JohnD Malcolm
1891 The Lancet  
168 stage, when the contraction is confined to the little finger, and has become spontaneously arrested with deformity; or in the third stage, when contraction increases from sixteen to twenty years of age, and all the fingers become involved, a complete cure may be obtained by operation followed by a long course of mechanical treatment-i.e., wearing an extension apparatus day and night for a period of from three to six months after the operation, and a metal retentive splint, adapted to all
more » ... fingers, afterwards at night for some months. We may therefore consider that this congenital contraction of the fingers, like Dupuytren's contraction previously described, has now been brought fairly under the control of the surgeon. SURGEON TO THE SAMARITAN FREE HOSPITAL. (Concluded from page 121.) CASE 4.-On Dec. 27th, 1888, I removed two ovarian tumours from a woman thirty-nine years of age, a patient of Dr. Curgenven. She was of unhealthy strumous appearance, and had evidence of mitral contraction with very excitable heart action. The larger tumour, which weighed 201b., had a twisted pedicle, and was very adherent to the abdominal wall and to the omentum. A considerable portion of the latter was tied off and removed. The pedicle, having been secured by silk in two pieces, the tumour was cut away. A small non-adherent tumour of the other ovary, about the size of a cocoa-nut, was also removed. In all the operations detailed above I had taken every care to prevent the access to the wounds of anything that was not absolutely clean, and also purified by carbolic solution. In this case, before closing the incision, I washed out the abdomen freely with warm water, and drained the pelvis with a glass tube. This tube was removed after seventy-two hours, there being then very little clear serum escaping from it. Flatus began to pass from the rectum on the morning of the day after the operation. At 9 A.M. on the second day the temperature had risen to 1024° in the vagina; the pulse was 112. A menstrual flow came on, and the temperature fell a little. All day the flatus caused a good deal of pain, and there was some localised distension of the abdomen to the right of the incision. The distension and pain passed off in the night. Between midnight and 2 A.M. the temperature, which had ranged from 1018° to 102° for twelve hours, rose suddenly to 103°. Ice was applied to the head, and kept on till the temperature had come gradually down to 984° on the seventh day. The wound did not heal well at its lower end, where the drainage-tube had been. The bowels were moved on the sixth day by enema. Subsequently there was occasional slight distension of the abdomen, which always passed off after an accion of the bowels. The patient had not been able to pass urine except through a catheter since the operation. On the thirteenth day there was an attack of cystitis. The bladder was washed out with a weak solution of quinine, and the urine became clear and sweet after two days. At this time an unhealthy sore formed on the back, the skin of which had been tender from the fifth day. The temperature rose with these complications, and continued to rise after all evidence of bladder irritation had gone. On the twentieth day there was marked distension and much pain in the abdomen. Both passed off after the action of a clyster, but there remained a hard sausageshaped mass above and to the left of the umbilicus, and evidently extending deeply into the abdomen. Next day the temperature rose to 1028°, the pulse to 124, The mass in the abdomen enlarged downwards towards the cicatrix, and on the twenty-fourth day the wound opened in its upper part, which had been completely healed for more than a fortnight. A great deal of pus was squeezed out. From its position I presume that this abscess had originated in connexion with the divided omentum. The condition of the patient, which had never been satisfactory, now completely changed; the lower end of the incision healed at once ; the bedsore assumed a healthy action, and the temperature fell to normal. The mass in the abdomen slowly disappeared, and on the thirty-fourth day the wound closed. The patient has had no trouble from the bowels or bladder since she went home. She suffered much from cardiac symptoms for some months, but is now quite well. CASE 5.-In June, 1890, a woman, thirty-one years of itge, and of evidently nervous temperament, was sent to the Samaritan Free Hospital by Dr. Cooper of Leytonstone. She was the mother of three children, and had been delivered of a stillborn child at the seventh month of gestation in 1887. Before then menstruation was normal, but she had since suffered much pain with each period. She was quite regular till April, 1890. On May 17th, being three weeks overdue, an apparently normal flow came on, and was very free for seven days. Then the patient, while engaged in scrubbing a floor, was suddenly seized with severe pain and became very faint. The pain continued, but not so severe as at first, and a hsemorrhagic discharge was more or less constant till I saw her a fortnight later. I found a rounded, elongated, fluctuating tumour, dull on percussion, rising out of the pelvis on the right side above the fold of the groin to the level of the anterior superior iliac spine. This was not very tender except when pushed downwards or backwards. A normal uterus was easily made out high up close to the pubes and slightly pushed over to the left side by the above mass. The whole pelvis behind was filled by an excessively tender, ill-defined swelling. Defecation was extremely painful, the bowels were very costive, and the complexion was dusky and unhealthy. An exploratory operation was performed on June 16th. I exposed and emptied a cyst growing from the right broad ligament; this being held aside, there was still a large swelling behind the uterus, almost obliterating Douglas's pouch. This proved to be a blood-clot enclosed in the left broad ligament. I ruptured its peritoneal covering and removed the clot. I was then able to bring together the two layers of the broad ligament and transfix them deep in the pelvis and close to the uterus, by a double ligature. With this I tied off the greater part of the broad ligament in two pieces. The haemorrhage had so stripped off the peritoneum from the wall of the pelvis that it was impossible to bring the outer end of the posterior layer of the broad ligament within the ligature. Some raw surface was consequently left, but there was no fresh bleeding. The pedicle on the right side was now secured, and the diseased parts, including both ovaries, were cut away. The peritoneal cavity in this case also was washed out with warm water, and a drainage-tube was inserted and fixed in the usual manner. The specimen from the left side showed much matting of the tissues, the fimbriated extremity of the tube being closed. There had been a rupture of the tube into the cavity which had contained the blood-clot. No foetus was found. The specimen from the right side was an ordinary broad ligament cyst. The drainage-tube was removed on the second day. The highest temperature for the first eight days was 100'6" in the vagina on the evening of the day of operation. From the fifth morning the bowels were moved every second or third day by enema, many hard masses of faeces being removed-At the end of a week the patient complained of much pain and throbbing in the lower part of the back. Two days later a large tender mass was felt behind the uterus. There was also a very tender point close to the fundus of the uterus, between it and the anterior abdominal wall. The pain here was greatly aggravated by any upward pressure on the cervix. On the twelfth day the mass in the pelvis was larger, and elongated towards the left loin. There was some abdominal distension, and always much pain before flatus passed. The wound was completely healed over, but the temperature had gradually risen since the eighth day to 1024°. I stopped all food by the mouth, and ordered rectal feeding, with twenty minims of tincture of belladonna every six hours. Next day there was much pain, and opium was substituted for the belladonna. The bowels were repeatedly moved by enema. The abdominal distension and the mass in the pelvis both diminished, but the tenderness on touching the uterus continued. The temperature gradually fell, till on the eighteenth day it was below 99° in the vagina, the pulse being then 64, and flatus passing without pain. Rectal feeding was now discontinued. On the twentieth day the wound reopened and several drachms of pus escaped, apparently from between the uterus and the abdominal wall. After this pressure on the uterus caused no pain. The discharge soon diminished and the temperature did not again rise above 99° in the vagina. The wound finally healed on the twenty-sixth day. The large mass behind the uterus
doi:10.1016/s0140-6736(02)01120-0 fatcat:lkjcqab64zhhbev6cvncw4moim