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DR. JOHNSON ON INJURY OF THE KNEE

EXTENSIVE WOUND OF THE KNEE JOINT, WITH DIVISION OF THE PATELLA, AND EXCISION OF A PORTION OF THE INNER CONDYLE OF THE FEMUR; AND PERFECT RECOVERY.

Gentlemen,—I beg to transmit to you an account of a very serious and somewhat novel injury of the knee joint, which perhaps you may deem not unworthy of insertion in your valuable Journal.

J. M., a boy of good constitution, aged eleven years, on the 7th April, 1843, while sitting astride on a low billet of wood, with his knees much bent, received a blow from an axe on the left knee from below upward; the axe first took effect on the lower extremity of the Patella, which it completely split, dividing it into an anterior and posterior portion, the inner edge of the instrument next came in contact with the inner condyle of the femur, from which it all but severed a portion of its articulating cartilaginous extremity. I was fortunate enough to see the case a very few minutes after the accident occurred. The limb was extended, and presented a large flap-shaped gaping wound over the knee joint; attached to, and drawn upwards with the upper portion, could be distinctly perceived the anterior section of the Patella, in the centre of the wound the articulating surfaces of the femur and tibia were felt; at the lower part, the remaining or posterior section of the Patella was found in situ, being retained by its ligament; while protruding from the inner angle of the wound, and attached only by a small pedicle of cartilage, was a portion of the inner condyle of the femur, measuring about an inch and a half in length by three quarters of an inch in breadth, and nearly half an inch in thickness; the whole under surface of which was lined by the articulating cartilage, the remainder being composed of the spongy end of the bone. There was no perceptible escape of synovia, the limb having been kept extended from the moment the injury was received. Notwithstanding the alarming nature of the accident, I decided at once to attempt to save the limb. To prevent as much as possible the shock to the system, as well as to relieve pain, I administered immediately a powerful dose of muriate of morphia to the boy; I then removed with the bistoury the protruding portion of the inner condyle, already so nearly separated as not to justify any attempt to replace it, or incur the risk of effusion of blood into the cavity of the joint by bending the leg; the edges of the wound were brought together by four interrupted sutures, with adhesive straps between them. A splint was placed under the joint, and the limb placed extended in a fracture box, and evaporating ice cold lotions constantly applied night and day over the wound; these were continued for eight days, after which period the lotion was applied without the ice for some days longer.—By those means the fever and inflammation were subdued. On the eighth day the first suture was removed, the next day another was taken out, and in two days more I removed the last two. The adhesive plaster was only found necessary till the thirteenth day, the parts beneath being adherent throughout their extent, after which, Liston’s red lotion was applied. There was no suppuration or formation of abscesses, so common in severe injuries about the knee joint. On the seventeenth day after the accident, the wound had nearly all cicatrized. In three weeks from the receipt of the injury, the Patella appearing to have united, the splint was removed, and very gentle passive motion of the limb commenced, without causing pain, which was continued and gradually increased every day afterwards for some time, the limb being returned to the fracture box after the motion. On the 5th of May, being the fourth week, the limb was taken out of the box altogether; by the fifth week, the lad was able to go about on crutches, to bear his weight on the wounded leg, and also to raise the leg by the power of its own muscles. At this time the knee joint remained somewhat puffy and swollen—which state was removed by applying the tincture of iodine. On the 15th of May, the boy could bend the leg backwards to a right angle with the thigh. From this time, the improvement in the motion of the limb was progressive; the patella, though considerably altered in shape, has perfectly united by bone, and its motion is as free as that of the other side. For some months the boy was slightly lame, but at present, he has perfectly recovered the use of the limb in every respect.

I have the honor to be,

Gentlemen,

Your most ob’t. servant,

Jas. B. Johnston, M. D.

Sherbrooke, Aug. 10, 1844.

DR. NELSON ON ACUTE PERITONITIS.

Gentlemen,—A very striking discrepancy having been noticed and commented upon in the evidence given by Dr. Holmes and myself, at the recent Coroner’s Inquest, I should feel obliged by your inserting the following communication in the next number of your valuable journal, and remain yours obediently,

Wolfred Nelson.

Montreal, 26th April, 1844.

Acute Inflammation of the Peritoneum is so fraught with pain, suffering and danger; so rapid in its course, and so often baffles the best efforts of our art, that the recital of Julien Champeau’s case cannot be devoid of interest, in a pathological point of view at least. I have placed this case in juxta-position with the symptoms as laid down by the best writers, and as received by the profession all over the world. Every man, even out of the profession, will, from the comparison, be able to judge whether or not this was a case of “intense inflammation,” as I felt bound in my evidence to maintain that it was.

I shall now give the Post Mortem appearance in the above, and place them likewise side by side with the appearances discovered after death, as laid down by the best Pathologists of the age, as denoting the existence of previous inflammation of the peritoneum:

I have been thus particular in my statements, and in producing authorities with regard to this truly unfortunate but interesting case, that no one of ordinary intelligence may mistake it. I maintain then, that Champeau did labour under “intense inflammation of the Peritoneum;” and I will proceed to quote a few irrefragable authorities, which I presume will be equally convincing, that the subject of this case had received ample cause for producing “intense peritoneal inflammation,” which at his time of life, in his plethoric state, and with his predisposition to inflammation, could hardly end otherwise than in death.

The celebrated John Bell, whose work on wounds is, or ought to be, in every surgeon’s hands, and who is looked upon as a sure and safe guide in these matters, says in his lectures—

I shall now produce other authority, and it would be very easy to multiply the citations to prove that Peritonitis may be caused by bruises and contusions alone; and the first will be from the best and latest surgical works of modern times.

Sufficient has been advanced, it is fair to suppose, (and wonderfully applicable to poor Champeau’s case,) to satisfy the most fastidious, that he had been exposed to abundant cause for the production of the disease which terminated his existence, in pain and in misery, in the flower of life, in all the pride and vigor of manhood, and when he was entertaining the fondest anticipations from a matrimonial connexion upon which he was about to enter. It is true, that he was in a state which predisposed him to violent inflammations; his summers were spent in boating and hard labour; his winters were a time of perfect repose; though a sober man, he was fond of good living.

It is likewise true, that a few years before he nearly lost his life from a violent attack of pleurisy, and subsequently from intermittent fever; as Travers further remarks:

The same writer also observes, “Continuous inflammation is most frequent in persons who incur injuries in a state of health and plethora.” Admitting this state of undue vigor as it were, and repletion and predisposition, in this case, how can we attribute his melancholy end to any other cause than to the wounds and contusions he received?

From what has been stated above, it must be very plain that Peritonitis, under the most favourable circumstances, is always a very painful and dangerous disease; in my patient it was doubly so, as was manifest from his high state of health, and the remains of former disease.

Dr. Craigie, in his Elements of Physic, alludes in a particular manner to the tendency which inflammation of the peritoneum has to extend to the abdominal parietes, and cause disease there; the matchless John Hunter, in his treatise on inflammation, mentions this as one of the terminations of peritonitis. It is therefore reasonable to conclude that injury to the external parts, penetrating to, and causing inflammation of, the peritoneum in the first instance, may ultimately act as a revulsive to the peritoneum, especially when, from free depletion, the constitutional excitement, if not subdued, is at least diminished. The violent contusion of the lumbar region, in the centre of which there was a wound, passed suddenly through the stage of high inflammation, effusion, infiltration, and lastly, into gangrene, as stated above, and was clearly established on dissection.

The medical gentleman to whom I have felt compelled to allude in my introductory note, to the report of this case, seemed to rest his conviction that there was no inflammation, on the absence of effusion, coagulated lymph; also because there were no new adhesions; forgetting that those are the products of slow or sub-acute inflammatory action, and when present, prove that it had been protracted and passed through some of its phases. It is only when the inflammation is less acute, that it provokes an increased action from the exhalents; that serum first, then coagulable lymph, and finally adhesions result; this likewise takes place when the inflammation has been in part subdued, and assumes the chronic character; then indeed, you have “effusion” enough. But we should know how to discriminate between the different degrees of excitement and inflammation, and their results, ere we pronounce dogmatically. It is known to every one that the first effect of high inflammation is to suspend all the secretions, hence, intense thirst, heat, dry skin, costiveness and scanty urine, &c. &c.

I deem it fitting to give one or two more brief extracts in this place, to convince the uninitiated of the correctness of the foregoing remarks.

I would call the reader’s attention, as further corroboration, to the post-mortem appearances, denoting intense peritonitis, which I have extracted from the works of the most enlightened pathologists of the age, and who did not write their books expressly to bear me out in my opinion of this individual case.

I owe it to the public, to the profession, and to my own character, to justify the treatment I adopted in this sad case, as well as my diagnosis; which, with all due deference, I must still continue to call “intense peritonitis.”

It is likewise proper to state what is the practice to be had recourse to in the local treatment of such wounds, and again I shall refer to the great authority I have just quoted, to satisfy the most captious, that “the thing was done right.”

Cooper, in his Surgical Dictionary, vol. 2, p. 475, et seq. says,

Such are the opinions and the practice of every well informed surgeon. I trust I have fully supported my assertion that there was intense inflammation in this case. It now becomes me to establish the fact that there was also gangrene; and as I do not wish this to rest on my own ipse dixit alone, I shall transcribe what is stated by a few of our best writers, as denoting the existence of gangrene, locally, also the constitutional symptoms resulting therefrom, that it may be seen if they are applicable to the case under consideration.

Now let any candid person compare the above with the state of Champeau’s lumbar region; which was swollen, livid, with vesications, bloody serum, cuticle peeling off, air and bloody matter escaping from the wound; the part infiltrated, soft, and decomposed; the hiccough; cold, clammy sweats, &c., and deny that gangrene existed there!

Ere I terminate, it is well to state that my friends, Drs. Beaubien and Munro, saw the poor man; the latter gentleman about 10 A.M., Saturday, with my son. He was struck with the man’s appearance, and after examining him closely, pronounced at once that he was labouring under Peritonitis, and would die. About 1 P.M., same day, Dr. Beaubien saw him with me and without hesitation drew the same inference.

I shall draw this long communication to a close, stating openly and in a very few words, what my convictions are: The wound near the umbilicus caused intense Peritonitis, which was arrested by the depletion, and also no doubt by the supervention of the state of collapse, resulting from the violent contusions on the lumbar region which became mortified, hence the cause of Champeau’s death.

REMARKS ON DR. CARTER’S CASE.

Gentlemen,—I have not been an inattentive observer of the case as described by Dr. Carter, and of the discussion which originated from it, between himself and Dr. G. W. Campbell.

Before offering you my opinion on the case, I may be allowed to say some few words animadverting upon the conduct of both gentlemen; and let it not be supposed an act of presumption, for I have now practised many years and have had cause to regret, even before the merits of this case were argued, that there did not exist a feeling of stronger faith and better understanding among the members of our profession.

The legal proceedings in the case adopted by the Defendant should not have been permitted by the Plaintiff: the question was not of skill or capacity, or of injury done—it was of debt. This was first to be decided, on the judgment being rendered, which must have been in favour of the plaintiff; the defendant’s course was to sue for mal-practice—for injury done. As long as any person, in what capacity soever his services may be, continues to be employed, so long is he entitled to remuneration, and that according either to agreement, or to a scale established by social and conventional, and therefore, well-recognised amounts. The defendant’s plan of action ought to have been to make a tender to the plaintiff, of a sum which he thought adequate to the remuneration of his services; this being refused, he would have felt himself blameless: as the case stands, he has subjected himself and friends to infinite annoyance for about £3. I know that the plaintiff’s first account was about £21, that for which he obtained judgment £18.

I allude to this course and to this part of the preliminaries, because many of us are ill paid or not paid at all, and because I would much like to see a fixed tariff established by the medical men—as we are now placed, all seem to have some mode of charging varying in some manner from the others; we are employed most probably on account of services we are supposed capable of rendering, and for these we should be paid surely a living price.

I find fault with Dr. Campbell for not having at once met Dr. Carter in the pages of your paper—there was not any thing in the communications which rendered silence laudable. Dr. Campbell, though placed high in the scale, ought not to have looked upon the summary of the case with indifference—even had there been misrepresentation: he had no reason to regard its publication as the price of his professional elevation, and in such a view to deem it a test of moral courage to disregard it: no, his silence may, with an appearance of justice be imputed to a dread of either the undertaking, or of the weakness of the cause: he owed it to those who held an opinion similar to his own, to be the ostensible supporter of their position; and when he did enter the arena—the contest had degenerated, and had taken the appearance of writing for the public—not for the profession. Dr. Carter, had Dr. Campbell discussed in your journal, would not, I am sure, have adopted the gazetteer as his mode of establishing his case. Dr. Campbell should have known that Dr. Carter has been for a longer period a practitioner, that he is his senior, and entitled to courteous consideration—that there was a possibility of his being in the right—that his conception of the case had been received at an early period of his attendance—that his treatment had been directed steadily to the same end—that his ideas at the conclusion of his attendance, could not have been arranged for the support of his hypothesis, (call it favorite if you will), since from the first he held them, and well digested too. He should have recollected that, before the patient, and in the presence strangers, he had offered an indignity to Dr. Carter. He should have called to mind that in his evidence he not only gave his testimony as a witness, but ventured far beyond his sphere in asserting that the plaintiff was not entitled to remuneration. And this too when he had been retained in the employ of the defendant, with his sanction, and perfectly to his satisfaction. All these considerations ought to have induced Dr. Campbell to offer the only means left in his power, the chance of Dr. Carter’s substantiating his diagnosis and proving it correct. I am far from being Dr. Carter’s champion; I am, in fact, not acquainted with him. I speak for the sake of justice. There appears to be no doubt that Dr. Carter is not blameless in the bed-side consultation; yet I had expected other things from Dr. Campbell than the course he subsequently followed.

In the history of the case given in your paper—after mature deliberation—I think that Dr. Carter has failed in satisfying the greater number of your readers, that there existed what he has termed lumbar or psoas abscess, or of the existence of an abscess in the iliac fossa, or even in the posterior gluteal region; but he has completely established the fact of there having been, and still existing at the first stage of his attendance, an enormous collection of hardened fæces in not only the cœcum, but I conceive a great portion of the ascending colon—a condition which appears to have been previously overlooked. I further consider that this state of distension, produced really by foreign matter, had superinduced an inflammatory condition of the parts; and that, the disease should have been termed—colitis, or rather typhlo-colitis: that Dr. Carter was justifiable in exploring, I also allow—and I fully concur in the indications which he persisted in fulfilling from the first, though many would have had recourse, after the evacuation of the scybala, to a milder plan of treatment.

I have mentioned that Dr. Carter has not established in my mind, the fact of the existence of pus—at least, to the extent spoken of by him—because the symptoms given are not characteristic of its formation—because the same signs would accompany the simple mechanical obstruction spoken of above—such as, the attitude in walking—the ease in the reclining posture—the character of the pain—the state of the pulse—blood-letting being attended to all appearance, by relief—and lastly, the sudden and unexpected disappearance of the swelling, all contribute to persuade me that the enlargement proceeded not from abscess, but from the stercoraceous accumulation, and after its evacuation, to temporary re-accumulation accompanied by flatus; much of the uneasiness, too, may have been produced by not only pressure on the muscles and nerves, but upon the ureter. (By the bye, not a word is said as to the state of the urine or of the bladder.)

Dr. Carter has Dupuytren as an authority, but he should remember that he had not an opportunity of examining except in one case, and that the opinions of that justly eminent man have been combated lately by Dr. John Burne, Physician to the Westminster Hospital, whose work was published in 1837, and with every appearance of success. Dupuytren’s opinion that an abscess may form in the cellular tissue behind the cœcum, sympathetic of some irritation of the mucous membrane of that intestine, was based on one of Broussais’ General Pathological Propositions, viz: “that whenever a local irritation reaches a certain height, it repeats itself in other and contiguous systems or organs, and always without change of nature.” Broussais too advanced that the nerves are the only agents of the transmission of irritations which constitute morbid sympathies. There can be no question that there are many irritations which are thus transmitted to remote parts through the agency of the brain, and thence by reflex action to sensitive or motor nerves, so as to produce pain, or even spasm. I need not instance an example; but of abscess occasioned thus, I know not that there can be cited a proper instance. Admitting that abscess exists in the pericœcal tissue, I would hesitate before pronouncing that even inflammation of the cœcum would produce it; there are instances of the whole substance of this species of second stomach being involved, and being absolutely cartilaginous without producing a vestige of such cellular abscess in the vicinity. I am inclined to look upon an abscess in this region, as the result of an ulcerative perforation either of the cœcum or its appendix, and one most likely to be circumscribed by peritoneal adhesions.

I know not how the patient has been since the event which gave rise to these “awful disclosures.” I suspect that she has been ailing since, and that from a similar cause she has been occasionally a sufferer: should the supposition be correct, I am inclined to think that the disease requires not now much diagnostic acumen.

I repeat that I am perfectly an impartial judge—unconnected with either party—that making allowances for the excited feelings of the said gentlemen, in whom the attempt at self-vindication has given prominence to particulars favorable to the one, while circumstances tending to exhibit responsibility or blame are suppressed—while the partial truth is but perceived—and while there are accusations of the improper application of facts, and even insinuations of falsehood, it is quite fair for a third party to carefully discriminate and judiciously to arrive at a conclusion.

I trust that I have not been too tedious, and remain,

ON DR. CARTER’S CASE OF PSOAS ABSCESS.

Gentlemen,—Will you do me the favor to insert in the forthcoming number of your valuable Journal, the accompanying extracts of letters from Drs. Elliotson and Hocken, which I received by the last mail, and oblige,

Your ob’t. servant,

C. Carter.

Montreal, Aug. 23, 1844.

Sir,—I have no doubt that Miss D. laboured under an obstruction and inflammation of, with great effusion of fibrine, and all the preliminaries of an abscess in and around, the Cœcum. Whether matter was actually formed, I cannot say. But this does not alter the case; for matter would have formed, but for Dr. Carter’s judicious and successful treatment.

Extract from Dr. Hocken’s Letter.

“Your cause, however, is so good, that it does not need any defence, except, perhaps, among those who are prejudiced at Montreal. In the last No. (July) of Dr. Johnson’s Review, he makes some remarks on the case, at page 274, under the head of “Medical Etiquette.” He remarks that, ‘there was a decided breach of medical etiquette and common prudence too, provided the statement be correct.’ ‘From certain symptoms that accompanied and followed these attacks, Dr. Carter believed that suppuration had at one time occurred. Of this we are not quite satisfied; but there was danger enough in these attacks to authorise the means employed.’ This was just the opinion I formed and stated several months ago, viz: that there could be no doubt that inflammation had been set up in the cellular tissue surrounding the cœcum from foecal accumulation threatening abscess of the iliac fossa; although I was not fully convinced from the mere narrative of the symptoms, that abscess had actually formed, believing at the same time, that many slight particulars may have satisfied you of its actual presence, whilst attending from day to day, at the bed-side of the patient, which were not mentioned in your report. Also, it must be clear to every unprejudiced person, that your treatment was not only justifiable, but judicious and proper.”

DR. LEE’S REPORT OF FATAL DISEASES IN ST. GEORGE’S HOSPITAL

We have been favored by our friend, G. D. Pollock, Esquire, with a report of the fatal diseases and post mortem appearances found, in 239 cases, in which death occurred in St. George’s Hospital during the year 1843—part of which we have transferred to the pages of our present number. It is indeed cheering to have these proofs before us of the increasing interest manifested for the science of Pathology; for we are convinced, that Pathology, with regard to disease and its treatment, occupies the same rank in Medicine, that Mathematics does to Logic.

We should be delighted to find the example set by the Medical Officers of St. George’s Hospital adopted by all those of the profession connected with institutions of the same class.—E. M. G.

The number of cases admitted during the year amounted to three thousand one hundred and fifty-five.

The number of fatal cases which occurred at St. George’s Hospital during the year amounted to two hundred and seventy-seven,^[1] including thirty-six cases admitted for various accidents and external injuries. In two hundred and thirty-nine cases, the body was examined after death; and in thirty-one of these, death was the result of external violence. The following account is therefore taken from thirty-one cases in which death was the result of accident or external violence; and two hundred and eight in which it arose from natural causes.

FEVERS.

Four cases of scarlet fever were examined after death: the lungs in all were congested, and in one instance partially condensed. The spleen was twice found softened, and congested, and once of very large size, much congested, and as firm in structure as the liver. This occurred in a boy three years of age. The fauces retained indications of inflammation in three instances; in one of which a quantity of pus and lymph was found in the sub-mucous laryngeal cellular tissue, as well as on the outside of the thyro-hyoid ligament.

Seven other cases of fever were examined, of which the intestines were found inflamed in four, and ulcerated in three. In one instance the ulceration had extended through all the coats of the small intestine, leaving a small round opening, closed externally by a firmly adhering layer of lymph; the fluid contained in the peritoneal cavity was of a brown colour and peculiarly offensive odour: of the seven cases, the substance of the lungs was inflamed in three, and congested in two. In one instance the mucous membrane of the lungs alone was affected. The membranes of the brain were twice found inflamed.

In one instance, where petechial spots remained upon the legs after death, the lungs and kidneys presented, scattered throughout their structure, numerous white, isolated granules; these were all about the same size, less than a line in diameter, and were each surrounded by a narrow circle of livid congestion.

Another case is recorded under the head of fever, in which considerable effusion of serum was found in the cavity of the chest, accompanied by deposit of lymph in the substance of the kidney, and some purulent effusion between the kidney and its capsule.

SECONDARY ABSCESSES.

Secondary abscesses were met with in twelve cases: four of these have already been mentioned under the head of compound fractures, and four succeeded amputation of one of the limbs. Two instances occurred after fracture of the spine; the situation of the affection being in the anterior mediastinum and lung in one case, and in the posterior mediastinum and cellular tissue around the kidney in the other. Of two remaining cases, one accompanied an abscess over the knee, communicating with the joint, and exposing the patella; the other occurred in conjunction with purulent effusion into the cellular tissue behind the peritoneum. In this case, the cellular membrane surrounding the transverse portion of the duodenum was occupied by a collection of ill-formed pus and lymph mixed with a quantity of cheesy matter: from this point the cellular tissue was infiltrated with purulent fluid in every direction; the suppuration had extended anteriorly between the layers of the mesentery, to the left along the pancreas, and upwards behind the peritoneum nearly to the under surface of the liver. In the substance of the liver were found in various situations clusters of veins filled with purulent fluid more or less tinged with bile. In several of these the pus could be propelled along the veins by pressure, but in others the veins were lined by a layer of lymph, which, confining the pus more or less perfectly, formed as it were so many small abscesses. The roots of the duodenum in contact with the purulent effusion were observed to be remarkably thin.

In the twelve cases, the lungs were the seat of the secondary abscesses in ten, the liver in three, the spleen in one, and the kidney in one. Deposit of matter was also found in the gastrocnemius muscle in the one case, and of the sartorius in another. In three instances the synovial membrane of the knee-joint was distended with purulent fluid.

In all these cases, with the exception of the one above related, the primary disease had originated in, or involved, some portion of bone. In former years it has been observed that the osseous system has been involved in a similar large proportion of cases in this disease: thus of seventeen cases of which notes are preserved, occurring in the year 1841-42, the osseous system was implicated in fourteen instances. If we add together the result of the three years, we have twenty-five cases in which secondary abscesses followed or were accompanied by disease of the bones; and four in which they were not.

The number of cases in which secondary abscesses occur appears to vary very much in different seasons and years. Thus, of twenty-five cases of compound fracture occurring during parts of the years 1840-41, secondary abscesses occurred in eight instances, while in the year 1842, of seventeen cases of compound fracture, secondary abscess followed in one instance only.

Diffuse cellular Inflammation.—Diffuse cellular inflammation, arising spontaneously, or from slight injury, was in eight cases the apparent cause of death: in three of these it was traced from the neighbourhood of the rectum into the pelvis, extending in one instance to the anterior surface of the aorta, and in another following the course of the ureter to the kidney: the cellular membrane of the leg was the seat of the affection in two cases, and in one was accompanied by the secretion of a very large quantity of purulent fluid into the peritoneal cavity. The cellular membrane of the back, of the posterior mediastinum, and of the side, were the parts affected in the remaining cases: some oval masses of organized lymph were found deposited in the right lung in one of these instances.

Abscess.—The first case of fatal abscess which presented itself was one in which the transverse portion of the colon, and the anterior margin of the left lobe of the liver, were firmly united to the anterior parietes of the abdomen. Between these parts and the anterior surface of the stomach was a large quantity of fetid pus, maintained in its position upon either side by adhesions. An ulcer, extending through all the coats of the stomach, existed at the upper part of its anterior surface. The opening in the peritoneal coat was of the size of a large pea, and although partially closed with lymph, appeared to have allowed the escape of some of the contents of the stomach into the abscess.

Thirteen other cases of fatal abscesses occurred, besides those already enumerated under the heads of scrofulous disease, and secondary deposit. In six cases the disease originated in affections of the lower dorsal lumbar vertebræ, and in three of these the structure of the bone was rendered much firmer than natural. In another instance the abscess made its way from the hip-joint through the acetabulum, into the pelvis, and thence descended below Poupart’s ligament.

In one patient both ovaries had become the seat of abscess, and the uterus consequently firmly fixed in the pelvis by adhesions: on the right side the sac of the abscess was flaccid, and contained some offensive dark-colored fluid: it communicated with the rectum by two oval ulcerated openings. On the left side the sac of the abscess was distended, and the pus which it contained was of its natural colour and appearance.

Senile Gangrene.—Senile gangrene proved fatal in two cases. In the first, ossification of the arteries had taken place to a great extent: in the second, the lower portion of the aorta and its bifurcation were chiefly diseased. In this case the aorta below the origin of the inferior mesenteric artery was irregularly dilated to about three inches in diameter. The internal coat was thickened, inelastic, and ulcerated in various situations; the ulcerated portions being covered with firmly adhering coagula of blood. A considerable cavity existed between the internal and middle coat, filled with a pulpy-brown semifluid substance mixed with a gritty deposit.

Inflammation of Lungs and Pleura.—Nine cases of inflammation of the lungs and pleura unconnected with tubercular disease proved fatal. In four instances the pleura contained pus, and in one a communication existed in the condensed lung between the pleural cavity and a dilated bronchial tube: the bronchus and trachea were filled with purulent fluid of the same character as that contained in the pleural cavity. In one instance the patient had been violently salivated before his admission, and a very large portion of the lower jaw had perished in consequence.

Bronchitis.—Bronchitis was the apparent cause of death in three cases. In the first the mucous membrane was universally inflamed, unaccompanied by any condensation of the lung; in the second, in addition to the affection of the mucous membrane, the pleural cavity contained some effused serum; and in the third case the bronchitis was accompanied by aneurism of the aorta; this was situated behind the lung: the last case was also complicated by the existence of an aneurism immediately in front of the trachea, which by its pressure upon the anterior surface of the tube, had diminished its antero-posterior diameter to one half its ordinary size.

Disease of the Heart.—Disease of the heart was apparently the immediate cause of death in five instances: the pericardium was in all these cases affected. In three it was universally adherent; in the fourth case, the lymph effused upon its internal surface had assumed a honey-comb appearance, confining separate small collections of serum between its numerous partitions; and in the remaining case the pericardium contained purulent fluid. A layer of very firm bone had in one instance been developed between the adherent layers of the pericardium. Disease of the mitral valve presented itself in three out of the five cases, and in two of these the aortic valves were also affected: the kidneys were diseased in two and congested in one of the above cases.

Disease of the Brain.—In many cases in which the supposed cause of death was found elsewhere the head was not examined, and therefore cerebral disease may have existed in some cases unobserved. Besides the cases of malignant disease already mentioned, disease of the brain was the cause of death in four instances; in three of these, effusion of blood had occurred to a greater or less extent in the substance of the brain, and in one, where erysipelas had preceded death, some effusion of lymph had taken place at the base of the brain, and the corpus callosum, fornix, and septum lucidum, were found softened. The remains of three separate extravasations of blood were found in one of the above cases, consisting of a transparent fluid in one cyst, a yellowish fluid in a second, and a brownish red semi-fluid substance in a third; in another instance, the cavity containing the effused blood, situated upon the surface of the brain, had become inflamed, and the secretion from its surface mixed with the extravasated blood.

The spinal chord was found in one case, for the extent of an inch at its lower part, converted into a pink soft substance. This was accompanied by a soft and spongy condition of the cancellous structure of the corresponding vertebræ, and with inflammation of the kidneys and bladder.

Disease of the Kidneys.—In the great majority of cases disease of the kidneys occasions death by inducing some other disease more immediately fatal. The cases of this nature which occurred have already been enumerated under different heads: five instances, however, occurred in which the kidney was the principal organ diseased, and in which no very evident cause of death was found elsewhere. The brain was examined in two only of these cases, and in both found to contain more fluid than natural, both in its ventricles and in its substance. In all the cases, with one exception, the kidney was reduced in size. Upon one occasion one kidney only was present: it was very small and hard, smooth on its surface, with the capsule remarkably adherent, while on the opposite side, the ureter, which was of its natural diameter, terminated above in a cul de sac; around this was some dense vascular cellular tissue, but no appearance whatever of a kidney. The kidneys were granular upon their surface in all the remaining cases.

A remarkable disease of the bladder accompanied the affection of the kidney in one of these instances. Several large varicose veins were observed in the submucous cellular tissue, near the prostate gland, and in the same situation were several tuberculated elevations, varying in size from a pea to a hazel nut; some of these of the largest size were filled with a white milky fluid; others contained a solid semi-transparent substance, and others again consisted of a yellow opaque matter resembling tubercular deposit. The remaining part of the mucous membrane of the bladder was healthy.

Affections of the Urethra.—Ulceration of the urethra permitting the escape of urine was fatal in three instances. In two of these the opening occurred in the bulbous portions, and in one in the membraneous portion of the urethra; the consequent extravasation of urine was situated in the former cases between the perineal fasciæ; in the latter, within the triangular ligament. A fourth case may be allied to these, in which advanced disease of the kidneys accompanied a confirmed stricture. Diffuse cellular inflammation occurred in this case, without any extravasation of urine.

Strangulated Hernia.—Of seventeen patients operated on for strangulated hernia during the year, six died. In one of the cases which proved fatal the patient had been delivered shortly before the operation; in the second the patient was labouring under disease of the brain; and a third was suffering from an attack of fever before the hernia had become strangulated. One of the remaining cases died in consequence of mortification of the bowel, and two proved fatal from inflammation of the intestine and peritoneum. In both these last cases, a sac, formed by the omentum, enveloped the bowel, in addition to the ordinary peritoneal sac. A separate account of these cases will shortly appear, and therefore no farther observations upon them will at present be offered.

Strangulation of the small intestine, unaccompanied by hernia, was in one instance the cause of death. A portion of the small intestine in the form of S had become inflamed, and the different portions glued together by recently effused lymph; a considerable mass was thus formed, the base of which was encircled by another double fold of small intestine likewise retained in its position by recent adhesions. The passage of the bowel was by these means completely obstructed. A diverticulum existed at one portion of the intestine, consisting of a canal about a quarter of an inch in diameter, and four inches long, considerably dilated at its closed extremity, and containing some foreign bodies. This did not appear to be connected with the cause of the obstruction of the intestine.

The following cases proved fatal each in one instance.

Hydatid cysts in the abdomen.—Erisypelas had in this case immediately preceded death. The body was greatly emaciated, but the abdomen enormously distended. The recti muscles were widely separated by the pressure of the abdominal contents, and the parietes consequently rendered so thin, that some small moveable tumors within the abdomen conveyed the sensation of being subcutaneous. On opening the abdominal cavity, numerous hydatid cysts were seen attached to the omentum: some of these were almost transparent, but in others the parietes had attained considerable thickness. A circumscribed, soft, elevated growth, resembling a warty excrescence, had developed itself from the internal surface of several of these cysts. Almost every part of the abdomen was similarly occupied by hydatids; the contents of the cysts in the neighbourhood of the liver had assumed in several instances a yellow colour, while in contact with the intestine they appeared as though tinged with fecal matter. One very large cyst was situated upon the under surface of the liver, and had become partly imbedded in its substance. Another cyst of very large size was situated above the liver, and by its pressure had made its way through the right side of the diaphragm, encroaching upon the corresponding lung. A smaller one upon the left side had also caused the absorption of the diaphragm and protruded into the cavity of the chest beneath the pericardium. Some small hydatid cysts were also developed from the peritoneum, covering the abdominal muscles.

Hæmatemesis.—The patient in this case died after repeated vomiting of large quantities of blood.

On the upper part of the posterior wall of the stomach the remains of an oval ulcer presented itself. It was perfectly healed, with the exception of one point, where a small rounded mamillary eminence projected from the surface. In the centre of this elevated portion was seen the open mouth of an artery, which proved to be the truncated extremity of the arteria coronaria ventriculi. A large branch was given off immediately before the termination of the artery in the cicatrix of the ulcer.

Effusion of blood on the surface of the spinal chord.—This occurred in a girl 18 years of age, who died suddenly upon the day of her admission into the hospital. The cells of the pia mater for the whole length of the spinal chord were distended with coagula of blood. The extravasation extended upwards upon both sides of the pons varolii, and communicated with a large quantity of coagulated blood which filled the fourth ventricle. The iter a tertio ad quartum ventriculum was also occupied by a narrow coagulum. This was continued into and filled the third ventricle. The lateral ventricles were distended with bloody serum; coagula of blood occupied the floor of each, extending backwards into the posterior horn, and communicating with the effused blood in the third ventricle. One of the vertebral arteries presented near its termination two small apertures, from which the hæmorrhage appeared to have proceeded.

Simple ulcer of the œsophagus.—This patient died in a state of extreme emaciation, having for a considerable time been unable to swallow any solid substance: about an inch above the bifurcation of the trachea an irregular shaped ulcer was found in the œsophagus. The tube was slightly contracted but not diseased above this point; the ulcer was about an inch and a half in length, not surrounded by any particular induration, and extended in one part through all the coats of the œsaphagus, but not into the cellular tissue surrounding it.

Imperforate vagina.—The vagina in this case terminated in a cul de sac about an inch and a half from its internal opening: from this point the canal was completely obliterated for about half an inch, and above this again became sufficiently distended to contain a pint of fluid. The walls of the vagina in the dilated portion were much thickened, and were lined internally by a uniform layer of greyish-white substance, resembling effused lymph, internal to which was a layer of black matter, apparently a deposit from the black fluid contained in the cavity. This patient died of peritonitis after an operation for the evacuation of the confined fluid.

Erysipelas preceded death in five instances: three of these have already been mentioned under the several heads of compound fracture, disease of the brain, and hydatid cysts in the abdomen. The remaining cases occurred, the one in conjunction with disease of the kidneys, the other accompanied by disease of the liver.

13, Dover Street, Piccadilly, April 14th, 1844.

THE MONTREAL MEDICAL GAZETTE.

MONTREAL, SEPTEMBER 2, 1844.

THE EDITORIAL NOTICES.

On Tuesday, the 6th August, the Montreal Branch of the Provincial Medical Board held its Trimestrial Session, for the Examination of Candidates, in the room of the Natural History Society, in consequence of the want of accommodation in the Court House, where such meetings were wont to be held. The successful candidates (who underwent their examination with much credit,) were Messrs. J. B. Lactance Papineau, Emery Codère, and M. Prevost. Without derogating from the merits of the two latter, we cannot refrain from making honorable mention of Mr. Papineau, to whom a well merited compliment was paid for his having exhibited very satisfactory indications, not only of a well cultivated mind, but also for having made the very best use of his time during the period devoted by him to his medical studies while in Paris.

Medical students in Canada must now have been made perfectly sensible of the necessity of directing all their energies to the acquisition of an extensive and minute knowledge of every branch of their profession, for as opportunities of obtaining knowledge are every day being made more abundant and easy of access, the more will be expected from them on the day of their examination.

Besides the above mentioned gentlemen, we hear that Messrs. Phileas Proulx, Eugène Hercule Trudel, and Alexander Long, submitted to the Board their McGill College Diplomas, which after having being duly looked at, the names of these gentlemen were registered for recommendation to the Executive for Licence to Practice.

This part of the ceremonious proceedings of the Board ought to be superceded by an extension of privilege on the part of the Legislature, to the Medical Faculty of the University of McGill College, whereby that faculty might be empowered directly to recommend for licence such candidates as they shall have considered worthy of their Summos Honores, or, in other words, their degree of Doctor of Medicine. As the law now stands, the Diplomas of the University of McGill College, as of all other Colleges and Universities, must be submitted to the Provincial Board, before whom the bearer of such Diploma has to make oath that he is the individual referred to in the said Diploma, and that he came by the same honorably. As regards foreign Diplomas, such an exaction is legitimately necessary; but for a Diploma of the University of McGill College, the ceremony becomes little short of a contemptible farce, more especially as the Quorum of the Montreal Branch of the Provincial Medical Board is chiefly composed of the Professor and all the Lecturers of that very same faculty of the University of McGill College, who have themselves taught the self-same candidate who produces the self-same Diploma which that self-same faculty conferred. This is, indeed, making certain doubly sure, countersigning their own testimonial of approbation.

We do not consider that we are at all arrogating to ourselves an undue privilege, as the guardians of matters appertaining to Medical Polity, in suggesting to the Legislature the adoption of this principle, that as the Faculty of Medicine of the University of McGill College have the power of conferring the degree of Doctor of Medicine, (and that only after the fulfilment of a rule contained in the statutes of that faculty which demands a certain period of study,) it should likewise have the power of recommending to the Executive for Licence to Practice, without any farther ceremony, all such as have earned their Diploma. We are aware it is the intention of the Lecturers of the new College of Medicine to petition the Legislature for an Act of Incorporation, and from what we know of their popularity, there is little doubt of success attending their petition, in which case this body will also obtain the right of recommending to the Executive for Licence to Practice such candidates as they shall find, from time to time, worthy of their Diploma.

When these changes shall have been brought about, it will follow as a very necessary consequence, that a corresponding change must be effected in the organisation of the Provincial Board. This Board, as it is now constituted, is almost entirely dismantled of power; in fact, it has none beyond the rejection of incompetent candidates. It cannot even enforce its own bye-law, which orders that such as intend to be examined, do give four days notice to that effect to the secretary. The statute under which its duties are detailed, is the old one of the 28th Geo. III. cap. 8.; it is styled, “An Act or Ordinance to prevent persons practicing Physic and Surgery within the Province of Quebec, or Midwifery in the towns of Quebec and Montreal, without licence.” The first clause enacts that, no person shall practise Physic, or vend or distribute Medicines by retail, for gain, except such as shall have been examined and approved of by a certain Board of Examiners. The second clause regulates the amount, and how to be levied, of the penalty to which individuals practising without this licence shall be subject. The first part of the third clause we must copy entire. It runs thus: “Provided always, and it is hereby enacted, that nothing in this Ordinance shall extend or be construed to extend to the subjecting such persons as shall have taken a degree in any University, or who have been commissioned or warranted as surgeons in His Majesty’s army or navy, to any examination previous to obtaining a licence,” &c. &c.

By this it is evident that the Board has no right to enquire into the existence of Indentures, period or nature of study, or the age of the candidate. In short, any carter has a right to walk in and demand his examination, and his examination must be granted!! Such a palpable evil, however, cannot be expected to last much longer, for it is to be hoped that, when the Legislature occupies itself about the framing of a Medical Bill, some attention will be directed to the formation of the Provincial Medical Board; and one of the most important points to which it can advantageously apply a remedy, will be the nomination of entirely disinterested members. The Board, as it is now composed, consists of nineteen members—seven of whom, residing in the country, are generally absent—the other twelve, in town. Of these twelve three have never been known to attend the regular meetings more than twice or thrice, at most; of the remaining nine two are very often absent—and it frequently occurs that even six of the twelve cannot be collected together for the transaction of business—the annoying consequence of which is, that, as seven is the quorum, the punctual members have to lose their time waiting in vain for the absentees, and the candidates have the mortification of remaining in suspense until the next day, when it is just as likely that again a quorum may not assemble. Then again, when there is a Quorum, of whom is it composed? The Professor and the other five Lecturers of the Faculty of Medicine of the University of McGill College! Against the individuals nothing can possibly be said, either as regards their favoritism or otherwise; nevertheless, the circumstance we know, does give rise to much apprehension on the part of candidates who have not attended the school presided over by these gentlemen, and we are forced to admit, upon very just grounds too, for although as far as our knowledge goes, we are not aware of their ever yet having abused the power thus vested in them, we cannot pretend to be blind to the fact, that they can and may exercise it whenever they please. That such a jealousy really exists, is proved by the fact, that a petition was last winter addressed to His Excellency the Governor General, signed by a large body of Students, requesting the counterbalancing of that power by the nomination of the Lecturers of the new School, as additional members to the Provincial Board.

In this, the Students exhibited much frankness, in not soliciting a more complete alteration, by the formation of a new Board, on which no public teacher should sit, and we must say, that there we are of opinion they erred, for if we be not very much mistaken, the Faculty of Medicine of McGill College have expressed a determination, through their Professor, to the Caput of that Institution, that although all the other branches of education there taught, were to be conducted on the principle of the English Universities, the Medical department would be regulated only according to the principle by which the Edinburgh University was governed. That being the case, the faculty should not have lost sight of the fact that the Professors of Medicine in the University of Edinburgh do not sit upon any other Medical Board but their own; nay, not even do the public teachers out of the University sit on the Board of the College of Surgeons. Therefore, if Edinburgh is to be their guide, they cannot object to the plan which we recommend for the formation of a Provincial Board, viz: that it be composed of individuals altogether unconnected with Public Medical Schools. It may be said, that the formation of such a Board would be rendered superfluous when the Schools have the power of directly recommending their respective candidates to the Executive for Licence to Practice. But that would not be the case so long as Students are not compelled by Legislative enactment to attend Public Lectures; and moreover, such a Board would at all times be the only competent authority to examine the Diplomas of strangers, and to have them duly attested. Its labours would necessarily be much diminished, but its existence would nevertheless continue to be indispensable.

In conclusion then, we say that the present statute should be repealed without loss of time, and a proper Medical Bill passed for enforcing a certain course of study, regulating the examination of candidates, and constituting District Branches of a Provincial Board for the examination or attestation of the holders of Degrees obtained at Foreign Universities and Colleges. As matters are at present, it is a perfect absurdity, and in direct contravention both of the letter and spirit of the law, that graduates of any University be subjected to examination by the Provincial Board.

In accordance with Dr. Carter’s request, we insert in this number, extracts of “two letters lately received by him and submitted to us for perusal, from Drs. Elliotson and Hocken,” on the subject of his case published in our May number—but we must be spared from inserting these portions of the letters which bear on the point of medical etiquette.

A very curious and interesting manuscript has been placed in our hands by Dr. Meilleur of this city, purporting to be “A Summary view of the St. Paul’s Bay Disease,” by Dr. Jas. Bowman, of Quebec, dated 1785. The disease there described certainly most closely resembles, except in degree, (in which particular, we think that it very much exceeded,) the Tubercular Leprosy now raging at Tracadie. Before perusing this manuscript, our own impression was, that the Maladie de Malbaie had been limited to the District of Quebec, but cases occurred and medicines were furnished to the Curés of Varennes and Boucherville, in our own immediate neighbourhood. We shall endeavour to make an epitome of this summary at some future time. Meanwhile we tender to Dr. M. our best thanks for his politeness.

At the last meeting of the Medico-Chirurgical Society of this City, held on the 3rd of August, Dr. Bouthillier of St. Hyacinthe, and Dr. E. Taché of St. Thomas, were unanimously elected Honorary Members.

MEDICO-CHIRURGICAL SOCIETY.

27th April, 1844.

Dr. Fraser, in the Chair.

The attention of the Society was directed to that interesting disease described by Underwood as the “Inward fits of children,” by Montgomery as “Thymic Asthma,” and by other authors as “Laryngismus Stridulus,” or “Spasmodic Croup.” Dr. F. detailed the case of a child ten months old, previously stout and healthy looking, who was suddenly seized on the night of the 12th January last, with dyspnoea and an apparent sensation of suffocation, which soon, however, passed away. At the time of Dr. F’s visit, the child labored under slight fever, short dry cough, and trifling sonorousness on inspiration—the pulse was not quick, tongue covered with a thick white fur, the gums were swollen, and teeth were evidently at hand. The gums were freely divided, and slight aperient medicines administered; on the next day, the child was much better; but the draw on inspiration still continued, for which assafœtida and ipecacuanha were given. From that time until the beginning of the present month, the child has varied much: he has had on two occasions, screaming fits similar to that which ushered in the first attack. During the same period, also, the gums have been repeatedly lanced, alterative and cathartic medicines given, and liniments applied to the chest and throat. On the 5th instant he was seized with general spasmodic symptoms, the wrists were flexed, and the fingers firmly clenched, the thumbs turned in to the palms of the hands, the toes, ankles and knees bent. The ordinary means, consisting of the warm-bath, liniments, cathartics and enemata were given. For the last four or five days, the cough has left him entirely. On the 23d the gums were again lanced and released two teeth; the breathing being very laborious, accompanied by a hard, sonorous, mucous râle, a blister was applied to the chest with great relief to the breathing; yesterday the fits being very frequent and the head hot, it was judged advisable to apply another small blister to the nape of the neck, with cold to the head; assafœtida with rhubarb and magnesia, had been given immediately.

Cases of the same disease were described by Drs. Holmes, Campbell, Crawford, Nelson and the Honorary Secretary—some of which, as in a case related by Dr. Crawford, the disease had proved rapidly fatal; in many there had been found on post mortem examination, enlargement of the Thymus or bronchial glands, in others no morbid appearance sufficient to account for death could be discovered.

Dr. Holmes mentioned an extraordinary case, in which both the Thymus and Thyroid gland were so much enlarged, that after death, they were found to be as nearly in contact as their relative positions would permit.

TRANSCRIBER NOTES

Obvious printer errors have been silently corrected, except for these noted below:

Otherwise, inconsistencies and variations in spelling and punctuation, including the accenting of French words, have been preserved.

In the article, “Dr. Nelson on Acute Peritonis”, the sections contrasting the author’s observations and the sources from which he quotes are presented sequentially instead of in a two-column format, to improve the readability on electronic devices.

[The end of The Montreal Medical Gazette, Volume 1, Issue 6 edited by Francis Badgley & William Sutherland]