On that day, the 24th August 1878, the patient was again put under chloroform, and the limb was amputated in the middle of the thigh. During this operation I unfortunately inoculated myself with the morbid fluid of the gangrenous leg, of which more hereafter. During my confinement in bed, my native doctor was not able to take due care of the skin-flap, which sloughed away, leaving an inch of the femur bare. Having recovered somewhat from the effect of the infection, I went to the side of the patient, and had the protruded bone sawn off by my native doctor; the sore gradually healed, only leaving an eight-anna bit bare, at the end of the divided bone, which I expect to cicatrize in a few days. Remarks.
(1.)?All sinuous ulcers, the walls of which can be brought into accurate contact by pressure of pad and bandage, scarcely require any other local treatment, the canal of the sinus being at once abolished by direct adhesion. In this way, sinuses in the axillary region, on the sternum, ribs, buttocks, groin, &c., may be rapidly cured ; cavities of abscesses fill up fast, even open ulcers rapidly contract and cicatrize by properly applied pressure ; extensive sloughs in carbuncles of the back, after crucial incision, rapidly separate by pressure of a pad and bandage, leaving a healthy granulating surface
SINUOUS ULCER OF THE KNEE, CAUSING ITS CONTRACTION; FORCIBLE EX-
TENSION, FOLLOWED THE
TURE THE
BY RUPTURE OF A LITER Y ; ITS LIGAFOLLOWED BY GANGRENE OF
POPLITEAL
LEG;
AMPUTATION,
AND
RE-
COVERY. By Assistant-Surgeon U. 0.
Kastagir,
North Suburban
Hospital. case Troylocko Bagdy's possesses especial importance, considering the serious turns it successively took during the course of treatment, ultimately ending in recovery. Troylocko was admitted on the 22nd July last, with a sinuous ulcer of syphilitic origin, which extended from above the flexure of his right knee to the lower part of the calf of the leg, bifurcating here, and opening externally by two mouths; owing to this, contraction of the tendons attached to the knee having taken place, the leg was permanently flexed on the thigh at an acute angle, depriving the patient of its use entirely. Long confinement in bed and debilitating discharges had made the patient When admitted, therefore, very weak and emaciated. cod liver oil with iodide of potassium, rum, opium, &c., were given to him internally, and .successive portions of
the sinus closed, by the tight pressure of a pad and bandage only requiring to be laid on in parts where its walls could not be accurately brought into contact by the pressure. Open ulcers were treated with carbolic oil and resin-ointment, with pad and bandage. This mode of treatment was continued for a month, when the ulcer healed ; but the contracts>n of the joint continued. On the 20th August 1878, patient being put under chloroform, the flexor tendons were divided ; and while other tissues were being torn by forcible extension of the leg, a jet of arterial blood spouted forth in a large stream. Immediately the skin, the superficial and deep tissues were divided, and it was found that the popliteal artery had given way. It was at once secured by silk ligature The leg and foot were next surrounded by a thick layer of cotton wool and gently bandaged. Stimulants and milk were given plentifully ; but nothing could prevent gangrene, which commenced on the second day of the ligature, and extended to the knee on the morning of the 4th day.
underneath which also contracts and cicatrizes fast, under the same application, over ordinary carbolic oil, or resin dressing. The importance of pressure in surgical diseases is not unknown to the profession. My own conviction is, that if more frequently and extensively resorted to, than it is at present, it will almost supersede all painful and complicated local applications. In this case, the greater portion of the extensive sinus rapidly filled up by pressure only. When the walls of the sinus could not be brought into proper apposition, as where it passed under tendons and muscles, which by their contraction prevented the walls of the sinus from remaining in contact with each other, it was then necesThe process of healing by sary to lay the sinus open. the use of syringe, or introduction of medicated lint into the sinus, &c., &c , is most dilatory, and ought not to be resorted to, unless the first two methods cannot be adopted, for special reasons. (2.)?I have had t wo cases of contraction of the knee ?effects of extensive burn in the part- which were cured by tenotomy, followed by forcible extension, without the serious accident of rupture of the popliteal artery. In these cases, the blood vessels were not involved in the adhesive process. In the present case, the sinuous ulcers which had extended to the artery, had involved its coat in the newly formed adhesions, which accounts for its rupture during extension. Had this been known before, its rupture could have been prevented by separating it from recent adhesions, before using the extension. (3.)?Ligature of the popliteal artery is an operation frequently had recourse to in surgical practice, without In the present case, long continued an untoward result. confinement in bed, and exrensive ulcers in the leg, had circulation as to make it much so far interrupted its leaner than the healthy leg. In such a state the ligature of the main artery at once gave rise to the gangrene, which commenced at the toes, and rapidly extended to the knee (4.)?The best application 24 hours after amputations of limbs, or removal of scrotal tumours, is, in my humble experience, simple water irrigation, or the same medicated with one percent of carbolic acid, or Condy'ssolution, the water falling continuously in a slender stream from a very small hole in the bottom of a pot suspended 4 inches above the stump. It should be continued for 3 or 4 days, or until the pain or heat in the part has greatly decreased, and the surgical fever abated. Icedwater application is not suited, as it may much weaken
A MIRROR OF HOSPITAL PRACTICE.
February 1, 1879.
the circulation in the part, and help in producing large of the flap. Application of water by the hand of ignorant and grumbling, or unwilling attendants, is invariably ineffectual to prevent violent inflammation, for it is never continuous, and a complete interruption to it invariably happens during the sleeping hours of the
sloughs
night.
The sloughing of the skin-flap in this case is to be attributed to my native doctor adopting the latter plan while I was helpless in my bed. After the removal of the protruded portion of the femur, the patient narrow ly escaped an attack of osteo-myelitis by water irrigation only. (5.)?Sawing off a protruded bone at the level of the stump is, I believe, bad surgery ; but I was myself helpless at the time ; besides the patient was so weak and emaciated, that I dared not undertake a fresh operation of forming new flaps, and of sawing the bone higher up. (6)?I shall conclude here with a few remarks on the subject of inoculation with putrid matter, to which I was myself a victim in the present case. During the previous night I had, by scratching my rk'ht middle finger, taken off its cuticle in one spot, and on the following morning, while removing the patient's gangrenous limb, I unknowingly inoculated my finger with the morbid fluid of the limb. Within 24 hours I had a shivering attack of fever, attended with a en awing pain through the whole length of my arm, which was also I marked out 12 places in my arm, very much swollen each one inch ions?, and had them scarified by my native doctor, but the relief was temporary. Dr. Partridge very kindly came to see me, and made an incision 3 inches long, down to the subcutaneous fascia, on the inner aspect of my upper arm, where the p lin and swelling was great, and the flow of blood from it relieved the tension and gave a me great relief; week after suppuration took place, in the form of an abscess, over the brachial vessels, two inches below the axilla, which being opened, about a pound of thick sanious matter escaped. In about a month I was able to use my hand ; its motion is even now restricted, for I cannot touch my back with my right fingers over the right shoulder. I sustained dissection wounds on two previous occasions, but their effects were slight. There was some local irritation, some swelling in the finger, and fe'orile excitement, which disappeared within a week. In the present case the effect was alarming, so much so that a medical friend of mine afterwards congratulated me on escaping from an attack of general pyaamia. I do not think I had really so serious an accident. Sir James Paget is, I believe, of opinion, that inoculation with specific septic poison such as the fluid of hernial or puerperal perronitis is alone dangerous to life, though he himself escaped from the effect of such an infection. He further says, that such fluids may enter into the system through sweat or hair follicles, even if the cuticle is uninjured. I am not aware if the fluid of a mortified limb, with which I was inoculated, is counted as a spe ific septic poison. If so, I had a narrow escape from its generally mortal effect. 2nd December 1878.
/
49
(1.)?All sinuous ulcers, the walls of which can be brought into accurate contact by pressure of pad and bandage, scarcely require any other local treatment, the canal of the sinus being at once abolished by direct adhesion. In this way, sinuses in the axillary region, on the sternum, ribs, buttocks, groin, &c., may be rapidly cured ; cavities of abscesses fill up fast, even open ulcers rapidly contract and cicatrize by properly applied pressure ; extensive sloughs in carbuncles of the back, after crucial incision, rapidly separate by pressure of a pad and bandage, leaving a healthy granulating surface
SINUOUS ULCER OF THE KNEE, CAUSING ITS CONTRACTION; FORCIBLE EX-
TENSION, FOLLOWED THE
TURE THE
BY RUPTURE OF A LITER Y ; ITS LIGAFOLLOWED BY GANGRENE OF
POPLITEAL
LEG;
AMPUTATION,
AND
RE-
COVERY. By Assistant-Surgeon U. 0.
Kastagir,
North Suburban
Hospital. case Troylocko Bagdy's possesses especial importance, considering the serious turns it successively took during the course of treatment, ultimately ending in recovery. Troylocko was admitted on the 22nd July last, with a sinuous ulcer of syphilitic origin, which extended from above the flexure of his right knee to the lower part of the calf of the leg, bifurcating here, and opening externally by two mouths; owing to this, contraction of the tendons attached to the knee having taken place, the leg was permanently flexed on the thigh at an acute angle, depriving the patient of its use entirely. Long confinement in bed and debilitating discharges had made the patient When admitted, therefore, very weak and emaciated. cod liver oil with iodide of potassium, rum, opium, &c., were given to him internally, and .successive portions of
the sinus closed, by the tight pressure of a pad and bandage only requiring to be laid on in parts where its walls could not be accurately brought into contact by the pressure. Open ulcers were treated with carbolic oil and resin-ointment, with pad and bandage. This mode of treatment was continued for a month, when the ulcer healed ; but the contracts>n of the joint continued. On the 20th August 1878, patient being put under chloroform, the flexor tendons were divided ; and while other tissues were being torn by forcible extension of the leg, a jet of arterial blood spouted forth in a large stream. Immediately the skin, the superficial and deep tissues were divided, and it was found that the popliteal artery had given way. It was at once secured by silk ligature The leg and foot were next surrounded by a thick layer of cotton wool and gently bandaged. Stimulants and milk were given plentifully ; but nothing could prevent gangrene, which commenced on the second day of the ligature, and extended to the knee on the morning of the 4th day.
underneath which also contracts and cicatrizes fast, under the same application, over ordinary carbolic oil, or resin dressing. The importance of pressure in surgical diseases is not unknown to the profession. My own conviction is, that if more frequently and extensively resorted to, than it is at present, it will almost supersede all painful and complicated local applications. In this case, the greater portion of the extensive sinus rapidly filled up by pressure only. When the walls of the sinus could not be brought into proper apposition, as where it passed under tendons and muscles, which by their contraction prevented the walls of the sinus from remaining in contact with each other, it was then necesThe process of healing by sary to lay the sinus open. the use of syringe, or introduction of medicated lint into the sinus, &c., &c , is most dilatory, and ought not to be resorted to, unless the first two methods cannot be adopted, for special reasons. (2.)?I have had t wo cases of contraction of the knee ?effects of extensive burn in the part- which were cured by tenotomy, followed by forcible extension, without the serious accident of rupture of the popliteal artery. In these cases, the blood vessels were not involved in the adhesive process. In the present case, the sinuous ulcers which had extended to the artery, had involved its coat in the newly formed adhesions, which accounts for its rupture during extension. Had this been known before, its rupture could have been prevented by separating it from recent adhesions, before using the extension. (3.)?Ligature of the popliteal artery is an operation frequently had recourse to in surgical practice, without In the present case, long continued an untoward result. confinement in bed, and exrensive ulcers in the leg, had circulation as to make it much so far interrupted its leaner than the healthy leg. In such a state the ligature of the main artery at once gave rise to the gangrene, which commenced at the toes, and rapidly extended to the knee (4.)?The best application 24 hours after amputations of limbs, or removal of scrotal tumours, is, in my humble experience, simple water irrigation, or the same medicated with one percent of carbolic acid, or Condy'ssolution, the water falling continuously in a slender stream from a very small hole in the bottom of a pot suspended 4 inches above the stump. It should be continued for 3 or 4 days, or until the pain or heat in the part has greatly decreased, and the surgical fever abated. Icedwater application is not suited, as it may much weaken
A MIRROR OF HOSPITAL PRACTICE.
February 1, 1879.
the circulation in the part, and help in producing large of the flap. Application of water by the hand of ignorant and grumbling, or unwilling attendants, is invariably ineffectual to prevent violent inflammation, for it is never continuous, and a complete interruption to it invariably happens during the sleeping hours of the
sloughs
night.
The sloughing of the skin-flap in this case is to be attributed to my native doctor adopting the latter plan while I was helpless in my bed. After the removal of the protruded portion of the femur, the patient narrow ly escaped an attack of osteo-myelitis by water irrigation only. (5.)?Sawing off a protruded bone at the level of the stump is, I believe, bad surgery ; but I was myself helpless at the time ; besides the patient was so weak and emaciated, that I dared not undertake a fresh operation of forming new flaps, and of sawing the bone higher up. (6)?I shall conclude here with a few remarks on the subject of inoculation with putrid matter, to which I was myself a victim in the present case. During the previous night I had, by scratching my rk'ht middle finger, taken off its cuticle in one spot, and on the following morning, while removing the patient's gangrenous limb, I unknowingly inoculated my finger with the morbid fluid of the limb. Within 24 hours I had a shivering attack of fever, attended with a en awing pain through the whole length of my arm, which was also I marked out 12 places in my arm, very much swollen each one inch ions?, and had them scarified by my native doctor, but the relief was temporary. Dr. Partridge very kindly came to see me, and made an incision 3 inches long, down to the subcutaneous fascia, on the inner aspect of my upper arm, where the p lin and swelling was great, and the flow of blood from it relieved the tension and gave a me great relief; week after suppuration took place, in the form of an abscess, over the brachial vessels, two inches below the axilla, which being opened, about a pound of thick sanious matter escaped. In about a month I was able to use my hand ; its motion is even now restricted, for I cannot touch my back with my right fingers over the right shoulder. I sustained dissection wounds on two previous occasions, but their effects were slight. There was some local irritation, some swelling in the finger, and fe'orile excitement, which disappeared within a week. In the present case the effect was alarming, so much so that a medical friend of mine afterwards congratulated me on escaping from an attack of general pyaamia. I do not think I had really so serious an accident. Sir James Paget is, I believe, of opinion, that inoculation with specific septic poison such as the fluid of hernial or puerperal perronitis is alone dangerous to life, though he himself escaped from the effect of such an infection. He further says, that such fluids may enter into the system through sweat or hair follicles, even if the cuticle is uninjured. I am not aware if the fluid of a mortified limb, with which I was inoculated, is counted as a spe ific septic poison. If so, I had a narrow escape from its generally mortal effect. 2nd December 1878.
/
49
