Facts and observations in medicine and surgery : with additional memoirs

Front matter

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IN

Preface

A Fact is the centre of a circle more or less extended, and to and from which opinions and theories radiate. Thus, some hooks are written to a Fact ; others, again, from a Fact ; and though both may be wrong, the Fact happily remains the same, the indestructible germ and nucleus of the most enlarged and momentous truths.

To communicate Facts, therefore, even in their simplest form, is to contribute a donation to science of the greatest value. Facts bear in themselves the properties of truth, the materiel of thought, and are not the less worthy for being unaccompanied by the ostentation of new hypotheses and theories.

In publishing this book of “ scattered leaves/’ which

VI

PREFACE.

are the u collectanea” of the last years of active practice, printed at intervals in the Medical Gazette, I offer no apology, seeking no merit further than that which is due to the labour of close observation and experiment. The following facts are therefore given to the profession, in the hope that they may become the materiel of useful practical induction.

Part I. — Surgery. Page

Mechanical Apparatus for the Treatment of Fractures . . 1

The Effect of Fractures on their surrounding parts, more particularly in reference to Fractures of the Lower

Extremity 38

Observations on the Treatment of Fractures 66

Fracture of the Femur, with Separation of the Epiphyses . 73

Dislocation of the Hip Joint 82

Dislocation of the Elbow Joint 84

Gun-shot Wound. Loss of Seven Inches of Rib. ... 86

Bony Tumour in the Meatus Auditorius 89

Granulating Surface measuring Six Hundred Square

Inches. — Recovery 90

Large Calculus in the Bladder of a Female Child, three and

a half years old 103

CONTENTS..

Vlll

Part II. — Medicine. Page

Importance of a sound knowledge of Therapeutics . . .107

On the importance of attending to the Premonitory

Management of Lunatics 142

On Epilepsy 144

Cerebral Affections from Deficiency in the Cranium . .152

Effects of Deficient Ossification of the Cranium . . . .156

Congenital Hydrocephalus ........... 168

Injurious Effects of the indiscriminate employment of

Ergot of Rye 192

Influence of the Vaccine Inoculation over Small-pox . .196

On Premature Vaccination ........... 197

Vaccination in the early months of Infancy . . . . .198

Fibrinous Diarrhoea; or, Diarrhoea Tubularis of Dr. Good . 203 Malformation of the Genitals . . . . . . . . . .214

CONTENTS.

IX

ADDITIONAL MEMOIRS.

PAGE

On the Therapeutic effects of Nitrogen in Typhus Fever 215 Remarks on Impetigo Capitis, or Crusta Lactea . . .232

On the Phosphatic Deposits in the Urine of Children . 236 Retrospective Remarks on the Therapeutical Effects of

Galvanism 2i0

On the Therapeutic effects of the external application

of the Aconitum Napellus 245

Operation for the removal of Contractions from Burns 248 On the Diagnosis and Treatment of Rupture of the

Tendon of the Triceps Extensor Cruris Muscle . 253 Oblique Laceration of the middle portion of the Flexor

Carpi Radialis and Palmaris Longus Muscles . .257

Partial Rupture of the middle portion of the Extensor Carpi Radialis Longior Muscles : with some observations on the term Sprain 260

On Abscess of the Cellular Tissue 266

On the effects of Concussion of the Spine . . . . 271

A case of Two Calculi in the Bladder ; one removed by

Lithotrity, while the other remained imbedded . 277

PART I.

SURGERY.

MECHANICAL APPARATUS FOR THE TREAT- MENT OF FRACTURES.

SPLINTS FOR THE UPPER AND FORE-ARM.*

Where the science of mechanics can be brought in aid of that of surgery, it must be very desirable to the humane practitioner, as in many cases, when applied with skill and ability, it will tend to alleviate the sufferings of the patient, and its application will redound to the credit of the surgeon.

For some years past, I have devoted much time and attention to the subject of fractures and dislocations of various bones, and the result has been the sugges-

* This paper was published in the “ Medical Gazette,” June, 1833.

B tion of certain splints and other machinery, which, as far as I know, are new, and which, in my extensive practice in this manufacturing district, have answered the end required to my perfect satisfaction. They have been exhibited in some of the lecture-rooms of the metropolis, and highly approved of by several hospital surgeons of the first character.

In the mechanical part of the treatment for fractures of the humerus, I have adopted the following plan, which combines two principles derived from Dr. Neil ArnotFs invention for compressing tumours, viz., a resistible and an irresistible support. This plan affords comfort with security, and is applicable to the treatment of all fractures of the extremities. The means which I term resistible consist of an Indianrubber cloth bag, made so as to fit the internal part of the splint, half filled with air. The pad should protect the limb from the edges of the splint, to prevent excoriation of the skin, and if this is not attainable, the next best plan is to line the splint with wool or fine charpie. The French surgeons use bags filled with oaten chaff, which form an easy support; but none of the latter plans equal the first for comfort to the patient. The wooden or sheet iron splints, whichever the manufacturer may adopt, form the irresistible support.

TREATMENT OE FRACTURES,

Fig. 1.

Fig. 1 represents the splints adapted for fractures of the humerus. No. 1 is a concave splint, capable of lengthening and shortening, by means of a long screw (2, 3), and fitted to the outer side of the upper arm. No. 4 indicates one of two metal pins, which secure the proper direction of movement of the upper and lower pieces of the splint when separated. Nos. 5, 6, and 7, are parts of a padded belt, intended to be carried round the chest of the patient, and beneath the axilla of the sound arm. This belt renders the upper part of the splint immovable, and at the same time fixes the scapula. The lower end of the splint

b 2 is concave, in order to protect the external condyle of the humerus from pressure. The figures 8, 9, 10, 11, represent the splints for the inner side of the upper arm ; they are intended to he used with the screw-splint, or, in delicate and weakly subjects, in whom the muscular power is below the standard, they may be applied without the screw-splint.

Fig. 2.

Fig. 2 represents the apparatus, shewn in the preceding figure, as applied to a fractured arm; the splints are adjusted to the length of the arm and

TREATMENT OF FRACTURES.

secured by straps. The position of the belt for the chest is also shewn.

Fig. 3.

Fig. 3 represents the form of two splints for the treatment of fractures of the ulna and radius. The radial, or inner splint (1), is so formed as to adapt itself to the palm of the hand; it keeps the flexor tendons of the fore- arm extended, leaving the fingers and thumb at liberty, and has the effect of completely preventing pronation of the hand. The ulnar (2), or outer splint, extends no further than the carpal bones. Both splints are secured with broad straps : they are more perfectly kept in their place by continuing the upper strap round the humerus, just above the condyles. When rightly applied, whether the arm be suspended in a sling, or hanging by the patient’s side, or in any other position, pronation of the hand is most effectually prevented. No. 1, the radial, or inner splint. No. 2, the ulnar, or outer splint. The third figure is intended to give a side view of the radial splint. Nos. 3, 3, indicate the curved extremity corresponding with the palm of the hand.

Fig. 4.

Fig. 4 represents the application of the splints for fracture of the ulna and radius. The artist in this woodcut has shewn the splints as not extending sufficiently towards the elbow joint. It is requisite that the ulnar splint should reach as far as the olecranon, and the radial to the bend of the elbow.

APPARATUS FOR FRACTURED CLAVICLE.

In presenting the following plan for the treatment of fractured clavicle, it may be right to premise its advantages. They are, firstly, that the parts are kept in apposition without excoriation. Secondly, that the arm is not suspended from the neck. Thirdly, that any application can be made to the region of the fracture without taking off the support. Fourthly, that the patient can undergo exercise, either in riding or walking, without pain.

Fig.

Fig. 5 is a view of the clavicular bandage, as laid flat on the table. No. 1 is the body of the bandage, padded on the inside, and fitted to the hollow of the back ; 2, 2, are padded belts, buckling on the front of the chest; 3, 3, are shoulder-straps, for fixing the shoulders and holding them back ; 4, 4, are rings for sustaining a sling for the fore-arm of the injured side ; 5 represents the manner of fixing the sling in fractures occurring on the left side.

Fig. 6.

Fig. 6 represents the clavicular bandage applied and viewed from the front; the fore-arm is supported in the sling. Fig. 7 represents the same bandage, as seen from behind.

TREATMENT OF FRACTURES.

Fig. 7.

SPLINTS FOR THE LOWER EXTREMITIES.

The first of these figures (Fig. 8) is intended to represent an apparatus for fractures of the os femoris, one of which I presented to Mr. Lawrence, in 1829, who gave the following description of it in his Lectures, as reported in the Lancet of 1829-30, page 317. He says, “ What I now shew you is a contrivance of this kind [speaking of double-inclined planes], to which a strap or band, calculated to fix the pelvis, is

Fig. 8.

attached. You observe that a double inclined plane is here obtained for the lower extremity, this part being adapted to the thigh, and this part to the leg. You will understand, of course, that when an addition of this kind to the bed is used, pads are placed over the wood, in order that the limb may lie easily. You will see that this apparatus is so contrived, that if care be taken, it presents a greater or lesser angle at the edge which corresponds to the ham ; and that part which corresponds to the thigh is so constructed, that its length can be increased or diminished at pleasure, so as to accommodate the board to different individuals. In the first place, the length of the part on which the thigh is to rest, must correspond exactly with the length of the sound limb, the apparatus for which underneath enables you to lengthen or shorten the

TREATMENT OF FRACTURES.

various parts, and is very simple. Then the foot-board (5) can be placed at appropriate distances by means of the holes which you see in the lower parts, so as to make that part correspond with the exact length of the leg. The lateral pegs may be of use to retain the leg in any one part. Then the other end, facing the posterior part of the thigh, fixes against the tuberosity of the ischium, and this band ( 7 ) goes round the pelvis, to keep that part of the body steady. There is another band (8) used for the purpose of fixing the other portion of the thigh; so that, as far as it can be accomplished by this instrument, you render the thigh, the leg, and the pelvis, fixed. But in this sketch there is a groove (9), constructed for the admission of the tendo Achillis, so as completely to prevent lateral motion of the heel. This groove I have added within the last three years.

No. 1. The tibial plane of the apparatus. 2. The crural plane, which may be lengthened or shortened at pleasure, by means of the adjusting mechanism, 4. 3. The hinge of the two planes, admitting of any increase of angle that may be required. 5. The moveable foot-board. 6, 6. Pegs, which may be removed or added at pleasure; they are intended to prevent the

* See also Medical Gazette, vol. vi. p. 429.

limb from slipping off the planes, and also serve to support pads. 7 . A padded belt, to secure the pelvis.

8. Another belt, for the upper part of the thigh.

9. A moveable grooved piece, for supporting the tendo Achillis. 10. Brass racks, for regulating the elevation of the planes.

Fig. 9.

Fig. 9 represents the splints which I find the best adapted for fractures of the thigh bone. No. 1 is the anterior splint, the broader being the upper end. No. 2 is the inner splint, the number being placed near its upper extremity ; the lower end is expanded

TREATMENT OF FRACTURES.

and concave, to receive the bulging part of the vastus internus and inner condyle of the femur. No. 3 is the outer splint, the rounded and expanded extremity being the lower end; this should extend from the trochanter major, to the outer condyle of the femur. The two latter splints have knobs for securing the straps by which they are fastened to the limb.

Fig. 10 represents the appearance of the apparatus and splints when applied. The belt should have been placed around the pelvis, instead of in its present position, and pillows beneath the limb have been omitted, in order to shew its precise position upon the apparatus.

ijy

APPARATUS FOR FRACTURES BELOW THE KNEE.

I shall now proceed to shew the method which I have used in fractures of the tibia and fibula. The following sketch of an apparatus represents a plan for suspending fractures below the knee : — -

Figs. 11 and 12 represent an apparatus for suspending fractures of the tibia and fibula. In fig. 11,

TREATMENT OF FRACTURES.

No. 1 is the horizontal plane, for the support of the fractured limb ; 2, is an inclined plane for the thigh ; 3, is a foot-board, moveable at will by means of the screw and nut (4); 5, 5, are the ropes for swinging the apparatus; they are lodged in deep, pulley-like grooves, in two projecting pieces, below the apparatus; 6, a padded belt for securing the injured limb; 7, another padded belt for securing the thigh; 9, a padded belt for securing the hips and keeping the upper part of the apparatus in place; this latter intention is additionally provided for by means of the straps (8).

Fig. 12 shews the position of the limb on the apparatus when suspended. The pillows on which the limb rests when put up have been purposely omitted, in order to shew the adaptation of the apparatus to the form of the limb. The belt for the trunk should have been placed lower down — namely, around the pelvis, and if properly employed the patient is enabled to move in any direction. After reducing the fracture, the usual splints for the leg are applied; the limb is then placed on a pillow, or pad, over the plane of the apparatus, and secured thereon by means of a broad strap (6), and the proximal end of the apparatus is secured to the thigh and the pelvis by two straps, one round the thigh (7) and the other (9)

round the pelvis. The apparatus is suspended by two ropes to anything which may be contrived at the top of the bed, or over a couch. An air pillow placed under the nates tends much to the patient’s comfort. The principle is due to M. Sauter, of Constance. It was afterwards published by M. Mayor, of Lausanne, who applied the suspension board to fractures of the thigh as well as those of the leg. His plan (which may be seen by referring to his work, published about seven years ago) I think not sufficiently applicable; neither is the motion of the swing so extensive as in the method I am now describing. I have at this time (August 9th, 1833,) a patient, an adult, with a compound fracture of the tibia (which happened July 28th) on the apparatus, who has experienced only a very slight catch of the limb on going to sleep ; and so trifling is the inconvenience, that he has slept seven hours at a time ; and, as a matter of course, the system suffers so much less from local and general irritation, a point of no small importance in the treatment of fractures. In conclusion, allow me to remark that all I claim in making public these adaptations of mechanism to surgical practice, is the humble merit of endeavouring to alleviate pain by giving a faithful description of those means which I have found effective in producing quietude in fractures of the extremities.

TREATMENT OF FRACTURES.

In corroboration of the utility of suspending fractures of the tibia, I beg to state that the wound of the patient mentioned above was healed on the twentieth day. Ossific union is now nearly completed, this being the twenty-ninth day from the time of the accident.

In the 44 Journal des Connaissances Medico-chirurgicales,” there is a paper on the suspension of fractures, from the pen of M. Mayor, which I regard as so important in its tendency, and which sets forth the advantages of suspension so ably, that I shall make no apology for quoting it in this place.

44 4 L’Histoire Chirurgicale du Siege d’ Anvers/ which Dr. H. Larrey has just published, records, methinks accurately, the present state of army surgery in France; and the general law laid down by him in his interesting work is the following (p. 280) : — 4 Amputate the thigh in every case of comminuted fracture complicated with gun-shot wound;’ and the author, a few pages further on, (p. 311,) adds: — 4 The head surgeon of the army earnestly insisted on the full application of the law, reduced in these cases to a single word, amputation.’

44 And, indeed, the question having been affirmatively answered by the most eminent and deeply-read surgeons of our day, the solution carries with it all the authority of a demonstrated proposition.

c

“ I, however, must appeal from the decision, and rest my opposition on the fundamental consideration, that the answer, although unanimous, is noways founded on the nature of the lesion itself, (and I can prove it,) but on the imperfection of the means we possess of maintaining the osseous fragments, and on the defective apparatus which in these serious cases is still had recourse to.

u In this, as in many other cases, the dressing is a consideration so fundamentally important, that if it were in our power advantageously to modify it and render it less offensive, the chances of success would be directly proportional to the extent of these modifications. For here we are circumstanced as in all surgical affections in which our greatest hopes of success are founded on the excellence of our instruments, and on the perfection of our deligatory apparatus; and if we be asked whether, in a given case, amputation is requisite, we should reply by another question, and in our turn inquire what means of treatment you possess? For, peradventure, if those means were detestable, you might reckon a mutilation for every fracture. There is, besides, a medical axiom familiar to all, — that the gravity or incurability of a lesion is never absolute, but only proportional, and in an inverse ratio of the therapeutic means opposed

TREATMENT OF FRACTURES.

to it ; in such sort that an affection which to one practitioner may appear far beyond the reach of art, may yield with the greatest ease to the skill and experience of another. Consequently, unless it be argued and proved that the mode now adopted for dressing complicated fractures of the femur is the ultimate term of perfection, we may be allowed to hope, that, better understood, or combined in a more simple and rational manner, dressing may some day become a means of preservation in many cases in which ablation is not deemed indispensable.

“ Let us, to throw more light on the question, divide it, and successively examine its two principal elements ; the state of the soft parts, the state of the bone; and let us see what experience teaches us on each of these two sections separately considered, and examined independently one of the other.

“We shall find, and daily observation tells us, that contused and lacerated wounds of the muscular system are generally curable ; and that a surgeon would be unpardonable were he in such cases to operate, especially where the lesions are not extreme. Again, we shall find that nature, well directed, easily triumphs over fractures, even though accompanied by some disorder in the surrounding tissues; and that a practitioner would fall into a serious error were he to reject

c 2 the natures vis medicatrix , and mercilessly mutilate all the poor wretches committed to his charge, who offered nothing hut comminuted fractures with unimportant complications.

u What is it then that, in both these cases, gives so much confidence to the physician, and makes him reject all idea of amputation? Is it not evidently the power which in both cases he possesses, of doing all that he thinks indicated, and of avoiding all that he may judge decidedly hurtful? Thus, in wounds which do not implicate the hone , and which have been produced by projectiles deeply contusing and ploughing up powerful muscles, those of the thigh for instance, the lacerated parts may be laid wide open, covered with leeches, cataplasms, or other appropriate topics ; and never need they be exposed to the irritating pressure of hard or heavy compresses ; the dressings may be repeated frequently, and occasion neither trouble nor pain ; the motions of the body and limb may take place without awakening the lively sensibility of the lacerated parts or disturbing the healing process, the patient is not necessarily condemned to keep his bed, etc., and all this because the hone is entire , that it maintains the tissues in their normal position , and that osseous fragments are not constantly irritating the soft parts , as is the case wherever the hone itself has been shattered.

TREATMENT OF FRACTURES.

“ Again, when the femur is fractured, and the soft parts but slightly wounded, the surgeon may overlook the latter lesions to fix all his attention on the injured bone ; he may neglect the soft and irritable tissue that surrounds it, so that he but succeed in fixing and reuniting the fragments of the important object, the broken bone. He will not hesitate in applying around the limb loads of linen and compresses, of bandages and cushions; he will not hesitate to bind the whole up, and leave the limb for months encumbered in this clumsy apparatus ; and that, because the state of the bone is then the important consideration, that its consolidation is his only aim, and that that aim cannot be attained (at least it is so said) but by the accumulation of all the retentive means which go by the name of ordinary apparatus. But is it not manifest that this very apparatus, with which the patient may recover in cases of simple fracture, must be evidently mortal in fractures with complication ? Is it not to the apparatus that must be attributed the fatal results occurring in patients affected with fracture, accompanied by serious lesions of the surrounding tissues ? The fact is so clear, that were you to apply it in cases of lacerated wounds without fracture , you would most certainly determine serious if not fatal accidents.

“ Let us suppose a simple fracture of the leg, with some lesions of the muscles, nerves, arteries, &c., ol the corresponding thigh, or a simple fracture of a thighbone, coinciding with similar lesions of the corresponding leg; evidently in neither of these cases would you amputate, and most certainly you would not be overanxious on the probable issue of the lacerated thigh, although the corresponding leg were broken ; but you might experience some difficulty in properly dressing a fracture of the femur and wounds of the leg on the same limb. Even more : I may affirm that, whilst, in the first place, the lesions of the thigh would cure of themselves, those of the leg, in the second, would give you serious alarm, and that, if you had recourse to your ordinary fracture apparatus, you would run the risk of determining accidents which might, sooner or later, necessitate the ablation of the limb.

u Practitioners will appreciate the value of these reflections, and perhaps they will call their attention to the necessity of simplifying, even in simple fractures, our different means of retention. The best apparatus would be undoubtedly that which would leave the limb entirely free, as though the bone were sound, and the lesion were limited to the soft parts. Now, that apparatus really does exist; it is within everybody’s reach, as we shall presently see, and it can be so accurately adapted to the nature of

TREATMENT OF FRACTURES.

the lesion, that its effects can never complicate, but must always tend to ameliorate its condition.

“ From all we have just said, it results that the problem may be thus couched : —

“ To find an apparatus which may permit the surgeon to neglect the pathological state of the bone , and enable him to concentrate all his attention on the lesions of its surrounding tissues. These are, in reality the vital parts, and where their laceration is not so extreme that all idea of preservation is ridiculous, I should lay down the following rule —

4 never amputate , whatever may be the state of the shattered bonej but have recourse to an apparatus which will give the surgeon elbow-room, and place the patient in the same condition as though the bone were entire, and that the only indications were to manage soft tissues more or less grievously lacerated. If, however, you cannot make use of this precious resource, or if you think you possess sufficient motives to bear you out in the use of the ordinary apparatus, then, indeed, you will do right to assert and loudly to proclaim the principle — amputate in all serious complications of fractures in general , and in those of the femur in particular.

u The question is consequently reduced to a simple question of apparatus, and its solution may be given in the following terms: amputation is always indicated when , in the treatment complicated fractures , recourse must he had to an apparatus incompatible with the exigencies of those fractures — amputation is never indicated when a suitable apparatus may he procured*

u But an apparatus, to be really suitable, must fulfil the following conditions : it must allow the surgeon to make free use of the bistoury, at a moment’s notice, at all times; it must permit him to observe and treat the inflammation, abscesses, haemorrhage, gangrene, &c., that may supervene ; to apply ice, cold water, leeches, topics of every description, as often and as long as he thinks proper; to set aside all that might wound or irritate the tissues; to render his dressings painless and easy; to move the body and the wounded limb without irritating the fracture or aggravating the state of the lacerated parts; to remove the patient from his bed whenever necessity may require, that he may enjoy the benefit of fresh air and fresh linen ; lastly — and this is of the greatest importance, the logical consequence of what has just been said — all this must take place as though the bone remained entire, and maintained all the tissues

TREATMENT OF FRACTURES.

in their normal position; in such sort that the two extremities of the broken bone be immoveable, and be not incessantly borne on the soft parts, as always happens when the bone, maintained by the common apparatus, undergoes some change of position.

u The surgical instrument which possesses all these advantages is the more precious that its application is most simple and easy; it is the suspended board of Sauter, which I have somewhat modified, and elsewhere described. Here I can only add one most important practical consideration, that apparatus, duly and properly applied, insures the patient against all amputation, and often, where an operation is indispensable, assures the success of that operation. Thus, the surgeon is seldom called before accidents of a serious character have supervened, and when it would be highly imprudent to add to the circulatory, the nervous, the functional derangement, all the consequences that an important operation must necessarily give rise to; or else he is called in when some considerable disorder has suddenly started up, and the conservation of the limb appears no longer possible; yet it is evident that its ablation cannot take place until conditions more favourable to the success of the amputation be previously obtained. In either of these cases, Sauter’s suspended board is the simplest and the safest means which can be had recourse to, and permits the operator to temporize for a while, and make use of all the general modifiers of the economy, without which, in such cases, the best performed operations are constantly unsuccessful.

“ I feel that I ought now to verify my deductions by facts, and I should be happy to choose, amongst those most serious cases, fractures from gun-shot wounds : the verification would be decisive, and would, besides, solve the question, both for the upper and lower extremities. But I must confess, that in these particular cases I have but little to offer to those who, not aware of all the practical bearing of the new apparatus, would wish to judge it by repeated trials. Nevertheless, if analogy be admitted, and that too much distinction be not made between gun-shot fractures and those produced by other contusing bodies, I may instance a certain number of fractures, complicated by all the lesions resulting from falling blocks of stone, carriage wheels, horse kicks, &c. ; I may even cite a comminuted fracture, determined by a musket-shot which passed through the inferior extremity of the leg, and shattered both bones. I may add, that I have treated femurs shattered to pieces, and whose osseous fragments had worked their way outwards, and lacerated all the surrounding tissues.