A MIRROR OF HOSPITAL PRACTICE. MYMENSING DISPENSARY.
SURGICAL CASES. By Surgeon T. R, Macdonald, m.b.,
Officiating
Civil
Edin.,
Surgeon.
I am indebted to Assistant-Surgeon Sonatun Bysa'ck for the notes from which these cases are summarised, as well as of his careful treatment of the patients. -COMPOUND FRACTURE OF THE LEG: AMPUTATION
:
TETANUS: RECOVERY.
Umesh Chunder Dey, a Hindu boy, set. 12 years, admitted into the Mymensing Dispensary on the 18th June 1884, for a compound fracture of the leg. He had fallen from a tree twelve days previously, and was first seen by the Civil Hospital Assistant of an outlying dispensary, who advised his immediate removal to Mymensing for amputition; but his friends called in a native practitioner, who treated his injuries by means of "cow'dung poultices." As he appeared to be getting worse, he was ultimately brought to us. On the morning of 19th June I visited the dispensary, and found that the boy had sustained a compound fracture of both tibia and fibula of the left leg, the former bone being broken just below the tuberosity, and the fibula about its middle. The bones were exposed to about half their length, and the soft parts of the
December,
1884.]
SURGICAL CASES.
'
36;
thin, and the sawn edge of the bone couH be seen pressin j on The remaining stitches vv re removed, the skin. and front and back of the leg in a sloughing and decomposed strapping substituted. Th : flan had pro > ably been "scored" condition as high as the tuberosity of the tibia. The boy the operation, and undue tension m ade on it afterwards. was very much emaciated, and had lost much blood at during the was ordered quinine in 2-grain doses very four liourv and time of the accident, and was now suffering from symptom';He of a milk and soup diet, on ft would be e iious to follow septicemia. Temperature io2?F., pulse 130. Tongue foulput ; of the the suffice it to case, progress say, t lat the anterior bowels tending to be loose. As amputation was his only daily flap sloughe 1 straight across its middle, in the course of three chance, though almost hopeless, the operation was proceeddays after I saw him, exposing the bone to hal its diameter. ed with. From the deficiency of soft parts recourse was Hopes were entertained that it would become covered by had to amputation through the condyles of the femur. granulations, but instead it became gradually m >re and more A semi-oval flap was formed from the skin in front of the dessicated, and the suppuration of soft parts became more proknee, not including the patella, and a short posterior flap The general condition of the patient was also becoming fuse. from the tissues behind the knee-joint About half an ounce critical, as he suffered from chills, profuse sweating, diarrhoea" of blood was lost during the operation, and four vessels and an evening rise of temperature,?in fact hectic. He been The washed
required ligature. thoroughly flaps having was becoming very weak and emaciated with some puffiness with 1?20 carbolic lotion, were brought together by soft iron about the face and legs, though he had no albumen in his wire sutures, and horse hair, ample provision being made urine. It was accordingly determined that re-amp nation was, for drainage, and the stump was dressed with carbolic oil though poor, his only hope, and on the 23rd August I operated, (1?40). The pulse after the operation was fairly good, and making two semi-oval flaps of skin and muscle, sawing be doses of Liq. ordered small was morphice with through the bone as low down as possible. About two the of the On the quinine. pulse operation evening drachms of blood were lost during the operation. Modified rose to IC3?F., and did not fall to normal until the 25th June. antiseptics were practised. He had troublesome diarrhoea During this time his temperature ranged from I04?F. on the a and the after for the first six operation, high temdays 20th June to 99?F. on the 24th June, and secretion and excietion perature, but Dover's powder with quinine and bismuth, lie continued was satisfactory, and nourishment well taken. On with a purely milk diet, held bad symptoms in check. to do well in all respects until the 28th June (nine days after his temperature fell to normal and diarrhoea the operation) when he complained of some stiffness in opening 29th August From this time his recovery was rapid. The stump ceased. his mouth and pain in swallowing. His temperature on this date had completely healed on the 23rd September, with the cicatrix way 120. Bowels regular; wound appears skin pulse dry, ioo?F., well back and was nicely rounded. His general health was healthy. He was ordered a mixture containing Chloral Hydt.much improved, and he was able to go about with the aid of a gr. v., Potas. Bromid. gr. vi , to be taken every four hours. On crutch. He was finally dismissed from hospital on the 30th the 4th July he had distinct tetanic Spasms of the muscles of the jaw, neck, and back ; opisthotonos being strongly marked. TheSeptember. last of the ligatures was taken away on this date. The bowels and castor oil being costive he was ordered a turpentine enema, which acted well. The dose of chloral was increased to be to and kept very quiet, and to be every foiir hours, disturbed as little as possible, as the approach of any person brought on spasms. He continued in much the same condition for ten days. On the 14th July some puffiness was noticed on 1 the anterior flap, and though no fluctuation was detected, a free incision was made into its substance, and a few drops of pus Bowels costive. Tongue foul and dry. Ordered evacuated. Calomel gr. ii., Pulv. Rliei. gr. vi., Sodi gr. v. This moved the bowels well, and brought away very offensive feces. Bromide and chloral to be continued. On the 16th July he could open his mouth a little wider, and spasms were neither so frequent nor so severe. Another abscess formea on the upper and outlaid open. Treatment as er aspect of his thigh, and was freely before. On the 30th July his spasms had stopped, and the and wounds were healthy, non-outrid, discharging pus freely. The bromide and chloral mixture were stopped, and a -quinine 6th the On and iron mixture substituted. August another small abscess was opened on the posterior aspect of the stump, which was now almost healed. At this time he was reduced to a skeleton, but steadily continued to improve under a generous diet, cod liver oil and tonics, until he was dismissed cured, with a good stump and in fairly robust health, on the 22nd September, after having been 96 days in hospital.
^grains
II?COMPOUND FRACTURE OF THE LEG INVOLVING THE KNEE-JOINT : AMPUTATION : RE-AMPUTATION RECOVERY. This case was first seen and treated by the Assistant Surgeon during my absence on tour. Abdulla, Mussulman, ata weakly 7 p. m. boy 3=t. 12. admitted into hospital on 20th July 1884, He fell from a tree about a week before admission, and came from Jamalpore,?a place about twenty-five miles distant. There was a lacerated wound of an irregularly triangular shape 5 in. x 4 in. x 2%, on the inner side of the left knee-joint, exposing the heads of the tibia and fibula, which were fractured througn their epiphyses. Amputation was performed by the Assistant Surgeon on the 21st July much in the same way as There was very slight I had amputated in the former case. l?ss of blood, and only one ligature used. The parts being well washed in 1?20 carbolic lotion, were brought together by
five iron sutures and dressed with carbolised oil. I saw the for the first time on the morning of the 25th July, when he bad a temperature of 104?F., pulse 130, weakand compressible. Tongue moist, skin dry. The wound was looking sloughy at its edges, and discharging putrid pus. and some of the stitches had given way. There were some suspicious-looking phlectenufe over the middle of the anterior flap which appeared
boy
'
SURGICAL CASES. By Surgeon T. R, Macdonald, m.b.,
Officiating
Civil
Edin.,
Surgeon.
I am indebted to Assistant-Surgeon Sonatun Bysa'ck for the notes from which these cases are summarised, as well as of his careful treatment of the patients. -COMPOUND FRACTURE OF THE LEG: AMPUTATION
:
TETANUS: RECOVERY.
Umesh Chunder Dey, a Hindu boy, set. 12 years, admitted into the Mymensing Dispensary on the 18th June 1884, for a compound fracture of the leg. He had fallen from a tree twelve days previously, and was first seen by the Civil Hospital Assistant of an outlying dispensary, who advised his immediate removal to Mymensing for amputition; but his friends called in a native practitioner, who treated his injuries by means of "cow'dung poultices." As he appeared to be getting worse, he was ultimately brought to us. On the morning of 19th June I visited the dispensary, and found that the boy had sustained a compound fracture of both tibia and fibula of the left leg, the former bone being broken just below the tuberosity, and the fibula about its middle. The bones were exposed to about half their length, and the soft parts of the
December,
1884.]
SURGICAL CASES.
'
36;
thin, and the sawn edge of the bone couH be seen pressin j on The remaining stitches vv re removed, the skin. and front and back of the leg in a sloughing and decomposed strapping substituted. Th : flan had pro > ably been "scored" condition as high as the tuberosity of the tibia. The boy the operation, and undue tension m ade on it afterwards. was very much emaciated, and had lost much blood at during the was ordered quinine in 2-grain doses very four liourv and time of the accident, and was now suffering from symptom';He of a milk and soup diet, on ft would be e iious to follow septicemia. Temperature io2?F., pulse 130. Tongue foulput ; of the the suffice it to case, progress say, t lat the anterior bowels tending to be loose. As amputation was his only daily flap sloughe 1 straight across its middle, in the course of three chance, though almost hopeless, the operation was proceeddays after I saw him, exposing the bone to hal its diameter. ed with. From the deficiency of soft parts recourse was Hopes were entertained that it would become covered by had to amputation through the condyles of the femur. granulations, but instead it became gradually m >re and more A semi-oval flap was formed from the skin in front of the dessicated, and the suppuration of soft parts became more proknee, not including the patella, and a short posterior flap The general condition of the patient was also becoming fuse. from the tissues behind the knee-joint About half an ounce critical, as he suffered from chills, profuse sweating, diarrhoea" of blood was lost during the operation, and four vessels and an evening rise of temperature,?in fact hectic. He been The washed
required ligature. thoroughly flaps having was becoming very weak and emaciated with some puffiness with 1?20 carbolic lotion, were brought together by soft iron about the face and legs, though he had no albumen in his wire sutures, and horse hair, ample provision being made urine. It was accordingly determined that re-amp nation was, for drainage, and the stump was dressed with carbolic oil though poor, his only hope, and on the 23rd August I operated, (1?40). The pulse after the operation was fairly good, and making two semi-oval flaps of skin and muscle, sawing be doses of Liq. ordered small was morphice with through the bone as low down as possible. About two the of the On the quinine. pulse operation evening drachms of blood were lost during the operation. Modified rose to IC3?F., and did not fall to normal until the 25th June. antiseptics were practised. He had troublesome diarrhoea During this time his temperature ranged from I04?F. on the a and the after for the first six operation, high temdays 20th June to 99?F. on the 24th June, and secretion and excietion perature, but Dover's powder with quinine and bismuth, lie continued was satisfactory, and nourishment well taken. On with a purely milk diet, held bad symptoms in check. to do well in all respects until the 28th June (nine days after his temperature fell to normal and diarrhoea the operation) when he complained of some stiffness in opening 29th August From this time his recovery was rapid. The stump ceased. his mouth and pain in swallowing. His temperature on this date had completely healed on the 23rd September, with the cicatrix way 120. Bowels regular; wound appears skin pulse dry, ioo?F., well back and was nicely rounded. His general health was healthy. He was ordered a mixture containing Chloral Hydt.much improved, and he was able to go about with the aid of a gr. v., Potas. Bromid. gr. vi , to be taken every four hours. On crutch. He was finally dismissed from hospital on the 30th the 4th July he had distinct tetanic Spasms of the muscles of the jaw, neck, and back ; opisthotonos being strongly marked. TheSeptember. last of the ligatures was taken away on this date. The bowels and castor oil being costive he was ordered a turpentine enema, which acted well. The dose of chloral was increased to be to and kept very quiet, and to be every foiir hours, disturbed as little as possible, as the approach of any person brought on spasms. He continued in much the same condition for ten days. On the 14th July some puffiness was noticed on 1 the anterior flap, and though no fluctuation was detected, a free incision was made into its substance, and a few drops of pus Bowels costive. Tongue foul and dry. Ordered evacuated. Calomel gr. ii., Pulv. Rliei. gr. vi., Sodi gr. v. This moved the bowels well, and brought away very offensive feces. Bromide and chloral to be continued. On the 16th July he could open his mouth a little wider, and spasms were neither so frequent nor so severe. Another abscess formea on the upper and outlaid open. Treatment as er aspect of his thigh, and was freely before. On the 30th July his spasms had stopped, and the and wounds were healthy, non-outrid, discharging pus freely. The bromide and chloral mixture were stopped, and a -quinine 6th the On and iron mixture substituted. August another small abscess was opened on the posterior aspect of the stump, which was now almost healed. At this time he was reduced to a skeleton, but steadily continued to improve under a generous diet, cod liver oil and tonics, until he was dismissed cured, with a good stump and in fairly robust health, on the 22nd September, after having been 96 days in hospital.
^grains
II?COMPOUND FRACTURE OF THE LEG INVOLVING THE KNEE-JOINT : AMPUTATION : RE-AMPUTATION RECOVERY. This case was first seen and treated by the Assistant Surgeon during my absence on tour. Abdulla, Mussulman, ata weakly 7 p. m. boy 3=t. 12. admitted into hospital on 20th July 1884, He fell from a tree about a week before admission, and came from Jamalpore,?a place about twenty-five miles distant. There was a lacerated wound of an irregularly triangular shape 5 in. x 4 in. x 2%, on the inner side of the left knee-joint, exposing the heads of the tibia and fibula, which were fractured througn their epiphyses. Amputation was performed by the Assistant Surgeon on the 21st July much in the same way as There was very slight I had amputated in the former case. l?ss of blood, and only one ligature used. The parts being well washed in 1?20 carbolic lotion, were brought together by
five iron sutures and dressed with carbolised oil. I saw the for the first time on the morning of the 25th July, when he bad a temperature of 104?F., pulse 130, weakand compressible. Tongue moist, skin dry. The wound was looking sloughy at its edges, and discharging putrid pus. and some of the stitches had given way. There were some suspicious-looking phlectenufe over the middle of the anterior flap which appeared
boy
'
