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EXTRACTS FROM A Clinical Lecture ON TWO CASES IN WHICH THE PLASTER JACKET WAS USED.
905 these three strips did not occupy twominutes. This rapid process with plaster only and early setting saves much trouble as well as time. One strip is put on round the centre of the trunk, the ends overlapping in front ; another ON strip is put on higher up, it reaches the axillse, and is so put on that a cone is formed with the base upwards ; the third TWO CASES IN WHICH THE PLASTER strip is put on below, it reaches the trochanters, and is so a cone is formed with its base directed downJACKET WAS USED. wards. These cones are not formed artificially ; they BY FURNEAUX JORDAN, F.R.C.S., naturally follow the neat adjustment, with moderate traction of the three strips to the trunk. The upper and lower strips SURGEON TO THE QUEEN’S HOSPITAL, PROFESSOR OF SURGERY AT well overlap the middle, which latter may be a little wider QUEEN’S COLLEGE, BIRMINGHAM ; CONSULTING SURGEON TO THE WOMEN’S AND THE WEST BROMWICH HOSPITALS. than the others. The central strip may be put on first or last. The three may be made to fit the trunk like a glove, 1. On the use of Pulley-extension in the application of a, and they secure double conicity more certainly than do the strips-continuous, or many-tailed. The Jacket, or of a Jacket and Jury-mast. 2. A rapid andnumerousofnarrow the multiple strips being adopted, the number convenient method of putting on a Plaster Jacket. 3. A principle used in each jacket may be varied-say four, six, or eight. simple and efficient plaster Jury-mast. Where the number is greater the width may be narrower. I SHOW you to-day two cases which illustrate a few modifications tending, I believe, to simplicity, ease, and efficiency in the Sayre-Walker jacket. In one case you see a jacket only on a man with caries of the lower dorsal vertebrae, witb which is associated a large psoas abscess. The other case is that of a girl with caries and a sharp curve in the uppermost dorsal vertebrae. She has on a plaster jacket, and united with it a plaster jury-mast, and both were put on while pulley-extension by means of a chin and occiput sling was being kept up. In this case the pulley was kept on for a week before the jacket and jury-mast were applied. The jury-mast maintains extension and immobility in the head and neck as completely as the jacket keeps up extension and immobility in the trunk. The two are also so con. tinuous and strong that the body cannot be moved independently of the head, nor the heabe moved independently of the body. There are three principles in the treatment of spinal diseases which I wish to bring before your notice. They may be considered and applied separately, although in practice they may be frequently used together. Understand that these three strips may be put on under the tripod as easily as on the bed should the tripod seem to 1. The ’use of a Pulley before and during the application ojj give a better position, and the rapidity, without hurry, of a Jacket, or a Jacket and Jury-mast. the process is no little benefit when suspension is adopted. For nearly two years we have adopted pulley-extension If put on in the horizontal posture, the strips are so arranged of the spine in the horizontal posture. To a chin and occi. that the patient is laid down on them ; if pulley-extension put sling a weight is attached which passes over the head of be used, the multiple strips may be first placed on a sheet of the bed, or couch, or table. A bag of shot (or pebbles) macintosh or paper, and then drawn under the trunk. allows easy adjustment of the weight as regards comfort I am not yet quite clear which answers best-six or eight and increased length of the trunk. In slight and early cases layers of checked muslin or two or three of thin honeycomb pulley-extension during the application and setting of the towelling. The towelling is more manageable, the muslin plaster apparatus is sufficient. In severer cases a few days contains more plaster. If a loop of twine be drawn through or weeks of preliminary extension may be beneficial. In the four corners of each strip the whole strip is readily drawn some cases the weight may be attached to the feet as well and smooth when taken out of water. I may here straight as to the head, or the head of the couch or bed may be suggest the utilitv of these multiple strips as splints in many raised. cases of fracture, diseases of the joints, talipes, &c. The I am indebted to my late house-surgeon, Mr. Brett, foi several strips are cut to the desired pattern, filled with plasthe interest he took in combining pulley-extension with the ter, put one on another, rolled up short-ways or any conapplication of jackets. In the case of a girl with dorsal venient way in one roll, dipped in water a few moments, caries, whose jacket was put on with a sliding weight unrolled and put along and around the adjusted limb. attached to the head and another to the feet, we found that 3. A Simple and Efficient Plaster Jury-must. she was taller than she was in a jacket put on under the In the case of this girl you see what I venture to call a tripod. solution of the jury-mast difficulty. The jury-mast itself is 2. A Rapid and Convenient IJfetlwd of putting on a Plaster so complete, and is also so immovably connected with the Jacket. jacket, that the little patient’s trunk and head and neck are The use of a continuous splint around the body, as intro- as fixed as if they were carved out of a single block of wood. duced by Professor Sayre, will rank with the leading events We not only turn the head when we turn the body, but when in the history of surgery. I, for my part, feel also indebted we turn the head we turn the whole body also. If we lift to Dr. Walker of Peterborough for showing how the benefits the body we lift at the same time the head without a jar or of a jacket may be secured by putting it on in the horizon- vibration. The effect is somewhat weird. We could, if we tal posture, with little assistance, with complete safety, chose, lean her against the wall or roll her along the floor with no cumbrous machinery, and no mental alarm. Dr. without the slightest movement in any single vertebra. Walker uses a many-tailed bandage, consisting of numerous This jury-mast is perhaps stronger than is needful. It is a muslin strips ; he takes a little time, and delays the multiple strip made up of ten layers of prepared muslin ; it is fifty-two inches long and two inches and a half wide. The setting of the plaster by adding gum to it. The two jackets you see to-day were put on by a simple strips may vary from two to three or four inches in width to modification of the Sayre-Walker method. I put on three fifty or sixty in length, according to age, size of head, and broad strips only. The strips were compound or multiple, length of neck of the patient. each strip consisting of several superimposed layers of It is put on thus:-The patient is reclining on a mattress muslin and plaster. In one case honeycomb towelling and with no pillow, pulley-extension is being made with a chin plaster were used. When ready to be dipped in water there and occiput sling consisting of two strips of adhesive plaster were practically three rolls. The leisurely application of to which thin webbing is sewn above the ears. The hair
EXTRACTS
FROM
A
Clinical Lecture
arranged that
,
longer
906
has previously been cut short. The prepared multiple strip of sight, treatment is hopeless. I hope shortly to report the in a single roll, atter being dipped a few moments in water, case of a woman recently under my care in the London is completely unrolled, its ceutre is then applied to the fore- Hospital who had become practically quite blind with head well away from the eyes, the two ends are next carried neuritis, and who got good sight again after treatment by along the sides of the head to the back of the neck where iodide of potassium and mercurial inunction. Double optic neuritis without defect of sight,.recont’,’,’° they cross-one end being carried under the neck first, then the other (pulley-extension being still kept up), they are under treatrnent.-Mr. B-, aged eighteen, was sent to me drawn firmly enough to closely embrace the head and back in June, 1879, by Mr. Baxter, of Cambridge, for slight epiof the neck ; the ends are brought forward one on each side leptic seizures, the first of which occurred a year before. The of the neck, where they again cross each other in front of patient looked well, but had headache and vomiting. There the neck and sternum, and lastly the two ends are fastened was no albumen in the urine. He could see well, but 1 disby a plaster jacket. Before the multiple plaster strip is covered double optic neuritis. Mr. Couper saw him also, applied a flannel strip or long fold of lint is put on in the and reported as follows:-
way, and a little cotton-wool is put over the ears and in front of the neck. The flannel strip and subsequentlv the plaster strip are put over the adhesive plaster chin and occiput sling, the uncovered poitions of which latter may be cut away when the plaster is set. Again, understand that this jury-mast may be put on during suspension so long as an adhesive plaster sling ie used. In cervical caries the use of pulley-extension in the horizontal posture some time before the head is fixed is preferable. In severe cases of cervical disease it would probably be admitted that suspension is inapplicable. Whether the pulley-extension be preliminary and prolonged, or temporary, the weight must not be more than that which can be borne with comfort.
" June 12tb, 1879.-I find normal acuteness of vision for and distant objects in F. K. B-’s eyes. There is also normal accommodation and field. At the same time there is well-marked double optic neuritis. The swelling. although not extreme, is yet sufficiently pronounced to admit of accurate optical measurement. It amounts in the right eye to an hypermetropia of and in the left to i.e., the macula being emmetropic, the highest part of the respective discs has H and 1B’ Tht’re is further objective proof of the swelling in the high pariillax between disc and retina, as seen by direct examination. adjoining " There is a high degree of capillary engorgement in the nerve-substance of both discs, the visible small vessels being much increased in number. This condition, together with the cedema and some increase of the connective-tissue ele. ments of the discs, wholly conceals the choroidal boundary in all directions. The course of the optic nerve fibre bundles in crossing over to the retina is visible as a filmUar appearance at the margin of the swollen disc, and radial to its centre. The veins of the disc and adjoining retina are distended, prominent, and abnormally dark in colour. The sheaths both of arteries and veins are somewhat thickered, and are seen as greyish lines parallel to the vessels, or aE, thin fibres crossing the surface of the larger trunks. Excepting one minute doubtful patch on the right disc there
same
near
CASE ILLUSTRATING THE
VALUE OF THE OPHTHALMOSCOPE IN THE INVESTIGATION AND TREATMENT OF DISEASES OF THE BRAIN. BY J. HUGHLINGS JACKSON, M.D., F.R.S., PHYSICIAN TO THE LONDON HOSPITAL, AND TO THE NATIONAL HOSPITAL FOR THE EPILEPTIC AND PARALYSED.
are no haemorrhages on either. "The maculae are normal with the exception of a very that marked times, urged very increase of grey colour in the retina immediately slight ophthalmoscopical changes may exist when sight is good. around the right fovea; this indicates a trace of oedema at Under treatment this pathological condition may disappear, that spot. But at neither macula is there a vestige of the corona of plaster white patches so often visible in renal or leave but slight and doubtful traces, sight remaining good. I am tempted to illustrate these two dicta once more by disease. "The state of the discs accurately corresponds to that facts from a very striking case. The statements to be made often associated with brain mischief." do not rest merely on the authority of a physician. The The patient took iodide and bromide, the former in doses examinations were made, not by myself only, but by Mr. of four grains, raised in July to six, up to his second visit Couper, whose reports are given. The patient never had to me in March, 1880, with but one week’s omission. He two "fainting fits "-slight any defect of sight, and thus, unless his eyes had been was much better, but had had To seizures. indirect examination the ordinary epileptic examined by routine, a very striking pathological condition discs seemed normal. Let the reader carefully compare must have been missed. The patient had, besides, what Mr. Couper’s second report on March 24th, 1880, with that looked like slight fits of epilepsy, and also headache and on June 12th, 1879. The patient’s sight was good; he knew vomiting. I say nothing of the nature of the case beyond of nothing wrong with it, except during his fainting fits," when he said he did not quite lose consciousness. There was remarking that such a condition of the discs usually points no albumen in the urine. Mr. Couper reports as follows :— to gross local cerebral disease. I make no predictions as to " March 24th, 1880.-I re-examined yesterday, and found the patient’s further progress. Unless I had examined with the translucency of both discs perfect. Their colour, the ophthalmoscope I should have thought I had to do with although somewhat full, is within normal bounds. By an ordinary case of epilepsy ; what I discovered led to direct examination, the redness of the left disc is seen to be different, or rather to additional, treatment. I only wish to somewhat patchy, and there is a little more projection of show in this note that double optic neuritis may exist with nerve substance than normal. Both these conditions are good vision, and that it may pass off without impairing absent in the right disc. There are no thickened sheaths, sight. I have seen and recorded cases like this before. This except a trace in the case of one retinal vein on the left is not a case of recovery from amaurosis ; the patient had disc. The maculae and their regions are healthy and free a pathological condition without any attendant symptom ; from greyness and cedema. Either his accommodation was he had no amaurosis to recover from. In all cases I have, unduly active, or a slight myopia has developed in the right. seen the recovery from optic neuritis has been under the It requires - 72 spherical to get lB-. Even the left got administration of iodide of potassium ; in this case bromide,,i8more easily with - 72. The amount of myopia, even if Whether the neuritis would pass off were: real, is of no importance. It thus appears that a very was given too. no drugs given is a question I cannot answer, nor am ever satisfactory improvement has come in the discs and retinse.’’ likely to be able to answer, as I should never fail to give the iodide in any case of optic neuritis; I would not risk itss THE JOHN HUNTER MEDAL.-This medal, of the omission. My impression is that early recognition of neuritisI value of fifty guineas, was executed by Wyon, and has on would save many patients from blindness or defect of sight. It is not meant to be implied that treatment by the iodidei the obverse in bold relief a striking likeness of Hunter, always causes disappearance of the changes of optic neuritis, with the simple inscription " John Hunter"; on the reverse and leaves sight good. I have now under my observation aL is a shield, surrounded by a wreath of laurel, on which is young woman who was treated by iodide, and later byI inscribed the Collegial-triennial prize, awarded to Mr. George mercurial inunction, who has become blind, although herr Arthur Woods, amember of the College, 1880. Hr. Woods sight was good wheu the iodide was first employed. Nor do) obtained the Astley Cooper prize in 1877. No award of the I wish to imply that when with optic neuritis there is defectt triennial plize has been made since 1858.
I HAVE many
since 1863,
’
,
EXTRACTS
FROM
A
Clinical Lecture
arranged that
,
longer
906
has previously been cut short. The prepared multiple strip of sight, treatment is hopeless. I hope shortly to report the in a single roll, atter being dipped a few moments in water, case of a woman recently under my care in the London is completely unrolled, its ceutre is then applied to the fore- Hospital who had become practically quite blind with head well away from the eyes, the two ends are next carried neuritis, and who got good sight again after treatment by along the sides of the head to the back of the neck where iodide of potassium and mercurial inunction. Double optic neuritis without defect of sight,.recont’,’,’° they cross-one end being carried under the neck first, then the other (pulley-extension being still kept up), they are under treatrnent.-Mr. B-, aged eighteen, was sent to me drawn firmly enough to closely embrace the head and back in June, 1879, by Mr. Baxter, of Cambridge, for slight epiof the neck ; the ends are brought forward one on each side leptic seizures, the first of which occurred a year before. The of the neck, where they again cross each other in front of patient looked well, but had headache and vomiting. There the neck and sternum, and lastly the two ends are fastened was no albumen in the urine. He could see well, but 1 disby a plaster jacket. Before the multiple plaster strip is covered double optic neuritis. Mr. Couper saw him also, applied a flannel strip or long fold of lint is put on in the and reported as follows:-
way, and a little cotton-wool is put over the ears and in front of the neck. The flannel strip and subsequentlv the plaster strip are put over the adhesive plaster chin and occiput sling, the uncovered poitions of which latter may be cut away when the plaster is set. Again, understand that this jury-mast may be put on during suspension so long as an adhesive plaster sling ie used. In cervical caries the use of pulley-extension in the horizontal posture some time before the head is fixed is preferable. In severe cases of cervical disease it would probably be admitted that suspension is inapplicable. Whether the pulley-extension be preliminary and prolonged, or temporary, the weight must not be more than that which can be borne with comfort.
" June 12tb, 1879.-I find normal acuteness of vision for and distant objects in F. K. B-’s eyes. There is also normal accommodation and field. At the same time there is well-marked double optic neuritis. The swelling. although not extreme, is yet sufficiently pronounced to admit of accurate optical measurement. It amounts in the right eye to an hypermetropia of and in the left to i.e., the macula being emmetropic, the highest part of the respective discs has H and 1B’ Tht’re is further objective proof of the swelling in the high pariillax between disc and retina, as seen by direct examination. adjoining " There is a high degree of capillary engorgement in the nerve-substance of both discs, the visible small vessels being much increased in number. This condition, together with the cedema and some increase of the connective-tissue ele. ments of the discs, wholly conceals the choroidal boundary in all directions. The course of the optic nerve fibre bundles in crossing over to the retina is visible as a filmUar appearance at the margin of the swollen disc, and radial to its centre. The veins of the disc and adjoining retina are distended, prominent, and abnormally dark in colour. The sheaths both of arteries and veins are somewhat thickered, and are seen as greyish lines parallel to the vessels, or aE, thin fibres crossing the surface of the larger trunks. Excepting one minute doubtful patch on the right disc there
same
near
CASE ILLUSTRATING THE
VALUE OF THE OPHTHALMOSCOPE IN THE INVESTIGATION AND TREATMENT OF DISEASES OF THE BRAIN. BY J. HUGHLINGS JACKSON, M.D., F.R.S., PHYSICIAN TO THE LONDON HOSPITAL, AND TO THE NATIONAL HOSPITAL FOR THE EPILEPTIC AND PARALYSED.
are no haemorrhages on either. "The maculae are normal with the exception of a very that marked times, urged very increase of grey colour in the retina immediately slight ophthalmoscopical changes may exist when sight is good. around the right fovea; this indicates a trace of oedema at Under treatment this pathological condition may disappear, that spot. But at neither macula is there a vestige of the corona of plaster white patches so often visible in renal or leave but slight and doubtful traces, sight remaining good. I am tempted to illustrate these two dicta once more by disease. "The state of the discs accurately corresponds to that facts from a very striking case. The statements to be made often associated with brain mischief." do not rest merely on the authority of a physician. The The patient took iodide and bromide, the former in doses examinations were made, not by myself only, but by Mr. of four grains, raised in July to six, up to his second visit Couper, whose reports are given. The patient never had to me in March, 1880, with but one week’s omission. He two "fainting fits "-slight any defect of sight, and thus, unless his eyes had been was much better, but had had To seizures. indirect examination the ordinary epileptic examined by routine, a very striking pathological condition discs seemed normal. Let the reader carefully compare must have been missed. The patient had, besides, what Mr. Couper’s second report on March 24th, 1880, with that looked like slight fits of epilepsy, and also headache and on June 12th, 1879. The patient’s sight was good; he knew vomiting. I say nothing of the nature of the case beyond of nothing wrong with it, except during his fainting fits," when he said he did not quite lose consciousness. There was remarking that such a condition of the discs usually points no albumen in the urine. Mr. Couper reports as follows :— to gross local cerebral disease. I make no predictions as to " March 24th, 1880.-I re-examined yesterday, and found the patient’s further progress. Unless I had examined with the translucency of both discs perfect. Their colour, the ophthalmoscope I should have thought I had to do with although somewhat full, is within normal bounds. By an ordinary case of epilepsy ; what I discovered led to direct examination, the redness of the left disc is seen to be different, or rather to additional, treatment. I only wish to somewhat patchy, and there is a little more projection of show in this note that double optic neuritis may exist with nerve substance than normal. Both these conditions are good vision, and that it may pass off without impairing absent in the right disc. There are no thickened sheaths, sight. I have seen and recorded cases like this before. This except a trace in the case of one retinal vein on the left is not a case of recovery from amaurosis ; the patient had disc. The maculae and their regions are healthy and free a pathological condition without any attendant symptom ; from greyness and cedema. Either his accommodation was he had no amaurosis to recover from. In all cases I have, unduly active, or a slight myopia has developed in the right. seen the recovery from optic neuritis has been under the It requires - 72 spherical to get lB-. Even the left got administration of iodide of potassium ; in this case bromide,,i8more easily with - 72. The amount of myopia, even if Whether the neuritis would pass off were: real, is of no importance. It thus appears that a very was given too. no drugs given is a question I cannot answer, nor am ever satisfactory improvement has come in the discs and retinse.’’ likely to be able to answer, as I should never fail to give the iodide in any case of optic neuritis; I would not risk itss THE JOHN HUNTER MEDAL.-This medal, of the omission. My impression is that early recognition of neuritisI value of fifty guineas, was executed by Wyon, and has on would save many patients from blindness or defect of sight. It is not meant to be implied that treatment by the iodidei the obverse in bold relief a striking likeness of Hunter, always causes disappearance of the changes of optic neuritis, with the simple inscription " John Hunter"; on the reverse and leaves sight good. I have now under my observation aL is a shield, surrounded by a wreath of laurel, on which is young woman who was treated by iodide, and later byI inscribed the Collegial-triennial prize, awarded to Mr. George mercurial inunction, who has become blind, although herr Arthur Woods, amember of the College, 1880. Hr. Woods sight was good wheu the iodide was first employed. Nor do) obtained the Astley Cooper prize in 1877. No award of the I wish to imply that when with optic neuritis there is defectt triennial plize has been made since 1858.
I HAVE many
since 1863,
’
,