ON FIXED AND LONG-CONTINUED PAIN IN BONE

H. Lee
1853 BMJ (Clinical Research Edition)  
1853. ORIGINAL COMMUNICATIONS. 7 I strongly advise that in Qpexations on the eye under chlorofonm, there should be at least one competent assistant besides the operator and the administrator of chloroform; each of these has his own department to engae his attention, and it is most embarrassing to have the patient partially recover and struggle just at a critical moment. This occurred in the first extration under chloroform perfomed by me; and, as it was the first case of tlio sort in which Dr.
more » ... sort in which Dr. Snow had administered the vapour, the patient had not a sufficient dose. It unfortunately happened that the gentleman who was to have assisted me was prevented keeping his appointment, but I imagined that the doctor anud I could manage the lady ourselves: in duie time, she appeared completely insensible, but just as the section was lein,g satisfactorily completed, the patient threw her head on one side and tried to sit ul; the conseqtuence was, that the operation was impeded, considerable prolapse of the iris took place, and a closed pupil was the result. The patient slhould be recumbent. In that posture he can rest qluietly after the operationi, ana is more manageable (luring the period of excitemient than when sitting in a chair. I have tried thle administration of chloroform oni a handkerchief, and by nmeans of Dr. Snow's apparatus, anud deridedly prefer the latter. When the hanlkerchief was used, it was in my way, anil the Itomes of the chloroform annoyed me,-mattens of iiii-Portanc,e in such a delicate proceeding as extraction. A jolt (lose of chfloroffOrm is necessary, andi the patient should not partake ot food fo)r five or six h(;urs prior to the operation; lhut hie may swallow a few fragments of iee joist before it is commened. and again as sona11s cOnsciouAnessreturns. Thiis (which I believe was first suggrested by l)r. Simpson of J.Edinburgrh) allays any tendtlency to vonmit. I prefer operating in thle aftenlloon, as% the soporific effect of the clilorot;riii continu.itn, genierally ensuires a good night; h .t the hands imust be Secured, andt the pIativiit carefully watched, as unider ordinary cirlviiii mlnces. W\itlh reg,ard. to the operation itself, it is important to have the point ot the extractiofn-knife as slharp, andl the etlge as keen as luissildle. If there be the least hIanqixg, the ey-e will lie nl)uhd.l before the kniiife, fronti the litter passiveness (f all the mscles, and unless the operator is prepared for this, there will lhe great prolbability of the couinter-punetuire beingr made, too near the cenitre of the cornea, whereby the section will lie too small. During extraction, as ordinarily performed, the lid is dropped as soon as the section is completed, an(l a lpaulis takes l)lave to perniit the eye to lbecome quiiet. UInder chilorofo;rm this, is unnecess%ary; tliere hieing nio spasm, the curette may be ussed1, a (I the cataract pressed ouit the innent the section is coniplete(l. Wh'len the lens lhas escaped, the eve presents a cu1riouis appearance, alwlays supposing enough chloroftorm has lbeen adminiister-ed; the inuscles being passive, the iris falls back in a concave foirm. andl the cornea having i10 1 sIupport, sitnks, hecominig as wrinkled as a shrivelled apple. The eye having been gently cleainsed, and tIme lid-s (Iried with a soft rag, therlupper lid sioldt l(ie lifted by the lashes andlI brought (dowii over the cornea; then two lIroad strips of adlhesive pllaister shouldlle crosse(l over the eye andl chieek, a bandage al-lied, anutd tIme patienit left quiet 1inr half-an-hour or ani hour. after w}licil lie cn lbe irenmovedl to bed. Whlen all fear of vomitinghba.s subsided, the plaister nmay be taken off: lmnt it muist le thoroughly softeite(d^iith walrni w:ater, and lifted witlh the utnost cautionS and gentleness, so that there lie no dra-gring oni the litds. T'ho subsequent proceedings ditlher in no respect front those lraetisedl after the oper-ation as ordinarily perfornied. In these renmairks I have especially merntionedi Extraction, lut the general diirections are eqnially applicat)le to all opefrnatiolns o*n tlhe eve; andl I imiay add, in conclu.sion, that wlhen operating o*n anl!ye in a state of inflammation, a; in the extractioni of a foreign bodv, a shot, a fragment of steel, or eopper ,ap, tile value of chlloroformii cannot be too highly estinmated. Assistant-Surgeon to King's College Hospital, etc. Is the concluiding voluime of the London Journal of Medicine, I ventuired to offer sonme observations on, andl to relate some cases of, fixed pain in the tibia, which had been relieved by perforating the bone with a treplhine. The cases appeared naturally to divide themselves into two classes, namely, those in which the pain depended directly upon the pressure of con. fined matter, and those in which some other source of irritaion, situated within the bone, had kept up a chronic inflammadon of the part The following case, wbich has since come under my care, appears especially interesting, as partak-ing of both the above forms of disease; the pain having fixed itself in the part before there was reason to suspect the formation of milatter, and having continued for some time after the pressure of the confined fluid was, artificially relieved. An apology will scarcelv be wanted for drawing attention to the (letails of such cases, as the uitilit oft' surgical interference is far from being universally acknowledged. Even in a -work of much authority, by a distinguished lprofessor of surgery in Edinburgh, as late as the year 1817, we tind it stated that the cases where the operation of trephining the tibia is-necessary, mu,st he extremely rare, as no case had presenltedI itself to the professor's notice during a long andl extensive pr'actice. CASE. During the last summner, a genitlemanii of a higilly nervous temitperament applied to mie, having suffered, for between two and( three years, very severe pain in lhis left leg. At that time there wastan oval swelling over the centre of thio tibia, evidently depending upon anu enlargement of the bonie; andI about thiree inclhes lower dlown, was a second snialler irojection, apparently of the same nature. T'he bone in both these pilaces was very tender to the totich, and the upper enlargemient presentel at one point a sense of flnctnation, as 'Iou11gh a sma11l11l quiantity of fluid(l were coutaineil bletweeni the pei-iosteuim antl the bone. The necesstuy examination ot the leg wus followed by a considerable iuncrease. of aching paini. Whon re-(Inestedl to point out thie part where he experieneed imiost suftfeoing, he wouil(l pass his hand {generally over the lower hart of the tiltia, buit would not point ouit any onie spot as habitually more painfuil than thIe rest. He however thought that the upper swvelling was miiore sensitive at night, aittl the lower one duIring the day wliemi the leg was hanging down. He stated, that twelve years previously, he lal takeni large quiantities of mercury for an affection of the throat, which there was no reason to believe was of a specific character. At that timle his mouith was kept solie for tive monthis, anid he took occasionally as mtelh a1s-twenty-five trains of luliie pill a day. Six years after this he lhadl the small-p,ox, whicil left hinl much debilitated. In the year 14f), lie became sub ject to a very severe cough, for whichl he consulted I)r. (rolding Blird, mill thlere was reason to believe, that a sl.11l cavity hind formed in one of hiis Ilings. During the early part of tihe following yealr hlis ankles became swollen, amad a pain settled in his left shin. About a fortniIht after the first appearance (of the pain, he struck Ihis leg severely. The pain then became suddenly increased, anid continiued withouit intermisi-sion foir mn:ny weeks. At lenigth, the pain in the leg subsided, ain( lie passed three mionithis, in tolerable coinfort; after this, however, all the fornmer symptonas again returned, in conseqluence, as lie supposed, of hiaving tak-eni a very long, watlk. In tle spring of the year 18l5, the leg wasm struck a second tilmle, and the pain then became of a miilcla milore severe mIharatcter than it hidtl Ii'ieviotisly. beenl. From this peliod the Paill Was S) severe as to prevent his sleeping at night. Between six and eight o'cio k in tle morning, thle limlb generally became bathe(d in perspiration, andl he wouild tlhen fall asleep. This was the only rest lie 'ot except wlmeii uinder the influence of the iodide of potLsssinum, wlihili hand been prescribed for him by Dr. bolding, Iirdl. After he hadl taken fi'Ve or six doses of this medivine, hsis pain was usually relieved, 1tl( he slept tolerably well; lhuit as soon as it wvas discontinued, the pain returnied witlh all its former severitv. Not wishingr to take the mnedicine mnnevessaril, he tried miiore tlanii once to do witlhouit it, and bkid(1, tinder these circtumstances, passed as mnuch as a montlh without any sleep, except the short nap that he got between six an1d eight o'clock in the morning. He was, therefore, driven latterl!y to have alhuo1st constunit recourse to his miiedicine, anI took froni eighty to a hundred grains of it a montl. At lengtlihe fouJnd, although the pain was relieved, that his gumbecanie spongy anidI apt to bleed, and in otier waYs it became apparent that the continued action of the nediCine was exerts ing an injurious etfect upon his system. It was un(ler these circuImstances that, with Dr. Golding Bird's concurrence, lie came to me to a.s ertain ulether any more permanent relief couild be affordedl by surgical means. The existence of pain in the part previous to the reception of the first injury, the tenderness of the bone, and the evident
doi:10.1136/bmj.s3-1.1.7 fatcat:64yi74kr3fabpj2laoct2peete