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A Mirror

OF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITAL’S OF LONDON.

WESTMINSTER HOSPITAL.

LARGE AND PAINFUL CARBUNCLE, TREATED SUCCESS-FULLY BY SUBCUTANEOUS SECTION.

(Under the care of Mr. CHRISTOPHER HEATH. )

Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborumet dissectionum historias, tum aliorum, tum proprias collectas habere, et interse comparare.—MORGAGNI De Sed. et Casts. Morb., lib. iv. Prooemium.

IN June, 1862, Mr. French, surgeon to the St. James’s In-firmary, brought before the Medical and Chirurgical Society aplan of treating carbuncle which he had pursued with greatsuccess for many years. It consists in the subcutaneous sec-tion of the indurated tissue by a tenotomy knife, which is in-troduced a little beyond the edge of the induration ; and, theforefinger of the left hand serving as a guide upon the surface,the tumour is divided just as a tendon would be cut through.The skin itself is left uninjured. If the carbuncle is large,-this process is repeated in different positions, so that themass is crucially divided subcutaneously. We have seen

a large number of cases treated by this method. The im-

mediate relief obtained, and the rapid recovery which fol-lows, are very striking. Every surgeon who has practised theold operation of crucial incision knows that it is necessary tocut’ deeply enough to divide the hardened base of the car-buncle. Mere division of the skin is useless ; more than this,it is mischievous, for a widely gaping wound is formed, whichis often most troublesome to heal, and leaves eventually a veryugly cicatrix. This is entirely avoided by Mr. French’s pro-cess.

The following is a case of carbuncle in which Mr. Heathpursued this plan with the highly satisfactory result re-

,corded:-

Henry W-, aged forty-six years, was admitted July 3rd,1865, with a large carbuncle on the back, measuring six inchesin diameter each way. This had been coming for ten days,and two days before admission the skin in the centre hadgiven way, exposing a slough, but the surrounding tissue wasgreatly swollen and inflamed, and he was suffering greatagony.July 4.th.-The patient having been placed under chloroform,

Mr. Heath made a crucial subcutaneous section of the car-buncle with a narrow bistoury. The knife was entered at the

margin of the inflamed skin, carried well beneath the carbuncle,-and the point brought up to the central opening, when thewhole thickness of the subcutaneous tissues were dividedcrucially, the knife being entered four times on account of thelarge diameter of the carbuncle. The haemorrhage was veryfree, and was checked by a pad and broad bandage. Low diet;beef-tea, two pints; wine, ten ounces. Aromatic spirit of am-monia, half a drachm; liquor of cinchona, fifteen minims;water, one ounce : three times a day.5th.-Passed a good night, the pain being greatly relieved

by the incisions. Pad removed. The inflammation has con-siderably subsided, and a small quantity of pus exudes fromeach puncture. Poultice.

12th.-Patient’s recovery has been uninterrupted. The in-flammation has entirely subsided ; the hole in the centre hasnot increased, and a slough of cellular tissue is now separating.

14th.—Water-dressing to wound, which is quite clean. Fulldiet. Dilute nitro-hydrochloric acid, twenty minims; liquorof cinchona, fifteen minims ; water, one ounce : three times aday.

21st. -Convalescent, and on the 25th he was dischargedcured.

! The same principle has been lately adopted by Mr. Shaw,at the Middlesex Hospital, in some cases of large and exceed-ingly painful syphilitic nodes upon the tibia. These swellingsare sometimes so hard as to give the idea of osseous growths,but they will generally be found to consist of thickened peri-osteum, rendered extremely tense by a semi-liquid effusionunder it. The pain experienced is intimately connected withthis tension. The section of the swelling by a tenotomy knife,introduced under the skin and made to cut downwards towardsthe bone, produces very rapid relief to the suffering, and thedisease itself is not rendered thereby less amenable to thecurative influence of iodide of potassium, which generally actsso favourably in such cases.

UNIVERSITY COLLEGE HOSPITAL.AMPUTATION OF BREAST ; EMPLOYMENT OF ACUPRESSURE

IN LIEU OF LIGATURES TO CLOSE THE ARTERIES.

(Under the care of Mr. BERKELEY HILL.)M. G , aged forty-five, was admitted on August llth,

with scirrhous disease of the breast. On the 16th the tumourwas removed by amputation, and the bleeding vessels weresecured with needles employed according to the directions

given by Dr. Simpson in his work on Acupressure. Theneedles used were about three inches long, lancet pointed,and tolerably stiff. Eight inches of iron wire were passedthrough the eye of each needle, to draw it out by whenthe time for removal arrived. So prepared, the needles wereapplied as follows :—The point was passed under the mouth ofthe artery and made to protrude half its length in the wound.A loop of iron wire was then carried over its point, and theends made fast by a half turn round the end of the needle,thus compressing the artery against the shaft. This methodDr. Simpson calls the third, and describes it at page 60 of hiswork. Seven arteries were so compressed; six others weresecured by carrying the point through the flesh beside thebleeding vessel, then passing it round the artery and thrustingit again into the tissue so as to twist the artery a little andpress its sides together. This plan is also described in Dr.Simpson’s work, at page 354, by Dr. Knowles of Aberdeen,who first suggested it. Both these plans stopped the bleedingat once without difficulty. In arranging the needles care wastaken that the ends should be directed towards the surface,that they might be readily withdrawn. From the large extentof skin which was removed, it was impossible to bring theedges of the wound together after the operation.At the end of forty-eight hours, during which time no bleed-

ing at all occurred, the needles were withdrawn very easily bymeans of the wire attached to the eye for that purpose, theloops of wire having been first untwisted. This operationcaused little pain and no bleeding at the time. Thirty hourslater, however, haemorrhage returned at two points near theinner angle of the wound, which was readily arrested with twoneedles passed underneath the points whence the blood issued.Since then no more blood has been lost.

Sept. 13th.-The patient is recovering her strength, and isable to walk about, though the wound is not yet closed; thedelay being due to the large amount of skin removed (withthe object of at least postponing recurrence of the disease) andto three attacks of erysipelas on the arm, rather than in thewound itself.In this case the advantages claimed for acupressure over

ligatures could not, in the nature of things, be all obtained.In the first place, suppuration was not avoided, as the woundnecessarily healed entirely by granulation ; secondly, thearteries were all small ones, and, therefore, the efficacy of theneedle-pressure in promoting a firm plug of the artery was notseverely tested. Nevertheless, the ease of application and thecomplete arrest of haemorrhage while the needles were in situ,afforded in this instance sufficient to encourage further trial incases where the arteries are larger, and the obstacles to unionwithout suppuration less complete. Probably also the needlesshould have been removed in twenty-four instead of forty-eight hours, as they were already bathed in pus when takenout.Mr. B. Hill informed us that this was the first operation in

which he had used the needles. He seemed, however, to haveno difficulty in their application, and although the bleedingvessels were small, they were, as is common in these opera-tions, very numerous, and in that respect the value of theprocess as regards the rapidity with which it can be applied

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was rather severely tested. We do not find, in the course ofour inquiries at the hospitals, that acupressure has been at allgenerally employed. Mr. Pearse, house-surgeon to the West-minster Hospital, however, gives us the following interestingparticulars of its application in one case :-In June last, Mr.Barnard Holt amputated the thigh of a young man, for knee-joint disease of three years’ standing. The femoral artery wastransfixed by a hair-lip pin, and silver wire twisted in a figure-of-8 form about it, so as to compress the vessel. Two smallervessels were also compressed in a similar manner. On thefourth day the pin was withdrawn from the femoral artery,and the wire thus freed was easily removed by pulling an endwhich had been left projecting from the wound. The wires

upon the smaller vessels had been removed forty-eight hourspreviously. No hæmorrhage occurred, and the wound hadhealed perfectly eight days after the operation, when unfor-tunately the patient died with effusion into the ventricles ofthe brain.At the Middlesex it has been used in several cases of divided

radial artery at the wrist, when it was found a very convenientmethod of staying haemorrhage. But, with the exception ofMr. Holt’s case, we do not hear of its application to any largevessel.

ST. GEORGE’S HOSPITAL.FOUR CASES OF DIFFUSE PERIOSTITIS ; GENERAL AND

LOCAL TREATMENT, WITHOUT INCISIONS;RECOVERY.

(Under the care of Mr. PRESCOTT HEWETT.)THERE is little doubt that in some, if not each, of the fol-

lowing cases many surgeons would have made incisions intothe affected limbs. Inflammation between bone and its peri-osteal covering is a most fertile source of those numerous casesof necrosis which are continually requiring the surgeon’s assist-ance in our hospitals. We are taught that early and vigoroustreatment is requisite in this condition; that the inflammatorylymph poured out has a tendency to degenerate rapidly intopus; and that unless timely incisions are made to give exit tothis fluid the periosteum will be extensively stripped from theunderlying bone, and death of the osseous structure will occur.And there is no doubt that such is too frequently the coursefollowed by diffuse periostitis. That such results do not al- Iways accrue is well shown in three of the following cases, inwhich, under rest, soothing applications, and general treat-ment, convalescence rapidly ensued without suppuration. Inthem it seems likely that the inflammatory elfusion becameconsolidated and organized in place of assuming the charactersof pus. That the treatment pursued in these cases was the best possible, is evidenced by the results. Had incisions beenmade no pus would have been found, but suppuration musthave followed in consequence of the admission of air to theinflamed and divided membrane; and it is scarcely conceivablethat some considerable amount of necrosis would not have etaken place. We do not, of course, record these cases with aview of basing upon them a theory that acute periostitis mightor should always be treated in this manner. Such a sug-gestion would be most illogical. But they are interesting andvaluable as contributions towards the natural history of thisdisease. They show that vigorous surgical interference is notalways expedient-not that it is not sometimes very necessary.It was the gradual mitigation of the symptoms which evidentlyinfluenced Mr. Hewett in his line of treatment. Had theypersisted, or much increased in severity, he would doubtlesshave resorted to incisions. From an observation of many suchcases in the various hospitals, we are disposed to think thatthe vigorous treatment of diffuse periostitis is, perhaps, toopositively insisted upon by various writers.The following notes were obligingly furnished to us by Mr.

T. P. Pick, surgical registrar to the hospital :-CASE 1. -James C aged eight years, admitted Jan. 19th,

under the care of Mr. Hewett. A short time before admissionhe jumped off a wall, a distance of four feet, and fell, strikinghis knee.On admission there was very great swelling from below the

knee up to the middle of the thigh, the greatest amount beingat the knee-joint, which was due to effusion within the joint.Ordered lead lotion with opium; calomel and scammony powder,eight grains, at night. Ordinary diet.

Jan. 21st.-There is more swelling up the thigh; the skin ishot, tense, and extremely painful, and of a peculiar shining

appearance. There is considerable febrile excitement; tonguefurred ; pulse quick, and there is constant pain, with startingof the limb, which prevents his sleeping.

27th.—There is less effusion in the joint, and the skin is notso tense ; does not suffer so much pain. The swelling in thethigh is still great and very resisting; it appears to be con-nected with the bone.

Feb. 4th.—The swelling is subsiding a little, but there isstill a great amount. The slightest movement causes muchpain, and he has an anxious expression of countenance.

10th.—The pain has now entirely left him, and his generalstate has much improved. He enjoys his food, and sleepswell. There is still considerable effusion in the joint, but theswelling above is much less, the skin over it being quite loose,and the swelling itself becoming more consolidated, and beingevidently due to thickening of the lower end of the femur.From this date he went on well till March 3rd, when all

effusion had disappeared from the joint, and, because of itshaving become contracted, a screw ham-splint was applied.On April 22nd the knee was nearly straight, and in conse-

quence of the splint having caused a sore from pressure, it wasdiscontinued. On the inner side of the lower part of the thighthere was a red spot, where there was an indistinct sensationof fluctuation.On May 6th he was allowed to get up, the softened spot

having entirely disappeared; and on the 17th he was dis.charged, being able to walk about, though there was still con-siderable thickening of the lower end of the femur, and con-solidation about the joint.CASE 2.-Sarah H-, aged fourteen, admitted Feb. 20th,

under Mr. Hewett. On the morning of the 17th, on gettingup, she found herself unable to stand from pain and swellingof the knee. This has continued and extended up the thigh.Has not been exposed to cold, nor can she assign any cause forher disease.On admission, the left thigh was much swollen; the skin

tense and straining, of a wax-like appearance, and acutelypainful. There was an enlarged gland in the groin, and a smallulcer over the tendo-Achillis, produced by the rubbing of theboot. Countenance very anxious ; tongue furred; pulse 116;skin hot. Ordered, calomel, three grains, at bedtime, withhouse medicine in the morning; effervescing saline draught,with ammonia, every six hours ; a lotion of lead and opium.Fish diet.

Feb. 23rd. —The swelling is still very great, and the skin isred. She still complains of very great pain, and cannot sleepat night. Ordered, linseed-meal poultice; iodide of potassium,with compound infusion of gentian.26th.-Has quite lost her former anxious appearance; sleeps

better, and suffers much less pain; tumour rather softer, but

still extremely painful to the touch.March 5th. - The swelling is very much softer, and is

threatening to point on the inner side of the thigh; patientcomplains of its throbbing at night. Ordinary diet, with halfa pint of porter.The swelling continued to disappear, the threatening abscess

became dispersed, and the spot consolidated.On April 23rd the swelling was all gone, except some thick-

ening of the bone, which still remained. She did not sufferany pain, and could bear the weight of her body on the limb.She was therefore discharged.CASE 3.-Julia M-, aged seventeen, admitted May 10th,

under Mr. Hewett. Two months previous the patient had" typhus fever," for which she was treated in the Fever Hos-pital. Soon after her discharge her left leg became muchswollen and inflamed, and has been very painful ever since.On admission there was considerable thickening of the left

tibia. Skin tense, covered with a patchy redness, and ex-tremely painful to the touch. There was a slightly enlargedgland in the groin. Tongue furred ; skin hot; pulse veryquick and weak. Ordered, iodide of potassium (five grains)and cinchona draught twice a day; lead and opium lotion;ordinary diet, with a pint of porter.May 15th.—The redness is subsiding; complains of an ach-

ing pain in the bone.21st.—Redness all gone ; skin less tense ; much less pain on

pressure ; pulse stronger ; tongue clean.28th.—Very little pain indeed-oiily "a feeling of numb-

ness" in the leg ; superficial swelling less ; the thickening ofthe bone much the same.June 17th.-Has had occasionally a little pain, principally

at night; the thickening of bone is rather less; she gets upand goes into the convalescent ward.