MAYO HOSPITAL, LAHORE. CASES Treated
by Surgeon-Major T. E. B. Bsown, Principal, Lahore College. A
CASE OF CUT THROAT.
\
Soorfe Ram, a Hindu, aired about 40 years, was admitted into the Mayo Hospital at. Lahore about the 19h!i of November 1875, suffering from an incised wound of the throat. He stated that ten days before his admission some person came into his house by night, and inflicted a severe wound on his throat witii a sword, that there was immediately profuse bleedins;, and that he fainted. When lie recovered his senses he found that the bleeding had ceased, but. he was extremely weak and everything that he swallowed came out through the wound
again.
Ou examination,
a
wound, about three inches in length,
was
the thyro-hyoid membrane into the had not injured either of the carotid arteries, but when the man attempted to drink, most of the liquid swallowed poured out of the wound again, and when he breathed or spoke, the air could be felt to pass out of it. There was no disease of the lungs nor any fevfrishness. As the patient was evidently suffering from inanition owing to an insufficient quantity of nourishment entering the stomach, it was determined to try to close the wound ; chloroform was administered and two silver wire sutures inserted 011 either side near the angles of the wound, thus reducing it to about one inch and a half in extent. Then a bandage was passed round the head, and connected with tapes with another passed round the chest underneath the armpits, so as to bend the head towards the chest, and to approximate the upper and lower edges of the wound. The central portion was not closed for fear of producing suffocation by food getting into the larynx, but it was found that after these arrangements very little liquid escaped through the wound, when the patient drank. The wound was then washed with a weak solution of carbolic acid 1 part to 40 of water, a grain of opium was given, and a diet of milk alone ordered. The next day lie stated that he suffered less from hunger than before, but the milk still passed from the wound 011 drinking and the bandage had shifted a little during the night. A cap vtas therefore made to fit his head, with three long strings fastened to its front border, and these were tied in front of the chest to the bandage beneath the armpits, so as to keep the head flexed and the wound closed. High pillows were also adjusted for the same purpose, and an attempt was made to close the wound by a pad of lint, but when he begun to drink, the water passed into the larynx and caused cough. The pad was therefore removed, and only a single layer of lint, soaked in carbolic acid and oil, was applied. This treatment was continued for a fortnight and the size of the wound was gradually reduced, and the patient improved in health and strength, bur, the sutures then began to give considerable pain, and ulceration occurred in one of the puncturesthey were therefore removed and the head buudnge tightened. The little ulcer caused by the suture soon lieaied, and riie wound greatly diminished, so that only one or two urous of
extending through pharynx. The incision seen
74
THE INDIAN MEDICAL GAZETTE.
wafer
escaped when the man swallowed it. Two more sutures then applied nearer the centre of the wound, and the cap and bandage adjusted as before. In this way the wound by the 15t.ii of December was reduced to the size of half an inch, and on the 20th of December it was found that the incision into the pharynx had quite healed, so that the patient could drink fluids without a single drop coining out of the cut. He continued to improve and the external wound to fill up till the 8th of January 1876, when the wound was nearly liealed and he left the hospital at his own request. This case is of interest from the severity of the wound inflicted, the whole of the air passage and part of the pharynx being divided, and it was very fortunate that the carotid arteries escaped injury, as otherwise it would probably have been fatal. The severe haemorrhage which occurred at first was caused by division of the branches of the superior thyroid vessels, and the loss of blood caused the man to faint, during which time the arteries seem to have contracted and closed, but he was afterwards so exhausted by the bleeding and inability to swallow sufficient nourishment, that he appeared likely to die from gradual starvation, and I had resolved to introduce a tube into the oesophagus, if the wound would not readily close. This fortunately was unnecessary, as it would have retarded the union of the deep-seated parts. were
\
FRACTURE OF THE SPINE REDUCED UNDER CHLOROFORM : RECOVERY. Gulabi, a Mahomedan woman, aged about 32 years, was admitted into the Lahore hospital, on the 1(> of December 1875, suffering from complete paralysis of both lower extremities. She stated that she was quite well on the previous morning, but that she fell off the roof of a two-storied house, aud when taken up she was unable to stand or move her legs. On examination a decided angular projection was seen at the sixth dorsal vertebra with a marked protrusion backwards of the spinous process. Intense pain at the injured part was complained of, and the patient was quite unable to move her legs in the least, and the skin was not sensitive to impressions in either of the lower extremities, nor could any reflex movement be excited by tickling the soles of the feet. From these symptoms it was concluded that a fracture of the body of the seventh dorsal vertebra had occurred, and that the lower fragment was pressing on the spinal cord, and it For this purwas resolved to attempt to remove this pressure. pose chloroform was administered and gentle traction made by Dr. Neil on the feet, while the shoulders were drawn upwards ; after a short time crepitus was distinctly felt and the projection was much reduced. Both the legs were then bandaged up. to the knees in such a way that a stirrup-like projection was left below each foot through which a cord was passed and placed over a pulley, a weight of ten pounds being suspended at the end of the cord. A bandage was placed also round the upper part of the chest and fastened to the head of the bed on each side. An opiate was then given, and the urine drawn off by a catheter, as it could not be passed by her own efforts. On December 17th, the paiu was found to be greatly diminished, and some sensation was felt in the left foot when pinched, but the urine was still retained and it required the use of a catheter to draw it off, but she could move the toes of The extension by the weight was still the left foot a little. continued, and an air bed was placed beneath the patient to prevent bedsores if possible. The pain in the back ceased after a few days, but the paralysis scarcely improved, and on the 28th of December a bedsore was found to have formed over the sacrum, and she complained of great pain in the legs and hyperaestliesia of the right thigh. Bromide of potassium was then given in doses of 20 grains, three times a day, and a poultice applied to the ulcer. This greatly lessened the pain. On the 7th of January she was found to have regained the power of bending the left hand, and the sensibility was restored in both feet. The extension by the weight was now removed, and she was told to be on the side to remove pressure from the bedsore. A current of electricity was now applied to the muscles of the affected limbs daily, and the power of motion gradually increased, so that on the 29th of January she could draw up both legs, and also extend them slowly and she had regained the power of passing urine. On the 1st of February she left the hospital at her own request, greatly improved, but had not quite recovered.
[Maech I,
1876.
The above case shows the advantage of extension in cases of fracture of the spine. The injury had evidently been a very severe one, and if left to itself it appeared probable that the pressure on the spinal cord would result in complete destruction of the nervous tissue, leading to total paralysis of all the body below the injury, but the gradual recovery which occurred after the prolonged use of extension was very satisfactory. The bromide of potassium was given principally to diminish the pain and liyperaesthesia which occurred, and this it appeared to do very completely. Electricity was not used till it was certain that mvtscular power had returned to the limbs.
by Surgeon-Major T. E. B. Bsown, Principal, Lahore College. A
CASE OF CUT THROAT.
\
Soorfe Ram, a Hindu, aired about 40 years, was admitted into the Mayo Hospital at. Lahore about the 19h!i of November 1875, suffering from an incised wound of the throat. He stated that ten days before his admission some person came into his house by night, and inflicted a severe wound on his throat witii a sword, that there was immediately profuse bleedins;, and that he fainted. When lie recovered his senses he found that the bleeding had ceased, but. he was extremely weak and everything that he swallowed came out through the wound
again.
Ou examination,
a
wound, about three inches in length,
was
the thyro-hyoid membrane into the had not injured either of the carotid arteries, but when the man attempted to drink, most of the liquid swallowed poured out of the wound again, and when he breathed or spoke, the air could be felt to pass out of it. There was no disease of the lungs nor any fevfrishness. As the patient was evidently suffering from inanition owing to an insufficient quantity of nourishment entering the stomach, it was determined to try to close the wound ; chloroform was administered and two silver wire sutures inserted 011 either side near the angles of the wound, thus reducing it to about one inch and a half in extent. Then a bandage was passed round the head, and connected with tapes with another passed round the chest underneath the armpits, so as to bend the head towards the chest, and to approximate the upper and lower edges of the wound. The central portion was not closed for fear of producing suffocation by food getting into the larynx, but it was found that after these arrangements very little liquid escaped through the wound, when the patient drank. The wound was then washed with a weak solution of carbolic acid 1 part to 40 of water, a grain of opium was given, and a diet of milk alone ordered. The next day lie stated that he suffered less from hunger than before, but the milk still passed from the wound 011 drinking and the bandage had shifted a little during the night. A cap vtas therefore made to fit his head, with three long strings fastened to its front border, and these were tied in front of the chest to the bandage beneath the armpits, so as to keep the head flexed and the wound closed. High pillows were also adjusted for the same purpose, and an attempt was made to close the wound by a pad of lint, but when he begun to drink, the water passed into the larynx and caused cough. The pad was therefore removed, and only a single layer of lint, soaked in carbolic acid and oil, was applied. This treatment was continued for a fortnight and the size of the wound was gradually reduced, and the patient improved in health and strength, bur, the sutures then began to give considerable pain, and ulceration occurred in one of the puncturesthey were therefore removed and the head buudnge tightened. The little ulcer caused by the suture soon lieaied, and riie wound greatly diminished, so that only one or two urous of
extending through pharynx. The incision seen
74
THE INDIAN MEDICAL GAZETTE.
wafer
escaped when the man swallowed it. Two more sutures then applied nearer the centre of the wound, and the cap and bandage adjusted as before. In this way the wound by the 15t.ii of December was reduced to the size of half an inch, and on the 20th of December it was found that the incision into the pharynx had quite healed, so that the patient could drink fluids without a single drop coining out of the cut. He continued to improve and the external wound to fill up till the 8th of January 1876, when the wound was nearly liealed and he left the hospital at his own request. This case is of interest from the severity of the wound inflicted, the whole of the air passage and part of the pharynx being divided, and it was very fortunate that the carotid arteries escaped injury, as otherwise it would probably have been fatal. The severe haemorrhage which occurred at first was caused by division of the branches of the superior thyroid vessels, and the loss of blood caused the man to faint, during which time the arteries seem to have contracted and closed, but he was afterwards so exhausted by the bleeding and inability to swallow sufficient nourishment, that he appeared likely to die from gradual starvation, and I had resolved to introduce a tube into the oesophagus, if the wound would not readily close. This fortunately was unnecessary, as it would have retarded the union of the deep-seated parts. were
\
FRACTURE OF THE SPINE REDUCED UNDER CHLOROFORM : RECOVERY. Gulabi, a Mahomedan woman, aged about 32 years, was admitted into the Lahore hospital, on the 1(> of December 1875, suffering from complete paralysis of both lower extremities. She stated that she was quite well on the previous morning, but that she fell off the roof of a two-storied house, aud when taken up she was unable to stand or move her legs. On examination a decided angular projection was seen at the sixth dorsal vertebra with a marked protrusion backwards of the spinous process. Intense pain at the injured part was complained of, and the patient was quite unable to move her legs in the least, and the skin was not sensitive to impressions in either of the lower extremities, nor could any reflex movement be excited by tickling the soles of the feet. From these symptoms it was concluded that a fracture of the body of the seventh dorsal vertebra had occurred, and that the lower fragment was pressing on the spinal cord, and it For this purwas resolved to attempt to remove this pressure. pose chloroform was administered and gentle traction made by Dr. Neil on the feet, while the shoulders were drawn upwards ; after a short time crepitus was distinctly felt and the projection was much reduced. Both the legs were then bandaged up. to the knees in such a way that a stirrup-like projection was left below each foot through which a cord was passed and placed over a pulley, a weight of ten pounds being suspended at the end of the cord. A bandage was placed also round the upper part of the chest and fastened to the head of the bed on each side. An opiate was then given, and the urine drawn off by a catheter, as it could not be passed by her own efforts. On December 17th, the paiu was found to be greatly diminished, and some sensation was felt in the left foot when pinched, but the urine was still retained and it required the use of a catheter to draw it off, but she could move the toes of The extension by the weight was still the left foot a little. continued, and an air bed was placed beneath the patient to prevent bedsores if possible. The pain in the back ceased after a few days, but the paralysis scarcely improved, and on the 28th of December a bedsore was found to have formed over the sacrum, and she complained of great pain in the legs and hyperaestliesia of the right thigh. Bromide of potassium was then given in doses of 20 grains, three times a day, and a poultice applied to the ulcer. This greatly lessened the pain. On the 7th of January she was found to have regained the power of bending the left hand, and the sensibility was restored in both feet. The extension by the weight was now removed, and she was told to be on the side to remove pressure from the bedsore. A current of electricity was now applied to the muscles of the affected limbs daily, and the power of motion gradually increased, so that on the 29th of January she could draw up both legs, and also extend them slowly and she had regained the power of passing urine. On the 1st of February she left the hospital at her own request, greatly improved, but had not quite recovered.
[Maech I,
1876.
The above case shows the advantage of extension in cases of fracture of the spine. The injury had evidently been a very severe one, and if left to itself it appeared probable that the pressure on the spinal cord would result in complete destruction of the nervous tissue, leading to total paralysis of all the body below the injury, but the gradual recovery which occurred after the prolonged use of extension was very satisfactory. The bromide of potassium was given principally to diminish the pain and liyperaesthesia which occurred, and this it appeared to do very completely. Electricity was not used till it was certain that mvtscular power had returned to the limbs.
