246

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

GUY’S HOSPITAL.

Dislocation of the Hip of three weeks’ standing in a Child fiveyears old; Reduction.

(Under the care of Mr. HILTON.)

Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum, etdissectionum historias, turn aliorum proprias, collectas habere et inter secomparare.-)10RGAGNI. DeSed.etCaus.llorb.,Iib.14. Prooemium.

RECENT dislocations of the hip are not reduced withoutgood management and well-directed force; and it is not un-

frequent, if we may judge from the cases with which we havebecome acquainted in the hospitals of London, that the sur- igeon’s patience is tasked to the utmost before reduction is 1Bobtained. It must be owned, however, that the inhalations of Ichloroform have wonderfully simplified these operations, and Ithat failures, in recent dislocations, are now quite the excep-tion. But chloroform, like many other powerful agents, hasalso its disadvantages; for it may happen that the forceexerted upon a limb be so great as to inflict severe injury ata time when the patient is unable to give warning of the im-pending danger. Indeed, it has often struck us, in witnessingoperations of this kind, that it is really strange that no moremischief be accidentally done, since the multiplied force ofthe pulleys is very considerable, and the patient insensible.The above remarks apply doubly to old cases of dislocation,

for it may be supposed that after three or four weeks haveelapsed, adhesions have taken place, which it is necessary tobreak down before reduction can be effected. This ratherviolent measure, when the patient is a child, is to be conductedwith the greatest caution, for the least exaggeration ill theforce used may severely injure the little patient. Mr. Hiltonlately surmounted these difficulties with great success in thecase of a little boy, who was brought from the country threeweeks after having suffered a dislocation of the hip, and re-duction was luckilv effected soon after admission.From the notes of Mr. Henry Leach, the dresser, we find

that the patient is five years of age, robust, healthy, and well-proportioned, and was admitted Jan. 12, 1853, under the careof Mr. Hilton. A heavy door, standing loose against the wall,on which he jumped, had fallen on the little patient, andstruck him on the head and hip. He was insensible for along time, and suffered a scalp wound and a dislocation of thehip-joint. It would appear that the nature of the injury wasnot made out at the time of the accident, and as no activemeasures were being taken, the symptoms did not abate, andthe leg, according to the friends’ statement, was getting cold and blue (probably from pressure upon venous or nervoustrunks.) The patient was brought to this hospital, as he couldnot stand without assistance, and on examination it was foundthat the head of the left femur was situated on the dorsumilii, the leg of course shortened, inverted, and the knee thrownpartly across the right thigh. Posteriorly, the left buttockwas considerably enlarged and thrown outwards.On Jan. 15, being just one month after the accident, the

boy was brought into the theatre, and after chloroform hadbeen administered, his pelvis was fixed by a jack-towel passedaround the perinaeum, and gentle traction was made upon thelimb, merely by taking hold of it with the hands, whilst Mr.Hilton was guiding the head into the cotyloid cavity. Thiswas continued for about three minutes, after which theaffected limb, on being compared with its fellow, was foundthe longest of the two by fully half an inch. As now the headof the bone could, by rotation, be felt in the groin, it was in-ferred that the reduction had taken place.The little patient was then carefully replaced in bed, and

a Liston’s long splint adjusted. On the fifth day after reduc-tion all the symptoms were extremely satisfactory, and thelengthening gradually diminished. The patient was keptvery quiet, and six weeks after admission he was sufficientlyrecovered to be sent liome, being able to walk without assist-ance.

We mentioned above that the nature of the injury had been

overlooked, and we may add that, especially with children, therapid swelling of the part, the pain given by an examination,and the difficulty of controlling young patients, may easilyaccount for such an error. This reminds us of a case sometime ago, under the care of Mr. Lee, at King’s CollegeHospital.The patient was an Irish labourer, forty-seven years of age,

who presented himself in the out-patient’s room the day afterhaving been knocked down by a cab in Oxford-street. Hecomplained principally of his shoulder, which was considerablyswollen and painful, so much so that he was desired to fomentthe part and come the next day. He, however, neglected todo so, and never showed himself again until five weeks after-wards, with a large carbuncle at the back of his neck. Hehad of course been unable to attend to his work all this time,and when the shoulder was examined, it was found that thehead of the humerus lay just beneath the coracoid process,the shoulder being at the same time much flattened, theacromial process very prominent, the arm slightly shortened,and the elbow directed outwards and downwards. Tractionwas immediately and steadily used, and in about ten minutesthe dislocation was reduced, and the arm fastened to the side’ of the chest by a bandage. Whilst the patient was under the influence of chloroform, Mr. Lee made a crucial incision intothe carbuncle, and the issue of the case was favourable inevery respect.

Being on the subject of dislocations, we would just allude toa case lately under the care of Mr. Ure, at St. Mary’sHospital.

ST. MARY’S HOSPITAL.

Dislocation of the Head of the Humerus, of seven months and ahalf standing ; Partial Reduction.(Under the care of Mr. URE.)

JANE P-, aged sixty-three, a stout country-woman, whohas always had good nourishment, and looks younger than she is,was admitted, Dee. 31, 1852, under the care of Mr. Ure. Aboutseven months before admission she fell down some steps, about theheight of six feet, her right arm at the time being extended.When the patient got up, she found she had no power over thearm, and was unable to raise it up to htr head; the elbow pro-jected outwards from the side, and the arm was in a flexed posi-tion. No remedial measures were resorted to, as the woman

supposed matters would get right of themselves. At last sheapplied to this hospital, and on examination a dislocation of thehumerus was detected, the head of the bone being situated underthe pectoral muscle, and the arm one inch and a half shortened.The patient used her limb pretty well, but she could not raise itabove her head, nor put a teacup to her mouth, ard often felta sensation of numbness about the fingers. She had been workingwith the arm for the last half-year, and after the accident wasonly laid up for one month. Attempts at reduction were madewithout the pulleys, but to no effect.On the 12th of January,being about a fortnight after admission,

the patient was placed on a bed, and after being narcot’zed withchloroform, the body was securely fixed to the shaft by strapsrunning round the axilla, which was protected by a pad. Astrong armlet was fixed above the elbow, and the traction wasexerted in a transverse direction, and somewhat upwards, whilstMr. Ure placed his knee under the arm, and steadied the scapula.The traction was steadily continued for about twelve minutes,and evidence was obtained that the head of the bone was leavingits position, the bands of adhesion gradually giving way, and atthe time Mr. Ure gave a push upwards, it appeared that the re-

duction was partially effected. The arm was then properlysecured, and the patient was discharged twenty-two days afteradmission, and ten after the partial reduction of this long-standing

dislocation. She could use the arm with facility in variousdirections, and had no difficulty in carrying her hand to hermouth.

Varicocele treated by the Needles and Twisted Sutures.(Under the care of Mr. COULSON.)

I It is not alwa) s an easy matter to decide whether the pallia-tive or curative treatment of varicose veins should be undertaken,

and the rules given in books wiil very frequently prove insuffi-cient. The occupation and station in life of the patient must betaken into consideration by the surgeon; for if the former canavoid violent exertion, and take advantage of the highly im-proved appliances for elastic pressure which have of late been in-’ trodaced, (see the department of New Inventions in this journal,THE LANCET, vol. ii. 1852, p. 473-Bourjeaurd’s stokings,) he

247

can hardly be advised to run the risk of an operation which maybe, and has been, followed by very serious consequences. Norshould it be forgotten that with the less wealthy patient the tem-perament and state of health should be carefully noted before the

. varicose veins are attacked, either with the caustic or the needle.For in scrofulous, weak, or unhealthy subjects, either operationmay cause such severe inflammation, such extensive abscesses,such alarming typhoid symptoms, that a fatal issue seems almostcertain.We write with a vivid recollection before us of a case of this

kind which came under our notice at one of our metropolitanhospitals, where very severe symptoms followed the tying ofvaricose veins. It also occurs pretty often in private practicethat this operation is followed by alarming results, and death haseven been known thus to take place. The secret, therefore,seems to be to make a proper choice of subjects, and also whenchosen to prepare them by rest, gentle purgatives, and moderatediet, for an operation which seems trifling, and which neverthe-less should not be performed without due caution. We mean todilate, as soon as an opportunity presents, upon two subjects con-nected with this and other operations-viz., the disuse in whichhas fallen the old custom of duly preparing patients for opera-tions, and the danger, especially in cold weather, of exposingthem in the operating-theatre with insufficient covering.When the veins of the spermatic cord are in a varicose state,

the choice between the palliative or curative treatment is likewiseof great importance to the patient; and there can be no doubtbut that in the slighter cases a well made suspensory bandage ispreferable to an operation. In fact, the latter should not bethought of, except there be constant pain, (unrelieved by arti-ficial support,) much inconvenience respecting trade or occupa-tion, or impending mischief to the testicle. When the curativetreatment seems advisable, it remains for the surgeon to chooseamong the various modes of operating which have been proposedand extolled by their authors. First, there is the actual cauteryapplied by a heated wire; then the caustic, as lately applied in aningenious manner by M. Bonnet, of Lyons. The operation, asdescribed in the Foreign Department of this journal, (THELANCET, vol. ii. 1852, p. 244,) is performed as follows :-"The operator, when the patient is insensible with chloroform,

seizes the cord with the four fingers of each hand, and tries tofind the vas deferens; as soon as he feels that duct, he allows itglide back from the veins, and keeps the latter fixed by hisfingers. One hand is then made to- rest against the inguinalring, and the other on the testicle, and an assistant is then de-sired to apply a peculiar kind of forceps on the veins which liebetween the operator’s hands. This forceps is supplied with twolittle rods, which produce the same compression as the handswhen the latter are taken off, and likewise keep the vas deferensat the back of the veins. When the forceps is properly fixed, atransverse incision is to be made across the veins, about an inchand a half in length, and the soft parts are divided until the veinscome into view, the operator taking care not to wound the latter.It is important that all the bleeding vessels, even the smallest,should be immediately tied: three or four ligatures are generallynecessary. The whole wound is then covered with a paste ofchloride of zinc, which is allowed to stay for twenty-four hours.The paste is taken off on the next day, and the layer of cauterizedparts is removed with the bistoury, their thickness being gene-rally about the one-third of an inch; and the forceps are thenalso to be loosened, so that the pressure be not exercised too long.A fresh layer of chloride-of-zinc paste is put on the spot whencethe eschar has been removed, and is again allowed to remain fortwenty-four hours. At the expiration of this time the forceps isremoved, and this concludes the operation. Eight or nine daysafterwards, a white eschar, about an inch square, falls off, andthis is found to contain the whole of the veins. The latter mayeasily be known by the dark blood filling the tortuous convola-tions. The pain is very severe for the first two or three days,

’ and there is indeed much suffering until the eschar finally fallsoff. The scrotum and testicles generally become cedematous andinflamed, but the excitement ceases immediately the cauterizedparts are detached. The fever and oedema are mostly trifling;no venesection or any other antiphlogistic means are ever re-quired ; as soon as the eschar falls off, the patient is as well as ifhe had not undergone any operation. He generally may leavehis bed a fortnight after the cauterization, and the whole treat-ment does not last more than one month."The veins mayalso be obliterated by being gradually rolled upon

a silver wire, the two ends of which. by being twisted, at last accom-plish the obliteration of the vessels. This method has been pro-posed by M. Vidal, of Paris. M. Ancelon, of Dieuze. France,finds f.:uit both with M. Bonnet’s cauterization and M. Vidal’srolling of veins. He prefers, and we think with justice, makingan incision over the veins without wounding them, and then

(without any danger of being mistaken) separating them from thevas deferens and artery. He also deprecates M. Bonnet’s re-peated applications of the chloride of zinc paste, and advises,when the veins have been laid bare, to keep away the vas

deferens aud artery by interposing a piece of card folded in theshape of a groove, and then applying caustic paste of thethickness of two lines, which should be left for ten minutes andthen taken off. Pain, time, and risk of doing harm to the sur-

rounding textures are thus saved. He operated thus upon ayoung man of twenty-two years, and in about twelve days thewound was healed, and the patient doing well.

Various other modes of operating have from time to time beenused, as Mr. Wormald’s ring, M. Ricord’s twisting by means of acord and metal bow, ,c. ; and, lastly, the transfixion of the veinsby needles, and the twisted suture applied over them, as usuallydone for ordinary varicose veins of the leg. This method seemsto have gained ground with us, for several hospital-surgeonshave lately adopted it; and we shall now devote a few lines to thecases which have come under our cognisance. Among these wefind one lately under the care of Mr. Coulson, the details ofwhich run as follow :-

Samuel M-, aged thirty-five years, was admitted Jan. 14,1853, under the care of Mr. Coulson. The patient’s health hadgenerally been good, but for the last fifteen years he had noticedan enlargement of the veins of the cord. He had also sufferedfrom stricture, for which ailment he had been successfully treatedby Mr. Coulson in this hospital one year before the present ad-mission.On examination, a considerable enlargement of the veins of the

cord on the left side was observed ; the vessels were partiallysurrounding the testicle, and this organ was painful to the touch,and appeared rather smaller than its fellow. Mr. Coulson, con-sidering this a fit case for operation, proceeded, on the 15th ofJanuary, to tie the veins of the cord.

After having carefully separated the varicose vessels from thevas deferens and the artery, he passed three hare-lip needlesunder the congeries of vessels, at a distance of about half an inchfrom each other, and the intervening portions were then strangu-lated by the twisted ligature. The operation was performedwithout chloroform, and the patient did not complain of muchpaiu.No constitutional symptoms followed, but some inflammation

of the epedidymis came on, which symptom was relieved bypoulticing and fomentations. The ligatures came away on thetwentieth day after the operation, the wound rapidly healed, andthe patient was discharged a few days afterwards in good con-dition.

KING’S COLLEGE HOSPITAL.

Varicocele, treated by the Needles and the Twisted Sutures.(Under the care of Mr. FERGUSSON.)

CHARLES B-, aged twenty-seven years, has always enjoyedgood health. Six years before his present admission, he firstperceived an enlargement of the veins of the cord, and a draggingsensation at the testicle, the parts feeling very heavy and uncom-fortable. He gradually became worse, and obtained some reliefby -wearing a suspensory bandage. This did not last long, anda stay in the county hospital was not of much avail. A surgeonat this time told the patient that if a portion of the scrotum wereremoved he would get relief: the operation was performed, andproduced considerable improvement, but the diseae returnedwhen he went to business again.The man was successively in various hands, and at last was

admitted into the Middlesex Hospital, where a ring was used toraise the scrotum towards the penis; this gave much pain, andwas left off. After undergoing different kinds of treatment forsome time, the patient was admitted into this hospital. Mr.

Fergusson performed the usual operation for varicocele, by passingneedles under the veins, and then twisting some silk over themjust as is done for hare-lip. The operation succeeded, and thepatient went out much relieved.

He, however, returned November 2; , 1851, as the veins hadenlarged again; and four days afterwards Mr. Fergusson usedthe needles and twisted suture a second time. The patient nowcomplained of some pain up the cord, and slept badly; fomen-tations gave relief, and on the second day he was much better.On the tenth day there was little pain and discharge, and thedragging sensation was gone. On the twentieth day after theoperation the ligatures came away, and the veins were very muchdiminished; there was for a little time some dragging sensationabout the testicle, but the patient was discharged much relieved

. about one month after admission.