A MIRROR OF
HOSPITAL PRACTICE-
MEDICAL COLLEGE HOSPITAL. CASE OF AMPUTATION OF THIGH FOR SYPHILITIC DISEASE OF THE TIBIA IN A PATIENT FAR ADVANCED IN PHTHISIS. By
Surgeon-Major J. O'Brien,
m.a., m.d.
The patient is a Chinaman, a carpenter by trade and a resident in India for some half-a-dozen years. He contracted syphilis as a young man. Three years ago he suffered from cough, which has continued with occasional intervals up to the present. Eighteen months ago he had a swelling below the left knee, abscesses formed, pieces of bone came away, and a purulent discharge has lasted since then. He was admitted into the hospital on 28th April, for syphilitic necrosis of the head and upper part of the shaft of the left tibia. There were several cloaca, exuding fetid pus in large quantity, round the head of the bone and, in front below the tubercle, there was a large circular gap surrounded by sclerosed cicatricial tissue from which a piece of the front of the shaft larger than a rupee had been exfoliated. The skin over the knee-joint showed no signs of inflammation, but there was slight thickening of the structures of the joint. However, as there was no fluid present, the joint was thought to be
healthy. The patient was very weak, emaciated to a degree, and his left lung was found to be almost completely destroyed, chest flattened on this side, percussion note dull and breathing cavernous over the apex of the lung. There was frequent cough, and about 2 oz. of nummular sputa were expectorated in the 24 hours. The man is also an opium eater. As it was plain that he was rapidly sinking, from the pain and wasting caused by the combined discharge from the lung and from the leg; I resolved to remove the latter by amputation through the knee-joint.
Phthisis is said to be a barrier to the administration of but in this case it was administered without causing trouble of any kind. The patient's breathing was not at any time distressed during the 25 or 30 minutes that he was anaesthetised. Amputation was performed after Carden's method through the knee-joint, the incisions being made so as to secure a long and broad flap from the front of the limb. On opening the joint, however, it was found to be extensively diseased. The spinous process between the articular surfaces for the attachin great part necrosed, ment of the crucial ligaments was leaving an aperture of the size of a two anna piece, which communicated by a sinuous passage with one of the external cloacce. The free drainage of pus through this explained the absence of fluid in the joint, and its apparently healthy appearThe synovial sac was covered with a loose shreddy ance. lining of plastic lymph of the color and thickness of wash leather. Under the circumstances it was thought best to remove the patella, and to amputate through the condyles A long posterior flap was taken close to the shaft of the bone. from the upper part of the calf, but, owing to the retraction of the powerful hamstring muscles, which were firmly matted to the skin by adhesions from inflammation of long standing, it was so dragged up that a small portion of the wound posteriorly had to be left open to heal by granulation. It is now a week since the operation. There has been some sloughing of the unhealthy indurated tissues of the posterior flap. Notwithstanding this the patient has gained in strength, and in a fortnight or so, when the wound is healed, I expect he will have so far improved in health as to find his life hitherto miserable, fairly enjoyable. I report the case merely, for the purpose of showing how, even under the most unfavourable and unpromising circumstances, serious operations for the removal of chronic disease may be undertaken with every prospect of success.
ch'oroform,
Calcutta, 14th May.
HOSPITAL PRACTICE-
MEDICAL COLLEGE HOSPITAL. CASE OF AMPUTATION OF THIGH FOR SYPHILITIC DISEASE OF THE TIBIA IN A PATIENT FAR ADVANCED IN PHTHISIS. By
Surgeon-Major J. O'Brien,
m.a., m.d.
The patient is a Chinaman, a carpenter by trade and a resident in India for some half-a-dozen years. He contracted syphilis as a young man. Three years ago he suffered from cough, which has continued with occasional intervals up to the present. Eighteen months ago he had a swelling below the left knee, abscesses formed, pieces of bone came away, and a purulent discharge has lasted since then. He was admitted into the hospital on 28th April, for syphilitic necrosis of the head and upper part of the shaft of the left tibia. There were several cloaca, exuding fetid pus in large quantity, round the head of the bone and, in front below the tubercle, there was a large circular gap surrounded by sclerosed cicatricial tissue from which a piece of the front of the shaft larger than a rupee had been exfoliated. The skin over the knee-joint showed no signs of inflammation, but there was slight thickening of the structures of the joint. However, as there was no fluid present, the joint was thought to be
healthy. The patient was very weak, emaciated to a degree, and his left lung was found to be almost completely destroyed, chest flattened on this side, percussion note dull and breathing cavernous over the apex of the lung. There was frequent cough, and about 2 oz. of nummular sputa were expectorated in the 24 hours. The man is also an opium eater. As it was plain that he was rapidly sinking, from the pain and wasting caused by the combined discharge from the lung and from the leg; I resolved to remove the latter by amputation through the knee-joint.
Phthisis is said to be a barrier to the administration of but in this case it was administered without causing trouble of any kind. The patient's breathing was not at any time distressed during the 25 or 30 minutes that he was anaesthetised. Amputation was performed after Carden's method through the knee-joint, the incisions being made so as to secure a long and broad flap from the front of the limb. On opening the joint, however, it was found to be extensively diseased. The spinous process between the articular surfaces for the attachin great part necrosed, ment of the crucial ligaments was leaving an aperture of the size of a two anna piece, which communicated by a sinuous passage with one of the external cloacce. The free drainage of pus through this explained the absence of fluid in the joint, and its apparently healthy appearThe synovial sac was covered with a loose shreddy ance. lining of plastic lymph of the color and thickness of wash leather. Under the circumstances it was thought best to remove the patella, and to amputate through the condyles A long posterior flap was taken close to the shaft of the bone. from the upper part of the calf, but, owing to the retraction of the powerful hamstring muscles, which were firmly matted to the skin by adhesions from inflammation of long standing, it was so dragged up that a small portion of the wound posteriorly had to be left open to heal by granulation. It is now a week since the operation. There has been some sloughing of the unhealthy indurated tissues of the posterior flap. Notwithstanding this the patient has gained in strength, and in a fortnight or so, when the wound is healed, I expect he will have so far improved in health as to find his life hitherto miserable, fairly enjoyable. I report the case merely, for the purpose of showing how, even under the most unfavourable and unpromising circumstances, serious operations for the removal of chronic disease may be undertaken with every prospect of success.
ch'oroform,
Calcutta, 14th May.
