A MIRROR OP HOSPITAL PRACTICE.
SOME SURGICAL OPERATIONS AND OTHER CASES. By Surgeon-Major Albert A. Gore, M.
x]
I.-.A Case
of
D.,
A. M. D.
Laryngo-tracheotomy.
Denis Sullivan, 65th Foot, Army, age 41, service 20}^ years, a worn-out man looking much older than his reputed age. Appears to have suffered from bronchitis at Devonport in 1871, and afterwards 29 days for pleurisy in the same year ; shortly after this he proceeded to India, where he landed on the 11th November. Served at Agra, Lucknow. Hazaribagh, and Morar, from which station he was invalided to Ilanikhet for change owing to general debility. On the march up from Moradabad he contracted measles from some children of the " Details" and was admitted to hospital and immediately isolated. This was on the 19th April, (he was discharged on the7th May.) The rash was general, characteristic with attending bronchial symptoms. Was treated with diaphoretics, Compound Tincture of camphor, poultices to chest, and afterwards ordinary expectorant mixture. He was not again in hospital until the 5th of November, when he was admitted into Dr. Morris's division with symptoms of bronchitis. Had constant, cough, pain in chest, restlessness, dry rhonchi and frothy mucus, with difficulty brought up. Was treated with expectorant mixture, to each dose of which 10 grains of nitrate of potash were added ; linseed poultice to chest. On the 10th 3 ss Vinum ipecacuanhas was added to each dose, and on the 12th Tartar emetic made up in pills with Extract of gentian was prescribed. There was some liuskiness of voice on admission which gradually increased with the difficulty of breathing. There was also great anxiety and spasmodic exacerbations. Had little or no sleep, and had to be propped up with pillows. Larsre doses of Bromide of potassium alone or combined with chloral afforded no relief. The cough became brassy and harsh, and the stridor and breathing most distressing to listen to. The dull percussion note over the base of both lungs posteriorly and low down, tubular breathing, viscid, rusty and adherent sputum showed that the substance of that portion of the lungs was becoming involved in addition. The patient was evidently becoming feebler ; paroxysms of difficulty of breathing occurred as the laryngeal obstruction increased. Turpentine stupes by means of spongio-piline were now constantly applied to the throat and chest, and the failing strength supported by wine and essence of beef, &c. Medicated vapours were constantly inhaled, and the temperature of the ward raised, and also kept moist by vessels of boiling water. On the night of the 17th he had a violent spasmodic attack followed by an extreme state of collapse, which nearly proved fatal. From the long and wheezing inspirations and movements of the chest, it was clear that respiration was performed with the utmost difficulty. The percussion note over the front of the chest was clear, but the respiratory sounds harsh and sonorous. No abnormal cardiac sound. Pulse 135, On the morning of the 18th the patient weak and feeble. No.
697, Pte.
seemed to me somewhat easier: the pulse had fallen to 112. The Roman Catholic clergyman had been with him. I left hospital a few minutes after noon, and had just finished breakfast when at 1-10 P. M. I was recalled. Durabsence the had ing my laryngeal symptoms suddenly become worse, the breathing at last ceased entirely, and the man became completely asphyxiated. As the pulse was still faintly perceptible at the wrist. Mr. Barrett, the apothecary, resorted to artificial respiration. After some time his efforts were rewarded by a long drawn and loud whistling respiration as the air was drawn through the closely approximated chink of the rima glottidis. When I arrived shortly afterwards, the condition of the patient, was most distressing. He was in a state of semi-collapse and breathing with the utmost difficulty; the countenance sunken and covered with a cold sweat. It was evident that life must speedily become extinct if operative measures were not immediately resorted to. The instruments being ready at the bedside, I proceeded at once to operate, assisted by Mr. Bra.lley and the Hospital Apprentices Messrs. Forrester and Neile. The bed was drawn in front of the window, the patient's head lowered, and this troublesome and often difficult and dangerous operation commenced by making a superficial incision in the median line over the upper rings of the trachea,, which was deeply situated owing to the short neck and high shoulders of the patient. The parts on either side retracted by means of aneurism needles held by were The intervening tissues Messrs. Bradley and Forrester. were separated as much as possible by the left index finger until the upper rings of the trachea were felt; these were then divided by the scalpel and the incision extended into the cricoid cartilage. During this stage some venous haemorrhage occurred and welled up out of the wound, but was quickly checked by a few applications of the cold sponge. The canula was inserted, through which immediately whizzed a quantity of air, blood and mucus. The relief to the patient He now breathed without was immediate and perceptible. difficulty, took some wine and beef tea ; the face became more life-like and less humid. For some minutes blood and mucus continued to come through the canula. This soon ceased, and it was afterwards kept clear by the insertion of a feather at intervals, and at no time subsequently became closed. I remained with the man until 3-30 P.M. A subordinate medical officer was told off for duty at intervals of two hours. Dr. Green visited the patient at 5 p. M , we saw him together at 7. He was breathing freely through the canula 5 wine, brandy and essence of beef had been taken at regular intervals without difficulty, but it was evident that he was sinking from exhaustion. The pulse was weak, 160. He was quite conscious, and indicated his desires by signs. He sank and died quietly at 8-30 P. M. On the 21st October I had made a careful inspection of the " Details in their barracks, and had certified this man among, others as fit to proceed to the plains, for which they were to leave on the 15th November. He then seemed well, and complained of no bronchial symptoms. His wife however appeared to think that he had never quite got over his attack of measles.
"
Towards the end of October the weather had turned sudafter sunset, when the reduction of temperature was marked and immediate. Soldiers are proverbially careless, and it is probable that he then contracted a chill which rested upon his weakest part.
denly cold, especially
The immediate results of the operation were the prolongation of life for some hours, the relief of urgent and most distressing symptoms, and time being given him to dispose of his property by will,?some three or four hundred rupees. His case is only one other exemplifying the well-known law so ably worked out by the late Dr. Bryden, that the tendency is rather towards death than life when old soldiers of 40 with acute disease in years of age and upwards are attacked India. The fact of his having contracted measles at so late a period of life is of interest. Such cases are. I believe, very An interesting case of this kind is noted in the uncommon. " Historical Records" of the Military Prison, Dublin, by Mr. Tufnell, where an adult prisoner, forty-Jive days after admission to that Institution, was attacked with measles which ran its usual course. A near relative of one of the medical officers here, I am informed, suffered from this disease at an advanced period of life. _
January 2,
A
1882.]
II.?Two Cases
of
MIRROR OF HOSPITAL PRACTICE.
Fistula in ano successfully
OPERATED ON.
No. 2411,Pte.W. H. Hickman, 30th Regiment, age 20, service
1A
years, was admitted to Hospital on the 13th March of the present year with a view to being operated upon. The previous history of his case presents some features of interest. On the 22nd of the previous October he had come under Dr. Gallwey's care suffering from gonorrhoea. I took over charge of the patient on the loth November. For some days lie had had slight fever for which he was given quinine : he then had a complete fistula. On the evening of the 14th the evening temperature was 104'. He had afterwards diarrhoea, rose spots, iliac tenderness, haemorrhage from the bowels, and went through a regular attack of enteric fever ; the temperature falling to normal on the 21st day. Became afterwards so exceedingly stout that he could with difficulty button his tunic. Th "fistula followed upon a small abscess which formed to the left of the anus ; a probe passed into the bowel from which wind and matter were conveyed to the external opening. In the operation 1 could not use the director supplied in the pocket case, as it could not be bentInserting a silver probe through the external opening and the left index finger into the anus, the patient being brought to the edge of the bed lying on his right side, I brought down the end of the probe through the anal aperture and divided the intervening tissues and sphincter with the curved bistoury. The small amount of bleeding was checked by wet lint. The wound was dressed with carbolic oil on lint. The wound healed from the bottom and the patient made a good recovery. He is now at his duty. Some years before I bad to treat a double fistula in ano at Ferozepore, one of the worst I have seen. It occurred in the person of a Driver of the Royal Artillery (4-5), a stout, healthy looking man. It followed upon a large anal abscess for which there was no apparent cause. The fistulas were complete and accompanied by much surrounding inflammation, a variety of injections and local applications were used with no effect whatever. Assisted by Mr. Slater, my apothecary, I operated on the right side only, pushing a silver director through the bowel, bending it through the anus and dividing the sphincter. The wound was nearly healed in April, when be was sent to Dalhousie for change, and returned in six months much improved in general health. Both fistulas were completely healed and he returned to his duty as a driver. III.?Incised Wound of Wrist. ?
No. 426, Drummer W. Righey, age 19, service 5 years, was admitted to hospital on the 1st January of the present year with a severe and jagged wound of the left wrist. He was brought to hospital after my evening visit; I was called to see him at 7 p. m. ; he was then smelling strongly of liquor. The injury was caused by falling through a window and thrusting the hand through one of the panes. There was a considerable venous haemorrhage. The superficial ulnar veins and filaments of the internal cutaneous nerves were completely divided, as well as the tendons of the superficial flexors, going on to be inserted into the little, ring and middle fingers. The tendons were turned backwards and bung out of the wound ; the ulnar artery and vein had escaped. The forearm was raised, the tendons carefully replaced in their original position, and the parts brought together by suture and enveloped in carbolic dressing. The wrist and hand were next flexed as much as possible on the forearm and kept in that position by long strips of plaster encircling the arm above the elbow ; the forearm was also flexed upon the arm and kept in that position, by which means all tension was taken off the sutures and the parts kept in perfect apposition. On the 5tli January the dressing was removed and re-applied without disturbing the position of the hand. The wound was again dressed on the 13th, when black wash was substituted for carbolic oil. The following note is made in my Case Book under date 11th February :? "Wound quite healed; tendons joined ; no loss of motion or sensation". March 6th.?" Perfect motion of joint and flexure of fingers." The man since then has been at his duty. IV.?Large Fibro-Cellular Tumour. Some months ago when visiting the Charitable Dispensary, my attention was called by the native doctor to a woman who had come in to be operated upon. She walked into the Female Ward apparently without difficulty. On making an examination I found alarge pendulous tumour, convoluted
11
and with two separate hemispheres. It would be exactly described if one could imagine a brain with a dark surface hanging from the vagina. There was a distinct pedicle about two inches or more in circumference. The tumour seemed to be an enormous hypertrophy of the left labia minora. After removal it was found to weigh 21bs 12oz.' The woman, a healthy and rather good looking young person, stated that it had been growing for five years. All sexual intercourse must have been impossible. Aided by the native doctor Kumroop and his assistant, after administering chloroform, I transfixed the pedicle with a needle to which was attached a strong double ligature. On the needle passing through the ligature was cut close to the eyelet; the ends were drawn tightly together and either halves of the pedicle strangulated. The pedicle was then immediately divided by the scalpel below the ligatures. Two arteries required to be ligatured. The surface was lightly touched with the actual cautery, and afterwards with perchloride of iron and dressed with a saturated solution of alum. There was not very much haemorrhage. In a few days carbolic dressing was applied, and not long afterwards the patient left the hospital, having made a good recovery. The tumour on section was found to be of a fibro-cellular and fatty nature with a dark convoluted border. V.?Removal op a Stone from the Female Bladder. Calculus in the male is common enough in India, but cases occurring in females do not so often come under observation. Shortly after the above operation I was called to see a woman at the dispensary, who was suffering from vesical symptoms, much irritability of the bladder, pain during and after mic-
turation, and intermittent flow of urine.
The sound at once detected the presence of a calculus. I had no means of rapidly dilating the urethra, and had to resort to a large forceps for the purpose of extraction. I found no difficulty in grasping the stone, but could not get it through the urethral canal. It is generally laid down in such cases that the stone should be either broken up or removed through the floor of the vagina ; as it was evident, however, that only a slight enlargement of the urethra was required, I effected this end by a small incision in the urethra on the left side, after which the calculus was easily removed,?a pretty large one of the phosphatic formation. The woman recovered in a few days (next day I actually found her sitting in the verandah) ; no incontinence of urine followed. VI.?A case of Arm Presentation".
Midwifery cases do not often come into a dispensary, probably only whan the cases are
charitable so serious all efforts on the part of the native hakims have after this I had a abortive. note from Shortly proved my native doctor (Kumroop), fttating that a Mahomedan woman had been brought to the hospital in labor, and that the hand was projecting out of the vagina. I rode down and found that she appeared to be at her on examining the patient full time, and saw just projecting between the vulva the small fingers of the child : the funis had also prolapsed. Having put the woman under the influence of chloroform, I proceeded at once to turn the child. With some difficulty I inserted the right hand and arm into the uterus, pushing well up towards the fundus and managed to get hold of a foot which was carefully brought down, encircled by a bandage and kept in position by my native assistant: my arm After was quite numbed by the strong grasp of the uterus. a minute or two I inserted it again ; in a little while got hold of the other foot, extricating it while at the same time pushing up with the left hand the presenting arm. The feet were now tied together, the child turned without much difficulty and quickly extracted. As soon as the patient got from under the influence of chloroform, the pulse became irregular, the respirations shallow, and the respiration and pulse finally ceased almost entirely. The body was immediately inverted by an attendant jumping on the table and raising the legs and feet; two large pillows were placed under the buttocks, cold water dashed on to the face and chest, and ammonia applied to the nostrils ; by these and other measures resorted to the woman at last came round, a few long inspirations being the first signs of returning animation. With some difficulty I now got her to swallow a draught containing ether, ammonia and rum. The placenta was retained, but only in the vagina, from which it was easily removed. She was now given a dose of ergot and kept qui6t. that
12
She the
THE INDIAN MEDICAL GAZETTE.
?
recovered
dispensary
completely without in due course.
a
bad
symptom,
and left
VII.?Cystitis following retention of the catheter. No. 1162, Pte. W. Hutton, age 28, service 4T9Z years, was admitted to hospital on 21st September under Dr. Morris'
care, suffering from stricture of the urethra apparently the result of an old gonorrhoeal attack. He had had also primary and secondary syphilis. Urine was passed guttatim and with much straining. Warm baths, alkalies, opiates, &c., had little effect. On the 24tli I passed a No. 1 silver catheter after much manipulation and difficulty through three tortuous and disThe tinct strictures, drawing off a quantity of urine. catheter was retained in the bladder for some hours and then removed. On the 26th I passed a No. 2, and on the 28th got in a No. 3 into the bladder. It was fixed in position with orders not to have it removed until the following morning : a sedative was administered. Next day he had fever, night temperature, rigors, pain above the pubes and in the periiiEeum ; afterwards passing blood and subsequently a thick piu-ulent discharge through the urethra. Was ordered hip baths, stupes over pubes and to perinasum, sedatives, alkalies, tincture of hyoscyamus in infusion of buchu, barley water ad libitum. Under this treatment the febrile symptoms subsided and the urine beca me again clear. He had afterwards large doses of iodide of potassium. On October 2nd it is noted that the water passed in a fairly good stream. The symptoms of cystitis have now
disappeared.
VIII.?Gluteal Abscess followed by recovery. Mr. 0. B., a Commissariat Clerk, was admitted to hospital on the 6th January, suffering from a large gluteal abscess of the left side. Tongue very foul ; swelling hard and brawny. Ordered a bitter stimulating mixture, milk diet, beef tea ; poppy fomentation and poultices to be applied over the swelling. On the 13th fluctuation was very evident. 1 opened the abscess on the 16th and evacuated a quantity of red, grumous, unhealthy pus. 23rd.?A great deal of heat, swelling and pain in the right knee-joint; discharge profuse. 25th.? Evening temperature 101'2? ; tongue red and glazed ; abscess burrowing; a good deal of sanious oozing with small clots. Taking bark and ammonia. 29th.?TonguQ cleaner ; temperature down to 99? ; pus more natural and healthy looking. 31st.?"Decreasing in quantity but evening temperature 101?, morning 98?.
February 11 th.?Very little discharge, tongue cleaner ; still having evening exacerbations of temperature ; on 10th as high as 103?. 13th.?Complains of pain in right hip; no inflammatory swelling in that situation. 22nd.?Some tenderness and swelling in hip ; evening temperature 102?. Had also an abscess in the left hip which was opened. Looking weak and anaamic ; muscles of right thigh shrunk. 16?A March.?Opened a large abscess in the right hip (1 lb. 9 oz.) A good deal of tenderness in lumbo-sacral articulation. Following evening pulse 84, evening temperature 99-6?; has become very thin. Taking eggs, brandy, extra soup, milk, quinine?25 grains daily ; slight fever every evening. 19th.?Diarrhoea ceased, passed a semi-solid stool ; morning temperature 983, pulse 76 ; very restless at night; small bed-sore forming on left hip ; ditto 23rd.?Matter on right. forming in right knee, which is glazed and red. April 2nd.?Abscess forming over right scapula; occasional diarrhoea and sleeplesness ; sinuses injected with carbolic lotion. 26th.?Only two or three ounces of matter coming away daily ; case transferred to Dr. Morris' care. Had a rigor yestferdav ; temperature 101-2?. Ordered sulphate of iron. 30th.?Diarrhoea again ceased, sleeps fairly May 5th.?A small quantity of pus only oozing away. 9th. ?Great pain in left leg, swollen in entire length owing to phlebitis?raised and fomented. 12th.?Swelling decreased considerably. 20th.?Improving but cannot move the leg. 29th.?Another abscess at back of right thigh ; poulticed. From this date the patient improved slowly, and was discharged after his severe illness on the 10th July, after a stay of six months in hospital. He is again employed in the Commissariat Office. The muscles have regained a good deal of their former strength, and he is able to walk and ride without difficulty. In walking there is a slight drag in the right leg only. Station Hospital, Banikhet, 26th November 1881,
J
[January 2,
1882.
SOME SURGICAL OPERATIONS AND OTHER CASES. By Surgeon-Major Albert A. Gore, M.
x]
I.-.A Case
of
D.,
A. M. D.
Laryngo-tracheotomy.
Denis Sullivan, 65th Foot, Army, age 41, service 20}^ years, a worn-out man looking much older than his reputed age. Appears to have suffered from bronchitis at Devonport in 1871, and afterwards 29 days for pleurisy in the same year ; shortly after this he proceeded to India, where he landed on the 11th November. Served at Agra, Lucknow. Hazaribagh, and Morar, from which station he was invalided to Ilanikhet for change owing to general debility. On the march up from Moradabad he contracted measles from some children of the " Details" and was admitted to hospital and immediately isolated. This was on the 19th April, (he was discharged on the7th May.) The rash was general, characteristic with attending bronchial symptoms. Was treated with diaphoretics, Compound Tincture of camphor, poultices to chest, and afterwards ordinary expectorant mixture. He was not again in hospital until the 5th of November, when he was admitted into Dr. Morris's division with symptoms of bronchitis. Had constant, cough, pain in chest, restlessness, dry rhonchi and frothy mucus, with difficulty brought up. Was treated with expectorant mixture, to each dose of which 10 grains of nitrate of potash were added ; linseed poultice to chest. On the 10th 3 ss Vinum ipecacuanhas was added to each dose, and on the 12th Tartar emetic made up in pills with Extract of gentian was prescribed. There was some liuskiness of voice on admission which gradually increased with the difficulty of breathing. There was also great anxiety and spasmodic exacerbations. Had little or no sleep, and had to be propped up with pillows. Larsre doses of Bromide of potassium alone or combined with chloral afforded no relief. The cough became brassy and harsh, and the stridor and breathing most distressing to listen to. The dull percussion note over the base of both lungs posteriorly and low down, tubular breathing, viscid, rusty and adherent sputum showed that the substance of that portion of the lungs was becoming involved in addition. The patient was evidently becoming feebler ; paroxysms of difficulty of breathing occurred as the laryngeal obstruction increased. Turpentine stupes by means of spongio-piline were now constantly applied to the throat and chest, and the failing strength supported by wine and essence of beef, &c. Medicated vapours were constantly inhaled, and the temperature of the ward raised, and also kept moist by vessels of boiling water. On the night of the 17th he had a violent spasmodic attack followed by an extreme state of collapse, which nearly proved fatal. From the long and wheezing inspirations and movements of the chest, it was clear that respiration was performed with the utmost difficulty. The percussion note over the front of the chest was clear, but the respiratory sounds harsh and sonorous. No abnormal cardiac sound. Pulse 135, On the morning of the 18th the patient weak and feeble. No.
697, Pte.
seemed to me somewhat easier: the pulse had fallen to 112. The Roman Catholic clergyman had been with him. I left hospital a few minutes after noon, and had just finished breakfast when at 1-10 P. M. I was recalled. Durabsence the had ing my laryngeal symptoms suddenly become worse, the breathing at last ceased entirely, and the man became completely asphyxiated. As the pulse was still faintly perceptible at the wrist. Mr. Barrett, the apothecary, resorted to artificial respiration. After some time his efforts were rewarded by a long drawn and loud whistling respiration as the air was drawn through the closely approximated chink of the rima glottidis. When I arrived shortly afterwards, the condition of the patient, was most distressing. He was in a state of semi-collapse and breathing with the utmost difficulty; the countenance sunken and covered with a cold sweat. It was evident that life must speedily become extinct if operative measures were not immediately resorted to. The instruments being ready at the bedside, I proceeded at once to operate, assisted by Mr. Bra.lley and the Hospital Apprentices Messrs. Forrester and Neile. The bed was drawn in front of the window, the patient's head lowered, and this troublesome and often difficult and dangerous operation commenced by making a superficial incision in the median line over the upper rings of the trachea,, which was deeply situated owing to the short neck and high shoulders of the patient. The parts on either side retracted by means of aneurism needles held by were The intervening tissues Messrs. Bradley and Forrester. were separated as much as possible by the left index finger until the upper rings of the trachea were felt; these were then divided by the scalpel and the incision extended into the cricoid cartilage. During this stage some venous haemorrhage occurred and welled up out of the wound, but was quickly checked by a few applications of the cold sponge. The canula was inserted, through which immediately whizzed a quantity of air, blood and mucus. The relief to the patient He now breathed without was immediate and perceptible. difficulty, took some wine and beef tea ; the face became more life-like and less humid. For some minutes blood and mucus continued to come through the canula. This soon ceased, and it was afterwards kept clear by the insertion of a feather at intervals, and at no time subsequently became closed. I remained with the man until 3-30 P.M. A subordinate medical officer was told off for duty at intervals of two hours. Dr. Green visited the patient at 5 p. M , we saw him together at 7. He was breathing freely through the canula 5 wine, brandy and essence of beef had been taken at regular intervals without difficulty, but it was evident that he was sinking from exhaustion. The pulse was weak, 160. He was quite conscious, and indicated his desires by signs. He sank and died quietly at 8-30 P. M. On the 21st October I had made a careful inspection of the " Details in their barracks, and had certified this man among, others as fit to proceed to the plains, for which they were to leave on the 15th November. He then seemed well, and complained of no bronchial symptoms. His wife however appeared to think that he had never quite got over his attack of measles.
"
Towards the end of October the weather had turned sudafter sunset, when the reduction of temperature was marked and immediate. Soldiers are proverbially careless, and it is probable that he then contracted a chill which rested upon his weakest part.
denly cold, especially
The immediate results of the operation were the prolongation of life for some hours, the relief of urgent and most distressing symptoms, and time being given him to dispose of his property by will,?some three or four hundred rupees. His case is only one other exemplifying the well-known law so ably worked out by the late Dr. Bryden, that the tendency is rather towards death than life when old soldiers of 40 with acute disease in years of age and upwards are attacked India. The fact of his having contracted measles at so late a period of life is of interest. Such cases are. I believe, very An interesting case of this kind is noted in the uncommon. " Historical Records" of the Military Prison, Dublin, by Mr. Tufnell, where an adult prisoner, forty-Jive days after admission to that Institution, was attacked with measles which ran its usual course. A near relative of one of the medical officers here, I am informed, suffered from this disease at an advanced period of life. _
January 2,
A
1882.]
II.?Two Cases
of
MIRROR OF HOSPITAL PRACTICE.
Fistula in ano successfully
OPERATED ON.
No. 2411,Pte.W. H. Hickman, 30th Regiment, age 20, service
1A
years, was admitted to Hospital on the 13th March of the present year with a view to being operated upon. The previous history of his case presents some features of interest. On the 22nd of the previous October he had come under Dr. Gallwey's care suffering from gonorrhoea. I took over charge of the patient on the loth November. For some days lie had had slight fever for which he was given quinine : he then had a complete fistula. On the evening of the 14th the evening temperature was 104'. He had afterwards diarrhoea, rose spots, iliac tenderness, haemorrhage from the bowels, and went through a regular attack of enteric fever ; the temperature falling to normal on the 21st day. Became afterwards so exceedingly stout that he could with difficulty button his tunic. Th "fistula followed upon a small abscess which formed to the left of the anus ; a probe passed into the bowel from which wind and matter were conveyed to the external opening. In the operation 1 could not use the director supplied in the pocket case, as it could not be bentInserting a silver probe through the external opening and the left index finger into the anus, the patient being brought to the edge of the bed lying on his right side, I brought down the end of the probe through the anal aperture and divided the intervening tissues and sphincter with the curved bistoury. The small amount of bleeding was checked by wet lint. The wound was dressed with carbolic oil on lint. The wound healed from the bottom and the patient made a good recovery. He is now at his duty. Some years before I bad to treat a double fistula in ano at Ferozepore, one of the worst I have seen. It occurred in the person of a Driver of the Royal Artillery (4-5), a stout, healthy looking man. It followed upon a large anal abscess for which there was no apparent cause. The fistulas were complete and accompanied by much surrounding inflammation, a variety of injections and local applications were used with no effect whatever. Assisted by Mr. Slater, my apothecary, I operated on the right side only, pushing a silver director through the bowel, bending it through the anus and dividing the sphincter. The wound was nearly healed in April, when be was sent to Dalhousie for change, and returned in six months much improved in general health. Both fistulas were completely healed and he returned to his duty as a driver. III.?Incised Wound of Wrist. ?
No. 426, Drummer W. Righey, age 19, service 5 years, was admitted to hospital on the 1st January of the present year with a severe and jagged wound of the left wrist. He was brought to hospital after my evening visit; I was called to see him at 7 p. m. ; he was then smelling strongly of liquor. The injury was caused by falling through a window and thrusting the hand through one of the panes. There was a considerable venous haemorrhage. The superficial ulnar veins and filaments of the internal cutaneous nerves were completely divided, as well as the tendons of the superficial flexors, going on to be inserted into the little, ring and middle fingers. The tendons were turned backwards and bung out of the wound ; the ulnar artery and vein had escaped. The forearm was raised, the tendons carefully replaced in their original position, and the parts brought together by suture and enveloped in carbolic dressing. The wrist and hand were next flexed as much as possible on the forearm and kept in that position by long strips of plaster encircling the arm above the elbow ; the forearm was also flexed upon the arm and kept in that position, by which means all tension was taken off the sutures and the parts kept in perfect apposition. On the 5tli January the dressing was removed and re-applied without disturbing the position of the hand. The wound was again dressed on the 13th, when black wash was substituted for carbolic oil. The following note is made in my Case Book under date 11th February :? "Wound quite healed; tendons joined ; no loss of motion or sensation". March 6th.?" Perfect motion of joint and flexure of fingers." The man since then has been at his duty. IV.?Large Fibro-Cellular Tumour. Some months ago when visiting the Charitable Dispensary, my attention was called by the native doctor to a woman who had come in to be operated upon. She walked into the Female Ward apparently without difficulty. On making an examination I found alarge pendulous tumour, convoluted
11
and with two separate hemispheres. It would be exactly described if one could imagine a brain with a dark surface hanging from the vagina. There was a distinct pedicle about two inches or more in circumference. The tumour seemed to be an enormous hypertrophy of the left labia minora. After removal it was found to weigh 21bs 12oz.' The woman, a healthy and rather good looking young person, stated that it had been growing for five years. All sexual intercourse must have been impossible. Aided by the native doctor Kumroop and his assistant, after administering chloroform, I transfixed the pedicle with a needle to which was attached a strong double ligature. On the needle passing through the ligature was cut close to the eyelet; the ends were drawn tightly together and either halves of the pedicle strangulated. The pedicle was then immediately divided by the scalpel below the ligatures. Two arteries required to be ligatured. The surface was lightly touched with the actual cautery, and afterwards with perchloride of iron and dressed with a saturated solution of alum. There was not very much haemorrhage. In a few days carbolic dressing was applied, and not long afterwards the patient left the hospital, having made a good recovery. The tumour on section was found to be of a fibro-cellular and fatty nature with a dark convoluted border. V.?Removal op a Stone from the Female Bladder. Calculus in the male is common enough in India, but cases occurring in females do not so often come under observation. Shortly after the above operation I was called to see a woman at the dispensary, who was suffering from vesical symptoms, much irritability of the bladder, pain during and after mic-
turation, and intermittent flow of urine.
The sound at once detected the presence of a calculus. I had no means of rapidly dilating the urethra, and had to resort to a large forceps for the purpose of extraction. I found no difficulty in grasping the stone, but could not get it through the urethral canal. It is generally laid down in such cases that the stone should be either broken up or removed through the floor of the vagina ; as it was evident, however, that only a slight enlargement of the urethra was required, I effected this end by a small incision in the urethra on the left side, after which the calculus was easily removed,?a pretty large one of the phosphatic formation. The woman recovered in a few days (next day I actually found her sitting in the verandah) ; no incontinence of urine followed. VI.?A case of Arm Presentation".
Midwifery cases do not often come into a dispensary, probably only whan the cases are
charitable so serious all efforts on the part of the native hakims have after this I had a abortive. note from Shortly proved my native doctor (Kumroop), fttating that a Mahomedan woman had been brought to the hospital in labor, and that the hand was projecting out of the vagina. I rode down and found that she appeared to be at her on examining the patient full time, and saw just projecting between the vulva the small fingers of the child : the funis had also prolapsed. Having put the woman under the influence of chloroform, I proceeded at once to turn the child. With some difficulty I inserted the right hand and arm into the uterus, pushing well up towards the fundus and managed to get hold of a foot which was carefully brought down, encircled by a bandage and kept in position by my native assistant: my arm After was quite numbed by the strong grasp of the uterus. a minute or two I inserted it again ; in a little while got hold of the other foot, extricating it while at the same time pushing up with the left hand the presenting arm. The feet were now tied together, the child turned without much difficulty and quickly extracted. As soon as the patient got from under the influence of chloroform, the pulse became irregular, the respirations shallow, and the respiration and pulse finally ceased almost entirely. The body was immediately inverted by an attendant jumping on the table and raising the legs and feet; two large pillows were placed under the buttocks, cold water dashed on to the face and chest, and ammonia applied to the nostrils ; by these and other measures resorted to the woman at last came round, a few long inspirations being the first signs of returning animation. With some difficulty I now got her to swallow a draught containing ether, ammonia and rum. The placenta was retained, but only in the vagina, from which it was easily removed. She was now given a dose of ergot and kept qui6t. that
12
She the
THE INDIAN MEDICAL GAZETTE.
?
recovered
dispensary
completely without in due course.
a
bad
symptom,
and left
VII.?Cystitis following retention of the catheter. No. 1162, Pte. W. Hutton, age 28, service 4T9Z years, was admitted to hospital on 21st September under Dr. Morris'
care, suffering from stricture of the urethra apparently the result of an old gonorrhoeal attack. He had had also primary and secondary syphilis. Urine was passed guttatim and with much straining. Warm baths, alkalies, opiates, &c., had little effect. On the 24tli I passed a No. 1 silver catheter after much manipulation and difficulty through three tortuous and disThe tinct strictures, drawing off a quantity of urine. catheter was retained in the bladder for some hours and then removed. On the 26th I passed a No. 2, and on the 28th got in a No. 3 into the bladder. It was fixed in position with orders not to have it removed until the following morning : a sedative was administered. Next day he had fever, night temperature, rigors, pain above the pubes and in the periiiEeum ; afterwards passing blood and subsequently a thick piu-ulent discharge through the urethra. Was ordered hip baths, stupes over pubes and to perinasum, sedatives, alkalies, tincture of hyoscyamus in infusion of buchu, barley water ad libitum. Under this treatment the febrile symptoms subsided and the urine beca me again clear. He had afterwards large doses of iodide of potassium. On October 2nd it is noted that the water passed in a fairly good stream. The symptoms of cystitis have now
disappeared.
VIII.?Gluteal Abscess followed by recovery. Mr. 0. B., a Commissariat Clerk, was admitted to hospital on the 6th January, suffering from a large gluteal abscess of the left side. Tongue very foul ; swelling hard and brawny. Ordered a bitter stimulating mixture, milk diet, beef tea ; poppy fomentation and poultices to be applied over the swelling. On the 13th fluctuation was very evident. 1 opened the abscess on the 16th and evacuated a quantity of red, grumous, unhealthy pus. 23rd.?A great deal of heat, swelling and pain in the right knee-joint; discharge profuse. 25th.? Evening temperature 101'2? ; tongue red and glazed ; abscess burrowing; a good deal of sanious oozing with small clots. Taking bark and ammonia. 29th.?TonguQ cleaner ; temperature down to 99? ; pus more natural and healthy looking. 31st.?"Decreasing in quantity but evening temperature 101?, morning 98?.
February 11 th.?Very little discharge, tongue cleaner ; still having evening exacerbations of temperature ; on 10th as high as 103?. 13th.?Complains of pain in right hip; no inflammatory swelling in that situation. 22nd.?Some tenderness and swelling in hip ; evening temperature 102?. Had also an abscess in the left hip which was opened. Looking weak and anaamic ; muscles of right thigh shrunk. 16?A March.?Opened a large abscess in the right hip (1 lb. 9 oz.) A good deal of tenderness in lumbo-sacral articulation. Following evening pulse 84, evening temperature 99-6?; has become very thin. Taking eggs, brandy, extra soup, milk, quinine?25 grains daily ; slight fever every evening. 19th.?Diarrhoea ceased, passed a semi-solid stool ; morning temperature 983, pulse 76 ; very restless at night; small bed-sore forming on left hip ; ditto 23rd.?Matter on right. forming in right knee, which is glazed and red. April 2nd.?Abscess forming over right scapula; occasional diarrhoea and sleeplesness ; sinuses injected with carbolic lotion. 26th.?Only two or three ounces of matter coming away daily ; case transferred to Dr. Morris' care. Had a rigor yestferdav ; temperature 101-2?. Ordered sulphate of iron. 30th.?Diarrhoea again ceased, sleeps fairly May 5th.?A small quantity of pus only oozing away. 9th. ?Great pain in left leg, swollen in entire length owing to phlebitis?raised and fomented. 12th.?Swelling decreased considerably. 20th.?Improving but cannot move the leg. 29th.?Another abscess at back of right thigh ; poulticed. From this date the patient improved slowly, and was discharged after his severe illness on the 10th July, after a stay of six months in hospital. He is again employed in the Commissariat Office. The muscles have regained a good deal of their former strength, and he is able to walk and ride without difficulty. In walking there is a slight drag in the right leg only. Station Hospital, Banikhet, 26th November 1881,
J
[January 2,
1882.
