90

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

Nulla est alia pro certo noscendi via, nisi quam plurimas et morborumet dissectionum historias, tam aliorum proprias, collectas habere et interse comparare.—MORGAGNI. De Sed. et Caus, Morb. lib. 14. Proœmium.

ST. BARTHOLOMEW’S HOSPITAL.INFLAMMATION OF MEDULLARY CANAL OF BONES.

(Cases under the care of Mr. STANLEY.)

MR. STANLEY, in bringing lately under the notice of his classthe following cases, referred toaverysevere inflammatory diseaseof bone, likely to arise, in some individuals, from neglect andcauses often the most trivial. No disease is so severe in its

consequences, none so fatal to life, he has found in a long ex-perience of such affections, as suppurating inflammation, ex-tending through the medullary canal of the bones. Several

very marked instances of this malady having occurred duringthe winter, we have selected them for illustration, as peculiarto cold and wet weather.

B. A-, a boy, sixteen years of age, was recently admittedinto St. Bartholomew’s Hospital, suffering most severely underhigh fever, and a terrible affection of the bone of one of hislegs. The only history he could give was, that six weeks pre-viously he sprained his ankle; his leg then got swollen andpainful. He had medical advice at home, but all seemed of noavail, and he was brought to the hospital. His sufferings onadmission were intensely severe and excruciating, both knee andankle were most painful, and the limb from the knee downwardin such a hopeless condition, swelled and tender, that Mr. Stanleydecided, after a few days, to amputate. On removing thelimb, the medullary canal was infiltrated with pus. Onsection, the periosteum appeared quite scarlet with vessels; allthe parts of the bone, in fact, seemed to suffer from intense in-flammation. Usually, however, in chronic inflammation, thedense fibrous tissue or membrane-like structure of periosteumbecomes soft and pulpy, or velvet-like and vascular, as re-marked by Mr. Stanley; but in the present case there wasreason to believe we had a much more severe affection-namely, suppurative inflammation through the medullary canal.In such cases we might even have circumscribed abscessanalogous to an abscess or vomica in the lungs; but here therewas so much constitutional disturbance, it was deemed advisable eto remove the limb, and not wait for abscess.

Mr. Stanley had also an opportunity, the same day, of

showing us the parts in another case, where the inflammationof the limb, so to say, had " settled" in the knee-joint, withabscess and purulent formation in that cavity, pointing in thepopliteal space, according to a peculiarity of the tendon of thepopliteus muscle, this part being covered with synovial mem-brane on one side, (first pointed out by Mr. Wormald,) thepurulent matter gravitating into a sort of pouch thus formed.As we had an opportunity of watching the progress of thiscase also, we may place it amongst our notes.

J. B-, aged twenty three, admitted live weeks previousto the day of operation. He ascribed his present ailment todrawing wet trusses of straw and hay, in his daily employmentas a farm labourer, close to his legs and knees, the cold andwet of the hay latterly chilling him very severely. He pre-sented an appearance not unlike that of the previous patient,but that the limb was alarmingly swelled above the knee, notbelow. There is an immense deposit of matter, says our note-book, either inside or outside the joint. Mr. Stanley findsvery great difficulty in saying whether purulent matter is insideor outside the joint. The pus, however, spread up the thigh,and there was no alternative but to open it, when fully twopints (!) of matter were discharged, to the very manifest reliefof all the symptoms.Watching the progress of this case for one or two days more,

we thought the worst was over. The limb was carefullybandaged, to endeavour, by pressure, to obliterate the cavity.Suddenly, however, (six days before operation,) all the symp-

toms became worse; that night (Thursday) he was worse. It was now feared the joint itself was involved. :r:such a case the most dreadful and rapid destruction talesplace. The patella and corresponding part of the excondyle always become destroyed first. Here, as in manyother such cases, the lower end of the femur itself, and all itsmedullary canal, is destroyed by purulent inflammation. Fr’mThursday to Monday, the young man was evidently becomingworse, when, on the latter day, to save his life, it was decided,if no amendment set in, to remove the limb. This was doneon Wednesday. There was no communication between theabscess inside and that outside the joint. The synovial mem-brane was soft and brown, as described by Sir B. Brodie a?, a

new disease, but erroneously. The cartilages were destroyedas we have indicated.

LONDON HOSPITAL.EPITHELIAL CANCER OF THE RECTUM.

(Case under the care of Mr. CURLING.)DISEASES of the rectum are very frequently brought under

notice in practice, indeed so frequently as to have become- tsubject of special study and description. Malignant diseasesof the rectum, from their very great severity and danger, h,ve,in a very particular manner, attracted attention. It is a

point of very considerable importance and interest, that inthe present discussions in hospitals, as to the value of the

microscope in clinical diagnosis of malignant disease, that how-ever practitioners may diifer as to the use of that instrument,we have, through its instrumentality, three elements elimi-nated, distinct in almost every particular-namely, the cancer-ous element, the fibrous element, and the epithelial. It wouldseem also, as regards their essential differences, that it is nolonger for us a matter of mere scientific curiosity or specu-lation, but one of every-day, practical importance at the bed-side. A case of the latter variety, or epithelial cancer of therectum, operated on lately by Mr. Curling, offers a good oppor-tunity to notice this specific disease, more curable perhaps thanother varieties of cancer.

Older practitioners will, perhaps, see nothing new in thesedistinctions; yet they cannot fail to remember the difficultiesand confusion with which the subject of cancer was at onetime surrounded. Indeed, it is to be feared, that even of lateryears, and up to the present time, sufficient attention is nob

paid to the study of the characters of so-called canceroustumours, or those at least of a curable nature; and thatamongst persons outside the profession, cures of a remarkablecharacter are daily efected from practitioners too readilylooking on all cancers as incurable, and giving them up assuch. Laennec was, perhaps, the first who recognised the trueanatomical character of cancer as a ground of classificationand diagnosis, so that the entire study has sprung up within avery few years; indeefl the most advanced opinions of Mandle,Lebert, and others, differ little from that held by Andral, whobelieved cancer to be, not so much a speciiic ulceration of apart, as a state of disease originating in lesions of nutritionand secretion, leading to ulceration of a malignant kind with-out any tendency to heal.True cancer always arises, perhaps, as a tumour, not as

ulceration. In this point of view it differs a little from thedisease under consideration, and styled by Hannover, " epi-thelioma." In true cancer, we may remind our youngerreaders, we have a milky juice, different from the ordinaryserous-like liquid, or limpid serosity of tumours not cancer-ous. We have, as in encephaloid, (the most marked form ofcancer,) a mass, very closely resembling cerebral structure,which, on histological examination, yields a congeries of cells andcell-like particles, with a small quantity of fibrous matter,acting as a stroma, which, if extirpated, is sure to return, and,in one or two years at the outside, perhaps to end fatally.

Contrasted with "epithelioma," cancer engaging the rectumitself is a disease of a much more formidable nature, indeed, onein which operation of any kind is inadmissable. It appears as a

degeneration or infiltration of the wall of the gut, with malig-. nant contraction and ulceration; or, again, as a flat, cauliflower

growth, of the familiar kind, found growing from the inner. surface of the intestine, hard and nodulated; or we may havea a scirrhous mass in the cellular tissue round the gut at last en-

gaging this and surrounding parts. Cancer of the bowel is

usually found some four or five inches above the anus : where--

as, the disease, in the present case, was of an epithelial cha-racter, formed round the anus, or at one side, as in other points,

as the lips, eyelids, &c., where the mucous and cutaneous surfaces