962

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

WESTMINSTER HOSPITAL.A CASE OF EXTENSIVE GUMMATOUS DISEASE AROUND THE

FEMUR AND THE HIP-JOINT WITH CHRONIC PERIOSTITIS

OF THE LINEA ASPERA; AMPUTATION ; RECOVERY.

(Under the care of Mr. W. G. SPENCER )

Nulla autem est alia pro certo noscendi via, nisi quamplurimas etmorborum et dissectionum historias, tum aliorum tum propriascoltectas habere, et iriter se comparare.-MORGAGNI De Sed. et Cau8.Morb., lib. iv. Prooemium.

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THE examination of the limb after removal in the case

recorded below makes it almost certain that the conditionwas syphilitic, but it does not appear that there were anysymptoms or signs by which a diagnosis could have beenmade before the operation. It is very doubtful if theadministration of potassium iodide would have succeeded incausing the absorption of any considerable portion of theextensive gummatous deposit even had the general conditionbeen better than it was. For the notes of the case we areindebted to Mr. Francis Riley, house surgeon.A man, aged 47 years, was on July 29th admitted into the

Westminster Hospital in an emaciated condition. His leftleg was much wasted and flexed at the knee and the thighwas fixed in a flexed and adducted position. An unhealedincision was present on the outer side of the thigh reachinghalf-way down from the great trochanter and covered withexuberant pale granulations, and through the opening hardroughened bone could be felt with the probe. Anotherincision was present on the anterior surface, reaching fromthe anterior superior iliac spine to the middle third of thethigh, and was covered with superficial granulations, dis-charging pus without any deep sinuses being present. Ahealed incision was also present over the course of Hunter’scanal and a counter opening at the level of the glutealfold posteriorly gave exit to a quantity of thick pus.The adductor region was swollen, indurated, and painful,and there was pain all down the shaft of the femur whichwas thickened. The patient complained in April of weaknessof the left hip and knee, which was followed by severe painthought to be sciatica. In May he first noticed a largeswelling in the upper part of the thigh and was taken to theRoyal Free Hospital, where the above incisions were made,and finally amputation was recommended but declined. Ashe was found by Mr. A. W. Austen to have albumin in hisurine, while the discharge of pus continued, and as his

general condition did not improve he was taken to theWestminster Hospital in order that amputation at the hipmight be performed.On August 3rd Mr. Spencer amputated at the left hip-joint

by the anterior racket method, but some difficulty was ex-perienced in avoiding the old incisions, the result being atongue-shaped flap on the anterior aspect of the thigh.There was very little haemorrhage. The patient sufferedfrom considerable shock, but was greatly benefited by hotenemata. A large quantity of purulent gummy materialwas found around the bone and infiltrating the muscleswhich were matted together and partly replaced by a

mass of fibro-cicatricial material. On examining the boneit was found to be greatly thickened mainly along thelinea aspera by rough, dense, periosteal bone. The hip-joint, including the acetabulum, was normal, but theknee-joint was subluxated backwards. Recovery from theoperation was rapid, but owing to the extensive suppura-tion small quantities of creamy pus continued to be dis-charged from beneath the anterior tongue-shaped flap. The

temperature after the operation sank to normal and theurine became free from albumin. On August 31st the con-dition of the patient had so much improved that he was sentto a convalescent home.

Remaarks by Mr. RILEY.-The main point of interest inthis case centred in the diagnosis. There was no history orevidence of tuberculous disease nor was there any history ofprevious injury or acute bone disease which would lead one

to suspect the existence of a sequestrum. Although therewas not any history of yph)lis to be obtained thecharacter of the gummy exudation and the extensiveperioEltitic deposit down the whole length of the shaftof the bone point strongly to that diagnosis. Withregard to the question of amputation the necessity of it wasclearly indicated by the failure of all palliative measures,the probable onset of lardaceous disease, and the fact thatthe patient was going down-hill. The pain complained of

. down the thigh and attributed to sciatica was probably due; to pressure upon the sciatic nerve caused by the development, of new bone on the posterior aspect of the femur as well as

to its involvement in fibro-cicatricial material, the result ofchronic inflammation.

Analptical RecordsFROM

THE LANCET LABORATORY.

(1) "TABLOID" HOLOCAINE HYDROCHLORIDE ; AND (2)"SOLOID" MICROSCOPIC STAINS.

(BURROUGHS, WELLCOME. AND CO., SNOW-HILL-BUILDINGS,LONDON, E.C.)

HOLOCAINE hydrochloride was introduced into ophthalmiaurgery about two years ago and an account of its use

appeared in THE LANCET of May 20th, 1897, p. 1466. It ie,aid that a 1 per cent. solution is equal to a 2 per cent. solu-ion of cocaine. It is a combination of phenacetin and para-)henetidin. It is claimed that holocaine produces anaesthesia:)f the eye in one minute, the effect being more rapid and}omplete than that produced by cocaine, while there is nanydriasis or disturbance of the accommodation, its action

being apparently due to the paralysis of the sensory nerve-endings. The tabloid contains one-fiftieth of a grain ofholocaine hydrochloride and the introduction of the dry saltin this convenient form does away with the objection thatsolutions of holocaine quickly deteriorate and diminishtherefore in therapeutic value. The same disadvantage ofthe tendency of solutions to decompose is avoided by theuse of soloid microscopic stains. The aniline dyes used forthis purpose are subject to deterioration by the action oflight, moulds, or some other agency. We have received afew specimens of a series of soloid microscopic stains com-prising the following : gentian violet, methylene blue, eosin,bismark brown, and fuchsine. A saturated solution of thesein water may be easily obtained by powdering one soloid intwo drachms of distilled water. The resulting fluid whendiluted 5 to 10 per cent. with distilled water will be

found to be convenient for ordinary staining purposes.Similarly a saturated alcoholic solution may be made, direc-tions being given in each case as to the quantities requisitefor the purpose. Those who are constantly in need of stainsin microscopical work will recognise the convenience and

advantages which this method offers.

ZINOLINE SOAP.

(BARTHEL AND Co., 50, RATHBONE-PLACE, OXFORD-STREET,LONDON, W.)

This soap is well adapted for delicate toilet purposes onaccount of its neutrality and its freedom from foreigninjurious substances. It gave a negative result when testedfor the presence of free alkali by the phenol-phthalein test.Its name appears to be derived from the fact that some zincoleate is used in its composition. We found, however, thatthe proportion of oleate of zinc was very small. The soap is

superfatted and free from irritating qualities.BRUT COGNAC.

(A. L. BOITEAU AND CO., COGNAC. LONDON AGENCY : J. N. BISHOP ANDSONS, 13, COOPER’S-ROW, CRUTCHED FRIARS, E.O.)

The evidence of chemical analysis is in favour of this

brandy being the product of the distillation of wine. It also

963

possesses that peculiar delicate vinous flavour and aroma oold and genuine brandy. Further, it contains a minimun

quantity of extractive matters and on that account is probably called "brut." Our analysis was as follows: extractives, 0 24 per cent ; mineral matter, nil; alcohol, by weigh 40 80 per cent., by volume 48’21 per cent., equal to prooJspirit 84 49 per cent. ; acidity reckoned as acetic acid,0.O34 per cent. ; and alcohol in ethers two parts in 10,00(parts. Thus the brandy contains a proportion of vinousethers identical with the quantity found in genuine old

.cognac. From the evidence, therefore, of chemical test andof taste and from other physical characters there is reasonfor believing that the spirit is a genuine brandy and wedefine genuine brandy as a wine-derived spirit, a definitionwhich excludes all spirits derived from cereals, starch, andother materials. According to this evidence of its qualitythe brandy is admirably adapted for clinical purposes.WAMPOLE’S PERFECTED AND TASTELESS PREPARATION OF

THE EXTRACT OF COD-LIVER OIL.

(H. K. WAMPOLE AND CO., PHILADELPHIA. AGENTS : MESSRS. EVANS,LESCHER, AND WEBB, 60, BARTHOLOMEW-CLOSE, LONDON, E.C.,

AND F. NEWBERY AND SONS, 1 AND 3, KING EDWARD-STREET, LONDON, E.C.)

This is a very complex mixture which is certainly tastelessas regards cod-liver oil, but it is redolent of certain aromatic

principles, the taste also corresponding with the odour. The

feature of the preparation’ is that it contains what aredescribed as the essential principles of cod-liver oil. Weobtained distinct evidence of the truth of this statement.Thus on shaking the mixture with ether, after acidifyingwith dilute sulphuric acid and separating the ether and

allowing it to evaporate, a residue was obtained which

responded promptly to the tests for biliary acids. The

theory that the therapeutic value of cod-liver oil is

due to active principles is strongly disputed by somephysicians, the contrary view being that cod-liver oil is

of value in wasting diseases because it is a nutritive of thefirst importance-in other words, that its therapeutic value is due to its effects as a food. It is highly probable, however,that the value of cod-liver oil is enhanced by the presence oftraces of constituents such as iodine, bromine, and phosphatesand certain alkaloidal bodies which contribute towards

making cod-liver oil the hasmatinic which it is well known

to be. It is well to bear in mind, also, that cod-liver oil is

the most easily assimilated oil, being readily digested andabsorbed with little tax on the digestive organs. The peculiarsubstances extracted from cod-liver oil exert probably a dis-tinctly favourable influence upon the processes of nutritionand repair, and thus act as a valuable tonic. The preparationbefore us contains many other ingredients which includeextract of malt, fluid extract of wild cherry bark, and syrup6f hypophosphites compound. It is pleasant to the tasteand is easily borne by the stomach. It has been stated thatthe presence of alkaloids in cod-liver oil was due to somedeterioration having taken place, but recent inquiry hasshown that cod-liver oil perfectly fresh from the livercontains something more than fats. In view of this state-ment the preparation before us would merit a trial, althoughit seems to us that it would be difficult to trace its thera-

peutic effect exactly to certain constituents, so complicated,as we have shown, is the mixture. The question of the efficacyof the " active constituents " of cod-liver ofl can only becleared up, it seems to us, by a trial of these unmixed withother medicaments.

NEW PHARMACEUTICAL PREPARATIONS.

(PARKE, DAVIS, AND Co., 21, NORTH AUDLEY-STREET, GROSVENOR-SQUARE, LONDON, W.)

We have received some examples of the important addi-tions which this firm has made to its list of pharmaceuticalpreparations. Of these may be mentioned globules ofsaw palmetto and santal oils, each globule containing thetherapeutically active oils from one drachm of fresh ripe

f saw palmetto fruit combined with three minims of purei santal oil. The combination would appear to be of. value in the treatment of gonorrhoea. The blennostatic- pills contain three grains of cinchonidine dihydrobromate,t which is said to be useful in coryza and otherF catarrhal inflammations of the respiratory tract. Three

, minims of methyl salicylate combined with of) colchicine appears to be a favourite formula in chorea.

These quantities are contained in one globule, one or twoof which may be administered three or four times a day.

, The extract of the leaves and twigs of Fabiana imbricatahas been found useful in some diseases of the kidney,

and recently some good effects have been announced as

following the use of this extract in gonorrbcea and

cystitis. The extract is called "fluid extract pichi." Itis said to allay irritation of the urinary tract and to favourthe expulsion of calculi. Lastly, we have received a

specimen of sterilised and concentrated saline solution to bediluted according to direction for intravenous injection in

haemorrhage. It will be admitted that these additions are ofinterest and value.

LIQUEUR SCOTCH WHISKY (INVALID).(W. J. WARD, 15, MAITLAND-STREET, EDINBURGH.)

The analysis of this spirit gave in our hands the followingresults : extractives, 0’21 per cent. ; mineral matter, nil;alcohol, by weight 40’30 per cent., by volume 47 67 percent., equal to proof-spirit 83 54 per cent. ; and acidityreckoned as acetic acid, 0’024 per cent. The whisky is

smooth and mellow to the taste and evidently mature. Itis non-acid and contains a minimum of extractives, so thatin conjunction with its purity of character and mellownessit should be well adapted for invalid dietetic purposes. It

possesses the character of a genuine malt spirit ripened byage.

EXTEMPORARY AIDS IN ANGINA PECTORIS.

(W. MARTINDALE, 10, NEW CAVENDISH-STREET, LONDON, W.)The convenience of two preparations like nitro-glycerine

and amyl nitrite being at hand in convenient form isobvious. Mr. Martindale now provides two small cases

which will easily go into the waistcoat pocket-one con-taining three glass capsules of amyl nitrite and the otherchocolate nitro-glycerine tablets. Where attacks of anginapectoris are anticipated such handy preparations would beof decided advantage.

PAPER CONVENIENCE COVER.

(M. PAGE, 473, CALEDONIAN-RJAD, LONDON, N.)This paper is impregnated with certain agreeable and anti-

septic oils. It is intended to be placed on the seat of awater-closet in order to avoid contact with any septic matterswhich may be left on the seat by a tainted person. There isno doubt that danger of infection may arise in this

way and we approve of the precaution which this

simple device suggests. To some extent it would be a safe-

guard to persons travelling in those countries where the

sanitary arrangements are likely to be unsatisfactory.

TYPHOID FEVER AT EXETER.-At the meetingof the Exeter City Council held on Sept. 27th, a specialreport was presented by the senior district medical officer ofthe city upon the recent epidemic of typhoid fever. Thisstated that from July lst to Sept. llth there were 85 casesof the disease notified and of these 58 patients had partakenof raw cockles at or from Exmouth. Nine of the patients hadonly visited Exmouth and one had partaken of other shellfishthan cockles. 17 patients had not been out of Exeter andhad not eaten cockles. 67 cases had been treated at thesanatorium with five deaths. One of the nurses there hadcontracted the disease. The cost of the epidemic would bebetween E1500 and E2000. During the discussion whichfollowed the reading of the report some of the members saidthat they ought to be grateful to their medical officers forthe steps which they had taken to cut short the epidemic.