coldstream guards' hospital

1
687 tion to the unusually weak action of the heart. The splints I were now taken off. The fragments, which were merely united by fibrous tissue, could be moved bodily from side to side, but not separated from each other. The upper fragment projected, but not so prominently as heretofore. In the arteries at the wrist the circulation could hardly be felt. The muscles were much wasted, and the veins dilated and turgid. The fragments were well rubbed together, surrounded by leather strapping, and the arm bandaged, after which the splints were readjusted. He was ordered full diet; a pint and a half of stout and six ounces of wine daily, and the fol- lowing mixture :-Syrup of phosphate of iron, one drachm; lime-water, one ounce : three times daily. At the end of a fortnight (March 26th), the arm was ex- amined ; union was now firmer, and the patient’s health much improved. No perceptible callus had been thrown out. April 20th.-Much less mobility of the fragments. He was ordered two drachms of syrup of phosphate of iron, with lime- water, three times a day. May ’7th.-Splints removed ; bone is consolidated. l8th.-Discharged, with complete consolidation of the bone. Remarks. -Four leading circumstances may be said to have delayed union in this case :-l. The obliquity of the fracture, and hence the impossibility of maintaining perfect coaptation of the fragments. 2. The interposition of a piece of fascia through which the upper fragment had protruded, and which by continued pressure ultimately became absorbed. 3. The probable rupture of the nutritious artery of the bone, and hence a deficiency in the formation of callus. 4. An im- poverished condition of the patient’s health. The good feed- ing and fair allowance of stimulants no doubt materially con- tributed towards the local repair. COLDSTREAM GUARDS’ HOSPITAL. LACERATED GUNSHOT INJURY OF THE PALM OF THE HAND ; THREATENED TETANUS ; RECOVERY. (Under the care of Surgeon-Major WYATT.) THE following is a good case of recovery from very suspicious symptoms of commencing tetanus :- H--, aged thirty-nine, a healthy man, but with a highly nervous temperament, sustained a severe contused injury of the right hand on the 13th of July, 1867, from the bursting of an experimental breech-loading rifle, by which the muscles of the thumb were extensively lacerated, and a deep wound in- flicted through the deep structures of the palm. The annular ligament and upper row of carpal bones could be distinctly felt. Several small pieces of steel were removed at the time, but after a prolonged and careful exploration no foreign body sufficient to have caused such an extensive laceration could be discovered, although a piece of steel bar, which had evidently been blown away from the breech of the rifle, might fairly have been supposed to have caused the injury, from the position in which the hand was placed at the time of the accident. There was but a small amount of powder in the wound, but great pain was experienced for a considerable time afterwards. This subsided during the night upon the exhibition of an opiate. The wound was dressed for the first few days with a weak solution of Condy’s fluid. The constitutional irritation and fever were not considerable, but on the evening of the third day very suspicious rigidity of the muscles of the arm and neck supervened, and on the following day the abdominal parietes appeared to be also affected. The wound was at once well syringed with a strong solution of sedative liquor of opium, and lint steeped in the same constantly applied night and day. The rigidity appeared to intermit, and after the second day was much less distinct, the bowels having also been freely acted on; but the opiate application was continued without intermission, the wound being dressed at first three times a day, and the forearm bandaged. It was considered most pro- bable that some foreign body remained deeply imbedded, but no exploration could detect it in any direction. A good re- covery, with very little contraction of the palmar aponeurosis or fascia, ensued; but five months subsequently the patient pre- sented himself for examination. The cicatrix of the wound was irregularly hard and rigid, and on one side there was a point as if of a foreign body, which could be made more dis- tinct by pressure applied from behind between the metacarpal bones. However, as it did not in any way interfere with the form or movement of the fingers, and produced no kind of un- easiness generally, it was considered more prudent to allow it to remain imbedded as it was, in the hope that it would become more prominent in time. Mr. Wyatt remarks that the thorough saturation of the wound by opium after it has been thoroughly cleansed has always appeared to him to have a more soothing influence, and to yield a more favourable result, than when the drug has been administered internally. The treatment of the wound by ex- ternal remedies when the disease has become established has too often, he thinks, been considered of secondary importance; for it should not be forgotten that, however much the disease may be supposed to have a central implication, the origin is a peripheral irritation. METROPOLITAN FREE HOSPITAL. MONOCYSTIC DISEASE OF THE OVARY; OVARIOTOMY; LIGATURED PEDICLE RETURNED INTO THE ABDOMEN; RECOVERY. (Under the care of Mr. J. BANKART.) FOR notes of the two following cases we are indebted to Mr. J. de Liefde, honse-surgeon :— A. B-, aged forty-five, married, and the mother of seven children, the youngest born seven years ago, came as an out- patient to Dr. Pye Smith complaining of abdominal pains and enlargement, which prevented her from properly performing her household duties, and have lately somewhat damaged her general health. She could not tell on which side the enlarge- ment began. She is a spare woman, of tolerably healthy ap- pearance ; had not menstruated for seven years. On examina- tion the enlargement evidently consisted of a fluid tumour, which reached to a point midway between the umbilicus and the sternum. It could be seen to move within the abdominal wall during the respiratory movements, and it came very pro- minently forward. The uterus was small, very high in the pelvis, and apparently quite free. Fluctuation was very dis- tinctly felt all over the tumour, which was thought to be a single cyst. On Feb. llth, at eleven A.M., ovariotomy was performed by Mr. Bankart. The room being at a temperature of 65° Fahr., chloroform was administered. An incision, about five inches in length, brought the cyst into view. It was seen to move within the abdomen. The cyst was then tapped, and fluid of the usual thick character drawn off. As the tumour dimi- nished in size, one or two efforts, as if to vomit, partially ex- pelled the cyst, which was then seized and drawn out, there being no adhesions of any kind. As the cyst escaped through the wound the abdominal wall was grasped closely around the pedicle by Mr. Bryant, who, being present, kindly assisted. There was no bleeding from the wound, and as soon as the cyst had emptied itself, which it did completely, a double ligature of whipcord was passed through the pedicle, and tied in two parts, the pedicle being about three inches in width, and of moderate length. The pedicle was then divided, and the ligatures cut off short, the pedicle slipping back into the abdomen as the last ligature was divided. There being no bleeding, and but little fluid having found its way into the ab- domen, no exploration was made of the interior; neither uterus nor intestines were seen, and neither sponge nor hand was allowed to come into contact with the peritoneum, except just the point of the finger in afterwards passing the sutures through the edges of the wound. Three deep sutures were passed through the wall excepting the peritoneum, and a thick pad of lint being placed over the wound the whole abdomen was covered with cotton wool, and firmly sewn up in a broad flannel roller. A suppository of opium was introduced before recovery from the chloroform, and the patient then placed in bed. The tumour proved to be composed of one large cyst ; but on turning it inside out, three very small secondary cysts were found at the lower part, the biggest about the size of a large pea. About an inch and a half of the Fallopian tube was spread out on the pedicle and lower part of the cyst, and was removed with it. On the day previous to the operation the bowels had been moved by a small dose of castor oil, and the lower bowel was emptied on the morning of the llth by an enema of warm water. - 8 P.M.: Had vomited once. Pulse 80, fair in tone. Ordered ice and arrowroot. - 12 P.M. : Vomiting continued. Complains of a pricking sensation in the wound ; skin cool and moist; pulse 100, good power. Urine to be drawn off two or three times a day. On inquiring about the vomiting, she stated that cold water always makes her vomit; the ice was therefore ordered to be discontinued.

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Page 1: COLDSTREAM GUARDS' HOSPITAL

687

tion to the unusually weak action of the heart. The splints Iwere now taken off. The fragments, which were merelyunited by fibrous tissue, could be moved bodily from side toside, but not separated from each other. The upper fragmentprojected, but not so prominently as heretofore. In thearteries at the wrist the circulation could hardly be felt. Themuscles were much wasted, and the veins dilated and turgid.The fragments were well rubbed together, surrounded byleather strapping, and the arm bandaged, after which thesplints were readjusted. He was ordered full diet; a pintand a half of stout and six ounces of wine daily, and the fol-lowing mixture :-Syrup of phosphate of iron, one drachm;lime-water, one ounce : three times daily.At the end of a fortnight (March 26th), the arm was ex-

amined ; union was now firmer, and the patient’s health muchimproved. No perceptible callus had been thrown out.

April 20th.-Much less mobility of the fragments. He wasordered two drachms of syrup of phosphate of iron, with lime-water, three times a day.May ’7th.-Splints removed ; bone is consolidated.l8th.-Discharged, with complete consolidation of the bone.Remarks. -Four leading circumstances may be said to have

delayed union in this case :-l. The obliquity of the fracture,and hence the impossibility of maintaining perfect coaptationof the fragments. 2. The interposition of a piece of fasciathrough which the upper fragment had protruded, and whichby continued pressure ultimately became absorbed. 3. Theprobable rupture of the nutritious artery of the bone, andhence a deficiency in the formation of callus. 4. An im-poverished condition of the patient’s health. The good feed-ing and fair allowance of stimulants no doubt materially con-tributed towards the local repair.

COLDSTREAM GUARDS’ HOSPITAL.LACERATED GUNSHOT INJURY OF THE PALM OF THE

HAND ; THREATENED TETANUS ; RECOVERY.

(Under the care of Surgeon-Major WYATT.)THE following is a good case of recovery from very suspicious

symptoms of commencing tetanus :-H--, aged thirty-nine, a healthy man, but with a highly

nervous temperament, sustained a severe contused injury ofthe right hand on the 13th of July, 1867, from the bursting ofan experimental breech-loading rifle, by which the muscles ofthe thumb were extensively lacerated, and a deep wound in-flicted through the deep structures of the palm. The annular

ligament and upper row of carpal bones could be distinctlyfelt. Several small pieces of steel were removed at the time,but after a prolonged and careful exploration no foreign bodysufficient to have caused such an extensive laceration could be discovered, although a piece of steel bar, which had evidently been blown away from the breech of the rifle, might fairly havebeen supposed to have caused the injury, from the position inwhich the hand was placed at the time of the accident. Therewas but a small amount of powder in the wound, but greatpain was experienced for a considerable time afterwards. Thissubsided during the night upon the exhibition of an opiate.The wound was dressed for the first few days with a weaksolution of Condy’s fluid. The constitutional irritation andfever were not considerable, but on the evening of the third dayvery suspicious rigidity of the muscles of the arm and necksupervened, and on the following day the abdominal parietesappeared to be also affected. The wound was at once wellsyringed with a strong solution of sedative liquor of opium,and lint steeped in the same constantly applied night and day.The rigidity appeared to intermit, and after the second daywas much less distinct, the bowels having also been freelyacted on; but the opiate application was continued withoutintermission, the wound being dressed at first three times aday, and the forearm bandaged. It was considered most pro-bable that some foreign body remained deeply imbedded, butno exploration could detect it in any direction. A good re-covery, with very little contraction of the palmar aponeurosisor fascia, ensued; but five months subsequently the patient pre-sented himself for examination. The cicatrix of the woundwas irregularly hard and rigid, and on one side there was apoint as if of a foreign body, which could be made more dis-tinct by pressure applied from behind between the metacarpalbones. However, as it did not in any way interfere with theform or movement of the fingers, and produced no kind of un-easiness generally, it was considered more prudent to allow itto remain imbedded as it was, in the hope that it would becomemore prominent in time.

Mr. Wyatt remarks that the thorough saturation of thewound by opium after it has been thoroughly cleansed hasalways appeared to him to have a more soothing influence, andto yield a more favourable result, than when the drug has beenadministered internally. The treatment of the wound by ex-ternal remedies when the disease has become established hastoo often, he thinks, been considered of secondary importance;for it should not be forgotten that, however much the diseasemay be supposed to have a central implication, the origin isa peripheral irritation.

METROPOLITAN FREE HOSPITAL.MONOCYSTIC DISEASE OF THE OVARY; OVARIOTOMY;

LIGATURED PEDICLE RETURNED INTO THE

ABDOMEN; RECOVERY.

(Under the care of Mr. J. BANKART.)FOR notes of the two following cases we are indebted to Mr.

J. de Liefde, honse-surgeon :—

A. B-, aged forty-five, married, and the mother of sevenchildren, the youngest born seven years ago, came as an out-patient to Dr. Pye Smith complaining of abdominal pains andenlargement, which prevented her from properly performingher household duties, and have lately somewhat damaged hergeneral health. She could not tell on which side the enlarge-ment began. She is a spare woman, of tolerably healthy ap-pearance ; had not menstruated for seven years. On examina-tion the enlargement evidently consisted of a fluid tumour,which reached to a point midway between the umbilicus andthe sternum. It could be seen to move within the abdominalwall during the respiratory movements, and it came very pro-minently forward. The uterus was small, very high in thepelvis, and apparently quite free. Fluctuation was very dis-tinctly felt all over the tumour, which was thought to be asingle cyst.On Feb. llth, at eleven A.M., ovariotomy was performed by

Mr. Bankart. The room being at a temperature of 65° Fahr.,chloroform was administered. An incision, about five inchesin length, brought the cyst into view. It was seen to movewithin the abdomen. The cyst was then tapped, and fluid ofthe usual thick character drawn off. As the tumour dimi-nished in size, one or two efforts, as if to vomit, partially ex-pelled the cyst, which was then seized and drawn out, therebeing no adhesions of any kind. As the cyst escaped throughthe wound the abdominal wall was grasped closely around thepedicle by Mr. Bryant, who, being present, kindly assisted.There was no bleeding from the wound, and as soon as thecyst had emptied itself, which it did completely, a doubleligature of whipcord was passed through the pedicle, and tiedin two parts, the pedicle being about three inches in width,and of moderate length. The pedicle was then divided, andthe ligatures cut off short, the pedicle slipping back into theabdomen as the last ligature was divided. There being nobleeding, and but little fluid having found its way into the ab-domen, no exploration was made of the interior; neitheruterus nor intestines were seen, and neither sponge nor handwas allowed to come into contact with the peritoneum, exceptjust the point of the finger in afterwards passing the suturesthrough the edges of the wound. Three deep sutures werepassed through the wall excepting the peritoneum, and a thickpad of lint being placed over the wound the whole abdomenwas covered with cotton wool, and firmly sewn up in a broadflannel roller. A suppository of opium was introduced beforerecovery from the chloroform, and the patient then placed inbed.The tumour proved to be composed of one large cyst ; but

on turning it inside out, three very small secondary cysts werefound at the lower part, the biggest about the size of a largepea. About an inch and a half of the Fallopian tube wasspread out on the pedicle and lower part of the cyst, andwas removed with it.On the day previous to the operation the bowels had been

moved by a small dose of castor oil, and the lower bowel wasemptied on the morning of the llth by an enema of warmwater. - 8 P.M.: Had vomited once. Pulse 80, fair intone. Ordered ice and arrowroot. - 12 P.M. : Vomitingcontinued. Complains of a pricking sensation in the wound ;skin cool and moist; pulse 100, good power. Urine to bedrawn off two or three times a day. On inquiring about thevomiting, she stated that cold water always makes her vomit;the ice was therefore ordered to be discontinued.