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MANCHESTER ROYAL INFIRMARY.
734
difficulty in extracting the stone, or the forceps, as they had witnessed in or subsequent haemorrhage, and other evil results of making a large wound, which would in such a patient soon turn the balance against him. However, he carefully considered all these matters, and unhesitatingly came to the conclusion that the best thing to do was to get the stone out of the bladder as quickly as possible. Fortunately, the operation was very simple, and the event had justified him in the selection of the treatment he had
may occur, such
breaking of
as
stone in the his hands not long ago, a
advised.
____________
MANCHESTER ROYAL INFIRMARY. OSTEO-CHONDROMA OF LEFT THIGH; FRACTURE OF FEMUR ; AMPUTATION AT HIP-JOINT.
trolled by means of Lister’s abdominal tourniquet and digital pressure, and antiseptic precautions adopted throughout. On recovering from the effects of the anesthetic the patient experienced great pain, which however was so far relieved by the exhibition of opiates that she was able to sleep during the greater part of the day. Evening temperature 99° ; pulse 150. She slept well during the night, and on the following morning (Feb. 14th) pain had almost dis. appeared. Temperature 99’4°; pulse 130. Nausea and vomiting came on about midday, and continued until the following day, when koumiss was ordered instead of the iced milk and soda-water she had hitherto been taking. The vomiting ceased, and did not recur. On Feb. 17th the patient experienced a slight rigor, and the temperature ran up to 100’6°-; with this exception the whole course of the case was satisfactory ; the temperature varied from 99 ’4° to normal, the pulse rapidly regaining strength and tone, and the wound progressed uninterruptedly to the formation of a healthy cicatrix. The patient left the hospital well on th&
(Under the care of Mr. F. A. HEATH.) FOR the following notes we are indebted to Mr. C. A. J. Robertson, house-surgeon :— 7th March. The amputated limb was examined by Mr. A. H. Young, Emma W, aged thirty-one, married, was admitted on to the infirmary, who reports as follows :—"The January 4th, 1882. She stated that her leftthigh had always pathologist new growth, which originated in the deeper layers of the been weak and painful, and that four years ago she noticed was limited to the upper part of the shaft of the for the first time a small, hard, round lump at the upper femur ; it extended from the great trochanter above to a and outer part. The lump was painless, and gave rise to no distance of five inches below this, and concealed almost twospecial discomfort, but it gradually and progressively in- thirds of the circumference of the bone, on its anterior and creased, and at the end of two years had attained such a lateral aspects. The tumour formed a large globular mass, considerable size that she determined to consult a medical which measured six inches and a half vertically, six inches and four inches anda half in its antero-posteior man..She was then told that the "lump’ was a bony transversely, its circumference diameters; (horizontally) was fourteen and was advised to to the Some -
periosteum,
tumour,
go
infirmary.
twelve months subsequently, the tumour in the meanwhile appearing to increase more rapidly, she acted upon this advice, but declining to submit to any operative interference, she left the hospital and returned home. During the following months the tumour continued to increase in size, occasioned considerable pain, and gave rise to great inconvenience. A week before admission the patient was going downstairs, when, in consequence of her foot slipping, she fell with considerable force and fractured the left femur. The uselessness of the limb and the excruciating pain she suffered induced her to again seek admission into the Royal Infirmary, and she came under the care of Mr. Heath. On admission, the upper part of the left thigh was seen to be greatly increased in size, measuring 29 in. in its greatest circumference. The enlargement was mainly caused by a large rounded tumour connected with the upper part of the femur, and apparently springing from its anterior and outer surfaces. The tumour was well defined, its surface nodular, and its consistence firm, in some parts presenting a bony hardness, whilst in others it was so elastic and tense as to closely simulate cystic formations. The skin over the tumour was not implicated in the new growth ; it was, however, somewhat tensely stretched over it, and its surface looked smooth and glistening ; in parts it was slightly pigmented, and some few atrophic linear striae were observed. Movement of the limb elicited crepitus in the region of the tumour, and revealed a fracture of the femur, apparently about the centre of the tumour mass. The whole limb was swollen, the skin of the thigh was reddened, very tender, and its temperature distinctly increased, whilst the temperature of the leg below the knee was slightly lower than that of the opposite limb. There was no shortening, and apparently no deformity beyond that due to the tumour and to the general swelling. The glands of the groin were of normal size. The patient presented a somewhat worn and anxious expression of countenance, but generally was welldeveloped, robust, and healthy. The increased rapidity of the later growth of the tumour, together with the coincidence of the fracture of the bone, and the condition of the limb being taken into consideration, amputation of the hip-joint was decided on. Mr. Heath operated on Jan. 13th, adopting for convenience, and to increase the facilities for strict antisepticity, lateral flaps (cut from without), and disarticulating at the hipjoint. The larger vessels were ligatured with catgut, the smaller ones twisted; flaps were then brought into apposition, and so retained by sutures, efficient drainage being secured by the introduction of two large rubber tubes. The wound was dressed antiseptically, and the stump slightly elevated on a cushion. During the operation the patient was under the influence of chloroform, haemorrhage being
inches and three-quarters. The surface was irregularly nodular and covered with a dense fibrous investment, by which the growth was distinctly circumscribed and encapsuled. On section the substance was found to consist mainly of rounded cartilaginous nodules (with the pale bluish and translucent appearance of hyaline cartilage), separated by a comparatively small amount of fibrous tissue, which, superficially, was continuous with the fibrous capsule of the tumour; in many parts calcareous deposits existed. Microscopically the cartilaginous nodules showed numerous rounded and ovoid cells in a hyaline matrix. In some parts the cartilage was undergoing ossification, and here the usual changes of intra-cartilaginous calcification and ossification were manifest ; the cells were proliferating and evidencing a tendency to dispose themselves in vertical rows. Numerous bloodvessels existed in the intra-cartilaginous connective tissue. The shaft of the femur was not implicated in the The new growth; the medullary tissue was also free. anterior part of the shaft in the region of the tumour was however slightly thinner than elsewhere, and probably the situation of the fracture of the femur was determined by this condition; the fracture, which was evidently the result of considerable violence, ran obliquely from before backwards between three and four inches below the great trochanter and corresponded to about the centre of the tumour."
JOHANNITER HOSPITAL, BEIRUT SYRIA. SURGICAL CASES.
of Dr. GEORGE E. POST.) CASE 1. F’rccctzcre of the Protuberance of the Parietal Bone, ccz2cl of the Greater TTling of the Sphenoid; Exoph-
(Under the
care
thalmos Henaicrania; Removal of Bone; Recovery.—A man,
struck with a club over the left way as to wound the scalp and break the parietal protuberance, and cause depression of£ the fractured bone to a slight degree. He received medical care from a native physician for two months, after which time he came two days’ journey by muleback, and entered the hospital. He stated that the wound over the parietal’ bone was the only one at the time of the injury, but that after several days he observed a swelling in the left temporal region, followed by exophthalmos and loss of sight of the left eye. The native physician opened the swelling by an incision parallel to the zygomatic arch, and half an inch above it, and evacuated a small quantity of pus. The opening was still discharging matter at the time of his entrance. On examination there was found : (1) A wound kept an inch in length, antero-posterior in direction, over the left con- parietal protuberance ; this wound was probed, and de-
aged twenty-five years, parietal bone in such
was a
difficulty in extracting the stone, or the forceps, as they had witnessed in or subsequent haemorrhage, and other evil results of making a large wound, which would in such a patient soon turn the balance against him. However, he carefully considered all these matters, and unhesitatingly came to the conclusion that the best thing to do was to get the stone out of the bladder as quickly as possible. Fortunately, the operation was very simple, and the event had justified him in the selection of the treatment he had
may occur, such
breaking of
as
stone in the his hands not long ago, a
advised.
____________
MANCHESTER ROYAL INFIRMARY. OSTEO-CHONDROMA OF LEFT THIGH; FRACTURE OF FEMUR ; AMPUTATION AT HIP-JOINT.
trolled by means of Lister’s abdominal tourniquet and digital pressure, and antiseptic precautions adopted throughout. On recovering from the effects of the anesthetic the patient experienced great pain, which however was so far relieved by the exhibition of opiates that she was able to sleep during the greater part of the day. Evening temperature 99° ; pulse 150. She slept well during the night, and on the following morning (Feb. 14th) pain had almost dis. appeared. Temperature 99’4°; pulse 130. Nausea and vomiting came on about midday, and continued until the following day, when koumiss was ordered instead of the iced milk and soda-water she had hitherto been taking. The vomiting ceased, and did not recur. On Feb. 17th the patient experienced a slight rigor, and the temperature ran up to 100’6°-; with this exception the whole course of the case was satisfactory ; the temperature varied from 99 ’4° to normal, the pulse rapidly regaining strength and tone, and the wound progressed uninterruptedly to the formation of a healthy cicatrix. The patient left the hospital well on th&
(Under the care of Mr. F. A. HEATH.) FOR the following notes we are indebted to Mr. C. A. J. Robertson, house-surgeon :— 7th March. The amputated limb was examined by Mr. A. H. Young, Emma W, aged thirty-one, married, was admitted on to the infirmary, who reports as follows :—"The January 4th, 1882. She stated that her leftthigh had always pathologist new growth, which originated in the deeper layers of the been weak and painful, and that four years ago she noticed was limited to the upper part of the shaft of the for the first time a small, hard, round lump at the upper femur ; it extended from the great trochanter above to a and outer part. The lump was painless, and gave rise to no distance of five inches below this, and concealed almost twospecial discomfort, but it gradually and progressively in- thirds of the circumference of the bone, on its anterior and creased, and at the end of two years had attained such a lateral aspects. The tumour formed a large globular mass, considerable size that she determined to consult a medical which measured six inches and a half vertically, six inches and four inches anda half in its antero-posteior man..She was then told that the "lump’ was a bony transversely, its circumference diameters; (horizontally) was fourteen and was advised to to the Some -
periosteum,
tumour,
go
infirmary.
twelve months subsequently, the tumour in the meanwhile appearing to increase more rapidly, she acted upon this advice, but declining to submit to any operative interference, she left the hospital and returned home. During the following months the tumour continued to increase in size, occasioned considerable pain, and gave rise to great inconvenience. A week before admission the patient was going downstairs, when, in consequence of her foot slipping, she fell with considerable force and fractured the left femur. The uselessness of the limb and the excruciating pain she suffered induced her to again seek admission into the Royal Infirmary, and she came under the care of Mr. Heath. On admission, the upper part of the left thigh was seen to be greatly increased in size, measuring 29 in. in its greatest circumference. The enlargement was mainly caused by a large rounded tumour connected with the upper part of the femur, and apparently springing from its anterior and outer surfaces. The tumour was well defined, its surface nodular, and its consistence firm, in some parts presenting a bony hardness, whilst in others it was so elastic and tense as to closely simulate cystic formations. The skin over the tumour was not implicated in the new growth ; it was, however, somewhat tensely stretched over it, and its surface looked smooth and glistening ; in parts it was slightly pigmented, and some few atrophic linear striae were observed. Movement of the limb elicited crepitus in the region of the tumour, and revealed a fracture of the femur, apparently about the centre of the tumour mass. The whole limb was swollen, the skin of the thigh was reddened, very tender, and its temperature distinctly increased, whilst the temperature of the leg below the knee was slightly lower than that of the opposite limb. There was no shortening, and apparently no deformity beyond that due to the tumour and to the general swelling. The glands of the groin were of normal size. The patient presented a somewhat worn and anxious expression of countenance, but generally was welldeveloped, robust, and healthy. The increased rapidity of the later growth of the tumour, together with the coincidence of the fracture of the bone, and the condition of the limb being taken into consideration, amputation of the hip-joint was decided on. Mr. Heath operated on Jan. 13th, adopting for convenience, and to increase the facilities for strict antisepticity, lateral flaps (cut from without), and disarticulating at the hipjoint. The larger vessels were ligatured with catgut, the smaller ones twisted; flaps were then brought into apposition, and so retained by sutures, efficient drainage being secured by the introduction of two large rubber tubes. The wound was dressed antiseptically, and the stump slightly elevated on a cushion. During the operation the patient was under the influence of chloroform, haemorrhage being
inches and three-quarters. The surface was irregularly nodular and covered with a dense fibrous investment, by which the growth was distinctly circumscribed and encapsuled. On section the substance was found to consist mainly of rounded cartilaginous nodules (with the pale bluish and translucent appearance of hyaline cartilage), separated by a comparatively small amount of fibrous tissue, which, superficially, was continuous with the fibrous capsule of the tumour; in many parts calcareous deposits existed. Microscopically the cartilaginous nodules showed numerous rounded and ovoid cells in a hyaline matrix. In some parts the cartilage was undergoing ossification, and here the usual changes of intra-cartilaginous calcification and ossification were manifest ; the cells were proliferating and evidencing a tendency to dispose themselves in vertical rows. Numerous bloodvessels existed in the intra-cartilaginous connective tissue. The shaft of the femur was not implicated in the The new growth; the medullary tissue was also free. anterior part of the shaft in the region of the tumour was however slightly thinner than elsewhere, and probably the situation of the fracture of the femur was determined by this condition; the fracture, which was evidently the result of considerable violence, ran obliquely from before backwards between three and four inches below the great trochanter and corresponded to about the centre of the tumour."
JOHANNITER HOSPITAL, BEIRUT SYRIA. SURGICAL CASES.
of Dr. GEORGE E. POST.) CASE 1. F’rccctzcre of the Protuberance of the Parietal Bone, ccz2cl of the Greater TTling of the Sphenoid; Exoph-
(Under the
care
thalmos Henaicrania; Removal of Bone; Recovery.—A man,
struck with a club over the left way as to wound the scalp and break the parietal protuberance, and cause depression of£ the fractured bone to a slight degree. He received medical care from a native physician for two months, after which time he came two days’ journey by muleback, and entered the hospital. He stated that the wound over the parietal’ bone was the only one at the time of the injury, but that after several days he observed a swelling in the left temporal region, followed by exophthalmos and loss of sight of the left eye. The native physician opened the swelling by an incision parallel to the zygomatic arch, and half an inch above it, and evacuated a small quantity of pus. The opening was still discharging matter at the time of his entrance. On examination there was found : (1) A wound kept an inch in length, antero-posterior in direction, over the left con- parietal protuberance ; this wound was probed, and de-
aged twenty-five years, parietal bone in such
was a