936

inward dislocation at the right ankle, with oblique fractureof the tibia. The joint was very much deformed. The soleof the foot presented itself inwards, as though the wholefoot had made almost a quarter of a revolution on its longaxis, and there was a large protuberance in place of themalleolus, with a hollow below. On the outer side therewas a wound in the integument, through which the externallower end of the fibula protruded to the extent of more thantwo inches. The bone was denuded of periosteum, but wasentire. The lateral ligaments were all torn through, and por-tions of the peronei muscles were exposed through the rentmade by the fibula in the skin. This opening was barelylarge enough to allow the passage of the bone, so that theedge of the skin was puckered and tucked in behind andbelow in such a manner that the bone could not be retractedwithout some help. It is not often easy to study the dis-placement in these cases, but in this case, after the reductionof the fibula, it was not difficult to do so. The treatment inrelation to the fibula was the first point to be considered,and Mr. Gay remarked that where reduction of a protrudedbone can be obtained by enlarging the wound, he thoughtit was much better to do so than remove a portion of thebone, unless the question relates to a portion of bone, orbones, as the astragalus, that has been so separated from itsconnexion as to leave no hope of its retaining or regainingvitality. Mr. Gay made a vertical incision through the skinedge, below the point of the malleolus ; but though the bonewas easily passed through this opening, it met with resist-ance at that in the deep fascia. This had therefore to beenlarged in the same direction and to the same extent as thatin the integument, when the bone was easily replaced.The nature and extent of the remaining injury could now beascertained. The end of the tibia had sustained an obliquefracture, which had separated the internal malleolus andalmost the whole of its articular surface ; and the foot hadmade partial rotation on its long axis, so that the head ofthe astragalus was lying partially on its outer side, and hadbeen carried inwards, driving the detached portion of thetibia with the malleolus before it. Mr. Gay could not dis-cover that the astragalus had parted company with the calcis.It was, indeed, apparently Potts’ fracture reversed. The re-duction, with the knee;joint flexed, was easy, and the footand leg were subsequently placed on a back iron splint witha foot support, and fixed by bandaging. A good dose of opiumwas given, with the effect of producing sound and salutarysleep. A series of abscesses (three) formed below the peri-osteum along the spine of the tibia, with a temperatureof 105°. These were opened with the effect of a reduction oftemperature, and are now discharging healthy pus. In allrespects the patient is going on well, with the prospect ofhaving a useful limb, if even the joint should ultimatelybe stiff.

FISTULA.

Mr. Gay lately operated on two cases of fistula. One in aboy ten years old-a blind track that originally led from theperineal side of the left buttock to a chronic abscess in oradjoining the gluteus, which had almost closed up. It hadremained stationary for six years, and still dischargedslightly. The opening that remained was found to be ofvery little depth. Mr. Gay laid it freely open.Another case was that of a woman aged forty-five, who a

month before was seized with symptoms of ischio-rectal ab-scess. It formed quickly, discharged a large quantity of un-healthy pus, and resulted in fistulous passages, one of whichled up behind the sphincter into the rectum, and another-aconsiderable sinuous passage-which led from it towards themedian perineal line, but which turned out to be a cul-de-sac. Mr. Gay cut through the sphincter as usual, re-

marking that the only unfortunate result to be apprehendedin these cases is the occasional permanent loss of powerover the sphincter, for which a reason might perhaps begiven.

Fortunately it is not often that patients submit to anoperation for rectal fistula until some time has elapsed ;they find the part does not heal; and this perhaps suppliesa reason why the consequence alluded to is comparativelyunfrequent. Mr. Gay therefore objects to early operationsin these cases, and to the use of any other instrument thanthe knife or sharp scissors ; and thinks that, as a rule, theyought not to be resorted to until the walls of the abscess,and as well as of the consequent fistulous track, have eassumed a condition of health and a disposition to takeon a healing process. Unless such a disposition exists in

these parts, the division of the sphincter should not beattempted. It is clear, on reflection, that the conditionswhich forbid the healing of such a fistula do not includean indisposition on the part of the tissues in which it liesto healthy and reparative activity. These relate simplyto the form, it might be, of the sore (the special fistuloustrack-surface), to the patient’s general health, or it may beto the deterrent influences of sphincter activity. A all events,these do not extend to and include the action of the tissuesin which the sore is situated. These must be in a sanitarystate, and disposed to heal on being released from the opera-tion of those conditions which interpose to prevent theirhealing, or an operation might be useless. The fistulashould be dry, and not unctuous with purulent discharge.Hence Mr. Gay, in these cases, recommends operation beingdeferred, as a rule, until the sac of the abscess had filledin, and nothing is left but the mere sinuous passage. Opera.tions done before this stage has been reached are thosemost likely to be followed with fæcal incontinence, and thisis readily explained by the amount of reparative action that,in the great majority of cases, is required before the partsare in a condition to resume healthy action, embracing aperiod which is partly occupied by tissue degradation anddestruction, preliminary to that of repair, and perchance inpart by processes which do not favour that kind of ultimatereunion of the divided textures, including the sphincters,which can alone ensure the restoration of their naturalfunctions.

UNIVERSITY COLLEGE HOSPITAL.

AMPUTATION OF BOTH UPPER LIMBS ; RECOVERY.

(Under the care of Mr. GODLEE.)FOR the notes of the following cases we are indebted to

Mr. Stanley Boyd, surgical registrar.At about 10 P.M., or a little earlier, on the night of June

30th, the patient was crossing a railway line near WillesdenJunction; he heard an engine approaching, and suddenlyfelt fixed to the spot. He became unconscious, and remainedso for a time. When he recovered his senses he stated thathe got up, and wanted to pick up his coat, which he hadbeen carrying on his arm. He then discovered that he wasunable to do so on account of the loss of both his arms. Hewalked about 250 yards towards the station, then met somefriends, who put him in a cab and took him the rest of theway. Tourniquets were at once applied, and he was con.veyed to hospital by the next train. At the time of theaccident patient was perfectly sober. He was never subjectto fits.At about 11.50 P.M. he walked into the casualty room,

assisted by two men. Both arms had been amputatedthrough the upper part of the lower third, the left ratherhigher than the right. A long narrow strip of skin, whichwould apparently have reached to the wrist, hung from theleft stump. The patient was much excited, but shock notat all marked.At about 2 A. Al. July 1st Mr. Godlee performed a modified

circular amputation on each side, saving all skin whichseemed likely to live. The bones were sawn near the meetingof upper and middle thirds. On the left side the incisionpassed through bruised triceps, and the skin seemed a littletight. The patient was a very muscular man. Drainage-tubes were introduced at the outer angles of the wounds,and antiseptic dressings were applied.He slept well on the first night ; ate fish on the second

day. On the third full diet was allowed. On the sixth every-thing was satisfactory, but no firm union had occurredbetween flaps.On the evening of the 7th the temperature rose to 1004°

sleep was disturbed, and epistaxis occurred on the followingmorning, when the temperature was 101°. Circumscribedervthematous patches were found about both knees andother parts.On the 10th the rash had almost gone, and the tempera-

ture had again become normal. Three stitches were re-

moved from the left and one from the right stump, and onthe thirteenth day all the stitches were removed, andboracic dressings were substituted for the antiseptic gauzeon the left side, the wound being almost healed. Two days

937

later the same was done for the right, and on the twenty-first day the man was discharged with only a singlegranulating point about one-eighth of an inch across onright side.Remarks by Mr. GODLEE.-The case presents two or three

points of some interest. It is difficult to understand, in thefirst place, how it is possible for a train to pass over thearms at the junction of the middle and lower thirds, withoutcausing some injury to the head. In the second place it isworth noticing that with careful antiseptic management, theincision of an amputation may be carried much nearer to theseat of injury than would be at all safe if putrefaction wereanticipated. On the left side, for example, the triceps atthe point of section was black from extravasated blood, yetthe stump healed without the appearance of the slightestblush or the discharge of a drop of pus. Lastly, it offers aninteresting problem to the instrument-makers to supply asuitable pair of arms to be of any material service to a strongyoung man nineteen years of age. It is proposed that heshould have a hook on one side, and on the other an arm witian elbow-joint which works stiffly, so that he can shift itsposition in such a way as to enable him to carry light parcel!of varying shapes.

RUPTURE OF CENTRAL PORTION OF EXTENSOR TENDONOF RIGHT THIGH, JUST ABOVE PATELLA, THE LATERAIEXPANSIONS FROM THE VASTI MUSCLES BEING INTACT

AND THE KNEE-JOINT UNOPENED.

(Under the care of Mr. Beck.)

The patient, a man of sixty, was going downstairs, light-ing his pipe, and had reached the last step, when he fellforwards on both knees on to the landing. As he did so heheard a loud snap, felt no pain, but found that he could notrise on account of something wrong with his right leg.Being set upon his legs he walked to the hospital, keeping the.right knee extended and getting off pavements sidewayswith the right leg first.When seen he was lying with the right knee fully ex-

tended. A slight depression was visible above the patella,causing it to appear unduly prominent. A finger could bepressed on to the condyles of the femur at the depressedpoint ; above the depression was the firm end of the trans-versely torn tendon; below it, and about one inch distantfrom the tendon, was the upper edge of the patella. Nodistinct portion of tendon could be felt on this ; but, on theother hand, no scale of bone seemed to have been detachedirom it. The lateral boundaries of the depression above thepatella were formed by the expansions from the vasti to thepatella. These were rendered very evident when the patientendeavoured to raise the limb from the bed, keeping the kneeextended-an action which he was quite unable to perform.The outer expansion then became a sharp fibrous band-the inner was softer and less prominent. The lower endof the tendon scarcely moved at all in the efforts at ex-tension.When the knee was flexed over the edge of the bed and

the leg hung vertically the patient was able to extend theknee very slightly. He could prevent passive side to sidemovement of the patella by the vasti muscles.There was not the least swelling of the knee-joint, no effu-

sion between tendon and patella, no bruising of skin, and nopain or tenderness.The limb was placed on a back splint, and both it and the

body were well raised on inclined planes. There was neveiany effusion into the knee. Gradually the lower end of thetendon became a little swollen and rounded off, and a firnmaterial filled up the gap to a certain extent, so that thEfinger could no longer be pressed on to the femur. Thereremained one-half to three-quarters of an inch separationbetween the tendon and the patella.On the twenty-ninth day the patient was discharged.

wearing a plaster-of-Paris splint from groin to ankle, ancwalking with crutches.The plaster soon rubbed the skin over the patella, and was

replaced by a simple back splint.On the fifty-sixth day this was removed. The depressioi

above the patella was very slight, and its boundariesgiven above, were still distinct. The lower end o

the rectus tendon was rounded and thickened. The interval between it and the patella was about threequarters of an inch ; apparently there were no adhesion!in the knee.

ALNWICK INFIRMARY.EXTENSIVE LACERATION OF BOTH FOREARMS WITH

FRACTURE OF THE BONES ; RECOVERY.(Under the care of Dr. MAIN.)

FOR the following notes we are indebted to Mr. F. A.McEwen, M.B., resident medical officer.

G. T-, aged six years, was admitted into the infir-mary on July 9th, 1880, suffering from extensive lacera-tion of the soft parts of both forearms, with fracture of thebones. On the day before admission he had been in thehayfield, where his father (a farm labourer) was driving ahay-reaper. He had, unseen by his parent, got close be-hind the knife-board while the machine was in motion, andfor some reason had reached over his left hand in front ofthe knives, and was caught by the middle of the forearm.Before the horses could be pulled up he tried with his righthand to extricate the left, with the result that it also wascaught in the same way and frightfully mangled.On examination it was found that the left forearm was

diagonally cut right through in the fleshy part of the upperthird, both bones being divided and the forearm all butsevered. A rude splint had been bandaged along the outeraspect of the forearm, and the wound had been stitched.The right forearm presented the following appearance :-Alarge portion of the muscular tissue on the anterior aspecthad been torn away in a mass, the ulna was fractured, andthe thumb had been amputated besides a part of one finger.The injured limbs were placed on pillows and the wounds

were dressed with carbolic oil (1-20). In two days thestitches in the large wound on the right forearm had to betaken out and the wound gaped considerably.For the first ten days after admission the pulse stood at

136, and the temperature varied from 99° to 1002°. Therewas slight sloughing of the large wound on the right forearm,after which it granulated healthily, and twenty days afterthe accident that arm could be moved about. On August15th the left forearm was put up in a starch bandage, thebones having united, and the wound having cicatrised to aconsiderable extent. The forearm was a little bent on itsanterior aspect, and the hand could not be pronated andsupinated. Patient was discharged on August 21st, with

’ the promise of two useful arms.’

eMr.—The case was first seen on the spot by Dr.:

Main, along with the local practitioner who was called in. at the time of the accident. It was thought then that double: amputation was the only chance of saving the boy’s life,: though there was naturally an anxious desire to try to save,

one limb. There was a difficulty in deciding which limb had: the better chance, and as the boy’s surroundings at home’

were not at all conducive to success he was admitted into

l the infirmary. The result was most gratifying.

Medical Societies.PATHOLOGICAL SOCIETY OF LONDON.

Osteitis Deformans-Rickets.THE ordinary meeting of the Pathological Society was

held on Tuesday, Dec. 7th, the President, J. Hutchinson,Esq., in the chair. Mr. Treves showed an interesting livingspecimen of osteitis deformans, and other specimens andcases bearing on the subject of rickets were exhibited. TheDebate on Rickets was resumed by Dr. Dickinson, and waschiefly remarkable for a vigorous speech from Sir WilliamJenner, after which it was again adjourned.Mr. TREVES brought forward a living specimen of Osteitis

Deformans, the subject being a woman, aged forty-eight,whose mother had been crippled with " rheumatism" for sixyears before her death; with this exception her family hadbeen very healthy and long-lived, and she herself had enjoyedrobust health, and had not suffered from rickets or anyserious disease. She was the mother of twelve children, thelast was born when she was thirty-four years old, was veryrickety, and died at two years and two months, four others