CLINICAL REPORT OF CASES ILLUSTRATING SUCCESSFUL OPERATIONS UNDER ADVERSE

CONDITIONS.

BY A. PRIMROSE, M.B, C.M. EDIN., M.R.C.S. ENG.

Surgeon to St. Michael's Hospital and the Hospital for Sick Children, etc.

THE

HE following cases seem worth reporting because they illustrate that successful results may occasionally be obtained, although the patient may be suffering from some grave constitutional trouble which would make operation unjustifiable were it simply one of expediency. The first two cases come under this head, whilst the third case is the record of the operation of lithotomy in a frail old man, eighty-two years of age. The first case is one in which the patient was suffering from chronic Bright's disease, and yet an amputation through the knee-joint was successful, so that the patient eventually left Hospital with the wound soundly healed. We are accustomed to look upon such cases as desperate, and we do so justly because we seldom succeed in operative procedures where advanced Bright's disease exists. One could hardly imagine a more unsatisfactory condition for a major amputation than that in the patient referred to. The result, therefore, illustrates that even under such unfavorable constitutional conditions, where an operation becomes imperative because of the local trouble, there is a possibility that we may attain success. The point is an important one because we are tempted to look upon such cases as hopeless, whilst it is obvious that we should give the patient the benefit of what chance there is of relieving him by operation.

The second case is one in which the operation of amputation above the ankle was successfully performed in a case of pulmonary tuberculosis where both lungs were affected.

CASE I. Amputation for extensive cellulitis of the leg in a patient who was the victim of chronic Bright's disease.

This man, 56 years of age, came under my care in July, 1897. A few weeks previously a doctor in the country had opened a cellulitis in the left foot. It was first opened on the dorsum of the

foot and subsequently in the sole. His doctor informed me that the patient had had chronic Bright's disease for the past two years at least. The openings did not discharge freely and acquired a very unhealthy appearance, the foot became enormously swollen and the cellulitis now began to spread up the leg. When he came under my care he had a tremendously swollen condition of the foot and leg, resembling in appearance a case of elephantiasis.

Under chloroform the limb was examined thoroughly and free incisions were made in various directions. On cutting into the tissues they presented on section a ground-glass appearance and were very firm and solid to the feel. In the calf free pus was found lying beneath the superficial fascia; this was of a thin ichorous character. Free incisions were thus made in the foot and leg. Subsequently the wounds were dressed frequently and well irrigated, but there was never a great deal of discharge and the swelling rather increased if anything, the tissues still maintaining a firm solid condition. An unhealthy granulation tissue, oedematous in character, formed about the edges of the incisions, but there was little tendency to contraction and healing of the wounds or to a diminution of the oedema. The patient's general condition was extremely bad and the urine contained a large amount of albumen, turning solid on boiling, and also contained tube casts. This condition continued with but little alteration for about six weeks; the only hopeful sign was that the cellulitis did not tend to spread beyond a point about three inches below the knee.

On consultation with my colleagues at St. Michael's Hospital it was agreed that an attempt should be made, by amputating the limb, to save the man's life. I must say that I was so doubtful as to the possibility of operating by amputation successfully that I at first discouraged the idea of operation, but I subsequently determined to operate.

Amputation was performed on Sept. 16th last. The operation which I chose was Stephen Smith's amputation through the knee joint. It occurred to me that this method of amputating would give the minimum amount of lacerated raw surface in the wound and that consequently it would permit of a more rapid healing of the wound. In the amputation to which I refer the semilunar cartilages are left attached to the lower end of the femur and the flaps are so planned that the length of skin edge requiring suture is reduced to a minimum.

The wound healed throughout by first intention excepting a small point at the posterior extremity. Here, however, a small amount

of discharge occurred which soon became purulent. The pus burrowed and the external semilunar cartilage sloughed away com pletely and the remains of it was removed from a sinus which formed over the external condyle. The wound was subsequently dressed daily, being irrigated with boracic lotion and dressed with plain sterilized gauze. It gradually took on healthy action and closed slowly. It was completely closed during the early part of January, four months after the operation. The man's general condition has greatly improved. He has put on flesh, has a much more healthy appearance and the amount of albumen in his urine has very noticeably diminished in amount.

CASE 2. Amputation of the leg for tuberculous disease of the tarsus and the bones of the leg, in a patient suffering from pulmonary phthisis.

The patient was a young man about 22 years of age. The trouble began in the ankle about nine months before he came under my care. He had for two years suffered from pulmonary tuberculosis, but the disease had not progressed rapidly. He injured his foot in the woods by slipping over an icy log, and wrenching his ankle severely; swelling occurred and pain of a severe character. Openings had been made and drainage provided for, but the condition got progressively worse; he suffered a great deal of pain, and he was anxious to have the foot removed. There was a great dea of swelling about the ankle, and the sinuses were discharging somewhat freely. The patient had a tubercular deposit in both lungs, and it was thought that if the disease in the foot proved to be very extensive, on examination under chloroform, it would be prudent to remove the limb. Subsequent events proved the wisdom of our decision.

On August 19th, amputation was performed two inches above the ankle joint. The disease was very extensive. It was found that every bone of the tarsus was diseased. On section of the bones one found numerous foci of softened bone of a dirty green appearance, each focus surrounded by a congested area of bone. The lower end of both the tibia and the fibula were in the same condition.

The wound healed by first intention; the stitches were removed on the sixth day, when the dressings were disturbed for the first time, and the patient was discharged three weeks after the operation, when he had a firm cicatrix.

Subsequently the patient improved very considerably in his general condition. He gained in weight, and his health was gene

rally better. The improvement was, however, only of a temporary nature, and he has failed of late; and it is quite evident that pulmonary tuberculosis is making steady progress, and the patient is now losing ground.

CASE 3. Vesical calculus the nucleus of which is the tip of a hard rubber catheter. Removed from a man 82 years of age.

The man came under my care in July, 1897. He had an enlarged prostate, and had been obliged to use the catheter for evacuating the bladder for the past three years. He habitually used a catheter made of gum-elastic material with a hard rubber tip. The tip had become detached, and the old gentleman cemented it in its place with shellac, and then proceeded to insert the catheter. The shellac was dissolved by the urine, and the catheter was withdrawn minus the tip. This accident occurred three months before he presented himself to me for treatment. He was then in a deplorable condition; he had incontinence, and had no voluntary control over the bladder; urine was voided more or less constantly, and his clothes and bedding became saturated. I found that regular catheterization did not prevent this, and I passed a sound for the purpose of determining whether or not a foreign body was present in the bladder; the patient's friends had some doubt as to the accuracy of the patient's statement regarding the catheter tip. I readily detected a calculus by means of the sound, and advised -operation.

I operated on July 6th, 1897, and removed the calculus through a median lithotomy wound. The wound healed up, the patient made a good recovery, and urine was subsequently drawn off by catheter, whilst there was no longer the distressing incontinence which previously troubled him. The patient was, however, a frail old gentleman, and had for years suffered from heart trouble, and was subject to peculiar attacks of unconsciousness, which had become more and more frequent during the last year of his life. He died suddenly at his home on October 11th, 1897, three months after the operation for stone.

The nucleus of the calculus in this case proved to be the tip of a catheter, with some red sealing-wax adherent to it. The calculus tip is about a centimeter long, and less than half that thickness; it is coated with a phosphatic encrustation about one millimeter thick. The case is of interest as an instance of operation for vesical calculus in a patient over eighty years of age.

APPENDICITIS WITH PERFORATION*.

BY DR. C. M. SMITH,

ORANGEVII.LE.

ALLED to H. S. on October 5th, 1896. Patient under care of Dr. Dunning, of Mono Mills. Patient's residence eleven

CA

miles from Orangeville and four from Mono Mills.

Some four or five years previous to this date, patient was treated surgically for fistula in ano. Was seized with pain in abdomen (general) on Friday, 2nd instant. Dr. Dunning had thoroughly emptied colon by enemata, had avoided narcotics and administered triturates of calomel and sodium-which served to control the nausea. visit found a young man of twenty-one or twenty-two lying on a settee near the kitchen stove in a low-ceilinged lean-to attached to a loghouse.

At my

Pulse 108; small, wiry. Temp. 102.5; tongue coated, with dry. centre. Marked swelling in right iliac region extending along inguinal canal, giving obscure impulse on coughing; tenderness over right lumbar and epigastric regions.

Large enemata brought away more or less liquid stools containing traces of oat hulls and what looked like grains of wheat. The triturates were ordered to be continued. Further examination disclosed two swellings over sacro-sciatic foramina, elastic, fluctuating and giving tympanitic resonance on percussion.

Advised operation within twenty-four hours. Did not hear from patient again until 8th instant, when Dr. Dunring wired that parents had consented to surgical treatment. When I reached the case found that valuable time had been lost and that the skin and subcutaneous tissues were infiltrated from anterior superior spinous process to external ring and some distance inward, shewing redness in addition to oedema.

Assisted by Dr. Dunning and Dr. Jas. Hunter, of Orangeville, I proceeded to perform section. An incision three inches long was made parallel with Poupart's ligament, one and a half inches internal to *Paper read at meeting of Bruce and Grey Medical Association.