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ABSTRACT OF A Clinical Lecture ON ABSCESS OF BONE.
815 In speaking of the symptoms of phthisis it is important to remember that the course of the disease is usually intermittent. A continuous implication of the lung is exceptional, and occurs only in some of the most intense and rapid forms of the disease. In all the more chronic cases the progress of the lung consolidation is interrupted by shorter or longer periods of quiescence, during which, although the lung symptoms may persist, the fever and constitutional symptoms are in abeyance. During these quiescent periods the general health and strength of the patient commonly improve, and where the disease is limited a very fair state of health may be maintained for many years. This accommodation of the system to the pulmonary lesion in the more chronic and located forms of phthisis is very remarkable, and I shall have occasion to allude to it again hereafter. lu concluding this preliminary sketch we must not forget the liability to such complications as haemoptysis, ulceration of the intestines, and disease of the larynx, all of which will be considered in due course.
I,
ABSTRACT
A
OF
Clinical Lecture ON
ABSCESS BY GEORGE
OF
WHERRY, M.B., F.R.C.S.,
SURGEON TO ADDENBROOKE’S
THERE is
BONE.
in Albert ward. Feb. 23rd, 1882, boy, aged thirteen, brought suffering from pain below his left knee. Eight days before admission be had a blow on the inside of the knee, but thought little of it during three or four days, until the limb began to be painful and to "keep him awake at night." There was no swelling of the knee or below it, and no effusion into the joint, but the superficial veins were enlarged ; the part was hot and tender to the touch. The boy was put to bed at once, and leeching relieved his pain to some extent; but Mr. Sheild, our house-surgeon, who is not likely to overlook any symptom of importance, told me that there still remained one tender spot. His relief from pain was only temporary, and be suffered so severely that he could neither eat nor sleep. Now, you must notice the temperature chart, which shows a rise on the first night to 104° F., and about that rise also on the four subsequent nights. There were no rigors, but sweating occurred at intervals. Then on the fifth morning after admission you were all of you witness to the writhe of pain elicited by pressure of my finger at one spot just below the inner tuberosity of the tibia; and I decided that there was an abscess in the head of the tibia bone. There was no disease in his chest and no evidence whatever of any other malady. The patient was put under chloroform, and an incision was made upon the spot before noted right down to the bone ; the periosteum was not thickened, and the bone beneath was hard. A perforator (in shape something like a large bradawl) was then driven slowly with slight lateral movements into the cancellous tissue, and the exuding blood was carefully watched. When the instrument had penetrated quite to the middle of the head of the bone flakes of pus began to escape, evidently from the interior. The pain immediatelv after the operation was intense, but very soon ceased. The temperature dropped to normal, and so has continued. The boy is now quite free from pain, there is no fever, no beat, no swelling, no tenderness in the parts; the abscess cavity, which for some days discharged pus freely, appears now (a week after the operation) to be nearly empty, and the parts inclined to heal, and the patient will probably make a good recovery. The head of the tibia is the most usual place for the occurrence of abscess of bone. The affection was first described by Sir Benjamin Brodie, who discovered it in the lower end of the tibia; it appears to be generally due to contusion of the bone, and often runs a much slower course than in this case. The localised tenderness is one of the most important signs, and if with this there is a rise in temperature, an operation must not be delayed. The loss of the neighbouring joint, the sacrifice of the entire limb, or
A
a case
of
HOSPITAL, CAMBRIDGE.
great interest was
now on
even of the patient’s life, will be the result if there is neglect or delay. The affection is more likely to be acute in a young subject, and perhaps in the case before you the abscess occurred near the epiphysial line; there is therefore the more urgent need of surgical interference. As soon as the surgeon can satisfy himself that his diagnosis is correct
he
must
do his best to find the abscess.
REMARKS ON
EPITHELIOMA AND ICHTHYOSIS OF THE TONGUE, BASED ON THE RECORDS OF SEVENTY-FIVE CASES. BY SURGEON
HENRY TO,
MORRIS, M.A., F.R.C.S.,
AND LECTURER ON SURGERY
AT, THE MIDDLESEX
HOSPITAL.
(Continued from page 778.) Some observations on the relative value of different methods the tongue are suggested by these cases. I will confine my remarks to the cases nperated upon by myself. Out of twenty operations performed on nineteen persons, six were done with the galvano-cautery ecraseur, and in one of these the cheek was divided obliquely downwards from the angle of the mouth, after the method of Gant. Seven were done with the twisted wire écraseur, and in one of them also the cheek was divided; in two the tongue was first detached by scissors from the floor of the mouth: in two the twisted wire-rope was passed into the mouth through a supra-hyoid incision, the incision in one case being made along the median raphe of the floor of the mouth, and in the other on one side of the raphe : in two the ecraseur was looped round the tongue without any preliminary incision-the absence of praemolar and molar teeth in one of these cases afforded ample room for operating upon the whole tongue, whilst in the other case it was only necessary to remove the anterior half. Three cases were done by the twisted wire ecraseur after median division of the tongue : in two of these the disease was limited to one lateral half of the tongue; in the other case the whole tongue was removed in two lateral halves. Four were cutting operations, either the scissors or the knife being employed. In two of these the tongue alone was affected, and in one of these the lingual artery was tied previously to excising the diseased part ; in the other the front half of the tongue was cut away with a knife after transfixing the tongue and holding it forward with two long needles, the hsemo]’rhage being quickly stopped by torsion. In the other two cases the floor of the mouth as well as the under surface of the tongue was involved; in one of these the symphysis menti and lower lip were first divided, and afterwards the diseased tissues were freely removed with the knife ; in the other case the diseased parts were freely cut away with scissors, curved at various angles so as to get well down behind the jaw, and Paquelin’s thermo-cautery was used for
of excising
checking haemorrhage. The average period of convalescence in five of the galvanocautery cases was 32’4 days. The shortest was 26 days, the longest 50 days. The sixth case died. The average period of convalescence of three cases in which the twisted wire ecraseur was used after median division of the tongue was 21 days. The shortest was 16 days, the longest 27 days. The average period of convalescence of five cases operated upon with wire-rope ecraseur was 19’2 days. Two patients The were well in 12 days ; the longest period was 27 days. sixth case operated upon with the wire rope quickly recovered from the wound of the tongue, but a supra-hyoid
fiatula remained for one year. In the seventh case recurrence took place before the wound was healed. The average period of convalescence of three cases in which the disease was cut away was 16! days. Two recovered in 14 days, the third in 21 days. In the fourth case the symphysis was divided ; and though the mouth healed well the bone was not united until the end of the fifth month after the
operation.
The amount of
not affect the of convalescence. The supra-hyoid incision should, I think, be avoided if possible. It is not at all requisite for drainage; the mouth can drain itself well
length of the period
tongue removed does
I,
ABSTRACT
A
OF
Clinical Lecture ON
ABSCESS BY GEORGE
OF
WHERRY, M.B., F.R.C.S.,
SURGEON TO ADDENBROOKE’S
THERE is
BONE.
in Albert ward. Feb. 23rd, 1882, boy, aged thirteen, brought suffering from pain below his left knee. Eight days before admission be had a blow on the inside of the knee, but thought little of it during three or four days, until the limb began to be painful and to "keep him awake at night." There was no swelling of the knee or below it, and no effusion into the joint, but the superficial veins were enlarged ; the part was hot and tender to the touch. The boy was put to bed at once, and leeching relieved his pain to some extent; but Mr. Sheild, our house-surgeon, who is not likely to overlook any symptom of importance, told me that there still remained one tender spot. His relief from pain was only temporary, and be suffered so severely that he could neither eat nor sleep. Now, you must notice the temperature chart, which shows a rise on the first night to 104° F., and about that rise also on the four subsequent nights. There were no rigors, but sweating occurred at intervals. Then on the fifth morning after admission you were all of you witness to the writhe of pain elicited by pressure of my finger at one spot just below the inner tuberosity of the tibia; and I decided that there was an abscess in the head of the tibia bone. There was no disease in his chest and no evidence whatever of any other malady. The patient was put under chloroform, and an incision was made upon the spot before noted right down to the bone ; the periosteum was not thickened, and the bone beneath was hard. A perforator (in shape something like a large bradawl) was then driven slowly with slight lateral movements into the cancellous tissue, and the exuding blood was carefully watched. When the instrument had penetrated quite to the middle of the head of the bone flakes of pus began to escape, evidently from the interior. The pain immediatelv after the operation was intense, but very soon ceased. The temperature dropped to normal, and so has continued. The boy is now quite free from pain, there is no fever, no beat, no swelling, no tenderness in the parts; the abscess cavity, which for some days discharged pus freely, appears now (a week after the operation) to be nearly empty, and the parts inclined to heal, and the patient will probably make a good recovery. The head of the tibia is the most usual place for the occurrence of abscess of bone. The affection was first described by Sir Benjamin Brodie, who discovered it in the lower end of the tibia; it appears to be generally due to contusion of the bone, and often runs a much slower course than in this case. The localised tenderness is one of the most important signs, and if with this there is a rise in temperature, an operation must not be delayed. The loss of the neighbouring joint, the sacrifice of the entire limb, or
A
a case
of
HOSPITAL, CAMBRIDGE.
great interest was
now on
even of the patient’s life, will be the result if there is neglect or delay. The affection is more likely to be acute in a young subject, and perhaps in the case before you the abscess occurred near the epiphysial line; there is therefore the more urgent need of surgical interference. As soon as the surgeon can satisfy himself that his diagnosis is correct
he
must
do his best to find the abscess.
REMARKS ON
EPITHELIOMA AND ICHTHYOSIS OF THE TONGUE, BASED ON THE RECORDS OF SEVENTY-FIVE CASES. BY SURGEON
HENRY TO,
MORRIS, M.A., F.R.C.S.,
AND LECTURER ON SURGERY
AT, THE MIDDLESEX
HOSPITAL.
(Continued from page 778.) Some observations on the relative value of different methods the tongue are suggested by these cases. I will confine my remarks to the cases nperated upon by myself. Out of twenty operations performed on nineteen persons, six were done with the galvano-cautery ecraseur, and in one of these the cheek was divided obliquely downwards from the angle of the mouth, after the method of Gant. Seven were done with the twisted wire écraseur, and in one of them also the cheek was divided; in two the tongue was first detached by scissors from the floor of the mouth: in two the twisted wire-rope was passed into the mouth through a supra-hyoid incision, the incision in one case being made along the median raphe of the floor of the mouth, and in the other on one side of the raphe : in two the ecraseur was looped round the tongue without any preliminary incision-the absence of praemolar and molar teeth in one of these cases afforded ample room for operating upon the whole tongue, whilst in the other case it was only necessary to remove the anterior half. Three cases were done by the twisted wire ecraseur after median division of the tongue : in two of these the disease was limited to one lateral half of the tongue; in the other case the whole tongue was removed in two lateral halves. Four were cutting operations, either the scissors or the knife being employed. In two of these the tongue alone was affected, and in one of these the lingual artery was tied previously to excising the diseased part ; in the other the front half of the tongue was cut away with a knife after transfixing the tongue and holding it forward with two long needles, the hsemo]’rhage being quickly stopped by torsion. In the other two cases the floor of the mouth as well as the under surface of the tongue was involved; in one of these the symphysis menti and lower lip were first divided, and afterwards the diseased tissues were freely removed with the knife ; in the other case the diseased parts were freely cut away with scissors, curved at various angles so as to get well down behind the jaw, and Paquelin’s thermo-cautery was used for
of excising
checking haemorrhage. The average period of convalescence in five of the galvanocautery cases was 32’4 days. The shortest was 26 days, the longest 50 days. The sixth case died. The average period of convalescence of three cases in which the twisted wire ecraseur was used after median division of the tongue was 21 days. The shortest was 16 days, the longest 27 days. The average period of convalescence of five cases operated upon with wire-rope ecraseur was 19’2 days. Two patients The were well in 12 days ; the longest period was 27 days. sixth case operated upon with the wire rope quickly recovered from the wound of the tongue, but a supra-hyoid
fiatula remained for one year. In the seventh case recurrence took place before the wound was healed. The average period of convalescence of three cases in which the disease was cut away was 16! days. Two recovered in 14 days, the third in 21 days. In the fourth case the symphysis was divided ; and though the mouth healed well the bone was not united until the end of the fifth month after the
operation.
The amount of
not affect the of convalescence. The supra-hyoid incision should, I think, be avoided if possible. It is not at all requisite for drainage; the mouth can drain itself well
length of the period
tongue removed does