2
118 without any recurrence of haemorrhage. The contused edges of the wound failed to unite. Although the cranial wounds followed an aseptic course, and the head symptoms steadily improved, the temperature rose and kept about 100° until the afternoon of Jan. 16th. The cause of this condition of febrility was in a lacerated and contused wound in the right groin; it suppurated. When it had been properly drained and dressed the temperature subsided. On the fourth day she was able to recognise her friends. She was occasionally very restless, pulling at the dressings on her head and trying to get out of bed. She frequently said, " Oh, I do feel so bad ! " or " Oh, my poor head ! " In the afternoon of the day she passed urine naturally for the first time since the accident. On the fifth day she was troubled with diarrhoea. On the sixth day, as she appeared to be flagging locally and generally, some stimulants were ordered. On the twelfth day she was less unmanageable and less restless. She called for her little boy at the top of her voice. She did not always call attention to her wants. On the fifteenth day.she was quite free from any febrility, but restless and peevish and contrary. She spoke more clearly, but used wrong words. The wound was slowly healing in the central part, where the lacerated con- tused edges had disintegrated and suppurated. On Jan. 6th she had frequently some trembling movements in the left leg, and these had been observed more or less since the third day, but they had been transient and pain- less, and never followed by any loss of power. They were now less frequent and milder than they were at first. She had all along required morphia to subdue her restlessness and to procure sleep. After the above date she began to sleep better and the diarrhoea became less frequent. On the 12th lucid intervals were observed, and during them she talked rationally. On the 15th she recognised her husband. On the 21st, or forty-one days after the operation, she could write legibly and intelligibly, but with such little mistakes in spelling as "Carilione" " or "Carilone." On the 23rd the eyes were examined with the ophthalmoscope. The optic discs and retinae were pronounced healthy. The improvement was steadilv maintained from this date. She could read and keep up her attention to the subject she was reading. She slept fairly well at night. The wound healed in the central part by granulation, sinuses remaining open in communication with pieces of dead bone which were separating from the posterior part where the bone forceps had been used. On Feb. 3rd she got up for the first time. She might have been allowed up earlier than this so far as the head wound was concerned, but the state of the healing wound in the groin had not permitted her moving about. Shewaskept in the hospital under observation until MaySth. As she seemed then to be fairly well able to take care of herself and to manage her own affairs, she was allowed to leave the hospital. She was provided with a metal plate to protect the injured part of the head. Since then she has changed her lodgings and has been lost sight of. Remarks by Mr. CROFT.—The remarks on this case may be arranged under the two heads of diagnosis and mode of operating. Under the first head there is little to be said, as the symptoms of compression were sufficiently definite and uncomplicated to indicate pressure from extravasation of blood between the dura mater and bone, and the symptom of paralysis of the right arm and leg was sufficiently marked to enable one to localise the situation of the blood-clot independently of the presence of the scalp wound. Under the second head there is more to be said, for it involves the consideration of the best way to deal with a lacerated and contused wound of the scalp when it is situated in the middle of the flap which the surgeon would wish to raise off the region of skull to be trephined. A wound of such a character as the one in the case narrated presented serious difficulties in, and obstacles to, obtaining primary union in all parts of the flap where such a mode of union is particularly desirable. The edges of the wound were cleaned and freshened, and sutured with a view to obtain- ing a watertight covering to the trephine holes, but the effort failed. The consequence of this perforation in the flap was that that portion healed by a slow process of granulation and cicatrisation based on the dura mater itself. I would advise that in such cases the bruised edges should be freely trimmed and carefully sutured, and that before laying down the flap plastic surgery should be brought into requisition so that primary union between the flap and the dura mater may be surely secured. Where the periosteum corresponding to the scalp wound has been injured, it should l be cut away, for if left it will prove an obstacle to rapid l healing. In this case it will have been noticed that necrosis ; took place at the edges of the bone, where bone forceps had , been used to clip and cut away the hard adult bone. I am i inclined to think that the saw is the preferable instrument, as it is less likely to lead to necrosis, and therefore it is . better adapted to promote rapid healing of the wound. B The success following such severe injuries as that of s C. S- does not bear comparison with the brilliant and rapid results of trephining where there is no scalp wound, and particularly the results of trephining for tumours of the brain ; for in such cases, if Mr. Victor Horsley’s plan of operating be carefully followed, complete primary union , should be the rule. The first case in which 1 trephined for compression and paralysis from blood-clot was performed in the days before antiseptic surgery-viz., in 1857. The result was perfectly successful, although no antiseptics were used. 18 SAMARITAN HOSPITAL FOR WOMEN, BELFAST. SIX CONSECUTIVE LAPAROTOMIES FOR CYSTIC DISEASE OF THE UTERINE APPENDAGES; REMARKS. (Under the care of Dr. MCMORDIE, M.Ch.) WE are somewhat surprised to find from Dr. McMordie’s remarks that medicinal treatment for, and tapping of, ovarian cysts is so much relied upon by the profession in Belfast as means of cure. We shall be pleased to know the experience of other members of the profession in that city on the subject. In England, tapping of an abdominal cyst of pelvic origin is rarely employed, and then only where there is a probability of its having commenced in the broad ligament, or where the case is urgent from dyspncca. Continued experience has only confirmed the opinion that tapping affords but temporary relief, and is not devoid of serious risk to the patient. There is no remedy known which exercises any effect on the growth of ovarian tumours ; the only use of medicine in such cases is to improve the general health or correct coexisting disease. Dr. McMordie makes a serious charge. CASE 1.-M. A-, aged thirty-eight, married, with seven children, the last one born two years ago. She was sent to the hospital for operation by Dr. Dundee of Ballycarry. She had been tapped four times. The tumour consisted of one large cyst with a solid base. The solid part of the tumour was steadily increasing, and was found to be larger after each tapping. An operation was performed on July llth. The cyst contained five quarts of dark thick fluid, and the solid part weighed 41b. She made an excellent recovery, and returned home on August 15th. CASE 2.-It-T. H-, aged forty-five (no family), under- went operation on July 18th. The left ovary, which was enlarged, cystic, and displaced in Douglas’s pouch, was removed for deep-seated persistent pelvic pain, resisting all manner of treatment for eighteen months. Discharged perfectly free from pain on August 20th. Has remained well ever since. CASE 3.-K. D-, aged thirty, single, was admitted on Aug. 7th. The growth of the tumour was of four years’ standing. During that time she had been treated medi- cinally by several doctors in her native town of New- townards. In this case medicine had been solely relied upon, and the aid of tapping was not called in. Afterwards a friend sent her to the Samaritan Hospital. She underwent operation on Aug. 22nd. There was a simple cyst on the right side, without adhesions, containing seven quarts of clear fluid. She made a good recovery, and was discharged in good health on Sept. 25th. CASE 4.—M. M’G——, aged forty-one, married, with eight children, the last one born six months previously to her admission. She was sent as a private patient to the hospital for operation by Dr. Currie, of Ballymena on Nov. 19th. This case had not been tapped. Enlargement was first noticed in July last. The operation was performed on Nov. 23rd. There was a cyst of the broad ligament, containing fonr quarts of thin dark fluid, and a quantity of soft material that appeared to be broken-down blood clot. The cyst wall 18 See Medical Times and Gazette, vol. ii. 1857.
