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BRISTOL GENERAL HOSPITAL.
522 The operation contemplated was an amputation at the upper third of the arm, and the condition of that portion of the shaft above the fracture affording room for doubt, it was considered that a high amputation with subsequent removal of the head of the bone, if necessary, would give the old man the best chance of recovery. Operation.-The patient having been previously treated for a few days with powders containing rhubarb and bicarbonate of potash, was, on the 15th of August, placed upon the table, and chloroform administered. Anterior and posterior flaps were then cut by transfixion, in the upper third of the arm. Lateral flaps were avoided on account of the opening on the outer aspect of the arm, otherwise they The saw passed through the bone are perhaps preferable. with remarkable ease, and, on examination of the remaining portion, it was found to be in a disorganised condition. The head and remaining portion of the shaft(about two inches) was then ca,refully removed by passing the knife round the bone until the joint was reached, and disarticulation effected.
The pus
joint was perfectly healthy, but a large quantity of escaped from the floor of the axilla. The bleeding having been arrested, the somewhat redundant flaps were stitched together, and the stump dressed with dry lint. The patient bore the operation well enough, but was
somewhat faint on removal to bed. The after-treatment consisted in free stimulation from the first, together with small doses of quinine and opium combined. The margins of the flaps showed a ready tendency to unite; but the cavity of the wound discharged freely for the first ten days, subsequently becoming much less in quantity and healthier in character. The condition of his chest gave cause for some anxiety, for his cough was occasionally very urgent, the sputa being frothy and copious. On the fifteenth day his pulse was standing at 86, and he was out of bed for an hour with his clothes on. It remains only to be said that the stump ha3 nearly healed, and the man pronounced convalescent. On examination of the amputated limb, the seat of fracture was united by fibrous tissue of cartilaginous hardness, and the entire shaft hollowed out, leaving a thin circumferential shell of a very fragile nature; there was no trace of the medulla, but the lining membrane, thickened and thrown into folds, contained numerous free cysts of the size of small grapes, with an opalescent and thin wall, and contents of a serous character, showing fatty granules under the microscope. Remarks.-The want of union in this case may be ascribed to the age of the patient, associated with general debility consequent upon the condition of his bronchi, at the same time not overlooking the decided tendency to arterial degeneration. The disuse of the limb probably hastened on those degenerative changes found in the humerus. It has been stated that the presence of arcus senilis contraindicates the administration of chloroform, but in this case, where each cornea presented well-marked fatty degeneration in its upper part, the anaesthetic was well borne and apparently taken with perfect safety. With regard to the operation, the high arm amputation, followed by enucleation of the head of the bone, may have diminished the shock to the patient. A similar course has been adopted to diminish the shock in a case of amputation at the hip.*
the medical attendant was induced to search the patient’s pockets, when he found an empty ounce bottle, corked, and labeled " poison." On smelling it, he at once detected prussic acid. He says he could not smell it in the man’s breath on account of the brandy that had been given him.
He observed no tetanic convulsions, nor was there any escape of fseces or urine. He had him put in a cab and brought to the hospital, but the patient died before arrival there. He did not give a scream or any cry before death. On admission, he was quite dead. There was a quantity of froth about his beard and mouth, but for the reason before given there was no smell of prussic acid. His face was blanched ; the eyes were open and glistening; the pupils were dilated ; the jaw had fallen. It was ascertained that he had been carrying the bottle about with him for at least three weeks, so that its quality must have become deteriorated, or he would have hardly survived so long as he did-namely, from thirty-five to forty minutes. The exact strength of the poison could not be discovererl, but it was in all probability an ounce of the ordinary Pharmacopoeia acid. The symptoms could not have been instantaneous, or he could not have corked the bottle and put it in his pocket. One of the people in the room observed him stoop down behind a desk some minute or two before he fell down. Autopsy, twe’l1ty-two hours after death.-The body was that of a well-nourished, full-grown man. There was some discoloration of the skin at the back of the neck. Necrosis of the right tibia existed, which had been going on for twenty years. On removing the skull there was an odour of the acid. The dura mater was not injected. The veins were full of dark liquid blood. The substance of the brain was pale. Serous fluid was present in the ventricles, which, on being examined for the acid with the sulphate of copper and nitrate of silver tests, gave the usual reactions. The lungs were very oedematous, frothy, and gorged with dark liquid blood. There were some pleuritic adhesions to the right wall of the chest. There was no distinct odour of the acid about either the lungs or heart ; the latter weighed sixteen ounces, and was empty. On opening the abdominal cavity there was a distinct odour of prussic acid. The stomach was almost empty of contents ; what little there were showed, on being tested, the presence of hydrochloric acid. There was no trace of prussic acid. The stomach itself was not analysed. There were some patches of congestion on the walls. The duodenum and ileum also showed some patches of congestion, but nothing else was noticed in the alimentary canal. The liver weighed four pounds fifteen ounces ; substance somewhat fatty ; slightly congested y faint odour of prussic acid. The bile in the gall-bladder was not coloured blue. The spleen weighed eight ounces, and was soft and congested. The weight of both kidneys was thirteen ounces and a half, and they were congested. The capsule readily peeled off. There was an odour of the acid about both spleen and kidneys. The blood throughout the body was everywhere fluid ; there was no coagulation.
Reviewsand Notices
of
Books.
Megrim, Sick Headache, and some allied Disordersaa Contributioa2 to the Pathology of Nerve-Storms. By EDWARD London: J. and A. LIVErNG, 1VLD. Cantab., &c. Churchill. 1873. On Nervous or Sick Headache:its Varieties and Treatment. By P. W. LATHAM, M.D., F.B.C.P., &c. Cambridgef Deighton, Bell, and Co. 1873. On
BRISTOL GENERAL HOSPITAL. PRUSSIC ACID POISONING; DEATH; AUTOPSY. FOR the
following
notes
we are
indebted to Mr. J. Howell-
Thomas, physician’s assistant. R. F-,aged forty-four, was brought to the hospital at 12.55 P.M. August 26th, dead. The history of the case was follows :-A few minutes past twelve he was suddenly observed by some people who were with him to fall down in what they thought was a fit. He became insensible. They gave him brandy, and sent for a medical man, who, on arrival, found the man insensible, skin cold and clammy. He was supported in a chair, but was quite unconscious. There was convulsive respiration at intervals, which was the only sign of life. From the circumstances of the case as
* In a case requiring hip-amputation in the Edinburgh Infirmary some at years ago, Mr. Annandale.amputated in the upper third of the thli
Professor
DR. LivEiNG’s volume is a most welcome and most valuable contribution to scientific medicine, and will prove a very lasting monument of the honesty, the originality, and, above all, of the industry of its author. The work has been ten years in preparation; the author has had ample time to digest the opinions of previous and contemporary writers, and to thoroughly consider and bring to maturity his own views on the subject. Moreover, the canons of logic are, as far as is practicable, strictly adhered to, and, as a natural consequence, the reader, while enjoying that repast which Dr. Liveing’s deep learning has provided for him, is never
.
The pus
joint was perfectly healthy, but a large quantity of escaped from the floor of the axilla. The bleeding having been arrested, the somewhat redundant flaps were stitched together, and the stump dressed with dry lint. The patient bore the operation well enough, but was
somewhat faint on removal to bed. The after-treatment consisted in free stimulation from the first, together with small doses of quinine and opium combined. The margins of the flaps showed a ready tendency to unite; but the cavity of the wound discharged freely for the first ten days, subsequently becoming much less in quantity and healthier in character. The condition of his chest gave cause for some anxiety, for his cough was occasionally very urgent, the sputa being frothy and copious. On the fifteenth day his pulse was standing at 86, and he was out of bed for an hour with his clothes on. It remains only to be said that the stump ha3 nearly healed, and the man pronounced convalescent. On examination of the amputated limb, the seat of fracture was united by fibrous tissue of cartilaginous hardness, and the entire shaft hollowed out, leaving a thin circumferential shell of a very fragile nature; there was no trace of the medulla, but the lining membrane, thickened and thrown into folds, contained numerous free cysts of the size of small grapes, with an opalescent and thin wall, and contents of a serous character, showing fatty granules under the microscope. Remarks.-The want of union in this case may be ascribed to the age of the patient, associated with general debility consequent upon the condition of his bronchi, at the same time not overlooking the decided tendency to arterial degeneration. The disuse of the limb probably hastened on those degenerative changes found in the humerus. It has been stated that the presence of arcus senilis contraindicates the administration of chloroform, but in this case, where each cornea presented well-marked fatty degeneration in its upper part, the anaesthetic was well borne and apparently taken with perfect safety. With regard to the operation, the high arm amputation, followed by enucleation of the head of the bone, may have diminished the shock to the patient. A similar course has been adopted to diminish the shock in a case of amputation at the hip.*
the medical attendant was induced to search the patient’s pockets, when he found an empty ounce bottle, corked, and labeled " poison." On smelling it, he at once detected prussic acid. He says he could not smell it in the man’s breath on account of the brandy that had been given him.
He observed no tetanic convulsions, nor was there any escape of fseces or urine. He had him put in a cab and brought to the hospital, but the patient died before arrival there. He did not give a scream or any cry before death. On admission, he was quite dead. There was a quantity of froth about his beard and mouth, but for the reason before given there was no smell of prussic acid. His face was blanched ; the eyes were open and glistening; the pupils were dilated ; the jaw had fallen. It was ascertained that he had been carrying the bottle about with him for at least three weeks, so that its quality must have become deteriorated, or he would have hardly survived so long as he did-namely, from thirty-five to forty minutes. The exact strength of the poison could not be discovererl, but it was in all probability an ounce of the ordinary Pharmacopoeia acid. The symptoms could not have been instantaneous, or he could not have corked the bottle and put it in his pocket. One of the people in the room observed him stoop down behind a desk some minute or two before he fell down. Autopsy, twe’l1ty-two hours after death.-The body was that of a well-nourished, full-grown man. There was some discoloration of the skin at the back of the neck. Necrosis of the right tibia existed, which had been going on for twenty years. On removing the skull there was an odour of the acid. The dura mater was not injected. The veins were full of dark liquid blood. The substance of the brain was pale. Serous fluid was present in the ventricles, which, on being examined for the acid with the sulphate of copper and nitrate of silver tests, gave the usual reactions. The lungs were very oedematous, frothy, and gorged with dark liquid blood. There were some pleuritic adhesions to the right wall of the chest. There was no distinct odour of the acid about either the lungs or heart ; the latter weighed sixteen ounces, and was empty. On opening the abdominal cavity there was a distinct odour of prussic acid. The stomach was almost empty of contents ; what little there were showed, on being tested, the presence of hydrochloric acid. There was no trace of prussic acid. The stomach itself was not analysed. There were some patches of congestion on the walls. The duodenum and ileum also showed some patches of congestion, but nothing else was noticed in the alimentary canal. The liver weighed four pounds fifteen ounces ; substance somewhat fatty ; slightly congested y faint odour of prussic acid. The bile in the gall-bladder was not coloured blue. The spleen weighed eight ounces, and was soft and congested. The weight of both kidneys was thirteen ounces and a half, and they were congested. The capsule readily peeled off. There was an odour of the acid about both spleen and kidneys. The blood throughout the body was everywhere fluid ; there was no coagulation.
Reviewsand Notices
of
Books.
Megrim, Sick Headache, and some allied Disordersaa Contributioa2 to the Pathology of Nerve-Storms. By EDWARD London: J. and A. LIVErNG, 1VLD. Cantab., &c. Churchill. 1873. On Nervous or Sick Headache:its Varieties and Treatment. By P. W. LATHAM, M.D., F.B.C.P., &c. Cambridgef Deighton, Bell, and Co. 1873. On
BRISTOL GENERAL HOSPITAL. PRUSSIC ACID POISONING; DEATH; AUTOPSY. FOR the
following
notes
we are
indebted to Mr. J. Howell-
Thomas, physician’s assistant. R. F-,aged forty-four, was brought to the hospital at 12.55 P.M. August 26th, dead. The history of the case was follows :-A few minutes past twelve he was suddenly observed by some people who were with him to fall down in what they thought was a fit. He became insensible. They gave him brandy, and sent for a medical man, who, on arrival, found the man insensible, skin cold and clammy. He was supported in a chair, but was quite unconscious. There was convulsive respiration at intervals, which was the only sign of life. From the circumstances of the case as
* In a case requiring hip-amputation in the Edinburgh Infirmary some at years ago, Mr. Annandale.amputated in the upper third of the thli
Professor
DR. LivEiNG’s volume is a most welcome and most valuable contribution to scientific medicine, and will prove a very lasting monument of the honesty, the originality, and, above all, of the industry of its author. The work has been ten years in preparation; the author has had ample time to digest the opinions of previous and contemporary writers, and to thoroughly consider and bring to maturity his own views on the subject. Moreover, the canons of logic are, as far as is practicable, strictly adhered to, and, as a natural consequence, the reader, while enjoying that repast which Dr. Liveing’s deep learning has provided for him, is never
.