821

will be seen that but few of its deaths are due to the operation itself. One section of the operations has been donupon patients already moribund from exhaustion, or frocthe occurrence of fatal injury. These deaths are to be sedown to improper delay, or to misdirected interference. lianother large section of the operations the deaths are to bdebited to causes preventable, and, of late, more clearly perceived. I allude to septic poisoning in the course of thoperation, and to the misdirected influence of opium, oalcohol, and of other drugs in the after-treatment. In someases the question must now be raised whether the treatment of the uterus by sutures has not also been a factor odeath, which, for the future, may be safely avoided. Considering the uncontrollable resistance of local muscles ir

operation about the soft palate, and the reflpx irritabilityof the sphincter ani in other painful diseases-consideringthat the uterus is the most powerful muscle in the humarbody, and an organ intensely endowed with reflex irrita.

bility, I venture to submit that, < priori, the onus justijicandTests upon those who would attempt to tie up this organ b3sutures. Still, high authorities have differed upon this sub.ject. and during this operation the very earnest convictionfof Dr. Routh did in the end sway Mr. Sibley’s judgment,while they made me feel that, in not yielding to his arguments, I was guilty of a questionable and impolitic hardi.hood. Moreover, I felt with Mr. Sibley that if ever therewere a case for sutures this was the one. The uterus havingbeen "cut on the cross," the incision gappd most formid-ably, and the edges were so remarkably everted under theinfluence of every contraction, that it, seemed possible theuterus might turn itself inside out. The danger, therefore,that a loop of intestine might become strangulated wasvividly present, while to the last moment Dr. Routh con-tinued to urge that the insertion of wire sutures wouldlessen the chance of hasmorrhage occurring after closure ofabdomen, yet I could not overcome my repugnance to thesuturing of this irritable muscular mass.In conclusion, I venture to submit that, but for uterine

baemorrhage after closure of the abdomen, the operation ofC&aelig;sarean section per se ought not to be more than half asfatal as the operation of ovariotomy. There are no adbe-sions to combat, there need be no extreme interference withthe abdominal peritoneum, and the complications of malig-nant disease are less frequent. Should it be proved thatthe mortality incident to Caesarean section is reducible to aratio of ten per cent., it is clear that some old and gravecontroversies will have to be reopened.With regard to the particular cases which have formed

the basis of this paper, it is an odd run of luck for two suchconsecutive recoveries to have occurred to any one prac-titioner. But the two operations having been practicallyidentical throughout, and every detail in each case halvingbeen recorded with rigid accuracy, it seemed to me that Imight venture to submit them fully to the Society. Boththese patients, in the first instance, had the good fortuneto fall under the care of judicious and experienced prac-titioners, who preserved them alike from premature or mis-directed interference and from undue delay. In each casewe had the advantage of that brotherly help from neigh-bouring practitioners which is one of our pleasantest expe-riences in the republic medical; and in this recent case wehad the good fortune to be counselled and assisted through-out by Dr. Routh and Mr. Sibley.

TESTIMONIAL.-It is always pleasant to us to recorda tribute of respect to a medical man. A very unusual onehas just been paid to Dr. Evan Pierce, coroner for thecounty of Denbigh. Few medical men have statues raisedin their honour, even after their death, but Dr. Pierce hashad this honour done to him while he is yet alive andcapable of enjoying the rare esteem which it implies. For

aday, Denbigh and the neighbouring country seems to haveabandoned itself to the duty of unveiling this statue, withevery manifestation of gratitude and respect to Dr. Pierce.His earliest diplomas date from 1836, but the gratitude ofhis neighbours and patients dates as far back as thecholera time of 1832 In acknowledging the tributepaid to him, Dr. Pierce spoke in very fitting terms of thehonour done through him to the medica.1 profession, and invery modest ones of his own merits. We congratulate himon the occasion.

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

GUY’S HOSPITAL.CASES OF COMPOUND FRACTURE IN WHICH THE WOUNDS

WERE CLOSED WITH COMPRESSES SOAKED IN

COMPOUND TINCTURE OF BENZOIN.

(Under the care of Mr. BRYANT.)

Molla autem est alia pro certo noscendi via, nisi quamplurimas et morborumat dissectionum historias, tum aliorum, turn proprias collectas habere, etI inter se compare.&mdash;MORGAGNI De Sed. et OauB. Morb., lib. iv. Prooemium.

THE following is a continuation of the series of cases ofcompound fracture treated by closing the wounds with com-pressas saturated with compound tincture of benzoin.CASE 9. Com_poundfractu7-e of left humerus near the condyle;

wound closed ivitlz compound tincture of benzoin; improved.(Reported by Mr. D. T. Evans ) - M. K , a labourer.aged forty-one, was admitted on the 18th November, 1872,with a compound fracture of the lower end of the humerus,reaching from about the tip of the external condyle to abouthalf an inch above the internal condyle, with probably afracture of the lower end of the bone between the condylesat right angles to the fracture across the bone. He com-

plained of great pain about the left elbow and over the

right scapula and shoulder-joint.The patient stated that he was walking along the railway

when he was struck on the right shoulder by the buffer ofa steam engine which was coming after him; his back wastowards the engine, and he was not aware that he was sonear the rails on which the train was running. He wasturned round by the blow, and the connecting rod of thewheels struck his left elbow, knocking him to the ground.His coat was torn away by some part of the engine, and hisboot was dragged off his right foot, which was injured tosome extent. He was much shaken, and was unable to walk,but he could stand on his left leg.As soon as he was admitted, the wound of the skin over

the situation of the fracture was closed with lint saturatedwith compound tincture of benzoin; and the arm was placedon an angular wooden splint reaching from the axilla tothe hand. Strapping and a bandage were applied over thearm, but a space of three inches above and below theprominence of the olecranon was left bare. There was muchtension of the skin in the vicinity of the fracture, and con-

siderable ecchymosis, but no pain, and he slept well duringthe night. Pulse 60; temperature 98-6&deg;.Nov. 20th.&mdash;The tongue was slightly furred. The man

slept badly in the night; his appetite was poor, his bowelsconfined, and there was great pain in the arm. Pulse 80;temperature 98-60 F.

25th.&mdash;The ecchymosis had disappeared, but there wasstill considerable tension of the skin round the elbow-joint.He slept a little during the night, but complained of thirst,and was troubled with a cough. Pulse 90; temperature101.1&deg;.

29th.&mdash;There was great tension and pain on pressure overthe region of the elbow-,joint; there was also considerableinflammation round the fracture. The pad of benzoin was

t removed, and water dressings applied to the wound over thefracture. The wound had closed by a dark-looking scab ; it

! was of the extent of about an inch by half an inch. The

splint was placed on the inner side of the arm in the same’ position as before, and rebandagad. Poultices were applied

over the elbow, and he passed a fair night. Pulse 90; tem-perature 100-4&deg;.The patient continued to be troubled occasionally with

cough, but did not expectorate. In other respects heseemed to be improving, and expressed himself as beingquite comfortable.

Dec. 27th.-Pulse 84 ; temperature 97-4&deg;. Poultices werestill applied to his arm ; all the parts seemed free from anyinflammatory mischief.30th.-The patient was very comfortable; he perspired

822

slightly, but slept well. His appetite was good. Pulse 80; temperature 98.5&deg;.

Jan. 2nd, 1873.--The splint was removed; the wound hadentirely healed. Tbere was motion in the elbow of aboutthree inches; the movement was free, and only checked bymuscular action and pain. All dressings were left off, andhe got up with his arm in a sling.

4th.&mdash;The movement of his elbow has brought on greatheat, swelling, and pain, but no rigors. His appetite wasgood. Pulse full, slow, and regular ; temperature normal.Ice was applied to the elbow, and splint resumed.12th.-He was up, and three days later left the hospital

with the splint on his arm. He had not tried to move hiselbow again.The man came to show himself in February, and he had

an excellent arm, with good movement of the joint.CASE 10. Compound fracture of ulna; simple fracture of

radius ; wound sealed with compound tincture of benzoin; im-proved. (Reported by Mr. W. D. Stamp.)-Emma R&mdash;,a married woman, aged twenty-two, was admitted on March6th, 1874, with a compound fracture of the right ulna aboutthe junction of middle with the lower third, and a fractureof the radius in the middle third. She had been standingbetween two mangles, and was about to take one of therollers out when both mangles were set in motion, andcaught her right arm.The wound, which was about an inch and a half long,

was sealed with compound tincture of benzoin, and thelimb was put in splints, the anterior one reaching from tipof the fingers to the elhow, and the posterior one from thewrist to about the same point.The arm was not touched until the 23rd, when the pos-

terior splint was removed, and the wound was found to beperfectly healed. She got up on the 26th, there being nopain, and she left the hospital on the 27th, with the armstill in splints.CASE 11. Compound fracture of fifth metatarsal bone, with ex-

treme laceration of skin; wound dressed with compound tinctureof benzoin ; improved. (Reported by Mr. G. E. Miles.)-John M--, a platelayer, aged twenty-seven, while on theline at Norwood Junction, on the 6th Feb., 1873, wasknocked down by a blow on the back from the buffer of aslowly-moving train. The wheel passed over the outer sideof the left foot, and inflicted the injuries below described.There was a wound three inches in length between thefourth and fifth metatarsal bones, as far as the cleft of thetoes ; there was also a wound on the ball of the little toe.The fifth metatarsal bone was fractured, and a tendon laidbare; there was slight haemorrhage. The wound was

plugged with lint soaked in compound tincture of benzoin,a pad of lint was put outside, and the whole foot strapped.The patient progressed favourably until the 15th Feb.,when the dressing of benzoin was removed and replacedby carbolic acid dressing; there was slight discharge, andalso shivering, headache, and thirst, which, however, onlylasted one day. Temperature 1005&deg;.On the 21st the sore was level with the skin, and on th(

10th March he left the hospital, the wound nearly well.CASE 12. Compound fracture of thumb; wound sealed with

compound tincture of benzoin ; recovery. (Reported by MrShadwell.)-Henry F-, a labourer at a brush-mill, agectwenty-five, was admitted on April 10th, 1872, with a wouncextending from the lower part of thumb inwards towardlthe palm of the hand ; the thumb was hanging bonly a very small piece of skin and muscle. It appeare(that he was sawing a broom-head, which was wet, and hi:hand slipped against the circular saw, which cut througlthe matacarpo-phalangeal articulation of the thumb, takinloff a small piece of bone from the base of phalanx, ancpassing downwards and inwards for about an inch.The parts were brought together, and sealed with com

pound tincture of bdDzdin. The hand was suspended b:means of a bandage to the bpd-rail. There was some bleed

ing the following day, and the hand was placed on a pillowApril 13th.&mdash;Pulse 88; temperature 98-4. The hand wa

much swollen.16th (sixth day).&mdash;The dreesing was removed; the woun,

seemed to be progressing favourably. The sensation ithumb was good, and the discharge only slight. It wadressed with cold water only, and bandaged up.26th.-There was only a slight discharge from the wounc

which was healing.

May 3rd.&mdash;The edges of the wound just behind the meta-carpo-pbalangeal articulation had united.

18th.&mdash;He left the hospital with very fair motion in histhumb and only about a quarter of an inch of shortening.

WESTMINSTER HOSPITAL.ACUTE ARTICULAR RHEUMATISM ; EXTREMELY HIGH

TEMPERATURE; COLD BATHING; SALICIN; DEATH,WITH ACTIVE DELIRIUM, AND EXTENSIVE PULMONARYCONGESTION.

(Under the care of Dr. STURGES.)A srOUT, well-nourished barman, of temperate habits,

aged twenty-seven, was admitted on Sept. 7th, 1876, witha second attack of acute rheumatism. The first attack wasfour years ago, and the second began three days beforeadmission, the pains showing themselves first in the ankles,then in the knees, and lastly in the arms.On admission, the upper limbs were fixed, patient was

sweating profusely, the sweat having an intensely soursmell. There were no heart complications. The aspectdenoted distress and anxiety, but the manner was quiet andrational. Pulse 120 ; temperature 1026&deg; F. ; respirationnot notably quickened. Ordered twenty grains of salicinin glycerine every two hours.During the three following days nothing noteworthy

occurred. Although the joint pains were at first relieved,he made little progress ; sweating was profuse ; temperaturehovering between 101&deg; and 102&deg;. On the 9th, at 10 r.na.(with temperature 102&deg;), there is a note: "All pains gone;.patient can move all his joints well except his fingers." Onthe following day, however (the third from admission) witha lower temperature (101&deg;), the pains in the knees andankles were severe. He had twenty-five grains of chloral

. that night, but got little sleep. The mental condition wasnatural, and he had no night wandering. The salicin, as

’ regards dose and time, had been continued the same through-. out. On Sept. 12th he got some snatches of sleep. Tempera-

ture in the morning 1006&deg;. In the course of this day the’ variations of temperature were sudden and extreme. At. 10 A.M. it had risen to 1026&deg;, and at 6 PM. it had fallen to

998&deg;. The bowels were moved; the pain was less. Thesame night, at 10 P.nz., the patient, having power of free

. movement in all his joints, became suddenly delirious.1 The account is continued in the words of Mr. H. Cane,:5 the house-physician, who watched the case with great, assiduity throughout, and, in the absence of the physician,. promptly adopted the measures to be presently de-, scrihed.i when called to the patient, at 10 P.M., the nurse stated1 that he had been, for a short time, very delirious, throwing7himself about, and striking the lookers-on with his fists,.

and was only kept in bed with great difficulty. He lay onohis back, breathing noisily, 60; pulse 180. The face had a

peculiar tallowy appearance; the eyes were wide open, andhthe conjunctives quite insensible, and there was profound’. coma.’ The skin was moist, but painfully hot to the touch.d On placing a thermometer in the axilla, the temperatured rose to 110&deg; in two minutes.s It was now determined to give him a cold bath. He was

y immediately stripped and laid on a sheet, and placed in ad bath, which was brought to the bedside, the temperatures of the water being about 60&deg;. After remaining in theh bath for about half an hour, the body temperature wasg reduced to 106&deg;. After the first fifteen minutes he showedd signs of collapse. An enema, consisting of two ounces of

brandy and two ounces of beef-tea, was then given peri- rectum. After this he rallied, but in another quarter of any hour he again showed such marked signs of approaching1- collapse that he was removed from the bath, and packedv. with sheets wrung out of cold water, over which larges lumps of ice were placed. His temperature then gradually

fell until, at 2 A.M., the thermometer registered 102&deg;. Atd 3 A.M. it was 101&deg;. The packs were now removed, and then patient placed between the blankets. During the wholets of this time brandy was frequently administered per rectum,

along with beef-tea and strong coffee. The pulse variedd, greatly, sometimes being full and bounding, and at other

times small, intermittent, and very rapid (160 per minute).