- Email: [email protected]
LIGATURE OF THE EXTERNAL ILIAC ARTERY FOR SECONDARY HÆMORRHAGE AFTER AMPUTATION OF THE THIGH.
470
CLINICAL NOTES.
unwillingness to submit the patient (who, in their opinion, is only suffering from a fainting fit and a stomach-ache, due probably to indigestion) to all the risks of such a severe operation. The diagnosis is so hard that it is important that every case, successful or not, should be accurately recorded for future guidance. I believe it to be essential to success that the operation should be performed before much of the gastric contents has invaded the peritoneal cavity, before distension and general peritonitis have set in, and before the collapse has lasted too long. In this case these symptoms came on in six hours ; the operation was performed twenty-four hours, and death occurred thirty-eight hours, after the attack. The operation should therefore be performed within the first three or four hours. If that is done, I see no reason why an equal amount of success should not attend this operation as attends that for the repair of ruptured bladder. In these days of antiseptics an abdominal exploratory operation is not so serious a matter as it used to be, and a patient should certainly be given the chance of cure which it affords; and even when the first four golden hours have passed there is a hope, though a forlorn one, that operative interference may be successful. Without operation I believe the patient is under the doom of certain death within forty-eight hours (or three days at the most). Senn describes a method of diagnosing this lesion by inflating the stomach with hydrogen gas until the whole abdomen is distended. If there is a perforation anywhere in the stomach or intestinal tract the gas will escape into the peritoneal cavity, which is shown by the disappearance of the liver dulness. However, an apparatus for this is not always at hand and requires time to arrange ; and whilst these preparations are being made, whilst the friends are hesitating and other surgeons are being called in, and the nurse is being procured &c., the favourable time has passed.
Wellington,
New Zealand.
Clinical Notes : OBSTETRICAL AND THERAPEUTICAL.
MEDICAL, SURGICAL,
LIGATURE OF THE EXTERNAL ILIAC ARTERY FOR SECONDARY HÆMORRHAGE AFTER AMPUTATION OF THE THIGH.1 BY ARTHUR C. DE RENZI, M.R.C.S. &c., RESIDENT SURGEON TO THE CHRISTCHURCH NEW ZEALAND.
HOSPITAL,
A LABOURER aged’ twenty-seven was admitted to the Christchurch Hospital, New Zealand, under the care of Dr. Stewart, suffering from extensive scrofulous disease of the knee-joint. The patient was in very poor health at the time, moist rales being heard over the upper half of the right side of the chest. Dr. Stewart performed excision of the knee. The joint on being opened was found to be extensively diseased ; both articular surfaces were deeply ulcerated and all traces of cartilage gone. General oozing of blood gave rise to considerable trouble after the operation. Though every care was taken as regarded the antiseptic treatment of the case it soon became apparent that the patient’s strength was not equal to the strain put upon it, and, as the lung mischief was extending rapidly, amputation above the middle of the thigh was determined upon and performed by Dr. Stewart on Dec. 12th, The whole thigh was in a very unhealthy con1891. dition, being nearly twice its natural size, hard and cedematous. General oozing again gave rise to anxiety as the patient was in a particularly bad state of health and could not bear much loss of blood. A carbolic gauze dressing was applied to the stump, which healed by first intention, with the exception of the outer angle of the wound, where the drainage-tube had been placed. On the 19th, seven days after the operation, I was suddenly summoned to the ward to see the patient. I found that there had been most copious haemorrhage from the opening in the stump left by the drainage-tube. The patient was completely 1 A paper read before the
Medical Association.
Canterbury Branch of
the New Zealand
blanched and the bed was saturated with blood, though thehead-nurse had immediately on noticing the bleeding applied From the sudden onset and amount an elastic tourniquet. of the hæmorrhage it was clear that the femoral artery had’ given way, probably owing to ulceration at the seat of the ligature (chromicised catgut) due to the unhealthy con.dition of all the tissues of the limb. Being unable to obtain the assistance of Dr. Stewart, under whose care the patient was, I determined that, on account of the unhealthy state of the tissues of the thigh, any attempt to open up the stump and secure the artery would almost certainly have been followed by a recurrence of the bleeding. I therefore decided that under the circumstances it would be better to at once apply a ligature to the external iliac artery. The patient was accordingly put under ether and the artery exposed by a semilunar incision above Poupart’s ligament carried up, beyond the spine of the ilium. The epigastric artery was. avoided, as was also the genito-crural nerve, which was seen near and superficial to the artery ; the vessel itself was ligatured with a stout piece of chromicised catgut. There was. no bleeding whatever during the operation, and all haemorrhage from the stump was completely arrested. The wound healed by first intention, and the patient made a rapid recovery ;his lung trouble has quite disappeared and he looks in good health. This case is interesting from the fact that in these days of antiseptic surgery secondary haemorrhage is so seldom met with. During the five years that I have been resident surgeon to the Christchurch Hospital, where the number of major operations performed annually is very large, this is the only case in which secondary haemorrhage occurred. In this case I think it is clearly to be attributed to the unhealthy condition of the limbcertainly not to any fault in the management of the case afteroperation. The idea of septic mischief was out of the question, for in neither instance did the temperature rise beyond 99 6°, and it was most usually normal. Another point worthy of notice is this :namely, that for the first fortnight after amputation it is a good and a safe plan to have an elastic tourniquet near the patient. I always have one hanging at the head of the bed. In this case the patient would most probably have lost his life had not the nurse had such efficient, means for the arrest of hæmorrhage within her reach. Theway in which the lung mischief cleared up after the removal’ of the diseased limb was also very striking.
REMARKABLE CONTENTS OF A LEFT INGUINAL HERNIA; DEATH FROM RUPTURE OF SMALL INTESTINE. BY GEORGE W. F. MACNAUGHTON, M.B., C.M. EDIN. A MELANCHOLIC PATIENT aged thirty-one, in the Worcester County and City Lunatic Asylum, half an hour after breakfast on Jan. 16th, 1893, complained of cramping pains in the On being visited, he was lying abdomen, and vomited. partly on his back and partly on his right side. His. face suggested collapse ; his pulse, however, was regular, although of low tension, and his extremities were warm. The’ pains were occurring over the abdomen generally and were not specially localised. On examination the hernia was found, to be very tense. No attempt at reduction by taxis was. made. Hot fomentations were applied, a solution of two quarter-grain sulphate of morphia tabloids in distilled waterwas injected hypodermically, and a small enema, containing one drachm of spirits of turpentine, was administered. Thebowels moved gently thereafter. Pain ceased and the patient, who had been tossing about, became more quiet, and appeared to be more comfortable. He continued in this state until 2 P. M., when he again became restless, and on attempting to sit up in bed fell back in a fainting condition. Restoratives wereapplied and he rallied temporarily. The pulse never regained strength, the extremities became cold, and he died at 3.40 p, M. The interest of the case centres round the results of the post-mortem examination, which are briefly noted below. Body pale and waxy-looking ; abdomen distended; the scrotum was represented by a large pear-shaped measuring seventeen inches in circumference and ten and a half in length, from its point of issue in the hypogastric and left inguinal regions. On opening the abdomen the coils of the small intestine appeared as if floating in blood. The walls of the intestine were congested and moderately distended.
swelling:.
CLINICAL NOTES.
unwillingness to submit the patient (who, in their opinion, is only suffering from a fainting fit and a stomach-ache, due probably to indigestion) to all the risks of such a severe operation. The diagnosis is so hard that it is important that every case, successful or not, should be accurately recorded for future guidance. I believe it to be essential to success that the operation should be performed before much of the gastric contents has invaded the peritoneal cavity, before distension and general peritonitis have set in, and before the collapse has lasted too long. In this case these symptoms came on in six hours ; the operation was performed twenty-four hours, and death occurred thirty-eight hours, after the attack. The operation should therefore be performed within the first three or four hours. If that is done, I see no reason why an equal amount of success should not attend this operation as attends that for the repair of ruptured bladder. In these days of antiseptics an abdominal exploratory operation is not so serious a matter as it used to be, and a patient should certainly be given the chance of cure which it affords; and even when the first four golden hours have passed there is a hope, though a forlorn one, that operative interference may be successful. Without operation I believe the patient is under the doom of certain death within forty-eight hours (or three days at the most). Senn describes a method of diagnosing this lesion by inflating the stomach with hydrogen gas until the whole abdomen is distended. If there is a perforation anywhere in the stomach or intestinal tract the gas will escape into the peritoneal cavity, which is shown by the disappearance of the liver dulness. However, an apparatus for this is not always at hand and requires time to arrange ; and whilst these preparations are being made, whilst the friends are hesitating and other surgeons are being called in, and the nurse is being procured &c., the favourable time has passed.
Wellington,
New Zealand.
Clinical Notes : OBSTETRICAL AND THERAPEUTICAL.
MEDICAL, SURGICAL,
LIGATURE OF THE EXTERNAL ILIAC ARTERY FOR SECONDARY HÆMORRHAGE AFTER AMPUTATION OF THE THIGH.1 BY ARTHUR C. DE RENZI, M.R.C.S. &c., RESIDENT SURGEON TO THE CHRISTCHURCH NEW ZEALAND.
HOSPITAL,
A LABOURER aged’ twenty-seven was admitted to the Christchurch Hospital, New Zealand, under the care of Dr. Stewart, suffering from extensive scrofulous disease of the knee-joint. The patient was in very poor health at the time, moist rales being heard over the upper half of the right side of the chest. Dr. Stewart performed excision of the knee. The joint on being opened was found to be extensively diseased ; both articular surfaces were deeply ulcerated and all traces of cartilage gone. General oozing of blood gave rise to considerable trouble after the operation. Though every care was taken as regarded the antiseptic treatment of the case it soon became apparent that the patient’s strength was not equal to the strain put upon it, and, as the lung mischief was extending rapidly, amputation above the middle of the thigh was determined upon and performed by Dr. Stewart on Dec. 12th, The whole thigh was in a very unhealthy con1891. dition, being nearly twice its natural size, hard and cedematous. General oozing again gave rise to anxiety as the patient was in a particularly bad state of health and could not bear much loss of blood. A carbolic gauze dressing was applied to the stump, which healed by first intention, with the exception of the outer angle of the wound, where the drainage-tube had been placed. On the 19th, seven days after the operation, I was suddenly summoned to the ward to see the patient. I found that there had been most copious haemorrhage from the opening in the stump left by the drainage-tube. The patient was completely 1 A paper read before the
Medical Association.
Canterbury Branch of
the New Zealand
blanched and the bed was saturated with blood, though thehead-nurse had immediately on noticing the bleeding applied From the sudden onset and amount an elastic tourniquet. of the hæmorrhage it was clear that the femoral artery had’ given way, probably owing to ulceration at the seat of the ligature (chromicised catgut) due to the unhealthy con.dition of all the tissues of the limb. Being unable to obtain the assistance of Dr. Stewart, under whose care the patient was, I determined that, on account of the unhealthy state of the tissues of the thigh, any attempt to open up the stump and secure the artery would almost certainly have been followed by a recurrence of the bleeding. I therefore decided that under the circumstances it would be better to at once apply a ligature to the external iliac artery. The patient was accordingly put under ether and the artery exposed by a semilunar incision above Poupart’s ligament carried up, beyond the spine of the ilium. The epigastric artery was. avoided, as was also the genito-crural nerve, which was seen near and superficial to the artery ; the vessel itself was ligatured with a stout piece of chromicised catgut. There was. no bleeding whatever during the operation, and all haemorrhage from the stump was completely arrested. The wound healed by first intention, and the patient made a rapid recovery ;his lung trouble has quite disappeared and he looks in good health. This case is interesting from the fact that in these days of antiseptic surgery secondary haemorrhage is so seldom met with. During the five years that I have been resident surgeon to the Christchurch Hospital, where the number of major operations performed annually is very large, this is the only case in which secondary haemorrhage occurred. In this case I think it is clearly to be attributed to the unhealthy condition of the limbcertainly not to any fault in the management of the case afteroperation. The idea of septic mischief was out of the question, for in neither instance did the temperature rise beyond 99 6°, and it was most usually normal. Another point worthy of notice is this :namely, that for the first fortnight after amputation it is a good and a safe plan to have an elastic tourniquet near the patient. I always have one hanging at the head of the bed. In this case the patient would most probably have lost his life had not the nurse had such efficient, means for the arrest of hæmorrhage within her reach. Theway in which the lung mischief cleared up after the removal’ of the diseased limb was also very striking.
REMARKABLE CONTENTS OF A LEFT INGUINAL HERNIA; DEATH FROM RUPTURE OF SMALL INTESTINE. BY GEORGE W. F. MACNAUGHTON, M.B., C.M. EDIN. A MELANCHOLIC PATIENT aged thirty-one, in the Worcester County and City Lunatic Asylum, half an hour after breakfast on Jan. 16th, 1893, complained of cramping pains in the On being visited, he was lying abdomen, and vomited. partly on his back and partly on his right side. His. face suggested collapse ; his pulse, however, was regular, although of low tension, and his extremities were warm. The’ pains were occurring over the abdomen generally and were not specially localised. On examination the hernia was found, to be very tense. No attempt at reduction by taxis was. made. Hot fomentations were applied, a solution of two quarter-grain sulphate of morphia tabloids in distilled waterwas injected hypodermically, and a small enema, containing one drachm of spirits of turpentine, was administered. Thebowels moved gently thereafter. Pain ceased and the patient, who had been tossing about, became more quiet, and appeared to be more comfortable. He continued in this state until 2 P. M., when he again became restless, and on attempting to sit up in bed fell back in a fainting condition. Restoratives wereapplied and he rallied temporarily. The pulse never regained strength, the extremities became cold, and he died at 3.40 p, M. The interest of the case centres round the results of the post-mortem examination, which are briefly noted below. Body pale and waxy-looking ; abdomen distended; the scrotum was represented by a large pear-shaped measuring seventeen inches in circumference and ten and a half in length, from its point of issue in the hypogastric and left inguinal regions. On opening the abdomen the coils of the small intestine appeared as if floating in blood. The walls of the intestine were congested and moderately distended.
swelling:.