SOME SURGICAL CASES Treated in the

Sambiiu Nath Pandit Hospital, Calcutta. By D. G.

CRAWFORD, M.B., MAJOR, I.M.S.,

Otficiating Civil Surgeon, 24-Parganas, Case No. 1. Fracture of leg and wound of foot.?Sheikh Amir Jan, Mussalinan male, 2(5, was brought to hospital on 25th July 1898 in

He said that, about noon that the afternoon. when carrying a drum of jute about 2 maunds in weight, it fell upon his right leg. There was a simple fracture of both tibia and fibula, a little above the ankle ; also a punctured wound, about inch in diameter, on the inner side of the right foot, from which arterial blood was flowing freely. The native doctor of the jute mill in which the accident occurred, who brought him to the hospital, stated that he had only been able to control the hemorrhage

day,

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1899.]

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police to hospital on 30th July 1898, suffering with lint soaked in from wounds on the back of the head, neck, left tinctnra ferri perchloridi, and bandaging it tightand hand, inflicted at her home, shoulder, ly. On the removal of this bandage and plug ICalkatola Abad in the Sundarbans, on the night the wound bled as freely as before. of the 28th July. She was not able to give any I was sent for to hospital to amputate the leg. account of herself, but her mother-in-law, who On first inspection I thought that amputation came with her, said that during the night she would be necessary, but after careful considera- had a quarrel with her husband, who attacked tion came to the conclusion that there was a her with a dliao. She was found to be suffering chance of saving the leg. The fractured bones from the following wounds:? were adjusted, and placed on a Maclntyre splint; A crescent-shaped wound on the left (1) the wound in the foot was thoroughly washed side of the back of the head, 3| inches lQDg> out, when it was found that the tarsal bones notching the occipital bone for 1^ inches. were extensively comminuted and plugged with (2) An incised wound, 6 inches long, gaping lint. inches wide, cutting through all muscles down 1| The next day the right foot was cold, and to across back of neck almost bone, several blisters had formed on it, which exuded from one extending ear to the other. reddish serum on being pricked. It seemed as (3) An incised wound, 2 inches long, one if gangrene of the foot were going to set in, and inch deep, beginning in the middle of the second the attempt to save the foot would fail. On the wound, and running below and parallel to that following day, however, the foot had regained wound. its natural warmth. The foot was dressed daily. (4) An incised wound, 3| inches long, half The patient suffered from fever, higher in the a,i inch below and running parallel to wound evening than the morning, for 14 days, 25th July No. 3, about one inch deep. to 7th August, the highest temperature being (5) An incised wound, 3 inches long, parallel 103? on 3rd August. For five days, 8th to 12th to and half an inch below wound No. 4, about August, the temperature remained normal, after an inch deep. which he had fever again, varying from 99 to (6) An incised wound over the supra-spinous 102 4, from the 13tli to the 16th. On the morn- fossa of the left 4 inches long, the ing of the 17th a large abscess, which had formed outer end gaping scapula, inches wide, and being so 1| on the outer side of the foot was opened, atid deep as to notch the bone, tailing off to a point about |ii pus evacuated. After this the case at the inner end. went on well, except that he passed dysenteric An incised wound, 2 inches long, gaping (7) stools on one day, 27th August, up to 16th inches wide, below the inner end of wound September. By that time the abscess which had No. G, cutting into the spine of the scapula, been opened on 17th August had healed, with the which was fractured. exception of a small sinus, which was laid open. (8 to 11) Four small incised wounds in the Dead bone was now felt in the wound on the space between the right scapula and the spine, inner side of the foot, and on 17th September, each from half an inch to one inch long, and skin under chloroform, the wound was enlarged, some loose pieces of dead bone removed, and the other deep. (12) An incised wound, 2 inches long, \ inch bones, which could be felt in the wound, scraped, on right side of nape of neck. deep, a quantity of dead bone being removed. On the (13) An incised wound, 3| inches long, on evening of 18th September the patient's tem- the right side of the back of the neck, dividing perature went up to 104?, and he had fever, more the pinna of the right ear and notching the or less, up to the evening of 22nd September. bone. From that date the case went on well, without (14) A scratch 4 inches long on left cheek. further complications ; and on 26th October he (15) An incised wound, one inch long, skin was discharged cured, with the wound healed, deep, on back of left hand, over metacarpal bone and walking fairly well upon the injured foot. of left thumb. Remarks.?In this case the Resident Surgeon (16) An incised wound, about 4 inches long, thought that amputation of the leg above the on back of left hand, reaching from the first fracture would be necessary ; and on first seeing of the middle finger to the ulnar side phalanx the case I thought so too. Afterwards, consiof the wrist, and dividing the metacarpal bones dering that there was just a bare chance of of the middle and little fingers, as well as ring saving the leg and foot, the patient of course got all the soft parts of the back of the hand, which the benefit of the doubt. After a somewhat prowas divided into two halves, connected by the tracted convalescence, he left hospital walking soft structures of the palm only. fairly well. The leg and foot were certainly The Resident Surgeon at once sent for me to not perfectly restored to their original strength amputate the left hand, while he set to work to as before the accident, but they were much more stitch up the wounds on the back of the head, useful than the best artificial substitute. neck, and shoulder. He had almost completed Case No. 2. Multiple incised wounds.? this task when I reached the hospital. It seemed Fudia, Hindu female, aged 20, was brought by the

by stuffing

the wound

i

?

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THE INDIAN MEDICAL GAZETTE.

to me that, if the woman survived the shock of her extensive injuries, there was a fair So, instead of chance of saving the hand. the I stitched wound, insertit, up amputating ing a drainage tube along the bottom of the wound. The wounds on admission were between 24 and 36 hours old (the exact hour of their infliction was not known), and were in a most filthy condition, having been plastered up with charcoal, which it was impossible completel}7 to clean away. The

patient

had

a

temperature

admission, and continued

of 102?

to suffer from

on

fever

for nine days, up to the morning of 7th August, the highest temperature being 102 4 on 31st July. On 5th August, several of the stitches in the wounds on the back of the head and neck

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tissue. It was amputated at the metacarpophalangeal joint. (2) Ring finger; all three phalangeal bones crushed and

and the soft tissues the palmar surface the wound extended from the linger 2 inches into the palm. The linger was amputated at the metacarpophalangeal joint. (3) Middle linger; a wound on inner side, 2h inches long ; the proximal and middle phalangeal bones were broken. The fractured fragments were removed, and the wound was stitched up. (4) Index finger ; there was a contused wound over the distal phalanx and the nail had been torn off. (5) A contused swelling on the back of the were

broken,

extensively lacerated;

on

hand.

hand and forearm. An abrasion, 2 inches long, on back of forearm. (7) Two abrasions on front of forearm. (8) Compound fracture of the radius, 3 inches above the wrist joint. (9) A transverse lacerated wound, 2J inches long, one inch above the wrist joint, communicating with the fracture of the radius. The ulnar artery was torn through. It was tied; and the wound stitched, after inserting a drainage tube. (10) A crescent shaped wound, about 3 inches long, from the middle of the palmar surface of the wrist to the top of the web between the thumb and index finger, raising a flap towards the thumb. A drainage tube was inserted and the wound stitched up. (11) The distal phalanx of the middle finger was crushed to fragments, and was amputated. (12) A wound, 2 inches long, on the dorsal surface of the index finger. It was stitched up. (13) A small wound on the distal phalanx of the ring-finger. (c) Head. (14) A cut, 1 inch long, skin deep, on the left side of the forehead. It was stitched up. I was absent from the station, on inspection duty, when this case was brought in, and did not see it till the 7th. The injuries were treated in the first instance by Assistant-Surgeon S. C. De, Resident Surgeon of the Hospital. The wounds of the right hand and of the head gave very little trouble, and healed kindly. It was very different with the much more severe injuries of the left forearm. The patient had fever continuously, the temperature only once failing to normal, on the 20th, and varying from 102 to 104 in the evenings. On the 9th August the left hand and forearm became cedematous, and on the lltli small blisters formed on the ing injuries:? forearm. A deep incision in the front of the (a) Right hand. forearm let out a quantity of pus, and the (1) The little finger was crushed to frag- patient's condition seemed to improve for the ments, and was hanging by a few shreds of soft next twenty-four hours; on the 14th another

having given way, transverse strapping was applied to keep the edges in apposition. On 12tli August all the stitches were removed from the wound in the hand; the drainage tube was removed on the 22nd. On 21st, and again on 29th August, small pieces of dead bone were removed from the wound over the spine of the scapula. The patient suffered again from fever?99?6 to 102'8?for 24 hours, on afternoon of 1st and morning of 2nd September. The wounds on the back of the head, neck, and shoulder had almost healed by 13th September, only a few small flat ulcers remaining, which were healed by the 30th September. The wound of the hand had completely and firmly healed on 9th October, but there was some stiffness and impairment of motion in the metacarpophalangeal joints of the left hand. On 10th October the patient was put under chloroform, and these joints were stretched, breaking down adhesions. On 17th October she was discharged cured. Remarks.?When I saw the condition of this patient on admission, suffering from 10 wounds, of which nine might be described as severe, all wounds inflicted more than 24 hours before, and full of dirt (charcoal), the patient also suffering from high fever, I had little hope of her recovery. After the first few days, however, she recovered with hardly a bad symptom. The hand, hanging in two halves, with metacarpal bones severed, looked worse than it really was, the soft structures of the palm, along with the principal blood supply of the parts, being intact. Case No. 3. Severe injuries of both hands. Gonesh, Hindu male, 27, admitted at noon on 5th August 1898, suffering from injuries sustained about half an hour before. He said that, in alighting from a moving tramcar, lie slipped and fell, and the hind wheel of the tramcar passed over both his hands, causing the follow-

(6) Left

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SOME SURGICAL CASES: CRAWFORD.

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mill in which he was employed. Some oozine to be made in the forearm, to of blood was coins: cn from this wound. The let out pus. On the 15th the arm above the arm was considerably swollen, but it was recogelbow became swollen and painful; a quantity nised that there were at least three fragments of ?f pus was let out by dee)) incision on thebone with two fractures. 17th, and a quantity of sloughing cellular tissue After admission he had fever continuously, the was removed from the same incision on the the 29th. on 18th. For the next two days he seemed tohighest temperature being 104'2 On that day the back of the left elbow was improve, and on the 20th his temperature fell swollen, and fluctuation being detected an into normal. On the 22nd, however, it was evi-cision was made, but only a little red serum dent that the attempt to save the arm had came From the 29th August to 2nd out. failed. On that day the lower end of the the September temperature was not so high, radius was found protruding from the wound On the between 99 6 and 102'4. on the front of the left forearm (No. 9), onfluctuating of 1st September the arm was very night removing the dressings, and the ulnar arterypainful, the took off his bandages and bled profusely. The bleeding was stopped. splints; the patient discharge was more profuse, and ?Amputation was advised, but the patient posi- the whole arm up to the shoulder was red and tively refused to consent, saying that he would rather die than lose his arm. On the 23rd his swollen. It became evident that the attempt to save the arm would fail, and that amputation temperature went up to 10-4 4, and the discharge from the arm was more offensive. On the 24th was necessary to save the patient's life. Accordingly, on the morning of 2nd September, the arm his friends removed him, against advice. I heard that he was taken to the Medical was amputated 2 inches below the shoulder joint. On cutting into the amputaCollege Hospital, a few days later, and that his / ted arm, it was found that the arm was amputated there; but it was then too humerus was longitudinally late to save his life, and he died two days after splintered from the middle the operation. downwards, the bone being Remarks.?This case lost his life owing to the fractured into no less than attempt to save his left arm and hand. Had five separate fragments, viz., his left forearm been amputated on first admisthe upper fragment, about sion, there is little doubt that the patient half of the whole bone ; two would have recovered. But on first admission separate splinters of the shaft; there seemed to be a fair chance of saving the and the lower fragment, also hand and arm. And into consideration taking fractured longitudinally down the crippled condition of his right hand, with the middle into two separate two fingers amputated, and a third of little use, The outer and inner. pieces, it was more important even than in an ordinary these two between fracture case to try to save the left hand. Had he been extended into the elbow pieces willing to submit to amputation on the 22nd, joint. The muscles of the when it became evident thatt he to save attempt whole arm were cedematous the arm had failed, the probability is that he and infiltrated with pus. would have recovered; but when he did conThe patient suffered severesent, five or six days later, it was too late. from shock, and his condily Case No. 4. Compound comminuted 7 fraction for the next twenty-four ture of left arm.?Gosai Laskar, Hindu male, hours after the amputation 23 was brought to hospital on the evening of cause considerable anxiety. 27th August, with a compound comminuted fracafter the operature of the left Immediately arm, and simple fracture of both tion was he bones of the left forearm. He stated that, about given a hypodermic of ether, and a hot 3 p.m. that injection day, he had got his left arm severely water twisted by some enema; while rum and stimulant mixture belting in which it become entangled, in the cotton mill in which he was were given every three hours. The skin was and clammy with perspiration, and the pulse pmploj'ed. lie had sustained the following cold small and compressible. However, he took very injuries:? (1) Simple fracture of left ulna, 1 inch above his food (milk and sago) well. On the wrist. morning of the 3rd he was much (2) Simple fracture of left radius, 2 inches better, the pulse having recovered strength. His above wrist. temperature rose to 100 6 in the evening, falling (3) Compound comminuted fracture of left to normal on the morning of the 4th. Next it was 99'6, but did not again rise humerus about its middle. There was a punc- evening tured wound at the middle of the outer side of above, normal. On the Gth he passed urine in his and on the 11th passed stools in the arm, evidently made by a sharp fragment his bedclothes, of broken bone. bedclothes.On the 15th he developed two The protruding point of bone small the sacrum, which had had been reduced over bedsores by the Native Doctor of the

incision had

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THE INDIAN MEDICAL GAZETTE.

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healed by the 20th. From the 7th to the 17th he was unable to pass water naturally, and the bladder had to be relieved by catheter. Otherwise his progress was uneventful, and he was discharged cured on 22nd October. When 1 was inspecting the mill in which the accident took place., on 27th October, he came to see me. He was then well and jolly, and had been given some light work, such as a one-armed man could do, in the mill. Remarks.?In this case of course the proper treatment would have been amputation of the arm on first admission, had it been recognised to what an extent the left humerus was splintered. The arm, however, being much swollen, this not diagnosed; and the external wound was being very small, a mere puncture, it was hoped that there was a fair chance of saving the arm. The attempt to do so nearly cost the man his life ; in the end, however, the result of the case was

satisfactory.

contrast to the above cases the following may be briefly described, in which the injuries, though certainly somewhat less severe, were very similar, but recovery was rapid and uninterrupted :?B. N. Paramanick, Hindu male 22, was admitted on 3rd December, 1898, suffering from a compound comminuted fracture of the right humerus, caused by a mill accident. The humerus was fractured in two places, 2 and 4^ inches respectively, above the elbow joint. The sharp end of the lowest fragment of bone had penetrated the skin of the inner side of the arm, making the fracture compound. This wound was healed by the 8th, and the fractures had soundly united by the 20th December ; the patient never having any rise of temperature, nor showing a bad symptom. Case No. 5. Wounds of throat.?Sahadut Hossein, Mussalman male, 27, was brought by the police on the afternoon of 1st August 1898. He stated that while he was sleeping, between two and three that afternoon, he was awakened by feeling some one cut his throat, and pointed to Inait Hosain (Case No. 0) as his assailant. He had a horizontal wound, 3? inches lon

Surgical Cases: Treated in the Sambhu Nath Pandit Hospital, Calcutta.

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