Thomas Cattell
1847 The Lancet  
306 acetate of ammonia, two ounces; tincture of opium, one drachm and a half; spirit of nitric ether, wine of antimony, of each two drachms; water, five ounces. Mix. An ounce to be taken every two hours. March 1st.—Goes on with slight yet gradual improvement; pulse down to 100, though a few days ago at 124. Finding so much less local pain, and less general querulousness of the patient, slight and very gentle passive motion of the joint was commenced under my own eye at the morning visit. In a
more » ... rning visit. In a short time it was used twice a day, taking care to give no uneasiness, and to cease the moment any such feeling was experienced, being then replaced in its usual slightly flexed position. Circumference half an inch more than the sound one. Discharge of turbid synovial fluid continues. On the 25th, it became more purulent, a lodgment of which seemed to have taken place near the head of the fibula, where there was some pain, which for a time extended across the joint. I The existence of heat also induced the application of fourteen leeches at twice; mixture, night draught, and lotion, continued, with occasional aperients when necessary. The diet had been strictly fever up to the 24th, when it was changed for low, (which, with us, gives half a pint of broth, but no meat,) to which a little rice pudding was added. 7th.-A small blister was applied on the 2nd,an inch or more below the inferior edge of the patella, which, either from his peculiar habit or sensitiveness, seemed to produce uneasiness locally and generally, the pulse having gone up to 110, with some heat and parched mouth. Medicines continued, and sixteen leeches applied-a few at a time, as circumstances seemed to require. 17th.—Some fluctuations in the state of the joint since last report, without apparent cause; becoming, on the 10th, more painful and swollen, which, from the remedies used, again gradually subsided; pulse varying from 84 to 104; to-day, 96; wound now nearly closed, discharging only fluid enough to tinge the dressing in the slightest degree; extends and flexes the joint himself pretty freely, without apprehension or pain. Between the 10th and 13th, thirty-two leeches were applied; and on the 15th, a blister, placed, however, more upon the internal condyle than I had intended, owing to misapprehension of my directions by an attendant; this was kept open with savine cerate for several days. Mixture and night draught continued; aperients of mild character nearly every morning. On the 12th he had fish for dinner, and two days afterwards fowl, which were alternated according to his inclination. 25th.-Original wound, which had been gradually closing, became completely so on the 20th; and this day the blister, borne with his characteristic impatience, had also skinned over. Pulse, for the first time, as low as 80; motion of the joint perfect, and with but slight degree of that stiffness to be expected from more than six weeks' confinement, and the inflammation consequent upon what is so often a serious injury. 'It seems, however, if our measurements be correct, to fluctuate occasionally in size, being to-day three-fourths of an inch in circumference more than the sound one. Was yesterday placed upon half diet, which includes half a pound of butcher's meat, this being the first he has had since admission. 31st.-Has been using a strong discutient liniment, in order to disperse slight thickening over the internal condyle. Applied a bandage for support; moves about the ward freely. April 7th.—Discharged cured, being fully able, as he states, to resume his duty, having now been sixty-two days in the hospital. Enlargement of the joint, at present, about a fourth of an inch, or less, than that of the opposite limb; and it continues slowly to diminish. How far the condyle was injured, in this case, could not, when I first saw it, be discovered; but that the corner of the chisel had penetrated it freely, and of course the capsular ligament, (or synovial membrane,) by the momentum of the fall, there could be no doubt. This, as far as the bone was concerned, might be a slight matter. The situation of the wound, however, and division of soft parts, became of more importance, as they imparted to it the more serious character of punctured wound of a joint. The irritability of the patient's habit; the uneasy, quick, and small, sharp pulse ; its standard for a long time, 112, which, after accidents, I have frequently found to indicate latent mischief; the degree of pain in the joint, and the discharge from it-made me apprehensive of some permanent structural disorganization. To meet this, the remedies were similar to those previously recommended, where the lesion had been of more formidable character, and with the same success. In addition to three general bleedings in the hospital, one took place at his residence previously, making together fifty ounces. Eight or ten leeches were applied before his admission, and 194 afterwards-always, I thought, with advantage; but as some of these were used a second time, the quantity of blood drawn in this way was not, perhaps, so great as may at first view appear, and the patient, as has been mentioned, was young and of powerful frame. Opium, likewise, it will be seen, was given freely. In the first five days after admission, he took altogether above a scruple in the form of Dover's powder, and about three drachms or more of the sedative solution in a diaphoretic mixture. For a month longer, or till March 10th, the quantity taken daily, making everv allowance for the interruptions caused by sleep, was a drachm and a half, or more-always, however, in combination with medicines having a tendency to the skin: these appear to add considerably to its usefulness, and to diminish the effect of what may be considered less desirable properties. Warm applications having been used locally in the first instance were continued for twelve days after admission, and then changed for an evaporating lotion, till March 4th. The latter application I prefer, though it may be necessary to be guided by circumstances, or the feelings of the patient. Feb. 15th, 1847.-Meeting to-day with a medical officer of the dockyard, (Dr. Derriman,) who had been attached to the hospital when this case was under treatment, he informed me that the man continued perfectly well, and at work ever since his discharge. ) * * * * In THE LANCET of May 9th, 1846, is given a severe case, occurring at Tunbridge Wells, of compound luxation of the knee-joint, terminating fatally in the attempt to save the limb. It appeared afterwards, that the popliteal artery was lacerated to some extent; severe haemorrhage occurred at the moment, followed on the fourth day by a repetition of it, the loss of blood being so serious, particularly on the first occasion, that he survived amputation very few hours. In this instance, however, there is nothing to invalidate the opinion on such an unfortunate complication, advanced in a former paper, to which allusion has been already made. Rupture or division of the artery, added to severe injury of the joint, is one of the cases expressly excluded there from the list of those in which a cure may be safely attempted. Added to the evil of uncovered bones, the destruction of so many parts, as integuments, muscles, ligaments, and bloodvessels, scarcely admits of reparation, in an articulation so exceedingly irritable. It is otherwise with the shaft of a bone. Cases are known, where, in compound fracture of the femur, with wound of the main artery, the vessel has been secured, and the patient done well. In the case just mentioned, we are told that constitutional irritation set in before the performance of the operation; but, excepting the closure of the wound in the usual way, by sutures and straps in the first instance, the general or local treatment adopted is not mentioned. WERE a person to suppose his mind absent while he is conscious of its absence, or to suppose the presence of perception and the absence of consciousness, would, in reality, be supposing himself conscious of the absence of all consciousness. It would be proving the absence of mind by the presence of mind, which is a contradiction. Absence of mind cannot therefore be proved. Besides, in the example which Dr. Wigan has adduced, there must be the absence of perception, consciousness, and memory, for consciousness, by which we experience the fact, is supposed to be both absent and present at the same time. It is important to observe, that consciousness and our recollection of it are two distinct ideas-the former must exist previous to the latter: absence of the mind in reading, if it fail to leave any trace in the memory, cannot have produced a consciousness of the subject read. For the absence of memory must have been preceded by the absence of attention, and where there is the absence of both memory and attention, there cannot be consciousness. The example, moreover, excludes the only two operations of the mind by which the consciousness of any fact can be ascertained; and makes the mind percipient and impercipient at the same time ; percipient, by a transfer of its attention
doi:10.1016/s0140-6736(00)63606-1 fatcat:wskkrk6dt5c3thqr45pqimacpa