Case Second.—Jerome De——, aged fifty-four years, native of France, single, was admitted to the Santa Clara County Hospital, July 20th, 1878. He was suffering from rheumatism, or at least complained of pains in various parts of the body, more particularly the long bones of the arms and legs. These pains were worse at night, pulse varying between 80 and 90, temperature natural. Suspecting a specific origin for this malady, I put him on the use of iodide potassium, with increasing doses. He slowly improved with the exception of a pain in the left humerus, anteriorily, and in the upper part of the middle third. This became localized to a spot no larger than a twenty-five cent piece. At times the pain was intense and excruciating: and about a week from admission this spot seemed quite tender to the touch. After the use of a blister and tincture of iodine for a week, he was somewhat relieved. Not entirely, however, for at times the pain was very severe. On Aug. 7th, he left the hospital thinking he could do some work. The next day, while attempting to climb a fence, and while in the act of raising the body by the arms, the left humerus was fractured transversely at the exact point of his previous suffering.
He was again admitted to the hospital, and the fracture dressed in the usual manner. After five or six days a gutta percha splint was used which encircled the arm. Bony union was slow in taking place. However, on Oct. 3d, nearly two months from the date of the fracture, he left the hospital, the union being complete, and he being entirely relieved from his pain; in fact, he was relieved from the moment of the fracture.
This case presents a question in pathology which is of interest. Was there a localized periostitis at this point? If so, why was it not entirely relieved by the treatment which consisted of blisters and iodine, externally, and mercury and iodide potassium internally? Was there a deficiency of nutrition at this point? or anemia from some change in the nutrient artery,—the result of the periostitis of the long bones? Or was it incipient necrosis? Prof. Hamilton gives the record of a case of fracture of the humerus, from muscular action, taking place three several times in the same individual, each time in a different place.
Case Third.—Dec. 29th, 1878, was called to see Mr. ——, male, married, aged about 40 years. Has led an out-door, active life. Has always been healthy. No venerial taint. Nervous temperament, spare built, and weighs about 140 pounds. Present condition: Has been sick two or three days; the attack commenced with a chill, followed by fever; has had fever ever since the chill; complains of pains in the back and legs; has vomited considerable; bowels costive; tongue coated; severe pain in right side corresponding to lower part of the lung, which I found solidified; there is considerable cough.
Ordered a cathartic; to be followed by an anti-pyretic of acetate of ammonia and aconite, and a blister over the lower part of the right lung. Continued this treatment for three or four days, when the pneumonia began to subside, and at the end of about ten days I considered my patient convalescent. About this time I was sent for in great haste after night. The patient, who is a very intelligent man, said he had felt worse during the day, and in the evening, his knee, which had been somewhat painful for two or three days, had become exceedingly painful. I gave morphine, hypodermically, and went home, leaving some morphine for the night.
The next day I saw him. The pain had been relieved by the morphine, still occasionally it was quite severe. There was no redness or heat, or even tenderness; nothing unnatural about the knee except pain, which was aggravated by any attempt to move the leg.
Ordered quinine as a tonic, and pill “C. C.” as a cathartic. Bandaged the leg pretty tightly from the toes to above the knee. The urine was natural; pulse and temperature only slightly elevated. After six or seven days of these symptoms, the knee began to feel hot and became very slightly swollen. Ordered a small blister over the inside of the knee as the greatest amount of pain seemed to be here. Dressed it with tartar-emetic ointment until the skin was very sore; using iodine on other puts of the knee. Used iodide potassium and colchicum, internally. This treatment for five days seemed to do no good. On Jan. 17th, twenty-two days from the beginning of his illness, and about twelve days from the first appearance of symptoms denoting any local trouble at the knee, a consultation was held, the result of which was a blister over the whole of the knee, to be dressed with unguentuin hydrargiri. The inflammation was but little influenced by this or any other treatment. The knee continued to slowly and surely enlarge. And this extended upward without first producing any great distention of the synovial sack under the patella. There seemed to be simply enlargement of all the tissues of the lower part of the thigh. This continued until about the 1st of Feb. when, from the general appearance of the patient, viz: a typhoid condition, feeble pulse, coated tongue, emaciation, loss of appetite, as well as from the local appearance of the inside of the knee, I suspected pus within the joint. Accordingly, I introduced an exploring needle into the inner part of the joint just above and anterior to the insertion of the tendon of the semimembranosis muscle. Finding pus, I made an incision only about half an inch long, and squeezed out perhaps an ounce of pus. Closed this up and again bandaged the leg. There was but very little pus discharged from this opening afterward, not, however, for want of drainage, since the cut was kept open by introducing the probe occasionally. About the 9th or 10th of Feb. fluctuation became quite apparent along the outer and lower part of the thigh. On Feb. 12th, consultation was again had, when fluctuation being very well marked over a considerable portion of the thigh in its lower and middle thirds, after giving the patient chloroform, an incision was made three inches long on the outer and posterior part of the thigh, from the junction of the lower with the middle third, downward through the posterior part of the vastus externus muscle. About two quarts of laudable pus was discharged. By introducing the finger upward and downward, the periostium could be felt smooth except within the knee joint, for this could be distinctly felt, the finger passing readily between the ends of the femur and tibia, and beneath the patella; the crucial and lateral ligaments seemed to be gone, and the cartilages somewhat roughened. A drainage tube was put in, the leg bandaged from the toes to the trochanter major, with compresses so arranged as to obliterate the sack, if possible.
The patient, up to this time, had been slowly losing flesh, and was now very much emaciated. A general typhoid condition existed, the temperature ranging from 101 to 103.5; the pulse from 115 to 135, tongue coated, poor appetite, and in short, the patient in a very critical condition. The use of chloroform, and the shock from the evacuation of the pus, added to the gravity of all the symptoms, and for about two weeks the patient was in great danger of death from asthenia. However, by liberal use of whisky, quinia, beef tea, cod liver oil, etc., he slowly rallied. Two smaller abscesses formed below the knee, but those gave no great anxiety, not so much as some bed sores on the back and hips. The sack or pouch became gradually obliterated, down as far as the knee. The cavity of the joint, however, did not seem to be well drained from the opening in the thigh, notwithstanding it had been kept open freely by tents. About three weeks from this last operation, the sinus or pouch within the knee-joint being so imperfectly drained as above indicated, I made an opening directly into the joint at the outer and posterior part, one inch long, through which I could introduce the probe between the ends of the femur and tibia, without any difficulty, through all parts of the joint. However, I discovered no necrosed bone by so doing. Put a tent into this opening, and let the one above heal up, which it did in about two weeks. This latter opening into the joint I kept open by means of tents until the joint became anchilosed and ceased to discharge pus. The patient made a slow and steady recovery, and about the middle of April was able to get out doors again.
The special points of interest in this case seem to be the obscure and insidious mode of attack; the slow progress of the inflammation, it being rather sub-acute than acute; and the fact of its being a sequela of pneumonia.