CONTRIBUTIONS TO CLINICAL MEDICINE

J GOODWIN
1862 The Lancet  
60 richly, and munches his food with the aid of his hardeneci gum and one tooth st'll left in the upper jaw on the opposite siue. Contrasting this case with that of the young lady abovementioned. the advantage is obvious of decaying the operation until the general health is brought to the highest attainable point, and the locally-morbid action completely arrested and defined. In that case. operative interference was urgently called for by the great local distress, and the opinions of some
more » ... nions of some experienced surgeons wele given in favour of it before I took any steps. But subsequently to the operation the disease continued to extend ; fresh sequestra were formed; ulceration and perforation of the cheek occurred ; trismus followed, and the patient sank. being at the tiale under the joint care of Mr. Rendle, of Southwark, and myself. Here, on the contrary, the results are in every way satisfactory. I have, however, met with many cases in which this rule of procrastination has been carried too far. CASE 2. Resection of the elboir-joint after disease of twenty-four years' standing : dislocation of the radius and ulna backccccrds; useful limb with good movement.-In a case in which llately ex. cised the elbow.joint at the West London Hospital, the patient had been left for twenty-four years with a disabled and useless limb, suffering from repeated accessions of local inflammation abscesses forming, and pieces of bone being discharged at fre quent intervals. During all that time the limb had been use less to him. When he came under my care the joint presentef the appearance seen in the engraving. The forearm measure( some three inches less than that of the opposite side, and was greatly atrophied. He suffered much nocturnal pain. With the assistance pf my colleagues,-Mr. William Bird and Xir. Christopher Heath.—1 excised the joint through a single posterior incision. The ulna and radius were dislocated backwards, obviously since some years. I removed the diseased extremities of bone, and then found that although the section presented a healthy appearance, yet if we stopped there we should get no movement in the new false joint ; for owing to the old condition of the dislocation the cut ends now just touched each other, and left no room for the movements of flexion. I consider that onlv half a success is obtained if there is not good movement after the operation. At the same time I was anxious not to remove too much bone, and espe- cially not to open the medullary canal, certainly a fertile cause of accident after that operation. By slicing carefully the ends of the bones concerned, and making extension, we got room enough. In the after progress of,the case the house-surgeon gave great care to the position of the joint and to its passive exercise, and the patient is now-three months after the operation-working at his trade of French-polisher with a very useful limb. Here the too long delav was undoubtedly prejudicial to the patient. and caused a difficulty in the operation. Usually it is very desirable not to sacrifice any healthy bone ; but this case seemed worthy of note because I deliberately violated the general rnle in connexion with it, and have reason to be pleased that I did so. The disadvantages of over-deliy are, I think, also illustrated by a case of hip joint disease which I am now attending with Dr. Duncan, of Richmond. CASE 3. Resection of the hip-joint,. head of femur ancl acetabulum extensively diseased; favourable progress.-In this case the parents, with over anxious suiicitude for a favourite daughter, would !,ot permit any operative interference until continued purulent discharge, wearing pain, and long confinement to bed had brought her to ihe last stage of weakness. 'When their consent was given to the necessary resection of the joint, I found the femur dislocated, and more than two thirds of it worn away by ulceration ; purulent matter welled away from the deep parts around the joint, and the acetabulum was so extensively diseased that after removing the loose and deatroyed parts the finger entered the pelvis. The powers 01 nature ate so great that this young lady has picked up in strength and gained fiesli to a remarkable extent since the operartion, Vtbi.e the healthy aspect of the wound promises a. favourable result ; but it cannot be doubted that many months of suffering might have been slmrea, and a successfull issue far more confidently anticipated, had this delay not occurred. PHYSICIAN TO THE SUFFOLE GENERAL HOSPITAL. TilE cases on record of eyl' hili :ic affections of the brain are not numerous, at least in this country, and materials are much wanted to furnish the clinical history of this important and interes' ing class of diseases. The three following cases are, I tliink, good examples of a not uncommon and very manageable form of disease, provided the real nature of the case be appreciated at a sufficiently early stage:-CASE 1. Syphilitic affection of brain; impairment of memory and mental power ; attacks of great exhaustion ; slight paralysis ; treatment by mercury ; recovery. -A, B-is. tall, large-framed man, about thit ty years of age, engaged in com. mercial pursuits. He first came under my care in the year 1852, and I learned that he had been living anything but a temperate life for some years; confesses to primary syphilis. several times, and states that he has had secondary and tertiary symptoms in the course of the last three years. His complexion is sallow and unhealthy, and he looks depressed. He was suffering from slight derangement of the digestive organs and diarrhoea, when I first saw him, for which I then prescribed. These ailments soon yielded to treatment ; but happening to. meet with certain occurrences which annoyed him very much, and caused him a great deal of mental anxiety, he fell into a very low and depressed state. When I went to see him at this time, about the middle or June, I found him sitting, looking the picture of misery. He paid very little attention to what passed around him, and seemed entirely to have lost his memory for recent occurrences, as, for instance, he had no recollection of having had his breakfast about an hour after that meal. His friends informed me that he usually sat quite quiet, perhaps making an occasional observation of an irrelevant nature, and frequently very absurd, his countenance bearing the impress of imbecility. I was also told that for the last week he had been complaining of occasional feelings of giddiness and of nocturnal pains in the head ; that his bowels had been and still were very constipated, and the motions were quite white. He ate freely, and would sleep a good deal. He could recollect events which occurred years ago, and for a minute or two he seemed to brighten up, and refer to bygone days. His pupils were sensitive to light, and were alike, but rather larger than medium size. He gave up all business, and left his residence, and was put under the care of an old family medical attendant, with whom I saw him from time to time. We looked upon the case as being one of cerebral exhaustion, the result of imperfect nutrition, and that this latter was the consequence of the syphilitic cachexia. In the course of a week from my first seeing him, symptoms of want of power in the left leg appeared, and much more general feebleness ; this was followed by a severe attack of vomiting, and in a few hours afterwards such alarming prostration supervened that death seemed almost inevitable. We got him to swallow some brandy with difficulty, and administered a large enema of turpentine and castor oil. This was followed by the passage of a large quantity of scybala, and he gradually revived ; but his pulse, which previously had been between 70 and 80, had become barely 50, extremely weak, and easily obliterated. The right pupil was now more dilated than the left, and the left leg was very distinctly paralysed. I He was supported with stimulants in moderate quantities, and ' beef-tea and milk ; he could not swallow solid food without . great difficulty, but more, I fancied, from want of energy to . make the effoit than from actual inability. He lay dozing, but occasionallv was a little excited. . About a week after this attack of exhaustion, another 00curred. He had been slightly improving up to this time ; his. r bowels had become a little more regular, and he had taken 3more nourishment. Ammonia and iron had also been given. -The second attack was preceded by vomiting and hiccough, f and after he had rallied there was a marked change in Mft
doi:10.1016/s0140-6736(01)12973-9 fatcat:2yj24uvaerdwhoft2rmhnswpyu