ST. BARTHOLOMEW'S HOSPITAL

Savory
1871 The Lancet  
445 traordinary circumstance if, when we find these influences having such a powerful effect on healthy people, it should not be the case that the larger a hospital, the greater, on that account, its mortality. I shall show the effects of aggregation in general cases elsewhere ; and, whatever be the results of my investigations, they will be candidly given, whether they confirm or upset my present views. I do not yet know the compiete results, but what I have seen of them certainly confirms Sir
more » ... tainly confirms Sir James Simpson's statements. Nulla antem est aliapro certo noscendi via, nisi quamplurimas et morborum I et dissectionum historias, tum aliorum, tum proprias collectas habere, et inter se comparare.—MORGAGNI De Sed. et Caus. Morb., lib. iv. Proœmium. ON the 25th March Mr. Holden amputated the thigh of a girl about twenty years of age. Seven weeks previously, while coming down stairs in a pair of high-heeled boots, she had slipped down and sustained a compound fracture of the lower third of the femur, with protrusion of the pointed end of the upper fragment through the integument immediately above the upper margin of the patella, and oozing of synovial fluid. Encouraged by the remarkable success of conservative treatment as applied to a case of compound fracture of the patella into the knee-joint some time previously under Mr. Holden's care, the house-surgeon in charge put up the injured limb in splints-a course which Mr. Holden approved on the occasion of his next visit. For six weeks the patient progressed so favourably that recovery with anchylosis of the joint was confidently expected; but a few days before the above-named date the patient had a rigor, the knee-joint became the seat of intense pain, and it soon became evident that amputation was imperatively necessary. After the operation the articular cartilages of the kneejoint were found to have been the seat of recent acute infiammation : in places they were completely destroyed. It was also noticed that no union had taken place between the fragments of the fractured femur. Though the patient was young and healthy, Mr. Holden's prognosis was not favourable. AMPUTATION AT THE SHOULDER-JOINT FOR MALIGNANT DISEASE. (By Mr. SAvonv.) The subject of this operation was a pale-looking lad of ten years. He is said to have received some time last summer a blow on the shoulder ; and shortly afterwards a swell-' i ing, which had ever since increased in size, appeared on the ' , part. ' , On admission, a tumour of the size and shape of half a large orange, smooth, and tense and elastic as though containing fluid, was found on the right shoulder; the superficial veins were rather unnaturally distinct, but the swelling was free from pain ; there were no glandular enlargements, and the movements of the arm were quite unimpeded. Suspecting malignant disease, Mr. Savory confirmed his diagnosis by means of an exploratory incision, and forthwith proceeded to remove the limb at the shoulder-joint. A longitudinal section through the tumour into the head and shaft of the humerus exhibited an excellent specimen of a medullary cancer, which had already invaded the cancellous structure of the subjacent bone to a depth of about half an inch. Mr. Savory ventured to predict that within another twelvemonth, or a little more, the patient would be afflicted with a return of the disease. ST. GEORGE'S HOSPITAL. CASES UNDER THE CARE OF DR. JOHN OGLE. Tumour of the Abdomen.—A highly interesting case of tumour below the right costal cartilages, in the situation of the left lobe of the liver, which attained the size of a hen's egg, and at the same time softened and became superficial. It was opened, and was found to be an abscess. The patient was a woman, aged thirty-nine years, who had only been aware of any swelling in the affected part nine days, but who three weeks previously had had an attack of pain at the pit of the stomach, with sickness. On admission, the ! liver appeared to be greatly enlarged, and the hard swelling in the abdomen seemed tobe continuous with the liver, having a roughened and somewhat nodulated base, which appeared to be the liver itself. Speculations as to whether the swelling was due to a hydatid, or to abscess, or to carcinoma of the liver, or to deposit superficial to the liver, existed. The tumour quickly increased in size, and became fluctuating; it was opened, proving to be an abscess, containing 4 oz. of pus. No bile or shreds of liver-tissue existed in the pus removed, and no 11 hooklets" were found. The patient is doing well. Case of Delirium Tremens, with Congestion of the Liver, and Spasmodic Stricture.-The patient was a footman. He had slight but decided jaundice, passed much bile and lithates in acid urine, and every now and then had spasmodic stricture (to which he had never been subject), requiring the catheter, as hot fomentations and baths gave no relief. Chloral was given with good results at bedtime; and alkalies, diuretics, and subsequently vegetable bitters, were given. No stimulants of any kind were administered until the urine and skin showed that the hepatic congestion was being removed, when a little brandy was given with his food, which at first consisted of milk and beef-tea, with light puddings, subsequently of fish, and then meat. After a time the urine became alkaline, and contained a little albumen. He has become very much thinner since his illness began, but otherwise he is now rapidly convalescing. It was found on several occasions that the temperature was high, being 1022°, again 101.8°, a little later 1004°, and now it is normal. Hemiplegia on the Right Side of the Body, Face and Tongue; Memory defective; Speech affected.-The patient was a woman aged thirty-two, who had had a child five years before marriage. Dr. Ogle suspected syphilis to be the cause of the disease; but no proof could be obtained. It appeared that she had been paralysed since a fall which she had in getting out of bed six weeks before admission, after which she lost her speech for some time. She suffered greatly from pain in the head, which did not seem to yield to bromide of potassium, but which under the use of the bichloride of mercury, with iodide of potassium and bark, and blisters to the nape of the neck (one of which was dressed with mercurial ointment), has, after fluctuations, gradually given way, the last report being that it had quite gone. For some days after admission the temperature in the arm on the paralysed side was much lower than that on the other. Thus at the right elbow it was 95.4°, whilst at the left it was 95-6° at the right hand it was 822°, whilst at the left it was 85.2°, there being no difference in the temperature of the axillse. The temperature of the right knee was two degrees lower than that of the left. At the present time the two sides are much more equal in temperature, and the power in the right limb has been much regained; but speech has not improved. Severe Case of Acute Rheumatic Fever.-This was a first attack in a patient, aged twenty-three, a brewer's man. Throughout the attack the heart remained quite free and healthy. The case was treated by diluents and opium in some form or other every three or four hours; mainly crude opium, with or without a small quantity of calomel to guard the secretions, but sometimes morphia or Dover's powder. Later on, a little brandy was given from time to time. At the end of ten days the opium was discontinued, and simple effervescing draughts, with neutral citrate of
doi:10.1016/s0140-6736(02)69312-2 fatcat:s6vj2fxzungyjklzwnlkh2rk7y