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OBSTETRICAL SOCIETY OF LONDON. WEDNESDAY, MAY 1ST, 1867

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629 ment. Without attempting as yet to pronounce any opinion on this point, we have already seen enough to convince us that the rapid and efficient application of the method necessitates some considerable acquired or natural dexterity-more, un- doubtedly, than the employment of a ligature. The following are examples of its recent application :- CASE 1. Amputation of the thigh.—J. S-, aged thirty-five, an agricultural labourer, was submitted to amputation of the thigh on the 27th of March, 1867, for gangrene of the foot and leg, occurring during the treatment of a popliteal aneurism by forcible flexion of the leg. The operation performed was the double flap by transfixion. The muscles were very soft and congested. Acupressure was employed to close the bleeding vessels : the femoral was secured by Simpson’s first plan ; the remainder, twelve in number, by the " quarter-twist method." The wound was closed at once with wire sutures. No external dressing was applied. March 30th.-Ten pins were removed after forty-eight hours had elapsed; that upon the femoral after seventy-two hours ; the remaining two could not be found, being buried in the wound, which had become greatly distended. A quantity of decomposing blood followed the withdrawal of the pins, and to allow of a freer vent several sutures were cut; there was no blush about the stump, and the man had experienced unusually little constitutional disturbance. April 7th.-On the previous day search was made for the missing pins, but unsuccessfully, and on the morning of this day bleeding occurred to the extent of six or eight ounces, ceasing spontaneously; in the evening it returned. It was noticed that the blood was dark-coloured, and flowed in a continuous stream. Lint saturated with tincture of perchloride of iron was passed into the upper part of the wound, and the stump firmly bandaged. On this occasion he lost about ten ounces of blood. 10th.—The bleeding had not recurred. One of the missing pins was extracted. The stump was consolidating. 20th.-Allowed to be up every day, the greater part of the stump having healed. No trace of the remaining pin could be obtained, and firm handling of the stump caused him no pain. CASE 2. Secondary amputation of the leg.-A. P-, a car- man, aged fifty-three, of feeble constitutional powers, was brought into the theatre on the 17th April, 1866, to have his leg removed at the lower fourth, in consequence of disorgani- sation of the ankle-joint, resulting from a severely lacerated and contused wound in that region. Anterior and posterior flaps were cut; and, after removal of the limb, five pius were required to secure the vessels. The wound was at once closed with wire suture. April 19th.—The pins closing the tibial vessels were removed forty-eight hours after the operation; two of the others twenty- four hours after; and the fifth fell out in the course of the first night. A portion of the anterior flap had sloughed, and there was a general exudation of pus between the sutures. The stump was dressed with carbolic-acid lotion. May 7th.—The slough slowly separated, and the wound (which was quite superticial) had nearly healed. The patient’s health had greatly improved. In alluding to the first case, Mr. Willett said the drawback to its success was caused by the circumstance that two of the pins became completely buried in the wound, owing to the great distension of the stump which followed the operation, one remaining lost up to the present time. Hæmorrhage fol- lowing so closely upon the search made for the missing pins was, without much doubt, induced by that step; and although there existed no cause for alarm, still the patient’s conva- lescence would be retarded, and the wound prevented from healing soundly, so long as the pin continued in its present situation. The occurrence of sloughing of a portion of the flap in the last case was no more than might have been expected, for the vitality of the parts had been much impaired by an attack of diffuse inflammation with sloughing of subcutaneous tissue before the operation Excepting the incidents stated, these patients progressed as favourably as would have been anticipated had ligatures been used instead of pins, whilst no advantage had resulted from the proceeding adopted. SLOUGHING PRODUCED BY LOCAL ANÆSTHESIA. WE examined, a few days since, in the Middlesex Hospital, 3. young woman whose case is of no little importance in refer- ence to the question of local as against general anæsthesia for operations. Mr. Lawson had diagnosed the existence of an ab- - scess behind the patient’s breast, and as the pus was very deep (under the pectoral muscle indeed) the refrigerator was used, paraffine ether being employed. Congelation was rapidly produced, and kept up for a few minutes. The resu1t has been, that a portion of skin, about an inch by three-quarters of an inch, over the upper part of the breast, has sloughed, and its healing will necessarily be attended by an unseen:ly scar. The patient is a maidservant; were she unfortunately a lady, the undress of the modern ball-room would be impracticable with- out revealing such a blemish as might seriously damage her value in the matrimonial market. The case is certainly excep- tional ; but the circumstance is worth remembering when exposed parts of the body are to be operated upon. Provincial Hospital Reports. DARLINGTON HOSPITAL. EXTRACTION OF A GLASS BOTTLE FROM THE RECTUM. (Under the care of Dr. HOWISON.) FOR particulars of the following unusually remarkable case we are indebted to Mr. A. O. Haslewood, house-surgeon. T. W-, aged thirty, a workman in the gas-house, was with some companions amusing himself with jumping over bottles placed above each other with their mouths uppermost. After he had in his turn jumped over the bottles, the top one was missing, and it appeared to have passed through a thin pair of flannel trousers into the rectum. The man, a patient of Dr. Howison, was brought to the hospital next morning. He gave very little appearance of anything being the matter. Immediately after the accident he felt very sick and faint. He went to bed, after trying to protrude the bottle. On his ad- mission, the base of the bottle was found at the extremity of the ascending colon, though, from his description of its situa- tion, soon after the accident it was just about the junction of the transverse and descending colon. An injection of warm soap-and-water was at once given. This had the effect of bringing the bottle within extreme reach of the finger. Dr. Marion Sims’ vaginal speculum was used to expand the rectum, and after several attempts to seize and draw it out by a pair of cesophageal forceps, it was at length expelled in a great mea- sure by the action of the bowel, assisted by manipulation. With the exception of the pain experienced in expanding the rectum, the extraction gave the patient little uneasiness, and he walked home seemingly very little the worse. He was directed to remain in bed for a day, and very soon recovered. The bottle is a castor-oil bottle, such as is usually sold by druggists, and is eight inches long, four inches round at the thick extremity, and one inch and a half round the neck. It is rather curious that the bottle should have been plumped down upon so exactly at the anal orifice as to pass up without much pain. What the consequences would have been had the bottle broken in its passage, it is rather unpleasant to conjecture. Medical Societies. OBSTETRICAL SOCIETY OF LONDON. WEDNESDAY, MAY 1ST, 1867. DR. HALL DAVIS, PRESIDENT. ON THE TREATMENT OF LABOUR COMPLICATED WITH OVARIAN TUMOUR. BY W. S. PLAYFAIR, M.D., ASSISTANT OBSTETRIC PHYSICIAN TO KING’S COLLEGE HOSPITAL. THE author commenced by relating the particulars of a case of labour obstructed by ovarian tumour which had come under his observation. The pelvis was occupied by a solid ovarian growth, which was not diminished by puncture, delivery being finally effected by craniotomy. He then proceeded to analyse the details of fifty-seven similar cases, collected from various sources, pointing out the results of the various methods of treatment employed. He showed that nearly one-half of all
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Page 1: OBSTETRICAL SOCIETY OF LONDON. WEDNESDAY, MAY 1ST, 1867

629

ment. Without attempting as yet to pronounce any opinionon this point, we have already seen enough to convince us thatthe rapid and efficient application of the method necessitatessome considerable acquired or natural dexterity-more, un-doubtedly, than the employment of a ligature. The followingare examples of its recent application :-CASE 1. Amputation of the thigh.—J. S-, aged thirty-five,

an agricultural labourer, was submitted to amputation of thethigh on the 27th of March, 1867, for gangrene of the foot andleg, occurring during the treatment of a popliteal aneurism byforcible flexion of the leg. The operation performed was thedouble flap by transfixion. The muscles were very soft and

congested. Acupressure was employed to close the bleedingvessels : the femoral was secured by Simpson’s first plan ; theremainder, twelve in number, by the " quarter-twist method."The wound was closed at once with wire sutures. No externaldressing was applied.March 30th.-Ten pins were removed after forty-eight hours

had elapsed; that upon the femoral after seventy-two hours ;the remaining two could not be found, being buried in thewound, which had become greatly distended. A quantity ofdecomposing blood followed the withdrawal of the pins, andto allow of a freer vent several sutures were cut; there was noblush about the stump, and the man had experienced unusuallylittle constitutional disturbance.April 7th.-On the previous day search was made for the

missing pins, but unsuccessfully, and on the morning of thisday bleeding occurred to the extent of six or eight ounces,ceasing spontaneously; in the evening it returned. It wasnoticed that the blood was dark-coloured, and flowed in acontinuous stream. Lint saturated with tincture of perchlorideof iron was passed into the upper part of the wound, and thestump firmly bandaged. On this occasion he lost about tenounces of blood.

10th.—The bleeding had not recurred. One of the missingpins was extracted. The stump was consolidating.20th.-Allowed to be up every day, the greater part of

the stump having healed. No trace of the remaining pincould be obtained, and firm handling of the stump caused himno pain.CASE 2. Secondary amputation of the leg.-A. P-, a car-

man, aged fifty-three, of feeble constitutional powers, wasbrought into the theatre on the 17th April, 1866, to have hisleg removed at the lower fourth, in consequence of disorgani-sation of the ankle-joint, resulting from a severely laceratedand contused wound in that region.Anterior and posterior flaps were cut; and, after removal of

the limb, five pius were required to secure the vessels. Thewound was at once closed with wire suture.

April 19th.—The pins closing the tibial vessels were removedforty-eight hours after the operation; two of the others twenty-four hours after; and the fifth fell out in the course of thefirst night. A portion of the anterior flap had sloughed, andthere was a general exudation of pus between the sutures.The stump was dressed with carbolic-acid lotion.May 7th.—The slough slowly separated, and the wound

(which was quite superticial) had nearly healed. The patient’shealth had greatly improved.In alluding to the first case, Mr. Willett said the drawback

to its success was caused by the circumstance that two of thepins became completely buried in the wound, owing to thegreat distension of the stump which followed the operation,one remaining lost up to the present time. Hæmorrhage fol-lowing so closely upon the search made for the missing pinswas, without much doubt, induced by that step; and althoughthere existed no cause for alarm, still the patient’s conva-lescence would be retarded, and the wound prevented fromhealing soundly, so long as the pin continued in its presentsituation.The occurrence of sloughing of a portion of the flap in the

last case was no more than might have been expected, for thevitality of the parts had been much impaired by an attack ofdiffuse inflammation with sloughing of subcutaneous tissuebefore the operation

Excepting the incidents stated, these patients progressed asfavourably as would have been anticipated had ligatures beenused instead of pins, whilst no advantage had resulted fromthe proceeding adopted.

SLOUGHING PRODUCED BY LOCAL ANÆSTHESIA.WE examined, a few days since, in the Middlesex Hospital,

3. young woman whose case is of no little importance in refer-ence to the question of local as against general anæsthesia for

operations. Mr. Lawson had diagnosed the existence of an ab- -scess behind the patient’s breast, and as the pus was verydeep (under the pectoral muscle indeed) the refrigerator wasused, paraffine ether being employed. Congelation was rapidlyproduced, and kept up for a few minutes. The resu1t has been,that a portion of skin, about an inch by three-quarters of aninch, over the upper part of the breast, has sloughed, and itshealing will necessarily be attended by an unseen:ly scar. Thepatient is a maidservant; were she unfortunately a lady, theundress of the modern ball-room would be impracticable with-out revealing such a blemish as might seriously damage hervalue in the matrimonial market. The case is certainly excep-tional ; but the circumstance is worth remembering whenexposed parts of the body are to be operated upon.

Provincial Hospital Reports.DARLINGTON HOSPITAL.

EXTRACTION OF A GLASS BOTTLE FROM THE RECTUM.

(Under the care of Dr. HOWISON.)FOR particulars of the following unusually remarkable case

we are indebted to Mr. A. O. Haslewood, house-surgeon.T. W-, aged thirty, a workman in the gas-house, was

with some companions amusing himself with jumping overbottles placed above each other with their mouths uppermost.After he had in his turn jumped over the bottles, the top onewas missing, and it appeared to have passed through a thinpair of flannel trousers into the rectum. The man, a patientof Dr. Howison, was brought to the hospital next morning.He gave very little appearance of anything being the matter.Immediately after the accident he felt very sick and faint. Hewent to bed, after trying to protrude the bottle. On his ad-mission, the base of the bottle was found at the extremity ofthe ascending colon, though, from his description of its situa-tion, soon after the accident it was just about the junction ofthe transverse and descending colon. An injection of warmsoap-and-water was at once given. This had the effect ofbringing the bottle within extreme reach of the finger. Dr.Marion Sims’ vaginal speculum was used to expand the rectum,and after several attempts to seize and draw it out by a pair ofcesophageal forceps, it was at length expelled in a great mea-sure by the action of the bowel, assisted by manipulation.With the exception of the pain experienced in expanding therectum, the extraction gave the patient little uneasiness, andhe walked home seemingly very little the worse. He wasdirected to remain in bed for a day, and very soon recovered.The bottle is a castor-oil bottle, such as is usually sold bydruggists, and is eight inches long, four inches round at thethick extremity, and one inch and a half round the neck. It israther curious that the bottle should have been plumped downupon so exactly at the anal orifice as to pass up without muchpain. What the consequences would have been had the bottlebroken in its passage, it is rather unpleasant to conjecture.

Medical Societies.OBSTETRICAL SOCIETY OF LONDON.

WEDNESDAY, MAY 1ST, 1867.DR. HALL DAVIS, PRESIDENT.

ON THE TREATMENT OF LABOUR COMPLICATED WITHOVARIAN TUMOUR.

BY W. S. PLAYFAIR, M.D.,ASSISTANT OBSTETRIC PHYSICIAN TO KING’S COLLEGE HOSPITAL.

’ THE author commenced by relating the particulars of a caseof labour obstructed by ovarian tumour which had come underhis observation. The pelvis was occupied by a solid ovariangrowth, which was not diminished by puncture, delivery beingfinally effected by craniotomy. He then proceeded to analysethe details of fifty-seven similar cases, collected from varioussources, pointing out the results of the various methods oftreatment employed. He showed that nearly one-half of all

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the cases left to nature had proved fatal, probably on accountof the bruising and contusion to which the tumour was neces-sarily subjected during the passage of the head. On the otherhand, all the cases in which the tumour had been diminishedin size by puncture recovered ; and he strongly advocated thistreatment, even when there was apparently sufficient room toadmit of delivery without it. One-half of the cases in whichcraniotomy was resorted to had also ended fatally. In severalof these cases perforation was only employed because the childwas dead, although there was sufhcient room for the passageof the head; so that the results of this treatment were alsomost unfavourable for the same reason as when the case wasleft to nature. Dr. Playfair concluded by brietly reviewingthe history of the other methods of treatment employed, suchas turning and the Caesarean section. ’

Dr. HicKs considered that the use of chloroform in thesecases was of great service by lessening the expulsive action ofthe uterus, which constituted one great obstruction to thereturn of the tumour.Mr. SPENCER WELLS said that in the case alluded to in the

paper, in which he had succeeded in pushing a tumour up fromthe pelvis into the abdomen, a trocar had been introduced bythe vagina; and on his arrival he found the canula remaining ’,,in the tumour, but no fluid escaping. On making a freer Iopening, it became evident that the tumour was not ovarian, i,but a uterine fibroid. It was agreed that he should try to Ipush it up before craniotomy or the Caesarean section were ’,discussed; and after the patient was well under the influenceof chloroform the tumour was pushed up without muchdifficulty, and the accoucheur then readily delivered thechild. ’

Dr. BARNES thought the paper one of great interest. Hethought one subject of importance had not been sufficiently ’,discussed-that was, the propriety of inducing labour when

’’

pregnancy was complicated with ovarian tumour. It mightbe laid down as a general law, that natu-re would not toleratethe concurrent progress of these two conditions. Nature couldhardly bear the simultaneous growth of two tumours like thepregnant uterus and an ovarian tumour. Something must giveway. He had observed three orders of events, which all pointedto the truth of this law and to the practice he recommended.1. He had seen the tumour burst and the patient die; and inanother case he had seen the tumour rotated on its axis so thatthe pedicle was strangulated, leading to rupture of vessels,labour occurring prematurely under the agony of death: orthe uterus may rupture. 2. He had seen repeatedly prematurelabour occur spontaneously with good result. 3. The distressin breathing and hectic induced may be so urgent as to compelthe physician to interfere. He had frequently acted in obedi-ence to this law, and with the best results. The indication !,seemed to be clear in all serious complications with pregnancy ’,to reduce the case to its simplest expression by eliminating one ’,of the elements of complication. The most fitting element toremove was the pregnancy. This done, the ovarian tumourcould be dealt with at a convenient time according to its ’,special circumstances. In reference to the remarks of Mr.Spencer Wells, he asked whether, in some of the cases inwhich tapping had been resorted to, premature labour did notset in all the same ? It was certainly incorrect to say that thechild was necessarily lost by inducing labour.

Dr. MURRAY said that in a case of pregnancy complicatedwith ovarian disease which had come under his care he hadinduced labour at the end of the eighth month, and, underchloroform, had delivered by means of the forceps. The childwas living. This course he followed, fearing that the cyst might ’,be ruptured during the process of labour at the full time. Hispatient had been pregnant before, and it appeared that whilstpregnancy was going on the development of the cyst ceased,and it only enlarged after and between the pregnancies. He ’,considered that operations of any kind, however simple, per-formed during pregnancy, tended to produce abortion or bringon premature delivery.

Mr. SPENCER WELLS said the question had several times ’’,come before him, in consultation on cases where an ovariancyst complicated pregnancy, whether the patient should beleft alone, or tapped, or premature labour be induced. Hewould be glad to learn from some of the accoucheurs presentwhat they had observed in such cases, and he would say thatthe result ef his own expetienee was strongly in favour of tap-ping. If the cyst were left alone, there was great risk that itmight burst as the pregnancy advanced. He had known thisto occur twice. He had repeatedly tapped ovarian cysts inpregnant women, and never saw anything unusual follow; andit appeared to him that inducing premature labour must be

more hazardous to the mother than tapping a cyst, while cer-tainly it injured if it did not destroy the child. In reply toDr. Barnes’s question, Mr. Wells said that he had only onceseen labour speedily follow tapping, and in this case it was

probably only a coincidence.The PRESIDENT considered that if the contents of the tumour

were fluid, tapping was preferable to the induction of prema-ture labour.

Dr. PLAYFAIR said that, with reference to the question ofpremature labour mentioned by Dr. Barnes, in none of thecases he had collected was it stated that the child was bornbefore the full period. He did not doubt, however, that pre.mature labour frequently occurred where ovarian tumour ex-isted ; but the child being small there would be little difficultyin the delivery, and, therefore, such cases had not been re-corded. He believed that, as a rule, it was chiefly the smallerovarian growths which were pushed down in front of the head.When the tumour was large it was more likely to remain withinthe abdomen, and would not be so likely to act as an obstruc-tion. From this it resulted that such a complication wouldseldom be discovered until labour had actually commenced,and, therefore, there would be no opportunity for discussingthe advisability of artificially inducing delivery.

Reviews and Notices of Books.Lectures on Public Health. Delivered at the Royal College of

Surgeons in Ireland. By E. D. MAPoTHER, M.D., Pro-fessor of Hygiene, &c. Dublin: Fannin and Co.THE man of science discharges few more valuable functions

than when he works down and adapts for popular apprehen-sion the facts and doctrines which have from time to timebeen scientifically arrived at and established. In this waythe public mind becomes educated, not to a supercilious in-dependence of scientific aid, but to an intelligent and sympa-thising co-operation in scientific work. It is a mistake to

suppose that by popularising such subjects as anatomy orphysiology-to say nothing of pathology-the educated publicbegin to suspect the infallibility of their medical advisers, andcease to have confidence in their judgment. On the contrary,the most querulous, capricious, and troublesome of patientsare the ignorant ones, who have no glimmering of the diffi-culties with which the practitioner has to contend, and whoare disappointed and discontented if he does not work amiracle and perform an instantaneous and a lasting cure. To

such persons, and also to a much higher class of readers,Dr. Mapother’s Lectures will come with the most enlighteningand salutary effect. They will understand, from his vigorous,flowing, and thoroughly well-informed exposition, what sani-tary blessings they enjoy as compared with their mediaeval

ancestors ; what it is to breathe pure air and to drink purewater; what classes of food and drink are best adapted forparticular climates, ages, and constitutions; how far a tho-roughly cleansed skin conduces to health; what kind of

dwellings are most compatible with a long and healthy life;how epidemics may be prevented when approaching, or coun-teracted when present; and how sanitary organisation may beachieved and perfected.

Delivered before the Royal College of Surgeons in Ireland,Dr. Mapother’s prelections have at once the scientific value ofacademic expositions and the popular value of lectures ad-dressed to a mixed audience. He goes over the ground alreadytraversed so well by Dr. Andrew Combe in his popular workon Physiology, and by Professor Gairdner in his little volumeon Air and Water. But his style is more literary than that ofeither of these admirable physicians; and his information,while more recent and better digested, is also more impres-sively and attractively conveyed. No better volume could be

placed in the hands of the educated non-professional public.No superior or more trustworthy guide could be resorted to bythe guardians of the public health, or by those of our muni-cipal authorities who remember that they have not only a

dignity to support, but also a duty to perform.


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