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Operation performed April 16th, with the assistance of Drs. Wunderlich and Thallon, and the hospital internes, several members of the visiting staff being present. Patient had been kept on milk for two days ; bowels emptied by oil and enema.
Circumference of abdomen, thirty-six inches.
A median incision was made about four inches long. Two long bands of adhesions to the abdominal wall were found, one extending toward the right, the other toward the left hypochondriac region. A few adhesions were found in either iliac region, but no omental or visceral adhesions. All were broken up by the hand. The tumor was from the right ovary and was composed of one large cyst and a number of smaller cysts. The liquid of the large cyst greatly distended its walls, which were very thin and easily torn, and was of the same character as that obtained by aspiration. The contents of the other cysts varied much in consistence, from a thin liquid to a very thick, gelatinous semi-solid. The cyst-walls were broken down by the hand introduced through the larger cyst, and their contents were evacuated. The pedicle was secured by a cautery-clamp, a modification of Dawson's, as devised by Drs. Skene and Thallon, being used. The cyst was removed by the knife, and the stump was desiccated after the method of Keith. The Staffordshire knot was also applied, and the pedicle was returned to the abdominal cavity. Four other ligatures were applied to adhesions. The cavity was thoroughly cleansed and was left dry, with a Thomas's drainage-tube placed in Douglas's cul-de-sac. The wound was closed by silk sutures. Rubber sheeting and sponge were applied to the end of the drainage-tube. Marine lint was put over the wound, and the abdominal walls were supported by adhesive plaster, cotton, and a flannel-binder. Antiseptic precautions were followed except the use of spray.
The ether was carefully administered, under the supervision of Dr. W. H. Martin, with an Allis's inhaler. The respiration and heart-action were several times very feeble, requiring the hypodermic administration of stimulants. The temperature immediately after the operation was 96o. The patient was placed in bed and surrounded with bottles of hot water. The temperature gradually rose to the normal standard ; subsequently, taken every three hours, it did not reach 100° till twenty-four hours after operation, and it declined to 99°, ten hours later. The patient was thought to be
doing well, until a period of severe retching occurred twenty-four hours after the operation, which was controlled by five minims of Magendie's solution hypodermically administered ; but the patient did not go to sleep for an hour. A few intermissions of the pulse were noticed at this time. The pulse increased in frequency, not being influenced favorably by stimulants administered per rectum and hypodermically. The patient gradually went into a comatose condition, which deepened and continued for the fourteen hours immediately preceding death. Four fluidounces of serum were removed from the drainage-tube during the first twelve hours, tinged with blood, which left a thin layer of corpuscles on standing. The quantity of serum somewhat diminished after this, but it was always pure and sweet.
AUTOPSY.—The borders of the wound were everywhere adherent except at the site of the drainage-tube ; and the latter being gently withdrawn, a canal was left where the recent lymph had united the intestinal and uterine walls. A small quantity of normal serum was found in the pelvic cavity. There was but a small quantity of lymph, and but little injection of the intestinal walls. All intra-peritoneal ligatures were hidden by a thin covering of lymph. The small intestine was collapsed for about two thirds of its length ; and near its junction with the large intestine it was doubled upon itself like the letter M.
Liver very fatty ; kidneys nearly normal in appearance ; lungs normal; heart small and thin-walled, containing a pale clot; fatty degeneration was suspected from its appearance, and this was confirmed under the microscope, by competent observers. The sections examined showed marked degeneration of the muscular fibers, the fatty globules being very abundant and the transverse striæ obliterated.
REMARKS.—It is believed that the fatty degeneration of the heart was the determining cause of death; and the enfeebled organ, having borne the shock of the operation falteringly, succumbed to the first unusual demand made upon it. The limited inflammatory involvement of the peritoneum seemed insufficient to cause death, except through some such organic disorder.
So far as the writer knows, this cause of death after ovariot
omy has been very infrequent, and the case is deemed worthy of record for this reason. No satisfactory explanation appeared, to account for the collapsed condition of the small intestine.
The pain and ædema of left lower limb led some of the surgeons to suspect that the tumor arose from the left ovary, but these symptoms were probably caused by the more solid part of the tumor, which extended into the left iliac region, making pressure upon the nerves and blood-vessels.
REPORT OF A CASE OF DISLOCATION OF THE FIRST PHALANX OF THE THUMB FORWARD.
By FREDERICK W. PUTNAM, M. D., of Broome County.
Read November 19, 1884.
U PON consultation of such standard authorities and files of leading journals as were accessible, I have been able to find but few cases reported of dislocation of the first phalanx of the thumb forward.
Dr. Hamilton, in the last edition of his work on "Fractures and Dislocations,” Philadelphia, 1880, p. 733, reports two cases occurring in his own practice and refers to four others collected by Malgaigne. Reference is also made to other cases seen by Nélaton, Lenoir, Ward, and Lombard. Dr. Holmes, in his “ Treatise on Surgery,” Philadelphia, 1876, p. 287, refers to four instances of this luxation, collected by Nélaton. Other examples of this accident have doubtless been reported, and it is presumed that cases have occurred which have never been published.
I have the following case of this accident to present :
T. J. C., a boy ten years of age, in the afternoon of May 24, 1884, fell from a swing, striking upon the ground in such a manner as to produce a forward dislocation of the first phalanx of the left thumb. He came to my office immediately, arriving within half an hour after the accident.
The two phalanges were extended upon each other and parallel with the metacarpal bone, the first phalanx being in front of it and in the same plane. He complained of severe pain, yet
there was only a moderate amount of tumefaction at the point of injury.
I reduced the luxation by grasping the dislocated thumb with my right hand and the patient's left hand with my left hand, making steady extension of the thumb and counter-extension of the hand, and then, suddenly, quite firm and forcible flexion of the thumb. I made a fixed point, as nearly as possible, of the distal end of the metacarpal bone, and used the index-finger of my right hand as a fulcrum in flexing the thumb. The dislocation was thus readily reduced.
The after-treatment consisted of a bandage loosely applied to the hand and a water-dressing to the thumb, the arm being suspended in a sling.
The case progressed very favorably, and all treatment was discontinued at the end of a week, the motions of the joint being unimpaired. A brief report of this case may be found in “The Medical Record," New York, June 21, 1884, vol. xxv,