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RADCLIFFE INFIRMARY, OXFORD.
465 no bleeding point could be seen, and no indications manifested of any collection of blood between the flaps. The subsequent progress of the case was apparently favourable up to the evening of Nov. 16th, when the dressing-! were found to be stained with blood. Early on the following morning, after renewal of the haemorrhage, the posterior portion of the extremity of the stump was found to be distended by a large and distinctly pulsating were at this date quite tumour. The edges of the united, save at the outer angle, where there was a small and long sinus, which led to a patch of necrosed bone at the ext.remity of the fragment of tibia. The patient having been placed under the influence of ether, the flaps were separated at the extremity of the stump by the knife, and dissected back as far as the kneejoint. The extremities of the leg-bones, together with the soft parts immediately surrounding these, and a considerable portion of the thickness of the posterior fla,p, were then removed, and the old skin-flaps were brought together over the lower extremity of the femur, the patella being le-ft ten sitic. Considerable difficulty was experienced in securing the popliteal artery, the coats of which were soft and
stump were
flaps
,
up the inside of the of the pelvis as high as the brim. The right internaliliac vein and some of its branches were filled with pale-brown adherent clots. The surface and substance of both lungs were beset with numerous ecchymoses of all sizes, each having a nucleus of firm pale fibrine. Most of the smallest visible branches of the pulmonary artery were plugged with fibrine. The right side of heart contained, besides an ordinary venous clot, an elongated mass of firm pale-brown fibrine made up of numerous very small separate bits. On the left side, besides much interstitial thickening of the free edge of the mitral valve, there were on its auricular surface two or three loosely adherent masses of fibrine. Numerous small buffcolonred spots on surface of liver and a few in its substance. Large fibrinous blocks in spleen and both kidneys. Several large patches of ecchymosis in mucous membrane of stomach, and smaller ones, with a central white nucleus to each, throughout whole length of intestinal canal. The brain, unfortunately, could not be examined. Acute periosteal abscess over tibia; cerebral symptoms for
the sciatic
days befole death; autopsy; pericarditis; secondary deposits in substance of heart, lungs, brain, and other organs.-Thomas B——, aged six years, was sent to the infirmary Jan. 22ud, 1879, as a case of rheumatism. He All that could was too ill to give an account of himself. he learned from his friends about his previous history was that a fortnight before admission he began to complain of pain below one knee, causing him to limp. This was attributed to frequent fa.)!s while skating. A week later he took to bed, feeling feverish and ill, and after two or three days’ slight amendment got gradually worse. On examination a soft tluctuating swelling without redness was found over the middle of the left tibia. This was immediately opened, and gave exit to a considerable quantity of pus. The bone beneath was laid bare for some distance ; there was no swelling of the leg. lie was only semi-conscious ; irritable if disturbed ; frequently crying out as if in pain ; face pinched and shrunken; right corner of mouth somewhat dropped ; lips and teeth covered with -,ordes;y tongue dry and brown. Heart-sounds very faint, but no murmur audible. Over front of chest respiratory sounds normal. He was too itl to permit of being auscultated behind. two
thickened. In the posterior fla,p was found an oval sac, of about the size of a pigeon’s egg, with a well-marked membranous wall, which was perforated at the outer surface. Opening into this sac, which was filled by coagulated blood, was seen the patent orifice of the stump of the popliteal artery.
after the second operaDec. 26th was able to get up. At the end of the month the stump was sound and healthy, and firm manual pressure could be appliod to its extremity without; exciting any pain. The patella remained fixed in front of the condyles, and there seemed to be no tendency in the posterior flap to retract to such extent as to draw this bone. over the lower extremity of the femur.
The
patient progressed favourably
tion, and
on
RADCLIFFE CASES
OF
INFIRMARY,
OXFORD.
ACUTE PERIOSTEAL ABSCESS, FOLLOWED WITH SECONDARY DEPOSITS ; DEATH.
BY
PYÆMIA,
(Under the care of Dr. GRAY.) periosteal abscess connected with one iliac bone;; symptoms of septicœmia;gangrene of portion of hands and feet; death; autopsy; secondary deposits in lungs and various systemic orguns.-Walter F-, aged seventeen, a tailor’s apprentice, was sent to the infirmary May 2nd, 1877, as a case of rheumatism. There was a histo’y of good health up to a fortnight before admission. He then got wet through, and let his clothes dry on him, but felt no ill effect till four days afterwards, when he began to have pain about the back of right hip. Three days before admission he had a rigor, vomiting, and great increase of the local pain. On May 3rd he had dry tongue, rapid weak pulse, and morning temperature of 104°. The right lumbo-sacral region was very tender, full, and tense, but not fluctuating. Deepseated suppuration being diagnosed, he was transferred to Acute
Breathing
!
the
care
of the surgeon.
high temperature,
lie became
one or more
notch, behind the peritoneum,
corresponding half
ivorse, with
gradually daily rigors, profuse sweating,
and diarrhoea, till May 12th, when he died. Meanwhile the. pus had come no nearer to the surface, and the attempts to’ reach it had been unsuccessful. The last five or six days before death successive patches of dark discoloration appeared on the soles of the feet. The skin over these patches> first reddened, then its epidermis became raised by bloody At the same time the lad complained of shooting serum. pains down both arms, and all the finger-tips but one hecame gangrenous. The left knee became a little distendedL with fluid, without any redness of skin. Also, just above the, left eyebrow, a patch of skin, about the size of a florin, became raised, puffy, and beset with numerous small vesicopustules. No murmur was at any time heard at the heart,, nor did any cerebral or pulmonary symptoms manifest themselves. The necropsy showed entire gangrene of the last phalanx: of each finger but one, and two or three gangrenous patchess on the sole of each foot, the toes being unaffected. The3 effusion in the one knee-joint proved to be only serous. Very deep under the right gluteol muscles was a collectiona of pus laying bare a considerable portion of the dorsum ilii,, involvingthe sacro-iliac articulation, and burrowingthroughi -
’
-
-
-
-
.
not
quickened.
Jan. 23rd.—Restless and noisy all night. Pupils equal. Novomiting. Every few minutes he cried out, and the whole body then became for a few moments slightly stiffened. Urine passed unconsciously. Radial pulse imperceptible. In the evening he died. Nccropsy.-Body much wa&ted. Lungs presented patches, some apoplectic, some congestive, some pneumonic, and were posteriorly adherent to the costal pleura by recent lymph. Substance of the lower margin of the left lung beset with numerous buff-coloured deposits-some firm, but the majority in various stages of softening, and with dirtybrown puriform contents. Pericardium generally adlici unt to the heart by a thick layer of recent lymph, except at one spot, where the lymph had softened down into a puriform flnid. Several branches of the pulmonary artery, as far as they could be traced, were filled with brown clot. Semilunar valves healthy. Along the auricular edge of the mitral valve was a line of small, pink, bead-like processes. At three or four places in the wall of the left vent were small buff-coloured spots like thuse at the base of the left lung. One of these at the apex was firm ; two others, just below the aortic valves, immediately under the endocardium, were softened down into small abscesses. Each abscess was sealed, andthus prevented from discharging its contents into the blood-stream bv a lid of nhrine over the spot where the endocarrlium had ulcerated through. Liver normal. Spleen small and firm. - Kidneys: Cuttices normal, but appearance of pyramids remarkable, each one seeming as if composed mainly of a bundle of pale-brown straight threads, winch conld be easily scraped off, and were evidently fibrinous threads blocking the vasa recta.-Brain : Veins of pia mater generally engorged. A plng of fibrine filled the cut end of the right internal carotid, and extended a little way into the middle cerebral arterv. Blucks were also found in other portions of the circle of Willis. The inner surface of the frontal lobes and portions of the substance of the middle lobes seemed somewhat softened, but their real consistence was felt to be doubtful owing to the surrounding atmosphere at the time being nearly at freezing point. There was no collection of matter in any part of the brain.
stump were
flaps
,
up the inside of the of the pelvis as high as the brim. The right internaliliac vein and some of its branches were filled with pale-brown adherent clots. The surface and substance of both lungs were beset with numerous ecchymoses of all sizes, each having a nucleus of firm pale fibrine. Most of the smallest visible branches of the pulmonary artery were plugged with fibrine. The right side of heart contained, besides an ordinary venous clot, an elongated mass of firm pale-brown fibrine made up of numerous very small separate bits. On the left side, besides much interstitial thickening of the free edge of the mitral valve, there were on its auricular surface two or three loosely adherent masses of fibrine. Numerous small buffcolonred spots on surface of liver and a few in its substance. Large fibrinous blocks in spleen and both kidneys. Several large patches of ecchymosis in mucous membrane of stomach, and smaller ones, with a central white nucleus to each, throughout whole length of intestinal canal. The brain, unfortunately, could not be examined. Acute periosteal abscess over tibia; cerebral symptoms for
the sciatic
days befole death; autopsy; pericarditis; secondary deposits in substance of heart, lungs, brain, and other organs.-Thomas B——, aged six years, was sent to the infirmary Jan. 22ud, 1879, as a case of rheumatism. He All that could was too ill to give an account of himself. he learned from his friends about his previous history was that a fortnight before admission he began to complain of pain below one knee, causing him to limp. This was attributed to frequent fa.)!s while skating. A week later he took to bed, feeling feverish and ill, and after two or three days’ slight amendment got gradually worse. On examination a soft tluctuating swelling without redness was found over the middle of the left tibia. This was immediately opened, and gave exit to a considerable quantity of pus. The bone beneath was laid bare for some distance ; there was no swelling of the leg. lie was only semi-conscious ; irritable if disturbed ; frequently crying out as if in pain ; face pinched and shrunken; right corner of mouth somewhat dropped ; lips and teeth covered with -,ordes;y tongue dry and brown. Heart-sounds very faint, but no murmur audible. Over front of chest respiratory sounds normal. He was too itl to permit of being auscultated behind. two
thickened. In the posterior fla,p was found an oval sac, of about the size of a pigeon’s egg, with a well-marked membranous wall, which was perforated at the outer surface. Opening into this sac, which was filled by coagulated blood, was seen the patent orifice of the stump of the popliteal artery.
after the second operaDec. 26th was able to get up. At the end of the month the stump was sound and healthy, and firm manual pressure could be appliod to its extremity without; exciting any pain. The patella remained fixed in front of the condyles, and there seemed to be no tendency in the posterior flap to retract to such extent as to draw this bone. over the lower extremity of the femur.
The
patient progressed favourably
tion, and
on
RADCLIFFE CASES
OF
INFIRMARY,
OXFORD.
ACUTE PERIOSTEAL ABSCESS, FOLLOWED WITH SECONDARY DEPOSITS ; DEATH.
BY
PYÆMIA,
(Under the care of Dr. GRAY.) periosteal abscess connected with one iliac bone;; symptoms of septicœmia;gangrene of portion of hands and feet; death; autopsy; secondary deposits in lungs and various systemic orguns.-Walter F-, aged seventeen, a tailor’s apprentice, was sent to the infirmary May 2nd, 1877, as a case of rheumatism. There was a histo’y of good health up to a fortnight before admission. He then got wet through, and let his clothes dry on him, but felt no ill effect till four days afterwards, when he began to have pain about the back of right hip. Three days before admission he had a rigor, vomiting, and great increase of the local pain. On May 3rd he had dry tongue, rapid weak pulse, and morning temperature of 104°. The right lumbo-sacral region was very tender, full, and tense, but not fluctuating. Deepseated suppuration being diagnosed, he was transferred to Acute
Breathing
!
the
care
of the surgeon.
high temperature,
lie became
one or more
notch, behind the peritoneum,
corresponding half
ivorse, with
gradually daily rigors, profuse sweating,
and diarrhoea, till May 12th, when he died. Meanwhile the. pus had come no nearer to the surface, and the attempts to’ reach it had been unsuccessful. The last five or six days before death successive patches of dark discoloration appeared on the soles of the feet. The skin over these patches> first reddened, then its epidermis became raised by bloody At the same time the lad complained of shooting serum. pains down both arms, and all the finger-tips but one hecame gangrenous. The left knee became a little distendedL with fluid, without any redness of skin. Also, just above the, left eyebrow, a patch of skin, about the size of a florin, became raised, puffy, and beset with numerous small vesicopustules. No murmur was at any time heard at the heart,, nor did any cerebral or pulmonary symptoms manifest themselves. The necropsy showed entire gangrene of the last phalanx: of each finger but one, and two or three gangrenous patchess on the sole of each foot, the toes being unaffected. The3 effusion in the one knee-joint proved to be only serous. Very deep under the right gluteol muscles was a collectiona of pus laying bare a considerable portion of the dorsum ilii,, involvingthe sacro-iliac articulation, and burrowingthroughi -
’
-
-
-
-
.
not
quickened.
Jan. 23rd.—Restless and noisy all night. Pupils equal. Novomiting. Every few minutes he cried out, and the whole body then became for a few moments slightly stiffened. Urine passed unconsciously. Radial pulse imperceptible. In the evening he died. Nccropsy.-Body much wa&ted. Lungs presented patches, some apoplectic, some congestive, some pneumonic, and were posteriorly adherent to the costal pleura by recent lymph. Substance of the lower margin of the left lung beset with numerous buff-coloured deposits-some firm, but the majority in various stages of softening, and with dirtybrown puriform contents. Pericardium generally adlici unt to the heart by a thick layer of recent lymph, except at one spot, where the lymph had softened down into a puriform flnid. Several branches of the pulmonary artery, as far as they could be traced, were filled with brown clot. Semilunar valves healthy. Along the auricular edge of the mitral valve was a line of small, pink, bead-like processes. At three or four places in the wall of the left vent were small buff-coloured spots like thuse at the base of the left lung. One of these at the apex was firm ; two others, just below the aortic valves, immediately under the endocardium, were softened down into small abscesses. Each abscess was sealed, andthus prevented from discharging its contents into the blood-stream bv a lid of nhrine over the spot where the endocarrlium had ulcerated through. Liver normal. Spleen small and firm. - Kidneys: Cuttices normal, but appearance of pyramids remarkable, each one seeming as if composed mainly of a bundle of pale-brown straight threads, winch conld be easily scraped off, and were evidently fibrinous threads blocking the vasa recta.-Brain : Veins of pia mater generally engorged. A plng of fibrine filled the cut end of the right internal carotid, and extended a little way into the middle cerebral arterv. Blucks were also found in other portions of the circle of Willis. The inner surface of the frontal lobes and portions of the substance of the middle lobes seemed somewhat softened, but their real consistence was felt to be doubtful owing to the surrounding atmosphere at the time being nearly at freezing point. There was no collection of matter in any part of the brain.