MEDI

VOL. IX.

NO. 2.

St. Louis College of Physicians and

Surgeons,

Surgical Clinique

OF PROFESSOR LOUIS BAUER.

A SERIOUS ACCIDENT TO AN ALREADY COMPROMISED KNEE-JOINT..

The present case, has been selected to exemplify the difference of the treatment of articular diseases in the past and present.

The patient had past her childhood under economical stringency, leaving her body for years in a condition designated by the learned term "Strumous Diathesis." At the age of ten the poor girl sustained a fall upon her right knee-joint, leaving it tender and when exercised, so painful as to lay her up for several days. This state of the articulation extended over ten years and kept her in feeble health, not changing by normal development into womanhood. During this proDuring this protracted sickness, she continued attending school and taking her share in household work. When about twenty, the patient committed the imprudence of exposing her heated and profusely

perspiring body to a very cold draft. She was almost immediately attacked by a severe chill of several hours duration, followed by intense fever. At the same time the knee-joint became more painful than ever before; in addition it swelled considerably. The slightest movement causing unbearable suffering. After the systemic disturbance had subsided, the local trouble continued, but slightly lessened in intensity, consigning the patient to the sick room for a term of years. Then suddenly the limb was drawn into and held in an angular position, whereupon the previous tenderness totally subsided. From that time onward, she enjoyed at least some rest and comfort, with marked constitutional improve

ment.

During her protracted sickness, several physicians were consulted, among them some of our best men in St. Louis. Without exception they all pronounced her lesion of strumous origin and effect, administering the usual remedies and divers local applications, without giving even temporary relief.

None of the attending physicians

seemed to have considered the fact, that the trouble had originated in traumatism and probably kept advancing by the indiscreet use of the affect ed joint. The fact also had escaped their scrutiny that the ordinary use of the limb seemed to do no harm, whereas its active use invariably intensified the local symptoms, ease always following when the patient suspended work and rested the limb. Even the significance of the unexpected and continuous relief from pain by the sudden contraction of the flexor muscles was lost to their consideration.

On the other hand, there was no pathological evidence to sustain the strumous diagnosis unless the chronicity was arbitrarily admitted. Nothing but the blind following of theoretical dogmatism could mislead men of good qualities, learning and honest aspiration. It is not my intention to indulge in unkind criticism, for with the balance of the profession, I have been myself an adherent to the same theory, until facts and logic relieved me of an unattainable and misleading doctrine, now laid on the shelf.

But I have submitted this case to your attention for the purpose of warning you of becoming blind followers of empty theories. I am the more urged on to bring this case to your earnest reflection as we are threatened with a similar theory, of arbritrary inferences; meaning, of course, tuberculosis. However, this is not the time to refer to this subject more in detail, reserving that for other occasions.

At the age of thirty-two; the patient came into my charge (1869). On examining the implicated knee-joint I found the extremity attenuated and the flexor muscles, particularly the biceps, so contracted as to hold the

knee-joint in an angle of 110 degrees. The patient was without any painful sensation on either presure or motion; the latter, of course being very limited. Aside of the deformity there were no conditions about the joint, which could have traced to the so-called "Strumous Diathesis." A moderate interarticular adhesion had evidently grown out of synovitis.

Her general health was about fair. At any rate not presenting appreciable contra-indications to the operation I had decided to advise. The patient was but too anxious to part with the enforced sedentary mode of life which had been enforced upon her for years, and therefore submitted to the proceeding with exceptional willingness.

Under full anaesthesia with chloroform, I divided the biceps and then straightened the limb by manual force, tearing, of course, all fibrous adhesions between the articular facets. With the exception of an insignificant happening, the operation was successful and returned the expected results. In a month, a brace replaced the plaster of Paris bandage. It held the joint in a straight, inflexible and immovable position. From that time onward, the patient was allowed to walk. In about six months, the brace was dispensed with. During the ensuing twenty-five years our former patient has derived good services from the implicated extremity, which held its own without any other inconvenience than the straight position and the limited mobility of the knee-joint naturally imposing, for as usual in the like cases their articular adhesions have reformed and offered about the same impediment, to the motion of the joint as before.

About two months ago the patient

met with a severe fall upon the compromised joint. I saw the case a few hours after the accident and found the articular cavity and the surroundings of the joint filled with blood. The increased mobility disclosed the fact that the inter-articular fibrous connections had been torn, besides some indication of contusion of the peri-articular structure. The pain was, of course, excessive, both on pressure and motion.

Considering the pre-existing condition of the joint and the character of the recent injury the prognosis appeared at least dubious to me.

Rest of the joint being the only therapeutic indications, I could do no better than to re-apply the old brace. And indeed it rendered again the same good services, which were derived from its action twenty-five years ago. The patient again is on her feet and walks as well as before and proving of as good constitution now as then. Demonstrating that rest and position. are not the most reliable remedies of traumatic injuries to joints.

DeSoto Building, 708% Pine St., Rooms 217-218.

A Report of a Few Cases of Diphtheria With the Use of Antitoxine.

BY HUGH P. MACK, M. D. First Assistant to Dr. Waldo Briggs, etc.

GENTLEMEN: Much has been said and written, pro and con., of the use of antitoxine in diphtheria, and I confess that at its first introduction to the public was as skeptical about it as any one as to its value, possibly on account of the "air bubbles" made by

Koch's lymph, Pasteur's serum, etc., having collapsed without establishing anything beneficial to the suffering humanity.

The antitoxine, when spoken of, had the same place, as I said in my mind, still I concluded that I would follow its progress for a time and if beneficial, fall in line and "give the devil his due." After some time spent in following reports and consulting several of my medical friends regarding it, I concluded to use it on the next case of diphtheria that came to my hands. Nor was my opportunity long in presenting itself. I used the antitoxine on this case with the most gratifying results, and what I considered at first another bubble, has found place in my estimation as the greatest boon in the treatment of diphtheria that ever was discovered. Since I began its use I am delighted to say that I have not lost but one case of diphtheria! This, of course, is a remark many doctors make about diphtheria, and can be met with the argument that all cases were not diphtheria. But, gentlemen, appreciating that fact, I was careful in having my diagnosis confirmed in every case, by the culture tube and the City Chemist, I am safe to say will bear me out (as he did before) that the cases I am about to report were true diphtheria.

The following is a report of cases in three families of children which are worthy of note,-lack of space alone preventing me to give more:

CASE 1. Fred. Wenert, age 6 years, residence 3321 Park avenue; six in family, three adults and three children. When I was called in I found the case thirty-six hours' standing. Membrane over entire extent of both tonsils, soft palate, and down the throat as far as

Upon the same day of giving the dose to my patient I gave the immunizing dose, 72 c. c., to the two children, aged 12 and 8, with good results, as neither of them showed any symptom of the disease during its entire course with the boy who was fully recovered from diphtheria in five days, with some slight heart trouble and anæmia, which was readily corrected with digitalis and moderate dose (71⁄2 gr.) of protonuclein.

CASE II-III. Willie Merrill, aged 8 years; 1800 Morgan street; four in family, two children and two adults. Case was seen about eight hours after the first. I was called to see the boy

in the evening of the first day that he was taken sick. Upon examination I found that the membrane had made its appearance upon the tonsils, but not very extensive. He had all the rest of the symptoms of diphtheria, I did not wait for report upon my culture, but applied for and obtained the antitoxine at once. At about 10:00 p. m. I called at the house and gave the boy a full dose of the antitoxine ("20 c c") and his little sister, aged 3 years, was given 71⁄2 c c, for immunization.

The following days the pulse, respiration and temperature was registered, as follows: