ordered two dozen leeches to be applied, hotfomentations, and to take calomel and opium every four hours.In the course of a few days the constitutional disturbancegradually subsided, but the size of the knee remained unaltered;the integuments now sloughed to a considerable extent, andthe discharge of synovia still continued very profuse. In aboutten days more he was attacked with a violent rigor in the night,and the whole train of inflammatory symptoms returned withrenewed force, but in the course of five days they gave way,but only again to be renewed at the lapse of a week, and thusthe case progressed for upwards of two months, when thewound commenced for the first time to wear a more healthyaspect, and the tenderness to subside, and in fifteen weeks fromthe infliction of the injury it was perfectly cicatrized. Themotion of the joint was at first very limited, but as time woreon it obtained greater mobility, and I have now the satisfactionof seeing him industriously employed in his wonted avocation,with his once afflicted knee as strong, as flexible, and of asmuch service to him as it was prior to the accident.South Ockendon, Essex, March, 1854.
A MirrorOF THE PRACTICE OF
MEDICINE AND SURGERYIN THE
HOSPITALS OF LONDON.
Nulla est alia pro certo noscendi via, nisi quam plurimas et morborumet dissectionum historias, tam aliorum proprias, collectas habere et interse comparare.—MORGAGNI. De Sed. et Caus. Morb. lib. 14. Proœmium.
KING’S COLLEGE HOSPITAL.
Tubercular Peritonitis; Death; Autopsy.(Under the care of Dr. TODD.)
CASES are now and then seen in the wards of our hospitals,which very forcibly tend to show how incomplete must neces-sarily be nosological arrangements, and how useless it is to
attempt the practice of the healing art without a fair amountof discrimination, judgment, and caution. Beginners are aptto think, on reading over the description of symptoms for eachindividual disease, or groups of affections, that, with such dis-tinct and clear delineations, it will be a comparatively easymatter to recognise disease and treat it. But those who mayhave committed this error should recollect that almost everycase presents peculiar features; these being the result of themodifications imprinted upon the usual symptoms of the com-plaint by the temperament, habits, previous diseases, sex,
age, &c. &c., of the patient. It is especially with women thatthe recognised characters of well-known morbid states are aptto be so altered, masked, and modified, that the most expe-rienced eye fails to discern the actual pathological changeswhich are going on in the patient.Nor is this all; but certain symptoms of minor importance
are now and then in some degree exaggerated, and rendered soprominent, as to engage exclusive attention, the principal com-plaint remaining all this time more or less unnoticed. Take,for instance, vomiting in tubercular peritonitis; it is statedthat this symptom may or may not occur in this affectionaccording as the peritoneum covering the stomach is affectedor not. It will be seen by the following case that vomitingmay form, in tubercular peritonitis, a prominent and all-en-grossing symptom, and in fact hasten the fatal termination.So also may protracted vomiting destroy pregnant women by
its mere continuance and resistance to treatment. Nor is thecase alluded to remarkable only for this uncontrollable emesis,but the peculiar ushering in of the disease, the admixture ofhysterical pains, the occurrence of a kind of exanthematousfever, seem to remove it altogether from the common run ofinstances of tubercular peritonitis. The following particularswill probably be read with much interest :-
Harriet B-, aged twenty-one years, a servant-maid, wasadmitted Dec. 5th, 1853, under the care of Dr. Todd. The
patient was, till three weeks before admission, a stout andflorid girl, and had never experienced any illness except aslight attack of scarlet fever two years before her presentapplication. Fifteen days anterior to the present examinationthe girl was attacked with the ordinary symptoms of fever,and was incapacitated from her work for a week, when theright knee became very painful and inflamed, so that she couldnot put her foot to the ground; the joint, however, becameless painful under the application of poultices and fomenta-tions.
State on admission.-The patient complains much of head-ache, which prevents rest at night ; the knee is also stated tobe very painful, so much so that the girl cannot rest her weighton it. She keeps her leg slightly flexed, and on an attemptbeing made to straighten it, the flexor muscles are found toenter powerfully into action; externally, however, no swellingor redness are apparent. The patient cannot get any sleep, andif she should doze a little, she is soon awakened by a frightfuldream. For the last few months she has not menstruatedregularly, but has never had fainting or hysterical fits of anykind, and she has also suffered for the same period from pal-pitation when excited, and also from shortness of breath.Bowels open every day. Saline mixture every fourth day.On the second day the symptoms assumed a somewhat
hysterical character; the patient complained of much pain inthe knee, but when her attention was not directed to the joint,she did not feel pressure made upon it. There is also globushystericus. Dr. Todd ordered five grains of colocynth pillevery night, also the acetate of ammonia and camphor mixture.Fourth day.-Much worse ; tongue covered with a dense
white fur; the patient cannot eat anything, and the medicinemakes her sick immediately after each dose. She was orderedeffervescent draughts, and galbanum and colocynth pill, fivegrains morning and evening.
Fifth day.-’-No rest at night; vomiting continues; but thepain in the knee is diminishing. The girl has been out of bed,and standing on the affected limb. An emetic of sulphate ofzinc was ordered, by which, on the next day, much green,bilious matter was evacuated. The stomach thereupon was nolonger so irritable. Calomel and colocynth pill, five grains ofeach, was now ordered to be taken for three successive nights.The purgative acted well, and the patient stated on the
eighth day that she was better, and would be nearly well ifshe could rest at night. Her knee was quite well, but shecomplained very much of pain under the left breast, to whicha mustard poultice was applied with some benefit. Dr. Toddordered a morphine draught at night.On the tenth day the pain on the left side moved to the same
region on the other half of the body. Severe sore-throat cameon, the tonsils being extremely inflamed, and the glands alongthe sterno-mastoid muscles much enlarged. There seemed tobe a redness all over the body which could not, however, becalled a rash, and the patient had rigors several times in thecourse of the day and night; tongue much furred, with a brownstreak in the centre. Six leeches were ordered to be appliedto the painful spot on the right side.
Twelfth day.-The pain has quite left the right side, but themouth is very sore from an aphthous state of the mucous mem-brane ; the patient is sick, and vomits almost all she takes;throat very painful; urine containing no albumen, nor has thatfluid presented any of the characters of hysterical urine. Dr.Todd now ordered effervescent draughts with ammonia.
Fourteenth day.-Better, but still very sick; the wholesurface of the body is desquamating; the throat continues verysore. For the next week the vomiting steadily continued,but the general health improved. The vomiting resisted forthe next eighteen days the administration of hydrocyanic acid,ice-water, the withdrawal of all food, calomel and opium,brandy, morphia, creasote, and lime-water.On the 10th of January, 1854, thirty-five days after ad-
mission, the patient was allowed to take what food she pleased;she chose chicken, but could not keep it down at all, andimmediately brought it up, together with much green fluid.She cannot bear the least pressure on the hepatic region, andgets no rest at night.
The vomiting continued for several days after the last reports;there was always the same green fluid, and previous to beingsick, she always had a sharp pain in the stomach; the urinecontained neither sugar nor albumen, but bile was found init; stools, excited by sulphate of magnesia, of a dark greencolour.On the 26th of January, fifty-three days after admission,
pus and lithates were found in the urine. The sickness hadnow continued for fifty days, when a blister was placed overthe stomach, and Dr. Todd ordered cod-liver oil. The vomit-ing was then relieved, and the urine was found to contain pus,(probably from the vagina,) lithates, and albumen.Nine days after this, the sickness came on again, and the
patient complained of great pain all over the abdomen, shehardly being able to bear the pressure of the bed -clothes. Shebecame gradually weaker, in spite of brandy, &c., the sick-ness did not yield to morphia, and creasote, and she died onthe 28th of February, eighty-five days after admission, thesickness having continued about sixty-two days.
Post-mortem, examination.-On opening the chest, scatteredtubercles in a crude state were found on the surfaces of bothpleurae, but the lung substance appeared free from them. Theheart was quite healthy. On cutting through the abdominalwalls, it was found impossible to remove the intestines,except en masse, as the whole sac of the peritoneum was com-pletely obliterated, from the deposit on its surface of tubercularmatter, and the consequent inflammation and agglutination;it was, therefore, decided not to remove them. The surface ofthe liver, where the peritoneum covered the organ, was thicklyincrusted with tubercles, but the structure of the liverappeared healthy on section. The kidneys were sound; on oneof them a small cyst, about the size of a bean, was found con"taining a clear fluid. There was nothing abnormal in thetrachea, the mucous membrane looking quite healthy.
ST. MARY’S HOSPITAL.
Idiopathic Trismus and Opisthotonose ; Effects of Chloroform.(Under the care of Dr. CHAMBERS. )
IDIOPATHIC TETANUS is an affection of very rare occurrence,its pathology being, however, just as obscure as when the
complaint is brought on by traumatic causes. We have hadbut very few idiopathic cases to bring before our readers; butamong these we would mention one which was treated by Dr.Gull at Guy’s Hospital, (THE LANCET, vol. ii. 1853, p. 165.)Here no tangible cause could be laid hold of, no protractedexposure to wet and cold, no depressing agent lowering thetone of the system. The only point of the history which couldbe connected with the tetanic seizure was an attack of scarletfever which the patient had suffered two years previously, anda subsequent derangement of the throat. In the case which
we have this day to report, the setiological part is much clearer,for the patient had "overworked himself in a damp gravel-pit,without attempting to change his wet clothes."As to the treatment, there is also in the case at St. Mary’s a.
feature of some interest, as Dr. Chambers employed chloroformto moderate the spasmodic symptoms. As several instancesare recorded of the beneficial effects of the inhalations of chloro-form in traumatic tetanus, it was natural that the anaestheticagent should be tried in an idiopathic case. The results, aswill be seen below, were momentarily favourable; and it ishardly possible that it should be otherwise, considering thehighly sedative powers of chloroform. But it is plain thatnone but transient advantages can be expected from its ad-ministration, and it will moreover be perceived, by the follow-ing details, that a certain amount of risk is incurred by usingchloroform with patients whose spinal marrow is in a morbidstate. Mr. Trotter, the resident medical officer, to whom weare indebted for the notes of the case, and who administeredthe chloroform, suspected that the mercury, under the influ-ence of which the patient was at the time, might have hadsome share in the alarming symptoms. We may perhaps begour readers to cast a glance at a few introductory remarks withwhich we prefaced Dr. Gull’s case; they will not be foundirrelevant, and may be said to apply with full force to thefollowing instance of idiopathic tetanus :-
G. L-, aged twenty-five years, single, a labourer in abrick-field, was admitted into St. Mary’s Hospital, under thecare of Dr. Chambers, Dec. 15, 1853. It appeared that thepatient had always had good health; in fact, he did not re-member having suffered from any illness, except syphilis six-teen months prior to his application here, no soreness of mouthbeing at that time produced by medicine. Previous to the