Dissertations on Inflammation, Vol. 2

by John Burns

CASE III.

James Walker received a stroke upon the outside of the foot, immediately below the ankle joint. A small tumor instantly formed, which continued stationary for several weeks, and gave him little uneasiness; but afterwards it began to increase, and was attended with a shooting pain. The tumor was elastic, pretty tense, and rather irregular in its appearance. I was anxious to operate, but the man would not give his consent. I therefore advised frictions with anodyne balsam, which at first gave him relief, but soon lost its effect. For several weeks I heard nothing of him; but, at the end of this time, he again applied to me. The irregularities of the tumor were much greater, more prominent, of a red colour, and one of them had burst: From this a soft half-organised fungus protruded, and a bloody fluid run out constantly. An operation was again urged, but the timidity of the patient made him again refuse. A month after this he came under the management of another surgeon. There were now three openings in the tumor, from each of which protruded a broad cauliflower-looking fungus, covered with thick fœtid matter; there was likewise a thin red serum discharged from the margins of the ulcers. The tumor was as large as a child’s head, and one of the inguinal glands was a little swelled. The man now consented to lose his limb, and amputation was accordingly performed. Whenever the turniquet was applied, a very copious stream of veinous blood issued from the tumor; but this ceased when the veins had emptied themselves. Unluckily it was considered as unnecessary to extirpate the diseased gland.

On examining the leg, all the bones of the ankle joint were found to be quite soft and carious; the tumor consisted of a soft substance, resembling the brain, with light membranous intersections. The cyst on the upper part was hard and thick, but beneath it was entirely wanting, having either never been formed betwixt the tumor and the tendons of the muscle, or having been destroyed. The former opinion is the most probable; for I have never in any stage found the cyst continued over the under or back part of the tumor, but it always terminated imperfectly in the part on which the tumor was seated.

The wound healed as well as could be desired, but the gland became rather larger, notwithstanding which no operation was urged. Two months after this I was requested to visit him. The gland was now as large as the head of a newborn child; it was soft and spongy, and had at one part an irregular prominence, but the skin was not coloured. The pulse was about one hundred and thirty, and the patient completely hectic. In this situation I proposed nothing excepting nourishment. He died in the course of a week after I saw him.

CASE IV.

The following case shows this disease in its most advanced stage. It is extracted from the fifth volume of the London Medical Journal, and is intituled, “An Account of the Fatal Effects produced by attempting to remove a Ganglion by Seton.” It was drawn up by Mr. W. Dease, surgeon in Dublin.

“In July 1781, a clergyman, aged thirty-seven, consulted me about a moveable ganglion, of the size of a small nutmeg, situated between the fore-finger and thumb of his right hand, near the wrist. He was eager to have it removed, and had been advised, for this purpose, to have a seton passed through it, as the best and most certain method; but, as he was apparently a robust healthy man, and the ganglion was attended with no pain, I advised him to consider it as a matter of no consequence, and not to meddle with it. Four months after this I was desired to visit him, and found him in a melancholy situation. A seton had been passed through the ganglion, and the consequences were, that the back of his hand had inflamed violently, that the ganglion had rapidly and amazingly increased, and that the openings made by the seton were filled with an ill-conditioned fungus, which sprung up as fast as it was removed, and was attended with frequent hemorrhage, and much pain. In consultation, it was agreed to remove this fungus by a free incision, which was done, and the metacarpal bones appeared bare and rough. Another opening was made through the thenar, and a seton passed through it, in order more effectually to prevent the growth of fungus. The bark was administered in large quantities, an opiate was given at night, and due attention was paid to the regimen of the patient. This method seemed to promise the most happy event. The fungus appeared to be entirely destroyed, a laudable suppuration took place, the swelling of the hand subsided, and the sores in a short time were so contracted as to indicate their speedy cicatrization. These favourable appearances, however, were not of long continuance; for, after some time, the fungus began gradually to rise again, and any mode of keeping it down, either by caustic, cutting, or pressure, seemed to produce no permanent good effect, as it increased rapidly, and at length degenerated into the most frightful cancerous fungus I have ever seen. Every local application that has been recommended in similar cases was tried in this, but without success; and internal remedies proved equally inefficacious. He took, for a considerable length of time, two ounces of bark in substance, in the course of twenty-four hours, so that he took, in the whole, twenty-eight pounds of that medicine. The extract of hemlock had also a fair trial, but produced no apparent effect.

“When he had laboured under this complaint fifteen months, he was advised to undergo the amputation of his hand; but before he would consent to submit to this operation, he chose to have an account of his case transmitted to the Royal Academy of Surgery at Paris, that he might have their opinion of it: The result of which was, that the members of the academy pronounced the fungus not cancerous, but merely scorbutic. This decision, by the bye, should make us extremely cautious in delivering our sentiments on similar occasions, without seeing the patient, as much depends on the general appearance of the sores in cases of this sort. The academy were of opinion, that the disease was entirely local, and required only local treatment. For this purpose, they advised that the fungus should be taken down by means of euphorbium, savine, &c. and afterwards washed with salt water. If this method proved ineffectual, recourse was to be had to the actual cautery, from the application of which they seemed to expect the most decisive advantages. To this mode of treatment the unhappy sufferer submitted; and, during the space of six weeks, the fungus was almost every day burnt down with the actual cautery; but his complaint all the while continued to gain ground apace; so that being now disappointed in all his expectations of relief from regular practitioners, he had recourse to quacks of every denomination. The arsenic plaster of Plunket was applied, and he was salivated for seven weeks. At length, after undergoing the operation of a variety of nostrums, he again placed himself under my care. In consultation, it was much doubted whether amputation should now be thought of, as the patient seemed to be in the last stage of a cancerous consumption. His limbs were swelled, and his whole habit was wasted by the repeated hemorrhage from the fungus, which was now so increased in bulk as to weigh down his arm, and entirely cover the back of his hand. In short, after every return of hemorrhage, it was apprehended that the next would put a period to his sufferings.