The following is the clinical history of the case:-The disease commenced about twelve years ago, and, although he is not aware of ever having injured the limb in any way, he remembers that he first complained of pain in the leg, just below the knee, after a game at cricket. The pain gradually became more and more severe, until at length it was associated with the formation of a large abscess on the front of the leg. The abscess was incised in several places, and for a period of fifteen months remained open, discharging pus and at times small fragments of bone. At the end of this time he made a good recovery, and remained well for a period of four years, although it must be noted that, while employed as a grocer, and thus standing a great deal, he was occasionally roused up at night by pain in the right leg near the ankle. The second severe attack, however, came on after a bad cold, and its chief symptom was pain in the head of the right tibia, worst at night. This attack confined the patient to the house for six months; and, when at length he was again able to go about, the limb was found to be slightly flexed and could not be straightened. Two years after this he had a similar attack of pain lasting about six months, since which he has remained well until the month of August last, when all the old symptoms reappeared. After staying at home for a period of four months, he was admitted to hospital as noted above. On admission the right leg was found to be slightly flexed at the knee-joint, and complete extension could not be effected. Numerous cicatrices were seen in front of the tibia, and in these situations the skin was firmly bound down to the bone. The anterior surface of the lower end of the tibia was rough and nodulated. There was some bulging at the sides of the ligamentum patellæ, and also at the sides of the rectus tendon. The circumference of the right knee was greater than that of the left, and the upper part of the leg was considerably increased in thickness. Firm pressure with the point of the finger upon the upper part of the tibia gave pain. The family history was satisfactory. 19th December.-To-day, the patient being under the influence of chloroform, Dr. Buchanan, by means of a crucial incision, exposed the tibia at the site of greatest intensity of the pain, just below the head. By means of a trephine about the size of a threepenny piece, a cork shaped piece of bone, about inch long, was removed, after which a few drops of pus flowed from the cavity. The internal end of the removed piece of bone was distinctly cup-shaped and lined with a very typical pyogenic membrane, thus verifying the diagnosis of abscess of the head of the tibia. 21st December.-Patient doing well, and pain greatly relieved since the operation. 22nd December.-Improvement still marked. The wound looks healthy, and the cavity in the bone is beginning to granulate up. 15th January.-Wound almost healed and pain gone. PURPURA.-M. C., æt. 14, was first seen by me on the evening of Monday, 3rd October, 1881. A week previously she had slight sore throat. On Sunday she had walked some distance into the country and come home much exhausted. On going to school on Monday she felt tired, and suffered from pains in the limbs, which caused her to walk very slowly; about midday these pains became so severe that shortly afterwards she had to be sent home. When seen in the evening there was comparatively little constitutional disturbance; "the patient eats and sleeps well but is 'weakly,' and is apparently overworked at school. Tongue clean; pulse 85; temperature, 100.2° F. The legs are very decidedly swollen and tense from knee to ankle, and a little above the knees, on the outer aspect of each thigh. These parts are firm and resistent, and do not pit on pressure; the slightest touch or movement causes most intense pain. Scattered over the swollen parts, on both legs and thighs, are numerous purpuric spots, varying in size from a mere speck as large as a pin's head to patches as large as sixpenny pieces. These spots are vivid red in colour, and do not disappear on firm pressure. There is no heat or itching. The spots appeared in the course of Monday afternoon and evening. There are no pains in the joints; the gums and mucous membranes generally are healthy, and there are no hæmorrhages." The patient was ordered a mixture of tincture of perchloride of iron and chlorate of potash, and was directed to remain strictly in bed. "4th October.-Spots darker in colour; swelling and general condition unchanged, with the exception that the pain on handling the parts is considerably less. Urine normal. No fresh spots. Pulse 84; temperature 98° F." "6th October.-Better generally; spots on legs yellowishgreen, like a fading bruise. Pain on touching or moving legs nearly gone. In both parietal regions, however, at symmetrical spots, are slightly painful circular swellings, about an inch in diameter. At symmetrical spots on both elbows also, just behind the outer condyles, are swollen bruised looking spots, yellowish-green in colour, and painful to pressure. The back of the right hand is swollen, painful to pressure, but not discoloured. All these swellings were discovered yesterday evening and last night." "7th October.-To-day the back of the left hand is swollen and tender, like the right; other swellings much smaller and less painful. Spots on legs fading fast, and swelling has nearly disappeared." In a few days more all these morbid appearances had gone, but it was some time before the patient regained her former strength. Remarks. This was not simple purpura; nor was it purpura urticans, as was shown by the absence of heat, itching, or wheals; nor was it purpura rheumatica, as the swelling and pain were not in the joints, and the girl had no rheumatic history or tendency; while the healthy state of the mucous membranes and the absence of hæmorrhages, forbade the idea of scurvy. It seems to have been a neurotic affection, due to exhaustion from over-fatigue, the chief evidence of this being the strikingly symmetrical character of the phenomena, the purpuric spots and the acute and circumscribed oedema probably ranking among the other symptoms of debility and exhaustion. On this view, the treatment by rest and tonics, especially iron, commends itself. MEETINGS OF SOCIETIES. GLASGOW MEDICO-CHIRURGICAL SOCIETY. MEETING III-1ST DECEMBER, 1882. DR. GAIRDNER, President, in the Chair. THE PRESIDENT read "Résumé of Koch's Observations on the Tubercle Bacillus," by Dr. G. A. Heron, London. (See page 94.) The bacillus was also exhibited by Dr. J. Lindsay Steven and Dr. Newman. Dr. Newman said that, at the close of the summer session, Dr. Coats and himself had arranged to carry out a series of investigations, not only on the tubercle bacillus, but on the organisms of other infectious diseases. They had already got the necessary permission from the Home Secretary to conduct the experiments, and only awaited the termination of Dr. Coats' other engagements to make a beginning. There were three methods of staining the preparations of the tubercle bacillus viz., Vigort's, Gibbes', and Ehrlich's methods. Koch's own method did not yield satisfactory results in his (Dr. Newman's) hands, though this might be partly due to his inexperience in using it. He preferred Gibbes' method, which was some time ago described in the British Medical Journal (Dr. Newman briefly described it). The experiments which he had made in this enquiry did not entitle him to say much on the subject. He had examined the sputa of 50 or 60 different patients, and had post-mortem examinations in a number of these. It was somewhat peculiar to these cases that in the sputa of the same patient the bacillus was sometimes present, and in abundance; while on other days it was entirely absent. It was thus not advisable to depend on one or two examinations; one must have perhaps six or seven. In one case of chronic bronchitis he detected the bacillus. The man died of heart disease; and in the lungs he could detect no tubercle, though it would be rash to say that none existed. Dr. Steven said that in Leipzig, from which he had lately returned, stress was laid on the necessity of having the post-mortem examination made within a few hours of death; otherwise the bacillus would not be found. He was not aware whether the principle here involved applied to the sputa; but the presumption was that to obtain reliable results it must be fresh. Dr. Steven said he preferred Ehrlich's method of staining, which he proceeded to describe. Dr. Macewen queried whether any of the investigators had found tubercle in the joints? The most important practical lesson from the subject seemed to be, that if the organism retained its vitality in dried sputa, it would be necessary to carry out rigorous sanitary precautions in medical wards of hospitals, as well as in private houses. Dr. Coats said that it appeared to him that these researches of Koch had put the copestone on the general views which had gradually been developing as regards tubercular disease. When he (Dr. Coats) began his pathological experience one thing had strongly struck him, viz., the apparent incompati bility between such cases as he would class under "acute tuberculosis," and cases of phthisis pulmonalis. He could not see how the two diseases were linked together by any pathological nexus. This made him exceedingly chary in applying the term " tubercular" to conditions generally so named. Acute miliary tubercle, he could see, seemed to be due to the presence of a poison in the blood. Phthisis, on the other hand, was universally believed to be due to some constitutional taint. In the post-mortem room Dr. Gairdner and himself had not a few discussions on the question constantly arising-Is this tubercle? In tubercle he could see nothing but the presence of some poison, and he came to regard it as a definitive infective disease. In regard to phthisis pulmonalis he was in a maze altogether, not being able to regard it as merely an inflammatory condition, but not seeing any pathological connection it had with acute tuberculosis. All this uncertainty had been changed by the researches of Klebs and Cohnheim and Koch. These men had proved beyond doubt that phthisis pulmonalis, as well as acute miliary tubercle, were diseases due to the action of a morbid poison, and to be placed in the same category as syphilis and leprosy, and the group of zymotics. This simplification of the problem had conferred a great mental boon on him. It reconciled the views of Laennec with those more recent views. He could now meet and shake hands with Dr. Gairdner; and it was only fair to admit that the change of position was his own, and that his conclusions, based exclusively on what appeared to be pathological data, stood corrected by the more mature and more extended views obtained from Dr. Gairdner's clinical experience. There were still some questions which remained to be investigated. One of these was in regard to the alleged heredity of phthisis. It must be remembered that in nearly all, if not all, the class of diseases with which phthisis could now be associated, there was a predisposition to them in certain families. This was the case in typhoid fever, diphtheria, and others. Some persons exposed to the contagion of typhus were sure to succumb to it, whilst some were almost proof against its attack. Take a hundred animals and inoculate them equally with the poison of splenic fever, or chicken cholera, some of the hundred would be found to have resisted the poison. Algerian sheep resisted inoculation with anthrax virus in small doses, though other species did not possess the same immunity. Cochin-China fowls resisted chicken cholera when inoculated with it. There were instances of immunity from the attacks of certain organisms undoubtedly hereditary. In regard to No. 2. M Vol. XIX. |