Embed Size (px)
wound. Pressure with a small sponge stopped the bsemor-rhage, but it recurred three or four times when the pressurewas removed, and so quickly that no vessel could be seen.Dr. Sheen succeeded, however, in grasping between hisfinger and thumb a portion of tissue from where the bloodappeared to issue, and the haemorrhage at once ceased.This was held for a few minutes, and turned out on exami-nation to be the anterior border of the sterno-mastoid.There was no further bleeding. Just before this, thepatient was very restless, partly from loss of blood,and partly from semi-consciousness of pain. A bypo.dermic injection of one-sixth of a grain of morphiastopped this restlessness almost at once. (The good effectof this treatment was very noticeable.) After the removalof the tumour a large deep wound was left, at the bottomof which the carotid could be seen distinctly pulsatingwithin its sheath. The stylo-hyoid and digastric muscles,with the hypoglossal nerve running across the space, wereclearly shown as if after a minute and elaborate dissection.A square inch of the ramus of the jaw ws bared ofperiosteum. The edges of the wound were broughttogether with hare-lip pins as well as the loss of skinwould permit.On the 31st he was up and felt "first-rate." The wound
had filled up considerably and looked healthy. On October5th he was made an out-patient. There was still an un-healed irregular surface of about an inch, with one or twosuspicious-looking spots about it and some gluey discharge,but no pain. Bare bone at the bottom. Much contractionof surrounding skin. General health very good.A few months later he passed successfully through a
severe attack of erysipelas of the face whilst in the country,after which the disease increased rapidly, and he died inMarch, 1876, of exhaustion, about six years after the firstappearance of disease in the lip.A similar case to this occurred recently at Guy’s Hospital,
and was operated upon by Mr. Durham. It is reported inthe Guy’s Hospital Gazette of November 6th, 1875.
ROYAL HOSPITAL FOR SICK CHILDREN,EDINBURGH.
CASE OF TRAUMATIC TETANUS, FOLLOWING INJURY OFTHE KNEE; AMPUTATION THROUGH UPPER PART
OF THIGH ; RECOVERY.
(Under the care of Professor SPENCE.)THE desirability of removing the peripheral source of
irritation in traumatic tetanus was very clearly shown in thefollowing case, for the notes of whichttve are indebted to Mr.J. Milne Chapman, M.B. It is, however, important not tooverlook the admonition contained in the appended note byProfessor Spence.Wm. M-, aged five, was admitted, under the care of
Dr. Macdonald, on February 19th, 1876. A month prior toadmission he fell from the back of a cart, and was drawnalong the ground, receiving what was described as a deepwound over the inner aspect of the left knee. A stitch andsimple dressing was all the treatment employed. 1-rom thefirst the inflammation spread superficially, and three weeksafter the accident the knee began to swell. For some timebefore entering the hospital it was observed that his mouthwas stifr, and that he could not swallow any solid food.On admission, an ulcerated area about the size of the
palm of the hand extended upwards from the level of theleft knee-joint, with which it communicated at its lowerpart by an opening through which the inner condyle of thefemur could be distinguished, exposed and roughened. Thepatient’s general health was much impaired, but his appe-tite remained good. The temperature was 102° F. He wasordered a draught containing ten grains of chloral alongwith fifteen grains of bromide of potassium, but yet he passeda very restless night.
Feb. 20tb.-Morning temperature 100°. In the afternoon,while retracting his tongue, his jaws closed on it, and onits being freed the teeth snapped together. Temperaturein the evening 103°. At eight P.M. he had an attack ofopisthotonos, which lasted about two minutes. He was atonce put under chloroform. Professor Spence, who wascalled in consultation, expressed the opinion that on account
of the injuries alone, amputation was required. He ac.cordingly, at 8.30, performpd amputation through themiddle third of the thigh by a long anterior and two shorterposterior flaps principally composed of skin. No sutureswere used-merely three strips of plaster to retain the flapsin position, and the stump was covered with a single layerof lint soaked in carbolised oil. During the operation thechild had two attacks of spasms, while under chloroform,The condyles of the femur were found to be split into theknee-joint, and the joint itself was filled with purulent fluid.Twenty grains of chloral were at once administered, but oncoming out of chloroform he had attacks of opisthotonosevery ten minutes for about two hours, when twenty grainsmore were given. The interval of rest then extended toforty-five minutes. After each spasm he had five grains ofchloral, and on three occasions hypodermic injections ofthree, five, and seven and a half minims of solution of thesulphate of atropia (B.P.)21st.-Slept soundly for about three hours In the morning.
During the day he had four spasms, at intervals of abouttwo hours. He took milk and chicken soup freely.-At10 P.m., he had a very severe attack, which lasted for fiveminutes. Seven minims and a half of atropia were injected,and a spinal ice-bag applied.He slept soundly, and had no more tetanic symptoms,
except on one occasion, when Prof. Spence, observing afixed expression on his face, ordered an atropine injection.His appetite continued good, and he was soon able to eatsolids. The chloral was kept up, however, in diminishingdoses for about a week. The temperature fell to 986° onthe second day after the operation, and continued to rangebetween 98° and 99° for nine days, when a considerable risetook place, coincident with the appearance of a measleyrash. By the 14th of March, the face had lost all itspinched appearance, and the stump was almost entirelyhealed by primary union.
Note by Professor SPENcE.-In recording the foregoingcase as a contribution to the treatment of a very obscuredisease, I would not wish to be understood as indicatingthe opinion that amputation would be successful in arrest-ing the tetanic symptoms in all cases where they arisefrom lesion of a limb, by removing the cause, and cuttingoff the continuity between the irritated peripheral nervesand the nerve-centres. Such an opinion would requiremuch larger foundation than a single successful case.
I have frequently performed amputation of laceratedfingers in tetanus, but without any benefit, although theoperations were performed early in disease. Indeed, theprogress of cases of traumatic tetanus would rather lead tothe view that when the symptoms fairly manifest them.selves certain changes have already occurred in the nerve-centres which the removal of the originating cause comestoo late to benefit. But the case just recorded warrantsme, I think, in saying that no remedial measures couldhave relieved the patient unless the injured limb hadbeen removed; and, in so far, the amputation must be re-garded as a main part of the curative measures. In thiscase the disorganised state of the knee-joint left no roomfor hesitation; but, from my experience of tetanus, I believethe irritable and ulcerated cutaneous surface was the realexciting cause, and the result of this case would certainlyencourage to amputate in similar cases even where the localinjury was less severe.
CAMBRIDGE UNIVERSITY REFORM.-A memorial,signed by a number of professors, fellows, &c., has beenforwarded to Mr. Diaraeli, urging the following reforms inreference to Cambridge University :-No fellowship shouldbe tenable for life, except when the original tenure is ex-tended in consideration of services rendered to education,learning, or sciences actively and directly in connexion withthe university or the colleges. A permanent professionalcareer should be as far as possible secured to residenteducators and students, whether married or not. Provisionshould be made for the association of the colleges, or someof them, for educational purposes, so as to secure moreefficient teaching, and to allow to the teachers more leisurefor private study. The pecuniary and other relations sub-sisting between the university and the colleges should be
revised, and, if necessary, a representative board of univer-sity finance should be organised.