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A CLINIC OF MANIPULATIVE SURGERY.
682
(2) That the larger the abscess and the longer it has lasted the easier, relatively, it is to cure with emetine I am, Sir, yours faithfully, .only. V. S. HODSON. London, W., March 19th, 1926.
these marks were placed three pieces of fine silver wire, fixed in position with adhesive strapping. A stereoscopic radiograph was then taken. This localised the fragment relatively to the skin pencil marks. The skin of the foot was now prepared for operation by the iodine method and, using local anaesthesia., two hypodermic needles were inserted at right angles to each other, down to where the fragment was judged to lie in relation to the pencil marks. The foot was now wrapped in a sterile towel and another stereoscopic radiograph taken. This showed the position of the fragment relatively to the hypodermic needles, the vertical one having passed just anterior to it and the horizontal one immediately above it; it lay in the angle between them. After a further injection of local anaesthetic I cut down upon the horizontal needle and had no difficulty in touching and removing the glass splinter, in spite of the facts that its small size (about 1x1x55 mm.) and transparency made it invisible until it was actually removed, and that no tourniquet was used. The little operation occupied about ten minutes. This contrasts so markedly with the prolonged search one has so frequently had to make for comparatively large and visible foreign bodies and the necessary dissection among tendons, with proportionate risk of infection, that the somewhat lengthy procedure for localisation seems to nie abundantly justified. It is true it merely transfers the labour and time from the operating theatre to the X ray room, but to the considerable advantage of the patient. These few points-which it would be impertinent to suggest to the expert radiographer-may be of help to an amateur like myself. 1. While the position of the limb is of little or no importance, the long axis of the films should be exactly at right angles to the stereoscopic shift of the tube in order to obtain the maximum stereoscopic effect. 2. The stereoscopic shift should be parallel to one of the needles, preferably the This needle will one it is intended to cut down upon. then give the best impression of the depth and thus 3. It is serve for localisation in two dimensions. hardly necessary to add that the incision should be" so placed as to lay bare only a portion of the " guide needles in order that both may remain in their original positions until the foreign body is actually removed. 4. It is an immense advantage to be able to look at the stereoscope, after one is prepared for operating, immediately before making the incision. I am, Sir, yours faithfully, MARTIN BUTTON, F.R.C.S. Eng. & Edin. Rye, March 12th, 1926.
*,*We have submitted Dr. Hodson’s letter to Dr. Manson-Bahr, who replies as follows :"Dr. Hodson is correct in stating that many observers agree with him that emetine therapy acts beneficially in liver abscess and that it has sometimes appeared to have rendered operative interference unnecessary, but it is extremely difficult, as I think ,most men who have had sufficient experience will agree, to distinguish actual formation of amoebic pus from an amoebic hepatitis, in which invasion of the liver tissue by entamoebee without pus formation has taken place. Aspiration is the only method capable of settling this question. The actual performance of aspiration is a simple matter and is certainly not attended with any more risk than the tapping of a pleural cavity ; it is certainly a method equal in its diagnostic importance and therapeutic effect. " The question at stake is the size of the abscess or abscesses and the results of the absorption of such a large amount of toxic matter on the individual. If a grave degree of toxaemia is present, as is usually the case, the sooner the pus is evacuated the better for the patient. It seems to me a very untherapeutic attitude to force an already toxic subject to absorb a large amount of dead tissue from his liver through his lymphatic channels, when a much more rapid and pleasant method is at hand. A liver abscess may be a comparatively trivial or it may be a very serious disease. When there has been formation of a large amount of pus (four pints or more) respiration is severely hampered and displacement, with consequent embarrassment, of important organs, such as the heart, may take place (as in a very serious case under my care at the present time). " Surely Dr. Hodson does not credit emetine with .such miraculous qualities that a few grains will suffice to dispel several pints of dead tissue and thereby relieve pressure on vital organs, nor can it possibly lessen the amount of septic absorption which is taking place. The cases quoted in my original paper with Dr. Morris (THE LANCET, Jan. 9th) are two specific instances where, firstly, emetine therapy had failed to prevent the recurrence of an abscess, and, secondly, had failed to prevent the re-accumulation of pus in an abscess which had already been drained. " It is probably unwise to dogmatise at present .on the action of emetine in abscess of the liver. Other drugs act in a similar mysterious manner; quinine does not cure every case of malaria, nor salvarsan every case of syphilis ; but to assert that the larger the abscess and the longer it has lasted the easier it is to cure with emetine, appears to be in ,direct contradiction to clinical experience."
A CLINIC
SURGERY.
To the Editor
of THE LANCET. SIR,-I wish to make a preliminary announcement concerning a clinic of manipulative surgery instituted in London in response to many requests from medical men
and others who feel that some such movement is needed to endeavour to place the matter
urgently
’
scientific basis. The clinic is primarily for the benefit of poorer patients in need of manipulative treatment, and the
upon
THE LOCALISATION OF SMALL FOREIGN BODIES : A CASE.
a
headquarters are at present at 59, Montagu-square, W. Treatment in the case of the necessitous poor will be
To the Editor
of THE LANCET. SiB,—A few months ago I was asked by a young man to remove a glass splinter from his heel. He informed me that he had trodden on some broken glass about two years previously, all of which had been removed at the time save this small fragment. That a subsequent unsuccessful attempt at removal had occupied two hours under general anaesthesia, and that, since the splinter gave him pain and disability, he wished, if possible, to haveit removed before proceeding to East
OF MANIPULATIVE
"
gratuitous.
The clinic is held at present on Tuesdays between the hours of 2 and 6 P.JB’L, and it is hoped when its activities are in full swing to arrange classes and demonstrations for practitioners and senior students, who are at all times welcome at the clinic. A scheme is also under consideration for the foundation of an institute for the scientific investigation and modern treatment of injuries and non-tuberculous diseases of Africa. The following method of localisation proved so help- joints, of which a further announcement will be made ful on that occasion, and has been so since in the case in due course. I am, Sir, yours faithfully, of embedded needles, that I venture to record the A. G. TIMBRELL FISHER. made a Three marks were with skin procedure. 59, Montagu-square. London, W. 1, March 22nd, 1926. pencil from side to side, encircling the heel. Over ,
(2) That the larger the abscess and the longer it has lasted the easier, relatively, it is to cure with emetine I am, Sir, yours faithfully, .only. V. S. HODSON. London, W., March 19th, 1926.
these marks were placed three pieces of fine silver wire, fixed in position with adhesive strapping. A stereoscopic radiograph was then taken. This localised the fragment relatively to the skin pencil marks. The skin of the foot was now prepared for operation by the iodine method and, using local anaesthesia., two hypodermic needles were inserted at right angles to each other, down to where the fragment was judged to lie in relation to the pencil marks. The foot was now wrapped in a sterile towel and another stereoscopic radiograph taken. This showed the position of the fragment relatively to the hypodermic needles, the vertical one having passed just anterior to it and the horizontal one immediately above it; it lay in the angle between them. After a further injection of local anaesthetic I cut down upon the horizontal needle and had no difficulty in touching and removing the glass splinter, in spite of the facts that its small size (about 1x1x55 mm.) and transparency made it invisible until it was actually removed, and that no tourniquet was used. The little operation occupied about ten minutes. This contrasts so markedly with the prolonged search one has so frequently had to make for comparatively large and visible foreign bodies and the necessary dissection among tendons, with proportionate risk of infection, that the somewhat lengthy procedure for localisation seems to nie abundantly justified. It is true it merely transfers the labour and time from the operating theatre to the X ray room, but to the considerable advantage of the patient. These few points-which it would be impertinent to suggest to the expert radiographer-may be of help to an amateur like myself. 1. While the position of the limb is of little or no importance, the long axis of the films should be exactly at right angles to the stereoscopic shift of the tube in order to obtain the maximum stereoscopic effect. 2. The stereoscopic shift should be parallel to one of the needles, preferably the This needle will one it is intended to cut down upon. then give the best impression of the depth and thus 3. It is serve for localisation in two dimensions. hardly necessary to add that the incision should be" so placed as to lay bare only a portion of the " guide needles in order that both may remain in their original positions until the foreign body is actually removed. 4. It is an immense advantage to be able to look at the stereoscope, after one is prepared for operating, immediately before making the incision. I am, Sir, yours faithfully, MARTIN BUTTON, F.R.C.S. Eng. & Edin. Rye, March 12th, 1926.
*,*We have submitted Dr. Hodson’s letter to Dr. Manson-Bahr, who replies as follows :"Dr. Hodson is correct in stating that many observers agree with him that emetine therapy acts beneficially in liver abscess and that it has sometimes appeared to have rendered operative interference unnecessary, but it is extremely difficult, as I think ,most men who have had sufficient experience will agree, to distinguish actual formation of amoebic pus from an amoebic hepatitis, in which invasion of the liver tissue by entamoebee without pus formation has taken place. Aspiration is the only method capable of settling this question. The actual performance of aspiration is a simple matter and is certainly not attended with any more risk than the tapping of a pleural cavity ; it is certainly a method equal in its diagnostic importance and therapeutic effect. " The question at stake is the size of the abscess or abscesses and the results of the absorption of such a large amount of toxic matter on the individual. If a grave degree of toxaemia is present, as is usually the case, the sooner the pus is evacuated the better for the patient. It seems to me a very untherapeutic attitude to force an already toxic subject to absorb a large amount of dead tissue from his liver through his lymphatic channels, when a much more rapid and pleasant method is at hand. A liver abscess may be a comparatively trivial or it may be a very serious disease. When there has been formation of a large amount of pus (four pints or more) respiration is severely hampered and displacement, with consequent embarrassment, of important organs, such as the heart, may take place (as in a very serious case under my care at the present time). " Surely Dr. Hodson does not credit emetine with .such miraculous qualities that a few grains will suffice to dispel several pints of dead tissue and thereby relieve pressure on vital organs, nor can it possibly lessen the amount of septic absorption which is taking place. The cases quoted in my original paper with Dr. Morris (THE LANCET, Jan. 9th) are two specific instances where, firstly, emetine therapy had failed to prevent the recurrence of an abscess, and, secondly, had failed to prevent the re-accumulation of pus in an abscess which had already been drained. " It is probably unwise to dogmatise at present .on the action of emetine in abscess of the liver. Other drugs act in a similar mysterious manner; quinine does not cure every case of malaria, nor salvarsan every case of syphilis ; but to assert that the larger the abscess and the longer it has lasted the easier it is to cure with emetine, appears to be in ,direct contradiction to clinical experience."
A CLINIC
SURGERY.
To the Editor
of THE LANCET. SIR,-I wish to make a preliminary announcement concerning a clinic of manipulative surgery instituted in London in response to many requests from medical men
and others who feel that some such movement is needed to endeavour to place the matter
urgently
’
scientific basis. The clinic is primarily for the benefit of poorer patients in need of manipulative treatment, and the
upon
THE LOCALISATION OF SMALL FOREIGN BODIES : A CASE.
a
headquarters are at present at 59, Montagu-square, W. Treatment in the case of the necessitous poor will be
To the Editor
of THE LANCET. SiB,—A few months ago I was asked by a young man to remove a glass splinter from his heel. He informed me that he had trodden on some broken glass about two years previously, all of which had been removed at the time save this small fragment. That a subsequent unsuccessful attempt at removal had occupied two hours under general anaesthesia, and that, since the splinter gave him pain and disability, he wished, if possible, to haveit removed before proceeding to East
OF MANIPULATIVE
"
gratuitous.
The clinic is held at present on Tuesdays between the hours of 2 and 6 P.JB’L, and it is hoped when its activities are in full swing to arrange classes and demonstrations for practitioners and senior students, who are at all times welcome at the clinic. A scheme is also under consideration for the foundation of an institute for the scientific investigation and modern treatment of injuries and non-tuberculous diseases of Africa. The following method of localisation proved so help- joints, of which a further announcement will be made ful on that occasion, and has been so since in the case in due course. I am, Sir, yours faithfully, of embedded needles, that I venture to record the A. G. TIMBRELL FISHER. made a Three marks were with skin procedure. 59, Montagu-square. London, W. 1, March 22nd, 1926. pencil from side to side, encircling the heel. Over ,