Assistant-Surgeon Devendra Nath Dey, M. B., showed a of almost complete ablation op the nose which had been Viiccessfulty IrteitecTby replacement and stitching. The patient, a young woman of about 25 years of age, was brought to hospital by the Police on the morning of the 15th April, with her nose completely cut off and suspended by a small pedicle of skin of about \ inch breadth to the right side of her cheek, she holding tile divided nose in her right hand close to her face. She had had a quarrel with her husband on the previous night, and lie, while under the influence of liquor, attacked her as she slept and wounded her with a table knife. Profuse bleeding followed. She arrived at the h?*pital one
case ,
THE CALCUTTA MEDICAL SOCIETY. The Fifth
Meeting of 1881 was held at the Medical College Wednesday, 11th May ; Dr. Cayley presiding. Assistant-Surgeon Behaiu Lall Chuckerbutty, M.B., exhibited a patient suffering from Empyema, of whose case he read the following notes :? Golap Sing, a boy of 16, was admitted into the Mayo Native Hospital on the 24th February 1881 with empyema on
of the left side. Previous history.?Since 20 days previous to his admission he has been suffering from fever, cough, and stitching pain on the left side of the chest. Condition on admission.?There was great prostration of strength, emaciation and dyspnoea ; tongue coated and dry. Temperature 103? F. There was bulging of the left intercostal spaces. The left chest was dull on percussion, with impaired respiratory movement. Respiratory murmur not audible on the left side. The heart-sounds were normal but audible on the right side ; the heart-apex being pushed below and to the inner side of the right nipple. The skin of the left side was (edematous. There was increased respiratory effort on the right side. He used to get occasional rigors. Subsequent progress and treatment.?His temperature ranged between 103? F. and 99? F., with evening rise generally of 2-5? F. The chest was aspirated for the first time on the 26th February 1881 and about a pint of thick healthy pus drawn out. It was aspirated twice more afterwards, but the pus was too thick to come freely out of the aspirator needle ; and on the 6th March a free incision in the 6th left intercostal space was made by Dr. Cayley, and two tolerably big and thick drainage tubes were inserted into the chestcavity, and antiseptic dressing was had recourse to. The discharge afterwards became foetid and very profuse. The cavity was washed every day twice with Tr. Iodine solution, and nitro-muriatic acid and bark mixt. was given him internally. Within a week the discharge became healthy and free from any offensive smell, and it also decreased in quantity. His temperature too became almost normal both morning and evening. He has been steadily improving from that time. For the first 3 weeks he was kept on pretty low diet. At present the discharge is only a few drops in 24 hours. The chest wall has fallen down to a considerable extent ; the heart sounds are audible on the left side ; vesicular murmur audible over the left apex only. The boy is much improved in health, and one of the drainage tubes has been taken out very lately. I hope within a few weeks more he will be completely cured. Considering the constitution of the boy at the time of his admission, and also the nature of the disease, he made a very rapid and successful recovery. Injection of Iodine solution proved very efficacious in this case. Dr. Cayley remarked that he had first inserted a small drainage tube. Patient pulled the dressing off and the tube could not be found, so that there was a doubt whether it had not slipped into the pleura. If such was the case, it did not appear to have done much harm. The advantage of a double tube of good size and frequent washing out with an antiseptic solution was, in his experience, very great. Dr. Coaxes had seen a case of liver abscess into which It healed up, and the India rubber tube had He had inherited the accident seemed to do no harm. from his predecessor a case of empyema of 6 years' standing which had opened spontaneously and continued to discharge profusely until he inserted a large drainage tube and washed the cavity out with a solution of chloride of zinc. The patient recovered rapidly, and is now working in a merchant's office. There was great difficulty in keeping the orifice patent, and there is still a small sinus from which a little watery fluid flows.
disappeared.
hour and a half after the wound had been inflicted. Condition on admission.?On examination it was found that the nose was cut off close to the bone, and the anterior nares were exposed with their cartilaginous septum. The lateral cartilages were divided close to the nasal process of the su perior maxillary. The nose was hanging by a pedicle which was attached over the right malar bone, and was twisted on its axis apparently from the suspension of the nose. The line of incision commenced in the right cheek, and then going across the bridge of the nose below the nasal bone, cutting off the cartilages, went below the left cheek and forming an acute angle coursed over the lip to the left ala nasae, cutting it off and also the columna ; it passed to the right ala, and then rising abruptly approached the point of starting, leaving a neck of about ? inch undivided. Treatment.?The nose, after being washed with carbolic lotion, was replaced and the parts were accurately brought into apposition and stitched together with horse hair. The wound was then protected with boracic gauze covered with a carbolic dressing, and small plugs of lint were put into the nostrils. There was no arterial bleeding, but venous oozing continued even after the parts were stitched. This led the medical officer on to run the risk of applying ice duty to the nose, and the application was kept up for 5 hours the without checking bleeding. Subsequent progress.?The next day the nose was quite discolored and cold to the feel, and void of all sensation, only a portion of the flap over the right cheek to the extent of about an inch seemed to be living and maintaining its color and warmth. The edges of the wound gaped a little over the left cheek, and the oozing of blood continued. The temperature of the patient up to this time was not above 100?. On the 17th. i. e.y 2 days after admission, the discoloration became deeper, and the nose assumed a bluish tint. A line of demarcation was visible separating the apparently dead tissue from the of the living portion flap on the right cheek, beyond which the whole of the nose looked sphacelous and cold ; the bleeding continued for the next 3 days and then stopped. The lips of the wound still gaped and became covered with lymph. The nose gradually assumed a greyish color, looked soft and pulpy, and the cuticle loosened. On the 20th a small excoriation was found at the tip of the nose, exposing a reddish surface, covered with lymph, showing that the parts were still living and the death was merely superficial, involving only the cuticle. The line of demarcation gradually faded, but the angle on the left cheek was distinctly gangreThere was never any formation of pus, the discharge nous. consisting of sanguineous serum without smell. The bleeding stopped now, the left side of the wound still gaped and one stitch gave way. The next day another excoriation was formed over the bridge of the nose, exposing a similar red surface, which being pricked with a pin gave out a drop of blood, showing that the vitality of the nose was intact, but the small tail on the left angle became distinctly sphacelous. No formation of pus yet; discharge being lymphy without smell. There was no more bleeding and no constitutional disturbance. The excoriations on the nose became larger and were covered with lymph ; and every part of the line of demarcation vanished, the nose seemed to live except the small tail at the left corner, which became gradually loosened at the edges, on raising which it was found to be adherent to the living being parts by healthy granulations. Only this small part, furthest from the pedicle, the source of supplying nutriment also the but the skin not only involving sphacelated deeply, subjacent fascia and areolar tissue. The slough agradually healthy became loose, and at last separated, exposing surface and an incomplete hole, which
granulating
leaving
/y V
June
1, 1881.]
THE CALCUTTA MEDICAL SOCIETY.
the remains of the original orifice in the left ala which she had for wearing pearls. A part of the hole having sloughed off, a crescentic margin was left with a small nodule at its outer part, which gradually becoming smaller at last disappeared, and the lower edge of the left ala was rounded off. The ulcerated surface healed up and left a cicatrix at the corner with two radiating line caused by the of the the skin of cheek. The nose is now puckering thoroughly united to the face ; the excoriations are healed up, except a small one over each ala,'and one on the left side of the nose and another at the left angle. There is some thickening of the flap on the right cheek, but this will gradually absorb and become thinner. The skin over this part is of normal color, but that over the bridge of the nose is pigmented, and is of dark-brown color, being newly formed. The skin on the tip of the nose is gradually resuming its natural color, but on the upper part of the nose is still pigmented. The cartilages inside, as also the alse and the septum, are well united to the subjacent parts. This case is highly instructive, inasmuch as it shows how wonderfully the parts of the head and face retain their vitality in spite of various untoward circumstances, which in this case consisted of the almost complete severance of the part, the application of ice over it after it had been stitched and the continuous venous oozing. The case amply justifies the rule of replacing all detached portions of the scalp and face, and although death may seem to have taken place at first, the apparently sphacelated part should not be too hurridly removed. Another point of interest is that the degree of tissue death was proportionate to the distance from the source of blood supply. The pedicle, which was close to and continuous with the uninjured cheek, lived entirely and showed no sign of disturbed nutrition, and as the distance from the pedicle became greater, tissue death became deeper, the middle of the flap lost its cuticle, and the end of the flap, which was most remote, sphacelated entirely and was cast off in the form of slough, exposing a granulating surface beneath. Mr. Wallace had seen a case similar to this, in which the nose had been completely1 "severed. It was replaced and carefully stitched, but sloughed off. [Dr. Harvey in his Medico-legal Report narrates the following case reported by Surgeon J. Backhouse. "A Hindu girl, jet. 19, was brought to the dispensary bleeding profusely. Her nose had been cut off by a table knife, and was brought after her by a policeman. It was at once stitched on, and when the report was sent off she was going on well, and there was every hope of saving the organ."] Dr. Coates had seen the tips of fingers, which had been completely cut off, replaced, with the result that they and vitality. ^adhered and retained their structure Dr. McLeod showed a case in which the RADICAL CURE OF oblique inguinal hernia had been attempted by an operation different in some respects from any hitherto resorted to. The patient, an East Indian male, fet. 37, a compositor, was admitted with right oblique inguinal hernia, of one years' duration, on the 15th May 1880. Wood's operation was performed antiseptically on the 20th May, the wire was removed on the 11th day ; the wound healed in 16 days. No descent of hernia took place during his stay in hospital. Discharged 23rd June 1880, Re-admitted 24th June 1880. A descent of the hernia took place when he began to walk about. The operation was repeated antiseptically on the 30th June, the wire was removed in 11 days, and the wound healed in three weeks. He was discharged on the 28 th July apparently cured. He was provided with a truss which he was strictly enjoined to wear. He was admitted for the third time on the 21st of March. His hernia came down to a slight extent, and he begged for a third operation, as he found it difficult to pursue his calling under these circumstances. On admission it was found that the hernia descended at each impulse of coughing and straining as far down as the middle of the scrotum, but it could be reduced without difficulty. The external abdominal ring was dilated, admitting two fingers with ease. The outer and inner pillars were distinct and yielding, more especially the former. Operation.?The patient was kept under observation for 9 days, during which he was free from all sorts of constitutional disturbance, and on the 30th an operation was was
175
performed under chloroform and strict antiseptic precautions. An incision about three inches long was made over the region of the right spermatic cord, extending from the site of the external abdominal ring obliquely down to the scrotum. The skin and the subjacent fascia having been divided, the sac o? the hernia was exposed and separated by the finger, as well as by a few strokes of the knife, from the cord as much as was necessary for invagination. The sac was then invaginated through the canal into the abdominal cavity, and secured in that state by means of a loop of thick catgut thread passed through the invaginated fundus by means of a curved needle, the ends of which were brought through the abdominal wall a little above the position of the internal ring and tied together in a knot. The inguinal canal was then closed up by approximating the two pillars by means of two catgut sutures, which also included and drew outwards the conjoined tendon. The ends of the catgut threads, instead of being cut off, were converted into drains and passed through the wound, which was then stitched up with iron wire and some horse hair sutures, and protected with boracic gauze covered with carbolic dressings and then bandaged. Subsequent progress.?In the evening the temperature was only 100? and the abdomen was somewhat tympanitic ; this however passed off after two doses of carminative mixture and fomentation over the abdomen. In the night the patient slept well after a morphia draught, and next morning the temperature was 99? and 100? in the evening. The tongue was clean and moist throughout, though now and then he complained of a bitter taste in the mouth ; the tympanitis subsided, but the patient complained of pain in right side of the abdomen and over the wound, which looked perfectly healthy, the discharge consisting of sanguineous serum soaking the deeper dressings ; the stitches held the edges of the wound in nice apposition, and there was no tension of the parts ; 1 ? grain of calomel with \ grain of opium was given every 6 hours, and the patient kept on milk diet and broth. The temperature gradually rose during the next week, ranging from 100? to On the 2nd of 102? but never above it. April the patient had one healthy motion ; the tympanitis and other disin the abdomen became much less. comforts passed off, pain The wound behaved in an aseptic manner throughout ; the and discharge was scanty, sweet lymphy ; no formation of pus was ever noticed during the whole progress of the case. On the 7th April, i. e. 9 days after operation, the wire stitches were taken out, the wound having united by primary adhesion, but the horse hair stitches wbre left ; one catgut thread was drawn out, and presented an appearance of having been partially absorbed. There was no pain in the part; no tympanitis ; the fever disappeared, bowels moved regularly, tongue remained moist and clean. On the 10th small semiorganized lymphy masses came out from the wound on pressure ; one catgut drain came out easily and some of the horse hair stitches were taken out. The catgut knot did not give way. On the 13tli all the stitches were removed, the wound being nearly healed by first intention. The catgut knot was a little loose, but was left, and on the lGth, i. e. 17 days after operation, the knot^ was taken out ; on pulling at its ends it got untwisted by itself and came out easily, and on examining the thread closely, it was found that the part where the knot was tied was swollen and softened, and the ends that lay outside were in a dried and stiffened condition ; the portion that was within the wound was found to be thinner than it was before, as if partly melted away and absorbed, but still it had retained its consistency for a period of 17 days. On pulling it out it broke at the thinnest portion which was inside the wound. The upper wound now became superficial, and has nearly healed. The lower wound has completely healed, leaving a linear cicatrix just above the cicatrix of the old wound. No impulse of hernia can be felt in the canal, which seems to be much contracted, admitting the forefinger with difficulty. There is some amount of impulse in the abdominal ring, but this is not much greater than that felt on the sound side, and is probably due to the relaxed condition of his abdominal wall. On the whole the third operation has succeeded better than either of the other two, and if the patient wears a truss, he will be able to spend the rest of liis life in comfort, even if, from the looseness of his abdominal walls, the operation cannot be pronounced a perfect success, and some degree of impulse and bulging still take place on coughing, though no protrusion occurs on standing and walking.
THE INDIAN MEDICAL GAZETTE.
3 76
The adjourned discussion on Diabetes was resumed by Dr. Cayley, who remarked that Dr. Goopta's paper had raised several very interesting questions relating to this important disease, on which information was very desirable. He had no doubt himself that the disease was sometimes transmitted hereditarily. It was seen running in families from generation to generation. He knew of one family in which the grandfather and father had died of .it, and two grown up sons had it. So strong was the taint in some cases that young children and women belonging to diabetic families suffered from the disease. His was that the disease was more prevalent in Bengal than in Upper India. He had seldom seen it up-country, but had often met it in Calcutta and other parts of Bengal. He could confirm Dr. Goopta's statement that it was more common among the better classes than among the poor. It was seldom seen in the Calcutta hospitals. As regards causes and causative conditions, the author of the paper had noted several circumstances which appeared to him to have some influence in establishing the disease which were worthy of consideration. He was not inclined to attach so much importance to brain work as Dr. Goopta. He had often seen the disease in persons who need not and did not over-exercise their brains. This cause could not explain the case of women and children. As regards alcohol, it might predispose or assist in developing the disease ; but he had often met with diabetes in persons who had never indulged in alcohol in any shape. Precisely the same remark applied to sedentary habits. He had seen the disease in people who had led active lives. He recollected the case of an overseer in the Public Works Department who was abstemious and led a very active life, and who became diabetic. It was therefore necessary to receive these assigned causes with The causation of the disease was obscure. caution. It seemed to result from mal-assmiliation of saccharine and to that food result ; and whatever contributed amylaceous might be considered a cause. His impression was that flesh and mixed feeders were not so liable to the disease as consumers of starchy and saccharine food. Baboo Behari Lall Chuckerbutty thought that Dr. Brown Sequard's experiment, by which he showed that glycusuria was capable of being established by irritation of the floor of the fourth ventricle, indicated that causes operating by way of excitement or exhaustion, on the central nervous system, might set up or intensify the disease. Excessive venery was known to be an exciting cause, and it probably acted in this way. Baboo Tara Prosunno Roy stated that the disease was recognised by the native community as an hereditary one. Baboo Kanny Lall Dey, K. B., was in a position to corroborate Dr. Cayley's statement that Bengalis were more subject to the disease than up-country men. Dr. K. G. Sircar believed with Pavy that the liver was mainly at fault in the production of diabetes. Dr. Coates had found sudden mental depression to be a very palpable and potent exciting cause of diabetes, more to the disease. especially in those hereditarily He had seen deaths, lost law suits, &c., followed by the appearance of sugar in the urine, and as the effects of the depression subsided the sugar disappeared. This was often the case in women. The mental depression probably affected digestion. He was under the impression that wheat-eaters were less subject to the disease than rice-eaters, and in the Madras presidency consumers of ragi and cholum were said to be less liable to the disease than those who lived largely or mainly on rice. There the disease was called the Brahmin's disease, and it was well known that Brahmins indulged in rich fare. Baboo Kanny Loll Dey could support Dr. Coates with respect to grief and mental distress causing temporary diabetes. Dr. Cayley had also seen cases of temporary due to some error of digestion. diabetes
impression
predisposed
apparently
Baboo Jadub Kristo Sircar had met with several cases in which excessive brain work could not be assigned as a cause. He thought that an excessive amylaceous dietary and defective exercise were the most common causes. It richer classes differed was in these respects that the mainly from the poorer. Ho had not found that Brahmins He had met with were specially prone to the disease. several instances in which the disease seemed to run in families. He knew of one in which three generations in the male line were successively affected. Among the symptoms _
[June 1,
1881'
of the disease he had noticed loss of teeth, loss of sexual desire, and in. three or four cases had observed burning of the surface. Mr. Wallace had found pruritus of the vulva a frequent complication in female diabetics. Dr. McLeod said that whatever the cause or causes of the disease might be, the most prominent feature of the diabetic state seemed to be tissue innutrition as indicated by great proneness to degeneration and death. The loss of hair and teeth, the cataract, arcus and phthisis so common in diabetics, all exemplified this. They were also subject to diffuse and gangrenous inflammations, large sloughing abscesses and destructive carbuncles, and were extremely bad subjects of injury or operation. He would like to know what the opinion of members was as regards the eligibility of diabetics for life assurance. His own feeling was that their tenure of life was so frail and uncertain that they were
absolutely uninsurable.
Drs. Coatks and Cayley and Baboos Tara Prosunxo Roy and Jogendra Nath G-iiose concurred. Baboo Lall Madhub Mookerjee had seen a diabetic who was apparently in good health fall ill and die within a week, and Baboo Kanny Lall Dey had seen a death occur within 15 days. Dr. CoATES found that when diabetics got fever, their temperature ran up suddenly to a very high figure. He was in favour of a regulated and had seen 30 grains of sugar per ounce disappear from the urine under the intluence of a
diet,"
judicious dietary.
Cayley did not think that a regulated dietary would cure the disease, but it would keep people in tolerable health ; better than if they continued to eat large quantities of carbon and oil. Dr.
radically
case ,
THE CALCUTTA MEDICAL SOCIETY. The Fifth
Meeting of 1881 was held at the Medical College Wednesday, 11th May ; Dr. Cayley presiding. Assistant-Surgeon Behaiu Lall Chuckerbutty, M.B., exhibited a patient suffering from Empyema, of whose case he read the following notes :? Golap Sing, a boy of 16, was admitted into the Mayo Native Hospital on the 24th February 1881 with empyema on
of the left side. Previous history.?Since 20 days previous to his admission he has been suffering from fever, cough, and stitching pain on the left side of the chest. Condition on admission.?There was great prostration of strength, emaciation and dyspnoea ; tongue coated and dry. Temperature 103? F. There was bulging of the left intercostal spaces. The left chest was dull on percussion, with impaired respiratory movement. Respiratory murmur not audible on the left side. The heart-sounds were normal but audible on the right side ; the heart-apex being pushed below and to the inner side of the right nipple. The skin of the left side was (edematous. There was increased respiratory effort on the right side. He used to get occasional rigors. Subsequent progress and treatment.?His temperature ranged between 103? F. and 99? F., with evening rise generally of 2-5? F. The chest was aspirated for the first time on the 26th February 1881 and about a pint of thick healthy pus drawn out. It was aspirated twice more afterwards, but the pus was too thick to come freely out of the aspirator needle ; and on the 6th March a free incision in the 6th left intercostal space was made by Dr. Cayley, and two tolerably big and thick drainage tubes were inserted into the chestcavity, and antiseptic dressing was had recourse to. The discharge afterwards became foetid and very profuse. The cavity was washed every day twice with Tr. Iodine solution, and nitro-muriatic acid and bark mixt. was given him internally. Within a week the discharge became healthy and free from any offensive smell, and it also decreased in quantity. His temperature too became almost normal both morning and evening. He has been steadily improving from that time. For the first 3 weeks he was kept on pretty low diet. At present the discharge is only a few drops in 24 hours. The chest wall has fallen down to a considerable extent ; the heart sounds are audible on the left side ; vesicular murmur audible over the left apex only. The boy is much improved in health, and one of the drainage tubes has been taken out very lately. I hope within a few weeks more he will be completely cured. Considering the constitution of the boy at the time of his admission, and also the nature of the disease, he made a very rapid and successful recovery. Injection of Iodine solution proved very efficacious in this case. Dr. Cayley remarked that he had first inserted a small drainage tube. Patient pulled the dressing off and the tube could not be found, so that there was a doubt whether it had not slipped into the pleura. If such was the case, it did not appear to have done much harm. The advantage of a double tube of good size and frequent washing out with an antiseptic solution was, in his experience, very great. Dr. Coaxes had seen a case of liver abscess into which It healed up, and the India rubber tube had He had inherited the accident seemed to do no harm. from his predecessor a case of empyema of 6 years' standing which had opened spontaneously and continued to discharge profusely until he inserted a large drainage tube and washed the cavity out with a solution of chloride of zinc. The patient recovered rapidly, and is now working in a merchant's office. There was great difficulty in keeping the orifice patent, and there is still a small sinus from which a little watery fluid flows.
disappeared.
hour and a half after the wound had been inflicted. Condition on admission.?On examination it was found that the nose was cut off close to the bone, and the anterior nares were exposed with their cartilaginous septum. The lateral cartilages were divided close to the nasal process of the su perior maxillary. The nose was hanging by a pedicle which was attached over the right malar bone, and was twisted on its axis apparently from the suspension of the nose. The line of incision commenced in the right cheek, and then going across the bridge of the nose below the nasal bone, cutting off the cartilages, went below the left cheek and forming an acute angle coursed over the lip to the left ala nasae, cutting it off and also the columna ; it passed to the right ala, and then rising abruptly approached the point of starting, leaving a neck of about ? inch undivided. Treatment.?The nose, after being washed with carbolic lotion, was replaced and the parts were accurately brought into apposition and stitched together with horse hair. The wound was then protected with boracic gauze covered with a carbolic dressing, and small plugs of lint were put into the nostrils. There was no arterial bleeding, but venous oozing continued even after the parts were stitched. This led the medical officer on to run the risk of applying ice duty to the nose, and the application was kept up for 5 hours the without checking bleeding. Subsequent progress.?The next day the nose was quite discolored and cold to the feel, and void of all sensation, only a portion of the flap over the right cheek to the extent of about an inch seemed to be living and maintaining its color and warmth. The edges of the wound gaped a little over the left cheek, and the oozing of blood continued. The temperature of the patient up to this time was not above 100?. On the 17th. i. e.y 2 days after admission, the discoloration became deeper, and the nose assumed a bluish tint. A line of demarcation was visible separating the apparently dead tissue from the of the living portion flap on the right cheek, beyond which the whole of the nose looked sphacelous and cold ; the bleeding continued for the next 3 days and then stopped. The lips of the wound still gaped and became covered with lymph. The nose gradually assumed a greyish color, looked soft and pulpy, and the cuticle loosened. On the 20th a small excoriation was found at the tip of the nose, exposing a reddish surface, covered with lymph, showing that the parts were still living and the death was merely superficial, involving only the cuticle. The line of demarcation gradually faded, but the angle on the left cheek was distinctly gangreThere was never any formation of pus, the discharge nous. consisting of sanguineous serum without smell. The bleeding stopped now, the left side of the wound still gaped and one stitch gave way. The next day another excoriation was formed over the bridge of the nose, exposing a similar red surface, which being pricked with a pin gave out a drop of blood, showing that the vitality of the nose was intact, but the small tail on the left angle became distinctly sphacelous. No formation of pus yet; discharge being lymphy without smell. There was no more bleeding and no constitutional disturbance. The excoriations on the nose became larger and were covered with lymph ; and every part of the line of demarcation vanished, the nose seemed to live except the small tail at the left corner, which became gradually loosened at the edges, on raising which it was found to be adherent to the living being parts by healthy granulations. Only this small part, furthest from the pedicle, the source of supplying nutriment also the but the skin not only involving sphacelated deeply, subjacent fascia and areolar tissue. The slough agradually healthy became loose, and at last separated, exposing surface and an incomplete hole, which
granulating
leaving
/y V
June
1, 1881.]
THE CALCUTTA MEDICAL SOCIETY.
the remains of the original orifice in the left ala which she had for wearing pearls. A part of the hole having sloughed off, a crescentic margin was left with a small nodule at its outer part, which gradually becoming smaller at last disappeared, and the lower edge of the left ala was rounded off. The ulcerated surface healed up and left a cicatrix at the corner with two radiating line caused by the of the the skin of cheek. The nose is now puckering thoroughly united to the face ; the excoriations are healed up, except a small one over each ala,'and one on the left side of the nose and another at the left angle. There is some thickening of the flap on the right cheek, but this will gradually absorb and become thinner. The skin over this part is of normal color, but that over the bridge of the nose is pigmented, and is of dark-brown color, being newly formed. The skin on the tip of the nose is gradually resuming its natural color, but on the upper part of the nose is still pigmented. The cartilages inside, as also the alse and the septum, are well united to the subjacent parts. This case is highly instructive, inasmuch as it shows how wonderfully the parts of the head and face retain their vitality in spite of various untoward circumstances, which in this case consisted of the almost complete severance of the part, the application of ice over it after it had been stitched and the continuous venous oozing. The case amply justifies the rule of replacing all detached portions of the scalp and face, and although death may seem to have taken place at first, the apparently sphacelated part should not be too hurridly removed. Another point of interest is that the degree of tissue death was proportionate to the distance from the source of blood supply. The pedicle, which was close to and continuous with the uninjured cheek, lived entirely and showed no sign of disturbed nutrition, and as the distance from the pedicle became greater, tissue death became deeper, the middle of the flap lost its cuticle, and the end of the flap, which was most remote, sphacelated entirely and was cast off in the form of slough, exposing a granulating surface beneath. Mr. Wallace had seen a case similar to this, in which the nose had been completely1 "severed. It was replaced and carefully stitched, but sloughed off. [Dr. Harvey in his Medico-legal Report narrates the following case reported by Surgeon J. Backhouse. "A Hindu girl, jet. 19, was brought to the dispensary bleeding profusely. Her nose had been cut off by a table knife, and was brought after her by a policeman. It was at once stitched on, and when the report was sent off she was going on well, and there was every hope of saving the organ."] Dr. Coates had seen the tips of fingers, which had been completely cut off, replaced, with the result that they and vitality. ^adhered and retained their structure Dr. McLeod showed a case in which the RADICAL CURE OF oblique inguinal hernia had been attempted by an operation different in some respects from any hitherto resorted to. The patient, an East Indian male, fet. 37, a compositor, was admitted with right oblique inguinal hernia, of one years' duration, on the 15th May 1880. Wood's operation was performed antiseptically on the 20th May, the wire was removed on the 11th day ; the wound healed in 16 days. No descent of hernia took place during his stay in hospital. Discharged 23rd June 1880, Re-admitted 24th June 1880. A descent of the hernia took place when he began to walk about. The operation was repeated antiseptically on the 30th June, the wire was removed in 11 days, and the wound healed in three weeks. He was discharged on the 28 th July apparently cured. He was provided with a truss which he was strictly enjoined to wear. He was admitted for the third time on the 21st of March. His hernia came down to a slight extent, and he begged for a third operation, as he found it difficult to pursue his calling under these circumstances. On admission it was found that the hernia descended at each impulse of coughing and straining as far down as the middle of the scrotum, but it could be reduced without difficulty. The external abdominal ring was dilated, admitting two fingers with ease. The outer and inner pillars were distinct and yielding, more especially the former. Operation.?The patient was kept under observation for 9 days, during which he was free from all sorts of constitutional disturbance, and on the 30th an operation was was
175
performed under chloroform and strict antiseptic precautions. An incision about three inches long was made over the region of the right spermatic cord, extending from the site of the external abdominal ring obliquely down to the scrotum. The skin and the subjacent fascia having been divided, the sac o? the hernia was exposed and separated by the finger, as well as by a few strokes of the knife, from the cord as much as was necessary for invagination. The sac was then invaginated through the canal into the abdominal cavity, and secured in that state by means of a loop of thick catgut thread passed through the invaginated fundus by means of a curved needle, the ends of which were brought through the abdominal wall a little above the position of the internal ring and tied together in a knot. The inguinal canal was then closed up by approximating the two pillars by means of two catgut sutures, which also included and drew outwards the conjoined tendon. The ends of the catgut threads, instead of being cut off, were converted into drains and passed through the wound, which was then stitched up with iron wire and some horse hair sutures, and protected with boracic gauze covered with carbolic dressings and then bandaged. Subsequent progress.?In the evening the temperature was only 100? and the abdomen was somewhat tympanitic ; this however passed off after two doses of carminative mixture and fomentation over the abdomen. In the night the patient slept well after a morphia draught, and next morning the temperature was 99? and 100? in the evening. The tongue was clean and moist throughout, though now and then he complained of a bitter taste in the mouth ; the tympanitis subsided, but the patient complained of pain in right side of the abdomen and over the wound, which looked perfectly healthy, the discharge consisting of sanguineous serum soaking the deeper dressings ; the stitches held the edges of the wound in nice apposition, and there was no tension of the parts ; 1 ? grain of calomel with \ grain of opium was given every 6 hours, and the patient kept on milk diet and broth. The temperature gradually rose during the next week, ranging from 100? to On the 2nd of 102? but never above it. April the patient had one healthy motion ; the tympanitis and other disin the abdomen became much less. comforts passed off, pain The wound behaved in an aseptic manner throughout ; the and discharge was scanty, sweet lymphy ; no formation of pus was ever noticed during the whole progress of the case. On the 7th April, i. e. 9 days after operation, the wire stitches were taken out, the wound having united by primary adhesion, but the horse hair stitches wbre left ; one catgut thread was drawn out, and presented an appearance of having been partially absorbed. There was no pain in the part; no tympanitis ; the fever disappeared, bowels moved regularly, tongue remained moist and clean. On the 10th small semiorganized lymphy masses came out from the wound on pressure ; one catgut drain came out easily and some of the horse hair stitches were taken out. The catgut knot did not give way. On the 13tli all the stitches were removed, the wound being nearly healed by first intention. The catgut knot was a little loose, but was left, and on the lGth, i. e. 17 days after operation, the knot^ was taken out ; on pulling at its ends it got untwisted by itself and came out easily, and on examining the thread closely, it was found that the part where the knot was tied was swollen and softened, and the ends that lay outside were in a dried and stiffened condition ; the portion that was within the wound was found to be thinner than it was before, as if partly melted away and absorbed, but still it had retained its consistency for a period of 17 days. On pulling it out it broke at the thinnest portion which was inside the wound. The upper wound now became superficial, and has nearly healed. The lower wound has completely healed, leaving a linear cicatrix just above the cicatrix of the old wound. No impulse of hernia can be felt in the canal, which seems to be much contracted, admitting the forefinger with difficulty. There is some amount of impulse in the abdominal ring, but this is not much greater than that felt on the sound side, and is probably due to the relaxed condition of his abdominal wall. On the whole the third operation has succeeded better than either of the other two, and if the patient wears a truss, he will be able to spend the rest of liis life in comfort, even if, from the looseness of his abdominal walls, the operation cannot be pronounced a perfect success, and some degree of impulse and bulging still take place on coughing, though no protrusion occurs on standing and walking.
THE INDIAN MEDICAL GAZETTE.
3 76
The adjourned discussion on Diabetes was resumed by Dr. Cayley, who remarked that Dr. Goopta's paper had raised several very interesting questions relating to this important disease, on which information was very desirable. He had no doubt himself that the disease was sometimes transmitted hereditarily. It was seen running in families from generation to generation. He knew of one family in which the grandfather and father had died of .it, and two grown up sons had it. So strong was the taint in some cases that young children and women belonging to diabetic families suffered from the disease. His was that the disease was more prevalent in Bengal than in Upper India. He had seldom seen it up-country, but had often met it in Calcutta and other parts of Bengal. He could confirm Dr. Goopta's statement that it was more common among the better classes than among the poor. It was seldom seen in the Calcutta hospitals. As regards causes and causative conditions, the author of the paper had noted several circumstances which appeared to him to have some influence in establishing the disease which were worthy of consideration. He was not inclined to attach so much importance to brain work as Dr. Goopta. He had often seen the disease in persons who need not and did not over-exercise their brains. This cause could not explain the case of women and children. As regards alcohol, it might predispose or assist in developing the disease ; but he had often met with diabetes in persons who had never indulged in alcohol in any shape. Precisely the same remark applied to sedentary habits. He had seen the disease in people who had led active lives. He recollected the case of an overseer in the Public Works Department who was abstemious and led a very active life, and who became diabetic. It was therefore necessary to receive these assigned causes with The causation of the disease was obscure. caution. It seemed to result from mal-assmiliation of saccharine and to that food result ; and whatever contributed amylaceous might be considered a cause. His impression was that flesh and mixed feeders were not so liable to the disease as consumers of starchy and saccharine food. Baboo Behari Lall Chuckerbutty thought that Dr. Brown Sequard's experiment, by which he showed that glycusuria was capable of being established by irritation of the floor of the fourth ventricle, indicated that causes operating by way of excitement or exhaustion, on the central nervous system, might set up or intensify the disease. Excessive venery was known to be an exciting cause, and it probably acted in this way. Baboo Tara Prosunno Roy stated that the disease was recognised by the native community as an hereditary one. Baboo Kanny Lall Dey, K. B., was in a position to corroborate Dr. Cayley's statement that Bengalis were more subject to the disease than up-country men. Dr. K. G. Sircar believed with Pavy that the liver was mainly at fault in the production of diabetes. Dr. Coates had found sudden mental depression to be a very palpable and potent exciting cause of diabetes, more to the disease. especially in those hereditarily He had seen deaths, lost law suits, &c., followed by the appearance of sugar in the urine, and as the effects of the depression subsided the sugar disappeared. This was often the case in women. The mental depression probably affected digestion. He was under the impression that wheat-eaters were less subject to the disease than rice-eaters, and in the Madras presidency consumers of ragi and cholum were said to be less liable to the disease than those who lived largely or mainly on rice. There the disease was called the Brahmin's disease, and it was well known that Brahmins indulged in rich fare. Baboo Kanny Loll Dey could support Dr. Coates with respect to grief and mental distress causing temporary diabetes. Dr. Cayley had also seen cases of temporary due to some error of digestion. diabetes
impression
predisposed
apparently
Baboo Jadub Kristo Sircar had met with several cases in which excessive brain work could not be assigned as a cause. He thought that an excessive amylaceous dietary and defective exercise were the most common causes. It richer classes differed was in these respects that the mainly from the poorer. Ho had not found that Brahmins He had met with were specially prone to the disease. several instances in which the disease seemed to run in families. He knew of one in which three generations in the male line were successively affected. Among the symptoms _
[June 1,
1881'
of the disease he had noticed loss of teeth, loss of sexual desire, and in. three or four cases had observed burning of the surface. Mr. Wallace had found pruritus of the vulva a frequent complication in female diabetics. Dr. McLeod said that whatever the cause or causes of the disease might be, the most prominent feature of the diabetic state seemed to be tissue innutrition as indicated by great proneness to degeneration and death. The loss of hair and teeth, the cataract, arcus and phthisis so common in diabetics, all exemplified this. They were also subject to diffuse and gangrenous inflammations, large sloughing abscesses and destructive carbuncles, and were extremely bad subjects of injury or operation. He would like to know what the opinion of members was as regards the eligibility of diabetics for life assurance. His own feeling was that their tenure of life was so frail and uncertain that they were
absolutely uninsurable.
Drs. Coatks and Cayley and Baboos Tara Prosunxo Roy and Jogendra Nath G-iiose concurred. Baboo Lall Madhub Mookerjee had seen a diabetic who was apparently in good health fall ill and die within a week, and Baboo Kanny Lall Dey had seen a death occur within 15 days. Dr. CoATES found that when diabetics got fever, their temperature ran up suddenly to a very high figure. He was in favour of a regulated and had seen 30 grains of sugar per ounce disappear from the urine under the intluence of a
diet,"
judicious dietary.
Cayley did not think that a regulated dietary would cure the disease, but it would keep people in tolerable health ; better than if they continued to eat large quantities of carbon and oil. Dr.
radically
