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