natural. April 11. Glands were still swollen. No erythema or œdema. Sulphite soda, ten grains three times a day, was ordered. On examining the urine and blood, for the first time, bacilli were found in both. April 12. Bacilli were again found in the blood. From this time, there was steady improvement. Temp. never rose above normal. The glands below the ear decreased in size, and the wounds rapidly healed. The meat-diet was continued until April 16, and nothing occurred to check further progress towards complete recovery. A microscopic examination of the excised "pustule" was made, but no bacilli were found in it. Mr. John Spear, who investigated the origin of this case on behalf of the Local Government Board, found that the two bales of hides handled by J. L. were imported from China; and that this same consignment had been the means of infecting three other men with "charbon." In the case of J. L., the period of incubation is very conclusively shown, as, beyond having to unload some hides Feb. 22, he had had no contact with anything capable of infecting him until March 26. So far as I can discover, this is the first instance of malignant pustule which has been recorded as occurring at St. Bartholomew's Hospital; I exclude, of course, so-called malignant carbuncle, of which we have had, in the course of years, many examples, and which, although sometimes confounded with charbon, is a totally different affection. The following case, however, which occurred in 1873, may have been one of anthrax. The history at least points to the possibility. "G. D., æt. 52, a builder, tall and well made, June 14, 1873. His face was very pale and his tongue thickly furred, the integuments of his neck of a dusky red color, but not brawny nor indurated, excepting at one point on the nape over the right splenius muscle. The skin of the lower part of the face was flabby, hanging in folds; his wife said it had never looked like that when he was in good health, the integuments of the upper part of the thorax were dusky and flabby without induration as in the neck. He stated that when working at a wharf at Hoxton, on June 11, he felt a gnat biting the back of his neck, and he struck down the insect. Next day he felt very ill, and the bite was exceedingly tender. His illness increased, so he came to the hospital for relief. Mr. Doran prescribed ammonia and bark, ordering a poultice to the neck. Two hours later, Mr. Willett visited the patient and ordered that the seat of the bite should be painted with tinct. perchloride of iron. At 10 P.M. the patient was sleeping comfortably, with no sign of dyspnoea. At 8 A.M. on the next morning, on attempting to get out of bed, he turned very livid, and died in a few seconds. Post-mortem: The back of the neck was the seat of a very large brawny mass, from which infiltration of the subcutaneous tissue extended down the back, around the front of the back, and down the front of the chest. Nothing was discoverable in any of the organs to account for death, which appeared to be due to the carbuncular infiltration and bloodpoisoning therefrom.' It transpired that hides and timber were being stowed in a warehouse at the wharf where the deceased had been working June 11." The diagnosis of charbon in the present instance was not difficult. The characters of the local disease, which led one instantly to suspect, as a cause, some animal poison, and to cross-examine the patient from this point of view, were quite different from any other; and the voluntary statement of the patient that he had been engaged in carrying hides left little doubt of the nature of the disease. The treatment by excision has been most marked. I am aware that all observers are not agreed as to the necessity for such radical treatment, in this particular case the greatest benefit was apparently derived from the procedure. Temp. fell; the erythema ceased spreading and began to fade; and the patient described himself as feeling altogether a different man within 24 hours after the excision. 44 The treatment by an exclusively animal diet is, I believe, usually recommended in cases of 'charbon," on account of the fact that the disease is not communicable to the carnivora. The plan seems rational and unobjectionable. I was induced to select sulphite of soda from the long list of antiseptics, as an internal remedy, by the marked success which has attended the treatment of this disease (splenic fever) in cattle, by this drug, in the hands of Mr. J. B. Gresswell. Fig. 2 represents the appearance of the intestine in a case of anthrax without external lesion, observed at Guy's Hospital. "The patient was a bargeman, Patrick G., t. 30, who had been unloading skins from his barge at a wharf. Among these skins were some Chinese kipps.' He is said to have been engaged in this work for only one day, and to have complained the same evening of feeling ill; three days before his admission, he complained of pain in the pit of the stomach and in in the night he had severe spasms, and became delirious. the head; the next day, he had profuse diarrhoea, and He was admitted on the fourth day; he was then suffering from convulsive attacks resembling those of tetanus; he became cyanosed and comatose, and died 11 hours after admission. At the necropsy, lesions characteristic of anthrax were found in the stomach, intestines, and lungs; extensive hæmorrhages into the cerebral and spinal meninges were also present; there was no external lesion. The drawing (see Plate, Fig. 2) represents one of the anthrax-nodules from the small intestine, very characteristic of the disease. -British Medical Journal, June 14. THE ANATOMY OF ACQUIRED FLAT- a few inches above the ankle, and kept for FOOT. BY J. SYMINGTON, M.B., F.R.C.S.E. THE anatomy of this comparatively common deformity does not appear to have received much attention in this country. Nearly half a century ago, it was considered by a writer in Todd's Clycopodia of Anatomy and Physiology as probably due to a relaxation of the inferior calcaneo-scaphoid ligament, but he admits that he had no opportunity of dissecting a specimen, his ideas on its anatomy being derived from a careful examination on the living body. special examination. A plaster-of-Paris cast was taken of the left foot. The right foot was frozen, and several sections were made of it, while the left foot was dissected in the usual way. The deformity was slightly more marked in the left foot than in the right, but in both the arch could be restored by manipulation, but could not be maintained without artificial support, the weight of the body being sufficient to reproduce the deformity. From external examination there appeared to be abnormal mobility in all the tarsal joints. Two valuable contributions, founded upon a careful examination of dissections, have been made to this subject by C. Heuter and G. Her-in mann von Meyer. By Hueter its anatomy is treated partly from a developmental point of view. He gives an excellent account of the position and shape of the tarsus in the newly-born child. The foot is then supinated, but as soon as the child begins to walk it becomes pronated. This prone position is followed by certain changes in the tarsal bones, especially in the os calcis, astragalus, and scaphoid. As a consequence of the altered position of the bones, certain surfaces are subject to increased pressure and atrophy, while others relieved of pressure, grow. Flat-foot he regards as an over-pronation of the foot, and the changes in the tarsal bones are to be explained by the effects of alteration in pressure. The bones specially involved are the three mentioned above. He considers that there is a general relaxation of the ligaments of the foot, but he refers specially to the inferior calcaneo-scaphoid ligament, the surface of which, he says, presents a marked increase. Dr. G. Hermann von Meyer, in his monograph, endeavors to disprove the current view, that in consequence of the relaxation of the inferior calcaneo-scaphoid ligament, the head of the astragalus is displaced downwards. He maintains that there is no elongation of the above-mentioned ligament, and also that the inner border of the foot is not increased in length. The most important part of his paper, which will be considered subsequently, is that in which he describes the mechanism of displacement of the astragalus in relation to the tarsal bones. Last winter I met with an adult male subject in my practical anatomy rooms, in whom both feet presented the appearances typical of advanced flat-foot. He was a big, heavy man, six feet in height, but the muscles of the body generally were soft and flabby. There were no indications of his having suffered from rickets. After the muscles of the leg had been dissected, the feet were removed by amputating As previously mentioned, Meyer maintains that the inner border of the foot is not increased length in flat-foot. He endeavors to prove this, not merely by the mode of displacement of the bones, but by actual measurements. He measured five flat feet and six normal ones. The average of the inner borders of the flat feet equalled those of the normal feet, but the outer borders of the former averaged 1 cm. less than the latter. From this he concludes that there is no increase in the inner border, but that the outer border is diminished. There is an obvious fallacy here, for the facts given can be equally, and, I believe, more correctly explained on the supposition that the normal feet selected were larger than the flat ones. This would account for the greater length of the outer borders of the normal feet, and the equality of the inner borders of the two sets may be attributed to an elongation in the flatfoot specimens. As both feet, in my case, were involved, they cannot be used for comparison; but there is another method by which this point can be determined. In a paper by Mr. C. Hilton Golding-Bird, it is stated that the middle of the inner border of the foot corresponds normally to the first cuneo-metatarsal joint. The inner arch of the foot only extends as far forwards as the head of the first metatarsal bone, so that the greater part of the arch is in the posterior half. If the arch be flattened the posterior half will be more increased by the change than the anterior. Mr. Golding-Bird measured a number of cases in the living body, and often found the posterior measurement to exceed the anterior by 1⁄2 to 34 of an inch. I have found this guide to the middle of the inner border of the foot to be a tolerably exact one. I examined nine feet very carefully in the dissectingroom, and found that in three of them the anterior and posterior measurements equal, in two the posterior excess was 5 cm., in one 75 cm., and in the remaining three, I cm. In the left foot in my possession, the excess of the posterior segment over the anterior was 2 cm. Although the increase in length of the inner border is not so great as were it would be were the arch flattened simply by extension in a longitudinal direction, there is still some increase in length. The muscles of the left foot were carefully dissected, but no peculiarity was observed, other than that the short muscles on the inner part of the sole of the foot were atrophied, and had undergone partial fatty degeneration. This was probably secondary, the result of the pressure of the fattened arch. Prof. Sayre attributes a very important action in the maintenance of the inner arch of the foot to the tibialis anticus, and he gives its partial or complete paralysis as the cause of flat-foot. I could detect no special change in this muscle in either limb. Mr. Golding-Bird says that he has failed to find the atrophy of this muscle described by Sayre in any of his cases,-50 in number. The peronei muscles were not contracted; but their synovial sheath communicated with the anklejoint by an opening in the capsule, which readily admitted the index finger. Ankle-Joint. The ligaments of this joint were so lax, that before any of them were divided, the tibia could be raised nearly threequarters of an inch above the astragalus, and the finger could be easily passed through the opening in the capsule already mentioned, between the tibia and astragalus. The only ligament requiring particular notice was the external. Its three fasciculi were not so well defined as usual; the middle one was nearly horizontal, inclining from the os calcis forwards to the fibula. The posterior fasciculus was very rudimentary, its middle and outer parts being almost worn away by the pressure of the fibula against the os calcis. The ligaments of the ankle-joint were divided in order to see the interior of the joint. The normal articular surfaces presented no marked alterations, but additional ones had been produced by the contact of the fibula with the os calcis. The surfaces of these facets were formed by compact osseous tissue. There was a facet on the lower end of the fibula between the depression on its inner surface, and the groove on its posterior surface for the peronei muscles. It was three-quarters of an inch long, and threeeighths of an inch in breadth. Another facet, smaller in size, was found close to the apex of the malleolus. These two facets articulated with two others on the outer surface of the os calcis (see illustrations). The external calcaneoastragaloid ligament was destroyed, and the synovial cavity of the ankle-joint was coutinuous with that of the posterior calcaneo-astragaloid, and also with the cavity between the abnormal articulations of the fibula and os calcis. Both Meyer and Hueter mention the articulation of the fibula and os calcis as always occurring in cases of advanced flat-foot. The conditions of the ankle are of interest to the surgeon in connection with Prof. A. Ogston's operation. After the examination of the ankle, and before any of the ligaments of the tarsus proper had been divided, the position of the astragalus in relation to the rest of the tarsus was determined. It is at the talo-tarsal joints that the deformity commences, and it is there that the displacements occur that constitute its most important features. G. H. von Meyer devotes special attention to the mechanism of the movements of the astragalus. When the sole of the foot is placed upon the ground, and pressure exerted upon the astragalus from above, its body glides forwards upon the os calcis, while the head of the bone sinks downwards and inwards. This momement is described by Von Meyer as occurring round an oblique axis passing from the inner side of the upper surface of the neck of the astragalus to the middle of the lower border of the posterior surface of the os calcis. He shows that the outer border of the trochlear or superior articular surface of the astragalus moves forwards and downwards, while its inner border will perform a smaller movement in the opposite direction. As a consequence of this, the axis of the trochlear surface will incline more inwards-nearer the big toe. By the same movement the trochlear surface will acquire an inclination outwards, for, as we have seen, the outer border moves down, and the inner up. The transverse axis of the trochlear surface, which we may represent by a line connecting its outer and inner borders, must, however, on account of its connection with the bones of the leg, maintain its parallelism with the base. It does this by causing a valgus position of the rest of the tarsus. By an excess of its normal movement, the astragalus becomes displaced towards the inner side of the rest of the foot. An excellent method of representing this has been devised by Von Meyer. He indicates the sole of the foot by a triangle made by uniting three points, viz., the centre of the heel, and the heads of the 1st and 5th metatarsal bones. This triangle, marked abe, is drawn in fig. I; but instead of the middle of the posterior surface of the os calcis, I have taken the posterior point of the support, viz., the internal tubercle of the os calcis. Instead of the whole of the astragalus being indicated it is represented by a point. This astragalus point is the highest spot on the axis of its trochlear surface, it is marked by a cross. According to Meyer, the astragalus point falls, in a normal foot, within the triangle, but in a flat-foot to the inner side of the big toe line, i.e., the line connecting the heel and the head of the first metatarsal bone. |