Part 85

[9] [Dr. Physick (_American Journal of the Medical Sciences_, Vol. VII., p. 304) was always in the habit of commencing the treatment of hip-joint disease by the administration of a mercurial purge. The preparation which he commonly used was calomel, of which he gave to a patient from six to ten years two or three grains at bedtime, followed the next morning, unless it should have previously acted well, by a dose of oil. If, after having kept the patient perfectly quiet for a few days, he found the parts inflamed, swollen, and tender to the touch, he abstracted from six to eight ounces of blood, by the application of a sufficient number of leeches. Unless the inflammation was very acute, with a good deal of febrile disturbance, he did not prescribe much reduction in the diet, which was generally of a light wholesome character. His next object was to institute a course of steady and systematic purging, which he regarded as far superior to emetics, fomentations, blisters, setons, and caustic issues, so much employed by other practitioners. The articles which he selected were cream of tartar and jalap, which were given every other day in sufficient doses to procure several copious evacuations. These medicines were occasionally changed, either as they lost their effect, or as the patient took a dislike to them.

Having pursued the above plan for a few weeks, and accustomed the patient to his confinement, the next object was to insure perfect rest to the diseased joint, the most essential item of the whole treatment. To this end, a carved splint, long enough to extend from the middle of the side of the chest nearly to the external malleolus, and sufficiently wide to reach nearly one-half round the parts into which it was to lie in contact, was adapted to the shape of the limb, carefully padded on the inside, and secured by two rollers, one of which was passed round the trunk, the other round the limb from the ankle to the top of the thigh. When the limb is much bent or distorted, it should by no means be forced into a straight position in the first instance; on the contrary, the splint should be angular, to accommodate itself to hollows and projections of the parts, and, as the cure progresses, another less crooked should be substituted. It is rarely that more than two splints are required, though Physick was sometimes obliged to use as many as three or even four in the same case. During the whole treatment the patient should lie upon a hair mattrass, and the apparatus kept steadily applied until all the symptoms of the disease have vanished, which is seldom under twelve months.—ED.]

[10] [The treatment of this affection must be chiefly of a local nature, although it may sometimes be necessary to resort to constitutional means, especially mercurial purgatives. When dependent upon a gouty or rheumatic state of the system, the different preparations of colchicum may be exhibited with a prospect of advantage, as also the hydriodate of potash in large doses. As a local remedy, blistering is by far the most prompt and effectual, and worth all the liniments and unguents that have ever been devised. The discharge from the vesicated surface may be maintained by savin or tartar emetic ointment; or, what is preferable, the fly may be reapplied as soon as the sore becomes dry. The operation of the blister should be aided with a bandage and a piece of oiled silk, or strips of adhesive plaster, to support the distended ligaments. Should these means fail, or the accumulation be so great as to impede the motions of the joint, and render it probable that absorption cannot take place, a small valvular incision may be made into the most dependent situation of the swelling, to draw off the fluid. Such a step, however, although justifiable under the circumstances here indicated, should not be taken without due reflection.—ED.]

[11] [Rachitis is emphatically a disease of infancy, being most frequently witnessed from the eighteenth to the twentieth month; it is occasionally congenital, and sometimes, though rarely, it takes place after puberty. Of three hundred and forty-six cases examined by Mons. Guerin, of Paris,[12] three occurred before birth, ninety-eight during the first year, one hundred and seventy-six during the second, thirty-five during the third year, nineteen during the fourth, ten during the fifth year, and five from the sixth to the twelfth. Of these cases one hundred and ninety-eight were observed in the female sex, the remainder, or less than one-half, in the male.—ED.]

[12] Memoir on the General Characters of Rachitis, translated by Dr. T. W. Colescott, of Louisville, and published in the Western Journal of Medicine and Surgery, for January, 1841.

[13] [The symptoms which characterize this affection are generally well defined. The face has a yellowish, sallow appearance; the eyes are large and brilliant; the nostrils unnaturally expanded; the lips, especially the upper, tumid and everted; the head big, and sunk between the shoulders; the chest narrow and contracted; the curvature of the clavicle increased; the articular extremities of the bones unusually prominent; the muscles thin and flabby; the motions constrained and difficult; the whole body has a short, stunted appearance, and the little patient exhibits all the marks of premature decay or old age. The respiration, short and laborious, is performed chiefly by the diaphragm; the abdomen is tense and tumid; and the skin, which is constantly moist, is often bathed during the night with acid perspiration. The appetite is weak, the digestion difficult, the thirst considerable, and there is nearly always diarrhœa, or diarrhœa alternating with constipation. The alvine evacuations are of a thin, watery character; the urine is copious, but not high coloured; the pulse is small and frequent; the action of the heart feeble, the sensibility remarkably keen, and the mind uncommonly active. The child feels averse to use his limbs, and the bones are so soft as to be bent with the greatest facility.

The alterations of the osseous tissue have been divided by Mons. Guerin, to whom we are indebted for the most able and elaborate account of this disease that has yet been furnished, into three stages. In the first, the bones seem to be saturated with a reddish, watery fluid; a considerable quantity of which is also interposed between their outer surface and the periosteum, on the one hand, and between the medullary membrane and their internal walls, on the other. At a more advanced period, this fluid is replaced by a sort of gelatiniform substance, that is particularly conspicuous in the situations here specified, becomes gradually organized and vascular, and ultimately adheres with great firmness to the parts with which it lies in contact. The periosteum is thickened and injected, the nutrient vessels are remarkably enlarged, and the medullary membrane is sensibly altered in its character; the changes which it has undergone being similar, though less in degree, to those of the fibrous envelope just mentioned. The lamellæ of the long bones, naturally so hard and compact, are a good deal softened, and the areolar structure greatly rarefied, many of the cells being more than double or even triple the natural size. Similar alterations are observed in the short and flat bones.

In the second stage, a peculiar spongoid substance is formed between the periosteum and the outer surface of the bones, varying from two to three lines, or upwards in thickness; and which, by the pressure which it exerts upon the lamellæ of the compact tissue, sometimes forces them inwards upon the medullary canal, thus greatly reducing it in size, or even entirely obliterating it. Simultaneously with these changes the bones are rendered so soft that they may be easily bent, cut, or even indented with the finger. In the third stage—that of resolution—the recently formed substance in the long bones, as well as in some of the flat and short, assumes a compact character, and becomes gradually identified with the pre-existing tissues, which at the same time regain their primitive solidity. Owing to the presence of this new matter, the bones are much larger than in the natural state, and their firmness—especially in the adult—resembles that of ivory. Hence the term _eburnation_ is sometimes applied to this state of the skeleton.—ED.]

[14] [Of sixty-three cases recorded by Mr. Hodgson, in his work on the Diseases of the Arteries, fifty-six were noticed in the male, and seven only in the female. The reason of the more frequent occurrence of aneurism in men than in women is found in the circumstance of the former being more exposed to all sorts of violence and disease than the latter.—ED.]

[15] [This disease is much more frequent in old than in young persons. Of one hundred and eight cases, collected by Dr. Bizot, of Geneva, from the writings of Morgagni, Corvisart, Laennec, Scarpa, Boyer, Hodgson, Richard, and S. Cooper, only a single one occurred before the twentieth year. Fifteen were noticed from the age of twenty to twenty-nine; thirty-five, from thirty to thirty-nine; thirty-one, from forty to forty-nine; fourteen, from fifty to fifty-nine; eight, from sixty to sixty-nine; two, from seventy to seventy-nine; and two, from eighty to eighty-nine. Thus it would appear that more persons suffer from this malady from the age of thirty to fifty than during all the other periods of life put together. (_Elem. of Path. Anat._ vol. i., p. 288.)—ED.]

[16] [The following table, extracted from the Cyclopædia of Practical Surgery, will place this subject in a clearer and more accurate point of view. It exhibits the relative frequency of spontaneous aneurism in the different arteries in 179 cases, excluding those of the aorta: it was drawn up originally by Mons. Lisfranc:—

1. Popliteal 59 { at the groin 26 2. Femoral { { at other points 18 3. Carotid 17 4. Subclavian 16 5. Axillary in the arm-pit 14 6. External iliac 5 7. Innominata 4 8. Brachial 3 9. Common iliac 3 10. Anterior tibial 3 11. Gluteal 2 12. Internal iliac 2 13. Temporal 2 14. Internal carotid 1 15. Ulnar 1 16. Fibular 1 17. Radial 1 18. Palmar 1

In another table, constructed by Mr. Hodgson, and founded upon sixty-three cases, including, however, twenty-nine of the aorta and innominata, the results are as follows:—

Carotid 2 Subclavian and axillary 5 Inguinal 12 Femoral and popliteal 15.—ED.]

[17] [This aneurismal diathesis occasionally exists in an astonishing degree. Thus, Pelletan relates an example in which there were upwards of sixty tumours of this kind; and a still more remarkable one is recorded by Mons. J. Cloquet. In this case the number of dilatations exceeded two hundred, the largest of which were not bigger than a common pea. (_Elements of Path. Anat._, vol. i., p. 283.) An instance similar to that in the text occurred at Cincinnati two years ago, in a man between thirty and forty years of age, in whom Professor Mussey secured the right femoral artery for popliteal aneurism. Three years previously the same operation was performed on the left limb for the same affection by Dr. Speer, of Pittsburgh.—ED.]

[18] [This is commonly called Brasdor’s operation, after the surgeon who devised it. Mr. Wardrop, of London, is its greatest advocate. It has proved successful only in a few cases out of upwards of twenty in which it has been performed.—ED.]

[19] [For some very interesting examples of this hemorrhagic tendency, the reader is referred to Mr. Wardrop’s excellent little work on Bloodletting, and to the first volume of my Elements of Pathological Anatomy. A few years ago a case came under my notice in which fatal hemorrhage was caused by lancing the gums over the two central incisors of the upper-jaw, in a male child between five and six months old. He was labouring at the time under an attack of cholera, so prevalent in our early summer months; and the day after the operation purpuric spots appeared in different parts of the body, the largest being situated on the abdomen and the scalp, just behind the ear. The bleeding was at length arrested by the twisted suture, made by transfixing the gum with three very small needles, the points of which were broken off close to the jaw, and the threads applied in the usual manner. Notwithstanding this, the child died exhausted on the fifth day, hemorrhage having, in the meanwhile, taken place from the stomach and bowels. It may be proper to add, that the infant had been delicate from his birth, and that there was no hereditary predisposition to the singular affection which carried him off.—ED.]

[20] [In one instance I succeeded perfectly in effecting a cure with the seton. The tumour, about the size of a twenty-five cent piece, occupied the vertex, and possessed all the properties of the erectile tissue. The child was eighteen months old, and the swelling had made its appearance a few weeks after birth. Half a dozen coarse silk threads were passed, by means of a curved needle, under the base of the tumour, where it was allowed to remain for nearly a month. Considerable suppuration supervened, followed by the complete obliteration of the enlarged vessels. In the hands of Mr. Wardrop, of London, the caustic potash, applied to the surface of the tumour, as in making issues, appears to have been attended with great success. The practice of tying the principal arterial trunks connected with the swelling almost constantly fails, and is rarely resorted to except by ignorant and reckless surgeons.—ED.]

[21] [The first accurate account of _osseous aneurism_ was published in 1826, by Mons. Breschet, in the second volume of the “_Répertoire Générale d’Anatomie et de Chirurgicale_.” It has since been noticed by other surgeons, particularly by Professor Lallemand of Montpelier, and Mr. Bell of Edinburgh, and there is reason to believe that it is of more frequent occurrence than is generally imagined.

The disease is most commonly seated in the head of the tibia. It has been observed also in the scapula, as in the case mentioned in the text, the femur, wrist, and ankle. The male is more liable to it than the female, and it rarely makes its appearance until after the period of puberty. The cause of the disease has not been satisfactorily explained. In some cases it is produced by external violence, as a blow or fall; in others, especially when seated near a large joint, it is traceable to gouty and rheumatic affections.

The enlargement, even in its early stage, is tense and painful; being attended with distention of the superficial veins, swelling of the surrounding structures, and slight discoloration of the skin. In a short time a deep-seated pulsation, or throbbing, synchronous with that of the left ventricle, and similar to what is witnessed in some erectile tumours, may be perceived in the affected part. In the advanced stage of the malady the beating is accompanied by a sort of undulating movement, and is easily interrupted by compressing the main artery of the limb, between the tumour and the heart. The enlargement varies in size. In a case mentioned by Mr. Bell, it was more than nine inches in circumference, by upwards of six in length. In some instances, pressure applied to the tumour with the finger imparts a peculiar crackling sensation, not unlike that of dry parchment or an egg-shell. The soft parts around the disease are generally œdematous, the whole limb is apt to be swollen, and the motions of the contiguous joints are constrained and painful. Towards the last the general health always seriously suffers.

On inspection, the outer table of the bone is found to be considerably attenuated, in many parts destroyed, and in some so flexible and elastic as to be bent with the same facility as cartilage. Frequently the bone is extremely brittle, and may be crushed like an egg-shell. The areolar texture is partially absorbed, and the medullary canal filled with coagula, which are often arranged in concentric layers, as in old aneurismal sacs in other situations. The investing membrane in the immediate vicinity of the disease is thickened, as well as preternaturally dense and firm, and the vessels ramifying through the tumour are greatly enlarged.

The only effectual remedy for this disease, provided its location be favourable, is amputation. In the early stage relief may possibly be afforded by securing the main artery of the limb. Lallemand relates a case in which ligature of the femoral artery completely arrested an aneurismal affection of the head of the tibia; but this must be regarded as an exception to the general rule.—ED.]

[22] [In this country we have a number of insects, the sting of which is sometimes attended with considerable pain and swelling, or even high inflammatory excitement. Of these, the most common are the bee, wasp, hornet, yellow-jacket, and humble-bee, which all secrete a subtle poison contained in a reservoir in the abdomen, from which it is projected by the barbed dart when in the act of stinging. Severe and even dangerous wounds are occasionally thus inflicted; indeed, in a few instances death has been known to follow, especially in persons of a nervous, irritable temperament. Another insect, from the bite of which a good deal of irritation often results, is the musketoe, which abounds everywhere, during the hot summer and autumnal months, along the water-courses of the western and southern states. The little punctures made by this animal I have known in several instances to degenerate into unhealthy sores, furnishing a thin, sanious discharge, attended with more or less itching, and exceedingly difficult to heal. The late Professor Dorsey mentions a case—that of a lady who previously enjoyed good health—in which the bite of the musketoe terminated in gangrene and death.

Of the great number of serpents inhabiting this country, only two—the rattlesnake and copperhead—are known to be venomous. Both are very active in warm weather, are furnished with long teeth, and secrete an acrid, virulent poison, of a yellow-greenish colour, which is lodged in a bag or reservoir at the roots of two of the teeth of the upper-jaw. When this poison is fairly infused into a wound of the skin and cellular tissue, it often proves fatal in a few minutes; in other cases, the patient either recovers, or death does not occur until a later period.—ED.]

[23] [The wounds made by the stings and bites of insects are best treated by stimulating lotions, such as salt-water, vinegar, alcohol, hartshorn, and camphorated spirits. These remedies generally afford prompt relief, and they possess the additional advantage of being always near at hand. Bleeding, purging, and opiates, may become necessary, when, besides much pain and swelling, there is a great degree of constitutional disturbance. When bees and wasps find their way, as they sometimes do, into the œsophagus, causing violent suffering and nervous agitation, almost instantaneous relief may be afforded by making the individual drink large draughts of vinegar or salt and water.

When a person has been bitten in one of his limbs by a venomous serpent, a ligature should be immediately applied, as tightly as possible, at a short distance above the wound, which is then to be carefully excised together with a portion of the surrounding structures. A cupping-glass is next applied, and after this has remained on for several hours, the sore is to be dressed with an emollient poultice or some simple unguent, or fomented with cloths wrung out of warm water and laudanum. The only internal remedy upon which the slightest reliance is to be placed, is arsenic, in the form of Fowler’s solution. It should be administered, as was first suggested by Mr. Ireland, an English surgeon, in doses of two drachms every thirty minutes until an ounce or upwards is taken, or until free vomiting and purging ensue.—ED.]

[24] [The above symptoms, together with deep-seated tubercles of the skin and mucous membrane, constitute what Mons. Ricord has lately described under the name of _tertiary_ syphilis. They seldom make their appearance under fifteen or eighteen months after the formation of primary sores, and some cases occur even after the lapse of many years. From two to three years may perhaps be considered as the average period for the development of the tertiary form of the disease. This, however, is still an unsettled point.—ED.]

[25] [It is somewhat surprising that the author has made no mention, in connexion with this subject, of the _iodide of potassium_, so justly lauded by Mons. Ricord and some other French surgeons. For the last two years or more I have been constantly in the habit of employing this article in tertiary syphilis, in mercurial disease of the bones, and in chronic rheumatism, in which, I am convinced, it is as much of a specific as quinine is in intermittent fever and miasmatic neuralgia. The medicine, to produce its full effects, should be administered in much larger quantities than are recommended in our treatises on the Materia Medica. In my own practice, I usually commence with ten grains, repeated three or four times a day, and gradually increased until it amounts to a scruple, or even half a drachm. Exhibited in doses of this size, it is truly surprising how rapidly, in most instances, it affords relief. Patients who have laboured under nodes and nocturnal pains for months, whose health has become greatly impaired, and who have not slept soundly perhaps for weeks together, have often perfectly recovered under this treatment in less than a fortnight. A very decided improvement generally takes place within the first forty-eight hours, the local uneasiness diminishing, and the sleep being rendered more refreshing. The medicine should not be laid aside as soon as the patient experiences relief, but be continued for several weeks after the symptoms of the malady have subsided. By neglecting this precaution a relapse will occasionally occur. The best vehicle for it is distilled water with a small quantity of simple syrup. Mons. Ricord administers it dissolved in hop-tea, made with an ounce of hops to a pint of boiling water; this is allowed to stand for four hours, when thirty-six grains of the salt are added, and the whole drunk during the course of the day. When given in the large doses above mentioned, it is said to be sometimes productive of diarrhœa or gastric irritation; but no such effects have followed its employment in my own hands, and I presume therefore that they are exceedingly rare. Should they take place, the quantity must be lessened, or the medicine entirely suspended for a few days.

In obstinate cases of tertiary syphilis it may be necessary to exhibit along with this medicine the compound decoction of sarsaparilla, or some of the preparations of mercury, such as the proto-ioduret, deuto-chloride, or cyanuret. The first may be given in doses of from one-half a grain to a grain, the second, from one-eighth to a fourth of a grain, and the last, from one-sixteenth of a grain to a grain, twice or three times a day. How the iodide of potassium acts in producing its beneficial effects in the diseases in which it is now so extensively used by our French brethren, as well as by some of the practitioners of our own country, has not yet been explained. That it is a powerful alterant must be admitted, and that it greatly improves the condition of the digestive organs is equally certain.—ED.]