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third of the left thigh; also one on the left side of the neck. Had, moreover, a large tumor on the right side of the neck, and a still larger one on the back, both tending, of course, to suppuration. Prescribed Verrhus Clemiana, two teaspoonfuls four times a day, to be increased in two weeks to four teaspoonfuls.
At the expiration of two weeks the abscess on thigh was discharging profusely, general appearance of patient improved, and he reported himself as feeling much better. Ordered the dose increased gradually to six teaspoonfuls, four times daily.
At the expiration of six weeks the abscess on thigh was still discharging freely; the one on neck scarcely at all. Ordered the suspension of the medicine for a week, during which time the discharge from abscess on thigh diminished perceptibly; the one on neck ceased entirely. On resuming the medicine the discharges from both abscesses became again profuse, and so continued for about two weeks longer, when they began to subside ; the tumors began to diminish in size, and in four months from the time the treatment was commenced all symptoms of the disease had disappeared. Advised him, however, to continue the medicine a few months longer.
*** Quinine pills and capsules are very insoluble, often being discharged uudissolved. Febriline, or Tasteless Syrup of Quinine, has been found to be just as reliable in all cases as the bitter sulphate of quinine, and physicians will find it to their advantage to use it for adults, as well as children, in place of pills and capsules. It is as pleasant as lemon syrup and will be retained by the most delicate stomach, having also the advantage of not producing the unpleasant head symptoms of which so many patients complain after taking the quinine sulphate. Possessing these advantages, physicians will find it superior to the quinine sulphate for all cases requiring quinine, particularly typhoid fever patients.
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On July 25th, 1891, I saw Willie S., white, male, aged 10 years, in consultation with Dr. Stephenson. The history of the case showed a scrofulous osteitis of the tibia, involving, as was supposed, the lower half. The family history showed the scrofulous diathesis well marked—one child having died some years before from scrofula. The disease dated back six months, commencing from a fall from a bed, slightly injuring, as was supposed, the leg.
At the time of my visit, a hurried examination revealed a limb enlarged from just below the knee to the extremities of the toes, much distorted, especially about the ankle, and contracted at the knee so as to flex the leg on the thigh almost at a right angle. The lower half of the limb was, and had been for more than a month, suppurating freely through several sinuses. The excessive pain and drainage had weakened the child much and reduced him to almost a skeleton. Probing revealed necrosed bone in all directions.
For want of time, the examination of the bone was not fully completed, and we did not at that time care to anesthetize VOL. XII – 13
him. He was at once put on syr. iodide of iron, Fowler's solution and cod-liver oil; syrup hypophosphites was continued. Whisky or wine in any pleasant form, and a nutritious diet were directed so as to prepare him for an operation, as was thought at that time, on the tibia. His pulse ranged from 120 to 140, and temperature from 101 to 103 during 24 hours.
Aug. 10th, visited W. S., prepared to operate. The limb was carefully cleansed, shaved and bathed in hot carbolized water, finishing up with a bichloride solution of 1 to 2000. The instruments and sponges were thoroughly carbolized and kept in carbolized water 1 to 30. The patient was put under the influence of chloroform, and an incision made along the spine of the tibia from extremity to extremity. It was found denuded of its periosteum in the lower half, and at the upper extremity the finger readily passed into a carious cavity which encroached
upon the cartilaginous covering of the head. The middle third was soft, though not so thoroughly disintegrated. The muscular tissues in the lower third of the leg had been destroyed greatly by the long-continued process of suppuration and were undergoing fatty degeneration. Finding the leg in this condition, and feeling sure that the child could not withstand the shock of an operation, followed by further suppuration which would be sure to result from any effort to save the limb, with the further danger of opening into the knee joint in any effort to remove the tibia, and with the further almost certainty of the system, in its devitalized condition, being unable to attempt to reproduce the tibia, I decided at once to amputate through the knee joint. I was unwilling to approach any nearer the trunk than I was compelled to do, and feared septic absorption if the extremity of the femur was touched.
With a small scalpel an anterior flap was made, and the ligaments of the knee joint being divided, the posterior flap of the same length as the anterior was rapidly made. The loss of blood did not exceed half an ounce, as the leg had been kept elevated, and just before making the first incision the flat band of an Esmarch's tourniquet had been wound snugly just above the knee, compressing the popliteal artery. Of course, in the diseased condition of the limb, no bandage had
been used on the leg itself. The flaps were made long; one artery tied; the band removed ; the limb held elevated and bathed with hot carbolized water; one muscular branch of the artery twisted and the stump was then carefully coapted, and five sutures passed. A dressing of carbolized cotton was applied damp, 1 to 30, and a dry pad outside of it. The stump was kept bent back; the patella being drawn under and between the condyles, but only held there by the loose bandage holding the dressing
A small portion of morphia was administered. Tonics were ordered continued; a solution of carbolic acid 1 to 30 was directed to be used to dampen the dressings when needed, and they were to be disturbed as little as possible.
At the end of the operation the pulse was 90 and the temperature about 100o. On the third day after the operation the pulse was 110, temperature normal. On the fifth day the pulse was 120, temperature was 103°. The dressings which had not been, up to this time, disturbed, were removed, and at one point a tablespoonful of pus escaped. The stump was redressed as before without any further disturbance. On the ninth day I saw the patient, removed the dressings and found union by first intention.
I removed some of the sutures but left the others, together with the ligature on the artery, which was very firm. There was no pus. Pulse 110, temperature normal. No complaint was made of pressure on the end of the stump, as there would have been had the saw or bone pliers been used. I dismissed the patient, requesting Dr. S. to remove the sutures as soon as possible, and to keep the stump bandaged and flexed on the thigh. I report this because it is possibly the only knee joint amputation that has been made in this country, and to call the attention of the members to the fact that it is a far better operation,in my judgment,than any operation which would encroach upon
the femur in the least. The advantages are, 1st: You keep as far from the trunk as possible. 2nd: No canaliculi are opened to become entering points for septic material. 3rd : No medullary canal is opened. 4th: You have a better stump for an artificial limb, inasmuch as it is longer—the long surfaces rounded, and, where the patella adheres properly under the
extremity of the femur, a point against which the artificial limb can press ; then, too, the stump is of such a shape as to help hold the artificial leg on, admitting of a strap around the stump just above the condyles. Other advantages are self-evident. Of course, in these days of antiseptic surgery, the bugbear of opening a joint amounts to nothing in such a case. The patella can be firmly fixed by wiring, ivory or steel pegs, or by dividing the ligamentum patellæ. It could, of course, be removed if diseased. Nothing of the kind was done in this case.
Aug. 19th, was called by Dr. W. to operate on J. A., whose right hand had been terribly mangled by a saw. An examination showed the thumb laid open from its extremity to the metacarpal articulation, the bones of the two phalanges being sawn into fragments lengthwise and fully two-thirds thrown out by the saw. The metacarpo-phalangeal articulation was laid open, and the muscular tissue in shreds. The index and next fingers were sawn entirely off through the first phalanx, leaving only about one-fourth of the bone of each. The ring and little fingers were sawn through the third phalanx of each.
In the mangled condition of the hand, with the extensive injury done the thumb, I, fearing tetanus would follow any attempt to save it, decided to remove it, which I did, afterward cutting off with bone-pliers the head of the metacarpal bone. The index finger was treated in the same way, the head being cut off obliquely to shape the hand. The next finger was simply disarticulated, without any interference with the metacarpal bone. The ring finger was disarticulated through the junction of the 2nd and 3rd phalanges. The little finger was amputated through the middle of the last phalanx. Esmarch's tourniquet being used, no blood was lost till the dressing begun. One artery was tied. Dressing was completed by thoroughly cleansing with hot carbolized water 1 to 30, stitching the flaps with iron-dyed silk, and then a pledget of absorbent cotton saturated with the carbolic solution, squeezed nearly dry, covering all, and then a bandage applied.
The next day there was some hemorrhage from some indiscretion. The dressing was not changed till the eighth daybeing occasionally wetted with a carbolic acid solution 1 to 30.