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39C A Mirror OF HOSPITAL PRACTICE, BRITISH AND FOREIGN. MIDDLESEX HOSPITAL. LODGMENT OF A LARGE PIECE OF STICK IN THE ORBIT OF A CHILD; COMPLETE PARALYSIS OF ALL THE OCULAR MUSCLES ; REMOVAL; RECOVERY. (Under the care of Mr. GEO. LAWSON.) Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborum et dissectionum historias, tum aliorum, tum proprias collectas habere, et inter Be comparare.—MORGAGNI De Sed. et Caus. Morb., lib. iv. Proœmium. E. M , a healthy boy of three years of age, was ad- mitted into the hospital on June 20th, 1877, suffering from the following symptoms:-The lid of the left eye was dropped over the globe without the slightest power of raising it. On lifting it with the finger the globe was seen to be bulged directly forwards about a quarter of an inch. The eye was quite fixed in the centre of the orbit, from complete palsy of all the ocular muscles, the pupil widely dilated, and, as far as could be made out in so young a child, absolutely blind. At the inner and lower portion of the orbit was a small fistulous opening, at the site through which the stick entered, and from this orifice there was a continued thin discharge. The history which the mother gave was that seven weeks previously the child was riding in a perambulator, and playing with a long piece of stick from the dried branch of a tree, when the perambulator was jerked against a stone, and the child was thrown forwards, and fell with his face on to the point of the stick. On raising the child, the point of the stick was found to have penetrated the inner and lower side of the left orbit, and the grandmother, who was in attendance, pulled out the stick from the wound, and she was quite satisfied that no part of it was left behind. From that moment the mother says she believes the sight of the eye was lost. The upper lid in a few days be!!an to droop, and the movements of the globe to be impaired, and these symptoms increased until she brought the child to the hospital, when the eye was in the condition above described. The child seemed in good health, and had not suffered constitutionally from the condition of the eye; but although he had no severe pain, still he was uneasy, and slept badly at night, frequently waking and crying out. Taking all the symptoms and the nature of the accident into account, Mr. Lawson came to the conclusion that there was probably still a portion of the stick in the orbit, and that the paralysis of all the ocular muscles and the levator palpebrse, and the protrusion of the globe, were due to in- flammatory exudation excited by the presence of a foreign body in the orbit. If the blindness was the immediate effect of the accident, as the mother imagined, it was pro- bably caused by direct injury to the optic nerve ; but if it had gradually come on with the palsy of the muscles, it was most likely due to an increasing pressure on the nerve from lymph effusion. Mr. Lawson accordingly determined to make a search for the foreign body. The child having been put under chloroform, a probe was passed into the sinus, at the inner and lower side of the orbit, but nothing could be detected by it. Guided by the probe, an incision was made along the floor of the orbit, intc which the little finger was introduced, and it at once came down upon a small hard point. A pair of fine forceps WRE then passed into the wound, and after a little trouble a piece of stick exactly corresponding to the woodcut wa! removed. The child recovered from the operation very rapidly. There was no suppuration. The wound quickly healed, and in four days he was able to leave the hospital. The protrusion of the eye subsided,: the levator palpehrse and the ocular muscles gradually regained their powera, and three weeks after the operation the lids were open, and the movements of the eye almost restored ; but, as far as could be ascertained, the eye was blind. LONDON HOSPITAL. DISORGANISATION OF CARPAL JOINTS AND WRIST, WITH SLOUGHING OF SOFT PARTS, IN A GOUTY MAN ; AMPUTATION OF FOREARM ; RECOVERY. (Under the care of Mr. RIVINGTON.) JAMES E-, aged sixty-two, was admitted on May 2nd. He stated that he had been a steady and moderately healthy man, but a severe sufferer from gout for the last twenty years. When admitted he had a severely inflamed hand, suppurating over dorsum. A splint was put on, poultices applied, and free irrigation practised, but the sloughing extended rapidly. By May 17th the extensor tendons had entirely sloughed, the wrist-joint was opened, and the adjacent tissues were completely disintegrated ; the patient’s health had suffered much, and a great deal of pain had been experienced in the hand and arm. On May 18th, with Mr. Rivington’s approval, the hand was removed by Mr. Allden, the house-surgeon, together with two inches of the lower end of the radius and ulna, antero- posterior flaps being made; silver sutures were used, and the stump dressed with oil lint. The carpal bones were found to be very extensively necrosed. Patient re- covered well from operation. Next day there was but little discharge, but the stump was a good deal inflamed, though not painful. Evaporating lotions were applied. There had been no rigors or vomit- ing. Bowels open, tongue red and dry, appetite fair. A week after the health was much improved ; there was very little discharge, and the flaps were uniting well, and considerably less inflamed and red. On June 3rd the pa- tient was not so well; he slept badly, the appetite was failing, pulse quick, tongue dry. Although there were no rigors, there was a feeling of nausea, and he complained of great weakness. The stump, however, looked very healthy. In two or three days these symptoms began to pass away, and he was stronger and the stump looked healthy. On June 23rd the stump was nearly healed; a little piece of dead bone was removed, the general health was much improved. On July 1st he was up, the wound was well healed and the general health good. In addition to the affection of the hand the patient was suffering on admission from a disorganised metacarpo- phalangeal articulation, belonging to the great toe of the left foot. The limb was placed on a McIntyre splint. Under - the influence of rest the joint became ancbylosed, the ul- cerated surface over it cicatrised, and the sinus leading to the ioint closed. SUSSEX COUNTY HOSPITAL, BRIGHTON. ACUTE RHEUMATISM; HYPERPYREXIA ; TEPID BATHS ; DEATH. (Under the care of Dr. KEBBELL ) SARAH H--, aged twenty-eight, was admitted on March 24th, 1877. The previous health had been good; she had been married eight years, and had four children, the youngest of which she was nursing up to the time of her admission. About three weeks before, after getting wet, she had a severe cold, followed by pains in the back, head, and lower extremities. On admission the pain was confined chiefly to the knees, ankles, and feet, which were slightly red and swollen. The heart and breath-sounds were healthy; tongue moist and slightly coated; abundant perspiration with sudamina on chest; pulse 108; morning temperature 1012°; evening temperature 101 8° ; urine, sp. gr. 1040, acid, high coloured, with copious deposit of lithates. A little extract of bella- donna with glycerine was applied to the mammea, which gave no further inconvenience. Ten grains of compound ! ipecacuanha powder were given at bedtime. The affected , limbs were covered with cotton-wool.

LONDON HOSPITAL

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39C

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

MIDDLESEX HOSPITAL.LODGMENT OF A LARGE PIECE OF STICK IN THE ORBIT

OF A CHILD; COMPLETE PARALYSIS OF ALL THEOCULAR MUSCLES ; REMOVAL; RECOVERY.

(Under the care of Mr. GEO. LAWSON.)

Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborumet dissectionum historias, tum aliorum, tum proprias collectas habere, etinter Be comparare.—MORGAGNI De Sed. et Caus. Morb., lib. iv. Proœmium.

E. M , a healthy boy of three years of age, was ad-mitted into the hospital on June 20th, 1877, suffering fromthe following symptoms:-The lid of the left eye was

dropped over the globe without the slightest power of

raising it. On lifting it with the finger the globe was seento be bulged directly forwards about a quarter of an inch.The eye was quite fixed in the centre of the orbit, fromcomplete palsy of all the ocular muscles, the pupil widelydilated, and, as far as could be made out in so young achild, absolutely blind. At the inner and lower portion ofthe orbit was a small fistulous opening, at the site throughwhich the stick entered, and from this orifice there was acontinued thin discharge.The history which the mother gave was that seven weeks

previously the child was riding in a perambulator, andplaying with a long piece of stick from the dried branch ofa tree, when the perambulator was jerked against a stone,and the child was thrown forwards, and fell with his faceon to the point of the stick. On raising the child, thepoint of the stick was found to have penetrated the innerand lower side of the left orbit, and the grandmother, whowas in attendance, pulled out the stick from the wound, andshe was quite satisfied that no part of it was left behind.From that moment the mother says she believes the sightof the eye was lost. The upper lid in a few days be!!an todroop, and the movements of the globe to be impaired, andthese symptoms increased until she brought the child tothe hospital, when the eye was in the condition abovedescribed. The child seemed in good health, and had notsuffered constitutionally from the condition of the eye; butalthough he had no severe pain, still he was uneasy, andslept badly at night, frequently waking and crying out.Taking all the symptoms and the nature of the accident

into account, Mr. Lawson came to the conclusion that therewas probably still a portion of the stick in the orbit, andthat the paralysis of all the ocular muscles and the levatorpalpebrse, and the protrusion of the globe, were due to in-flammatory exudation excited by the presence of a foreignbody in the orbit. If the blindness was the immediateeffect of the accident, as the mother imagined, it was pro-bably caused by direct injury to the optic nerve ; but if ithad gradually come on with the palsy of the muscles, it wasmost likely due to an increasing pressure on the nerve fromlymph effusion. Mr. Lawson accordingly determined tomake a search for the foreign body.The child having been put under chloroform, a probe was

passed into the sinus, at the inner and lower side of theorbit, but nothing could be detected by it. Guided by theprobe, an incision was made along the floor of the orbit, intcwhich the little finger was introduced, and it at once camedown upon a small hard point. A pair of fine forceps WREthen passed into the wound, and after a little trouble a

piece of stick exactly corresponding to the woodcut wa!removed.

The child recovered from the operation very rapidly.There was no suppuration. The wound quickly healed,and in four days he was able to leave the hospital. The

protrusion of the eye subsided,: the levator palpehrse

and the ocular muscles gradually regained their powera,and three weeks after the operation the lids were open, andthe movements of the eye almost restored ; but, as far ascould be ascertained, the eye was blind.

LONDON HOSPITAL.DISORGANISATION OF CARPAL JOINTS AND WRIST, WITH

SLOUGHING OF SOFT PARTS, IN A GOUTY MAN ;AMPUTATION OF FOREARM ; RECOVERY.

(Under the care of Mr. RIVINGTON.)JAMES E-, aged sixty-two, was admitted on May 2nd. He

stated that he had been a steady and moderately healthyman, but a severe sufferer from gout for the last twentyyears. When admitted he had a severely inflamed hand,suppurating over dorsum. A splint was put on, poulticesapplied, and free irrigation practised, but the sloughingextended rapidly.By May 17th the extensor tendons had entirely sloughed,

the wrist-joint was opened, and the adjacent tissues werecompletely disintegrated ; the patient’s health had sufferedmuch, and a great deal of pain had been experienced in thehand and arm.On May 18th, with Mr. Rivington’s approval, the hand

was removed by Mr. Allden, the house-surgeon, togetherwith two inches of the lower end of the radius and ulna,antero- posterior flaps being made; silver sutures were used,and the stump dressed with oil lint. The carpal boneswere found to be very extensively necrosed. Patient re-covered well from operation.Next day there was but little discharge, but the stump

was a good deal inflamed, though not painful. Evaporatinglotions were applied. There had been no rigors or vomit-ing. Bowels open, tongue red and dry, appetite fair.A week after the health was much improved ; there wasvery little discharge, and the flaps were uniting well, andconsiderably less inflamed and red. On June 3rd the pa-tient was not so well; he slept badly, the appetite wasfailing, pulse quick, tongue dry. Although there were norigors, there was a feeling of nausea, and he complained ofgreat weakness. The stump, however, looked very healthy.In two or three days these symptoms began to pass away,and he was stronger and the stump looked healthy. OnJune 23rd the stump was nearly healed; a little piece ofdead bone was removed, the general health was muchimproved. On July 1st he was up, the wound was well

’ healed and the general health good.’ In addition to the affection of the hand the patient was

suffering on admission from a disorganised metacarpo-phalangeal articulation, belonging to the great toe of the

’ left foot. The limb was placed on a McIntyre splint. Under- the influence of rest the joint became ancbylosed, the ul-

cerated surface over it cicatrised, and the sinus leading to’ the ioint closed.

SUSSEX COUNTY HOSPITAL, BRIGHTON.ACUTE RHEUMATISM; HYPERPYREXIA ; TEPID BATHS ;

DEATH.

(Under the care of Dr. KEBBELL )SARAH H--, aged twenty-eight, was admitted on March

24th, 1877. The previous health had been good; she hadbeen married eight years, and had four children, the youngestof which she was nursing up to the time of her admission.About three weeks before, after getting wet, she had asevere cold, followed by pains in the back, head, and lowerextremities.On admission the pain was confined chiefly to the knees,

ankles, and feet, which were slightly red and swollen. Theheart and breath-sounds were healthy; tongue moistand slightly coated; abundant perspiration with sudaminaon chest; pulse 108; morning temperature 1012°; eveningtemperature 101 8° ; urine, sp. gr. 1040, acid, high coloured,with copious deposit of lithates. A little extract of bella-donna with glycerine was applied to the mammea, whichgave no further inconvenience. Ten grains of compound

! ipecacuanha powder were given at bedtime. The affected, limbs were covered with cotton-wool.