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LONDON MEDICAL SOCIETY. February 18, 1828.
811 nus, Dutrocliet, and still more recently, Brown, have examined with great care the structure of this organ. The direct experiments by which it has been attempted to prove the necessity of fecundation for the formation of the embryo, are, either by iso-
LONDON MEDICAL SOCIETY.
18, 1828.
February
I lating the sexes, or by irregular fecundations, which leave very little doubt on this
Dr. HASLAM, President,
in the Chair.
on the conillit. A31FSBUHY introduced to the notice preserve it, to show the kind ofinflu- of the Society, the following interesting parence of the pollen in fecundation. 1B1. Brown ticulars of a case of non-union of the femur, endeavours to prove the existence of gene- recently treated at St. Thomas’s Hospital. will be observed, from the subjoined ration, not by the result of experiments, which always leave some doubt, but by report, that three dinerent methods were positive facts which the eye may follow; that I pursued in this case ; first, is, by studying the structure of the diffe. the use of the ingenious apparatus of Mr. rent organs which assist in generation. aud by which pressure and rest were obtained secondly, the introduction by examining successively ail the mena which accompany and follow fecunda- of a seton; thirdly, the operation of cuttion. It is bv these means that M. Brown down upon the fracture, and destroylias endeavoured to establish the part which ingan artificial ioint which had formed. the spermatic bundles, contained in the The ivliole of these means, it will be regrains of the pollen, perform in the act ofmarked, were unsuccessful; so that,’ at fecundation, and the necessity of theirlength, amputation was resoitecl to. The assistance for the formation of the vege-case was as follows :Malcolm M’Lean, a strong healthv sailor, table embryo. It is by means of the f’xcel1ent microscope of D’Amici, that he has xtat. 36, was admitted into St. Thomas’s obtained results which confirm his theory, Hospital, March llth, 1827, under the care and that lie has seen the grams of the pol- of Mr. Green, having a very loose oblique len filled with granules, different in size, fracture of the upper part of the middle third opacity, and perhaps in form and motion. of the thigh, which had existed twenty-four The granules penetrate into the tissue of the weeks. The injury was occasioned by a fall stigma ; from thence, becomiug mixed with upon deck, from a height of about sixty feet, a copious fluid, secreted only at the time of and the back soon became much swollen and fecundation, are carried across the interstices very painful. There being no medical man to the point of the placenta, which corres- on board, ten days elapsed after the occurrence of the accident, before ativ surgical asponds to the ovula. From these facts, it is evident that the sistance could be procured. At the end of vegetable embryodoes not pre-exist before this time, the ship arrived at a port ia fecundation, and that the spermatic fluid is Monte Video, where lie was received into not limited to its vivification ; the theory of one of the Portuguese Hosnitals. Durinothe union of the germs is then as little the time he was in that fixed in the vegetable as the animal king- was employed to support the limb but short dom. It appears equally certain, says splints, extending from the pelvis to the M. Brogniart, that one of the spermatic gra- knee. These proved very inadequate, motion nules does not alone form the embryo, and and displacertent being produced almost as that, consequently, this embryo does not ex- readily as if tie case had been left to nature; ist quite formed in the fecundatingfluid. the pain swelling, however, gradually Generation does not consist then, uniformly, subsided, Ten weeks after the accident, in sending it to the male in order to be from the Hospital, to redeveloped. The assistance of the Darts turn to England, there was no pain, and formed 1 the male organ (the spermatic very little tumefaction in the limb. but thev were re-produced, in a slighter degree, by granule) and of the parts formed by the male organ (the vesicle of the embryo, and his exertion co get to the ship, which he acthe mucous granules), for the formation of complished, with the assistance of crutches, the embryo, does not appear, on the con- the limb being surrounded with short splints trary, to be well proved, and the theory of as before. On the 19th of March, twentv-five weeks epigenisis is thus found to agree better than any other, with the different facts, not only after the accident occurred, and a week after in the animal, but also in the vegetable the man’s admission into the Hospital, Mr. transferred the management of the kingdom. case to Mr. Ameshury. Upon attentively examining the limb, the fracture was discovered extending obliquely downward and outward, through the upper part of the mid.
subject. Some physiologists, trary,
It ineffectually IAmesbury, pheno-fully
I ting I
Hospital, nothing
fe-
and
when he removed ’
Green
812
dle third of the bone. The fractured ends; of consideration, what should next be done order to effect it. Mr. Green concurred very loosely connected, so that they could be freely moved in all directions. The with Mr. Amesbury in the opinion, that the upper portion was bent upon the pelvis, andI probable cause of failure, was the existence the lower portion was retracted, upwards ofF of an artificial capsule, containing a fluid retwo inches and a half along the inner side ofsembling synovia, and that it would be adto destroy its integrity by the introthe upper. By gentle extension, the limb could be brought to nearly its natural length,duction of a seton, which would, at the same force wastime, have the effect of excitingahigh acbut the moment the discontinued, the displacement again re- tion between the ends of the bone, and in turned. Thus, the extent of motion whichthe neighbouring soft parts. This operation the fractured ends had upon each other, in was determined upon as the most’simple of the longitudinal direction, was about two likely to be advantageous, when had inches and a half. The fractured part felt recourse to, in conjunction with means cal. somewhat tender, when firmly pressed with culated to support the fractured ends in apthe fingers, but scarcely any pain was pro- position and at rest. The man was placed upon one of the frac. duced by freely rubbing together the broken extremities. The lower portion could ’be ture-beds, and the thigh extended, to its carried out of a natural line, with the upper proper length, where it was confined in the end almost bent upon it, without producing bent position. He was brought to the edge any inconvenience calculated to give rise to of the bed, with the limb extended over the ;; middle and lower planes of the bedstead as complaint on the part of the patient. 1. Treatment by Pressure and Rest.—As before, and, while in this position, Alr. Mr. Amesbury had not had a case of non- Green passed a long curved seton needle, union of the thigh so loose, he remarked, armed with silk, through the thigh, directing that he was unable to say how far the plan it between the fractured extremities of the of treatment which he had found successful bone. The needle was introduced at the in other cases, would prove beneficial in and back part of the thigh, and brought this. He doubted whether an " artificial anteriorly without difficulty. The neecapsule," contuininga fluid resemblingsy- die being removed, the ends of the silk were novia, had not formed. It was, at length, hanging, and were covered with only a determined to apply the apparatus which piece of simple dressing. The man was now Mr. Amesbury has invented for simple frac- shifted back to the middle of the bed, withtures of the middle and lower thirds of the out suffering any retraction of the limb to thigh, for simple and compound fractures take place, and, when confined in that situa. of the leg, and simple and compound dis- tion, by fixing the foot and the pelvis, a locations of the ancle, in such a manner assplint was applied along the outer side of to retain the limb of its proper length, and tu the limb, and secured in such a manner as to press the fractured surfaces strongly tobether. keep the fractured surfaces gently together, The apparatus had the effect of producing without pressing upon the soft parts sur. the fracture. pain in the fracture in a few hours after it On the following day, the limb was rather was applied. The pain increased, and became very severe on the third day, accom- swollen round the setoil, and the pulse had panied with startings of the limb : the pain, increased in frequency: tree suppuration however, though severe, was not of a de. took place in the course of two or three scription to produce any marked effect upon days, and the constitutional disturbance bethe system. On the fourth day the uneasi- came rather severe. The openings soon ness had much subsided, and the straps were discharged a large quantity of pus daily ; now tightened, which had the effect of in- and this being continued for some time, had creasing the pain in the fracture, but it soon a manifest effect in reducing the system. became moderate. He wore the apparatus About a fortnight after the introduction for about ten weeks, suffering more or less of the seton, it was observed that the matter pain in the fracture duringthe whole pe- began to burrow beneath the fascia, preriod, with the exception of two or three senting itself at the upper and inner part of days; but, notwithstanding the existence the thigh. This affected his constitution of the symptoms which precede union still more ; so much, indeed, was the man’s (pain and tenderness in the fracture) were health disturbed, that it was not deemed much more severe than in anv former case safe to allow the seton to remain in any Mr. Amesbury had witnessed, the only ap- longer, and it was accordingly removed on parent benefit derived, was a closer confine- the nineteenth day. It had produced great ment of the fractured ends, by the adhesion thickening of the soft parts surrounding the of the soft parts around them. fracture, such, Mr. Amesbury observed, as 2. Introduction of the Seton.-The plan of has been often mistaken for callus ; and treatment, by pressure and rest, having when the fractured ends were pressed to. failed in producing ull.iQu, it-became gether strongly, he experienced severe pain
, in
were
visable
extending
those
outer out
left
rounding
matter,
813
in the part. The matter was daily evacu- tured end of the upper portion of the bone ated from the upper part of the thigh, was brought into view. Upon clearing away where it lay very deep ; and it was found the muscles, it was seen that the two broken that the contents of the abscess gradually extremities of the bone were connected by diminished in quantity, and ultimately dis- a thick dense capsule, resembling the capappeared through the openings made by the sule of the hip-joint, the inner surfaces of seton needle. perfectly smooth and shining. After the seton was withdrawn, the con- The integrity of this capsule was destroyed, stitution soon began to rally, under the in- by a portion of it from the upper in consequence of the diffifluence of tonic medicines and a generous diet, so that the man was sufficiently reo. culty whichwas experienced in getting at covered, in the course of a few days, to feel the fractured end of the lower portion, himself able to take the common food of the (which, as has been said, lay on the inner hospital. Great care was taken to keep the side of the upper,) it was left, covered with surfaces in close apposition and at the ligamentous matter. In removing about rest, duringthe suppurative process; but, half an inch of the fractured end of the upper as it was necessary, for some time, to move fragment, by means of Hey’s saw in order the splints daily, in order to evacuate the to gain room, it was found that the bone matter which had burrowed along the outer had become soft and spongy at this part, side of the limb, for about two inches be- apparently from interstitial absorption. neath the vastus externus, as well as that From the manner in which the ends of the which had collected on the inner side, so bone lay, it was evident that the lower porthat the parts could not be kept in that per- tion could not be cleared of the ligat-nentous fect state of quietude, which it was desirable deposit which covered it, without enlarging at this time to maintain ; the matter could. the wound in the soft parts, a proceeding not be evacuated, without producing motion which, in the opinion of Mr. Green and some other surgeons, appeared objectionof the fractured extremities of the bone. At the expiration of about five weeks! able. Two or three small vessels were secured, from the time the seton was introduced, the discharge from the wounds had ceased, and the cut surfaces were suffered to fall but there still remained considerable tender- together, where they were lightly confined ness in the fracture, and thickening of the by a couple of adhesive straps, and a poulsurrounding parts. Three additional splints tice was then applied over the wound. The were now applied, and the whole secured pelvis was confined by the strap attached to round the limb, as the patient laid upon the the upper plane of the fracture bejstead, fracture bed, care being taken to press the (upon which he was placed previous to the fractured surfaces strongly together, and to operation,) and the foot was secured to the maintain them in tight apposition and at foot-board, The thigh was left free from rest. These splints were thus continued splints and bandages, being preserved of its upon the limb for a month ; and, at the ex- proper length and at rest. piration of this period, being nine weeks The man did not suffer much from the from the time the seton was introduced, operation, except when the finger was passed they were removed, and the limb examined, into the artificial capsule between the oblique but no ossific union had taken place. The surfaces of the fractured ends, which was limb was rendered stiffer by the thickening done in order to ascertain its extent. The of the soft parts, and this was the only capsule possessed a high degree of sensidifference that the seton had produced. bility, so much, indeed, that when the finger 3. The operation of ctttting down upon the was passed into it, the man could not help ends of the Bone.—The man was removed to crying out. He said, that the pain produced a common bed, and sometime afterwards it by the incision through the integuments was determined, in consultation, to cut down and muscles, was nothing compared to that upon the fiactured ends, with a view to as- which he experienced when the inner surface certain, if possible, the cause which still of the capsule was pressed with the finger. prevented the processof bony union, and He was a considerable time under the opethen to act in that manner which, upon ex- ration, and felt chilly when it was over, but posing the ends of the bone, might appear soon recovered his natural heat. most advisable. The man was again placed He passed a good night, and was so free upon the fracture-bed, with the limbs in the from constitutional disturbance, that he was bent position, in order to secure to the ope- ordered full diet on the day after the opera-
which were removing fragment ; but,
fractured
command over the muscles of A semicircular incision was made by Mr. Green, commencing at about the middle of the rectus, and then carried round through the belly of the vestus externus.
rator
a
perfect
the
thigh.
The
flap
was
The limb became moderatelv swollen. of incision, and was established on the third day. The greater part of the cut surfaces adhered, however, so that there was only asmall opening at the tion.
suppuration
at the seat
dissected back, and the frac- upper and outer
part of
the wound for the
814
Some of the pus bur-( view to remove the artificial capsule, a piece rowed towards the upper and inner part of of the fractured end of the upper portion was removed, and it was observed that the the thigh, where an abscess formed, bone was soft and spongy, apparently from made its way to the surface, producing but not severe, excitement of the interstitial absorption. This, however, was not the case higher up ; where the bone was The matter was evacuated by two made within a few days of each other, and sawed off in amputating, it was found perthe man’s health soon became good. On the fectly healthy. Though the integrity of the tenth day a splint was padded and applied artificial joint had been destroyed, it was along the outer side of the limb, with a view now again complete. The greater part of it of producing absorption of the ligament, was nearly the thickness of the capsule of which covered the fractured surfaces, by the hip joint, but, at the upper part, it was forcing them together ; but this was done in thin, like the capsule of the shoulder. The such a manner as not to press upon the capsule was accidentally torn at this part, wound, which could easily be dressed with- with the finger, and the inner side was seen out moving the splint. There was much smooth, and had very much the appearance tenderness in the fracture for the first month of synovial membrane, being moist and shinafter the operation, especially where even ing. Thp ends of the bone were rounded, the slightest motion was given to the limb. and, where they came in contact, they were Seven weeks after the operation, the flattened and covered with a dense fibrous splint was removed, and the limb examined. structure, very similar in appearance to the No union of the bone had taken place. The intervertebral substance, when divided horipunctures made for the evacuation of the zontally, but especially that part of it which found half way between the centre and matter of the abscess had now healed ; but there was still remaining a considerable por! In a few remarks, with which Mr. Amestion of the wound over the fracture. Thinking it possible that the splint cloth, bury followed up the case, he especially which had been placed round the limb over dwelt upon the circumstance of the man the splint, had not been sufficiently power. being’ in good health, a fact in perfect aeful in its action to produce absorption of the cordance with what he had observed in lio’amentous matter, which covered the ends forty-five cases of non-union that had fallen of the bone, a splint was applied on the under his care. The want of uuion in all inner side of the limb, extending the knee these cases, he thonght was attributable to to within a very short distance of the frac- the inadequacy of the means emploved, in ture ; and the outer splint being appiied as order to keep the fractured extremities in before, the limb was surrounded by the web apposition and at rest, although the plans of a tourniquet, which passed over the adopted were various. In the case undrr splints immediately below the fracture. By consideration, an artificial joint had formed pursuing this plan, the ends of the bone in the short space of six months, which he were very strongly forced together, by turn- considered as corroborative of the opinion, ingthe screw of the tourniquet. These that, where the fracture is very loose, and means did not, however, produce any mate- the powers of the constitution strong, artirial excitement on the fracture. There was ficial capsules form much sooner than where pain occasionally, but it was only slight and the ends of the bone are so connected, as to allow of but slight motion. transient. The action of the tourniquet was kept up The case of M’Lean, with another of as powerfully as the man could bear it for seven months standing, Mr. Amesbury said, a fortnight, making nine weeks from the were the only instances in which he had time of the operation. It was then removed, failed to procure union, by means of perfect and, on examining the limb, it was found rest, with pressure, under the use of his that no good whatever had resulted from own apparatus ; but, although it had failed the operation, or the treatment by which it in effecting a bony union in these two cases,it was followed. produced symptoms more severe, but similar The limb was perfectly useless ; and, see- in kind to those which preceded the uniting ing that all endeavours to bringabout union process, in all the successful instances. of the bone had failed, the poor fellow was Eighteen cases of non-union have been suenow desirous of losing it, which was accord. cessfully treated by Mr. Amesbury, with most of which the fracture had existed ingly agreed to. The operation was performed on Friday, above six months : one was of nine months Feb. la, in a very masterly manner, bv Mr. standing, one ten, one eleven, and two, Green. The bone was taken off fourteen months. None of the cases were above the artificial joint, and about half an under treatment more than ten weeks, and iach below the trochanter minor. some not more than a month. Examination of the Bone.—At the time of In contending for the superiority of his the operation, which was performed with a plan of treatment, whilst he admitted that matter to escape.
and
some, system. punctures
is circumference.
immediately
815
instsnce of failure
might now and then exerted in a straight line, whereas the feAmesbury argued upon its ad- mur has a considerable curvature forwards. vantages, by contrasting it with the twenty- The double inclined plane, now ordinarily four caseshe had seen otherwise treated, employed, was said to be objectionable, in in only one of which was union effected. In consequence of its allowing the body to ‘
an
occur, Mr.
(
like that under consideration, a very gravitate downwards in the bed, and thus loose fracture of long standing, he considered the upper part of the femur is tilted forit would be better after having unsuccess- ward. fully tried the plan of pressure and rest, to The whole of these defects, Mr. Amescut down upon the fractured ends of the bury contended, are obviated under the use
cases
i
with the knife, any liga-of his apparatus, of which, we presume, it is with which they might be unnecessary to enter into a full description, covered, and then to wash the ends of the it having been for some time before the bone with some stimulating iiuid calculated and probably is well known to our to produce inflammation, or to destroy the readers. connecting medium by caustic, and then The debate which ensued was brief. Mr. have iecourse to the assistance of me- CALLAWAY, whilst he bore testimony to the chanical support. A similar treatment had ingenuity of the apparatus, and admitted its been proposed in the case of M’L.ean, in great utility in some cases, at the same lieu of sawing off the ends of the bone ; time considered Mr. Amesbury was somebut Mr. Green (to whom Mr. Amesbury what too sweeping in his denunciation of paid a high compliment for his liberality) all other methods of treatment. Non-union, was fearful that it would be productive of Mr. Callaway said, is a rare circumstance, amidst the many thousand cases treated andangerous constitutional disturbance. The discussion which followed was brief, nually in the hospitals, showing that the as a large portion of the time of the society treatment there employed, although differhad been occupied in the reading of the ing much from that of Mr. Amesbury, is case, and the observations. Dr. Clutter- adequate to the cure of the accident. Duck objected to the expression " artificial Mr. BRIANT spoke of numerous cases of capsule," considering the phrase ’ pre- fracture of the thigh, which had fallen under ternatural capsule" as more applicable. his observation, successfully treated under Dr. Calso objected to the use of caustic, Some questions use of short splints. with a view of producing inflammation were put to Mr. Amesbury, with respect to the bone, arguing, that, under such a con- the essential difference between his appadition, the bone was not disposed to unite. ratus and the common double.inclined plane, Mr. LLOYD said, that he did not regardand this terminated the business of the the ordinary methods of treating fractures! Society. ofthe thigh, with short splints, to be so objectionable as 1Blr. Amesbury had stated. He (Mr. Lloyd) had treated a large number of cases at St. Bartholomew’s Hospital, WESTMINSTER MEDICAL SOCIETY. according to this plan, and perfect union, Saturday, February 23, 1828. without deformity, had been the invariable result. Mr. MAYO, in the Chair.
bone, and
remove
mentous matter
! public,
I
I inthe
Dr. BARRY, (with reference to the preceding discussion on diabetes,) in a manly Mr. AMESBumY this evening entered into and candid explanation, proved, to the saa long dissertation on fractures of the thigh, tisfaction of the Society, that a slight error illustrating his opinions by reference to va- as to dates, of which lie had been unconrious drawings. After speaking of the dif- sciously guilty, and which had been since ferent kinds of fracture in reference to di- corrected by a letter from the patient, rerection, Mr. A. proceeded to the considera- conciled the apparent contradictions betion of the plans of treatment employed in tween himself and Dr. Ayre, and fully acthese accidents. The use of short splints quitted patient and all of every thing like
February 85,
1828.
intentional incorrectness in their respective statements of the case. Dr. Barry then submitted to the consiprevent motion in the lower part of the deration of the Society some peculiar pathobone. The position, usually called Pott’s, logical views, .and a particular mode of was charged with the same defect; and, in treatment of typhus fever, contained in a addition, it was amrmed that the foot usually lecture delivered and published by his friend, becomes everted under this treatment. The Dr. W. R. Clanny, of Sunderland, to whose practice of Boyer, with the long splint, was talents he paid a well-merited tribute of
to the
thigh, placing the foot on the heel, pillow under the ham, was condemned, on the ground of its total inadequacy to
with
a
opposed, on the principle of the force being praiae.
The first
were
derived from
re’
LONDON MEDICAL SOCIETY.
18, 1828.
February
I lating the sexes, or by irregular fecundations, which leave very little doubt on this
Dr. HASLAM, President,
in the Chair.
on the conillit. A31FSBUHY introduced to the notice preserve it, to show the kind ofinflu- of the Society, the following interesting parence of the pollen in fecundation. 1B1. Brown ticulars of a case of non-union of the femur, endeavours to prove the existence of gene- recently treated at St. Thomas’s Hospital. will be observed, from the subjoined ration, not by the result of experiments, which always leave some doubt, but by report, that three dinerent methods were positive facts which the eye may follow; that I pursued in this case ; first, is, by studying the structure of the diffe. the use of the ingenious apparatus of Mr. rent organs which assist in generation. aud by which pressure and rest were obtained secondly, the introduction by examining successively ail the mena which accompany and follow fecunda- of a seton; thirdly, the operation of cuttion. It is bv these means that M. Brown down upon the fracture, and destroylias endeavoured to establish the part which ingan artificial ioint which had formed. the spermatic bundles, contained in the The ivliole of these means, it will be regrains of the pollen, perform in the act ofmarked, were unsuccessful; so that,’ at fecundation, and the necessity of theirlength, amputation was resoitecl to. The assistance for the formation of the vege-case was as follows :Malcolm M’Lean, a strong healthv sailor, table embryo. It is by means of the f’xcel1ent microscope of D’Amici, that he has xtat. 36, was admitted into St. Thomas’s obtained results which confirm his theory, Hospital, March llth, 1827, under the care and that lie has seen the grams of the pol- of Mr. Green, having a very loose oblique len filled with granules, different in size, fracture of the upper part of the middle third opacity, and perhaps in form and motion. of the thigh, which had existed twenty-four The granules penetrate into the tissue of the weeks. The injury was occasioned by a fall stigma ; from thence, becomiug mixed with upon deck, from a height of about sixty feet, a copious fluid, secreted only at the time of and the back soon became much swollen and fecundation, are carried across the interstices very painful. There being no medical man to the point of the placenta, which corres- on board, ten days elapsed after the occurrence of the accident, before ativ surgical asponds to the ovula. From these facts, it is evident that the sistance could be procured. At the end of vegetable embryodoes not pre-exist before this time, the ship arrived at a port ia fecundation, and that the spermatic fluid is Monte Video, where lie was received into not limited to its vivification ; the theory of one of the Portuguese Hosnitals. Durinothe union of the germs is then as little the time he was in that fixed in the vegetable as the animal king- was employed to support the limb but short dom. It appears equally certain, says splints, extending from the pelvis to the M. Brogniart, that one of the spermatic gra- knee. These proved very inadequate, motion nules does not alone form the embryo, and and displacertent being produced almost as that, consequently, this embryo does not ex- readily as if tie case had been left to nature; ist quite formed in the fecundatingfluid. the pain swelling, however, gradually Generation does not consist then, uniformly, subsided, Ten weeks after the accident, in sending it to the male in order to be from the Hospital, to redeveloped. The assistance of the Darts turn to England, there was no pain, and formed 1 the male organ (the spermatic very little tumefaction in the limb. but thev were re-produced, in a slighter degree, by granule) and of the parts formed by the male organ (the vesicle of the embryo, and his exertion co get to the ship, which he acthe mucous granules), for the formation of complished, with the assistance of crutches, the embryo, does not appear, on the con- the limb being surrounded with short splints trary, to be well proved, and the theory of as before. On the 19th of March, twentv-five weeks epigenisis is thus found to agree better than any other, with the different facts, not only after the accident occurred, and a week after in the animal, but also in the vegetable the man’s admission into the Hospital, Mr. transferred the management of the kingdom. case to Mr. Ameshury. Upon attentively examining the limb, the fracture was discovered extending obliquely downward and outward, through the upper part of the mid.
subject. Some physiologists, trary,
It ineffectually IAmesbury, pheno-fully
I ting I
Hospital, nothing
fe-
and
when he removed ’
Green
812
dle third of the bone. The fractured ends; of consideration, what should next be done order to effect it. Mr. Green concurred very loosely connected, so that they could be freely moved in all directions. The with Mr. Amesbury in the opinion, that the upper portion was bent upon the pelvis, andI probable cause of failure, was the existence the lower portion was retracted, upwards ofF of an artificial capsule, containing a fluid retwo inches and a half along the inner side ofsembling synovia, and that it would be adto destroy its integrity by the introthe upper. By gentle extension, the limb could be brought to nearly its natural length,duction of a seton, which would, at the same force wastime, have the effect of excitingahigh acbut the moment the discontinued, the displacement again re- tion between the ends of the bone, and in turned. Thus, the extent of motion whichthe neighbouring soft parts. This operation the fractured ends had upon each other, in was determined upon as the most’simple of the longitudinal direction, was about two likely to be advantageous, when had inches and a half. The fractured part felt recourse to, in conjunction with means cal. somewhat tender, when firmly pressed with culated to support the fractured ends in apthe fingers, but scarcely any pain was pro- position and at rest. The man was placed upon one of the frac. duced by freely rubbing together the broken extremities. The lower portion could ’be ture-beds, and the thigh extended, to its carried out of a natural line, with the upper proper length, where it was confined in the end almost bent upon it, without producing bent position. He was brought to the edge any inconvenience calculated to give rise to of the bed, with the limb extended over the ;; middle and lower planes of the bedstead as complaint on the part of the patient. 1. Treatment by Pressure and Rest.—As before, and, while in this position, Alr. Mr. Amesbury had not had a case of non- Green passed a long curved seton needle, union of the thigh so loose, he remarked, armed with silk, through the thigh, directing that he was unable to say how far the plan it between the fractured extremities of the of treatment which he had found successful bone. The needle was introduced at the in other cases, would prove beneficial in and back part of the thigh, and brought this. He doubted whether an " artificial anteriorly without difficulty. The neecapsule," contuininga fluid resemblingsy- die being removed, the ends of the silk were novia, had not formed. It was, at length, hanging, and were covered with only a determined to apply the apparatus which piece of simple dressing. The man was now Mr. Amesbury has invented for simple frac- shifted back to the middle of the bed, withtures of the middle and lower thirds of the out suffering any retraction of the limb to thigh, for simple and compound fractures take place, and, when confined in that situa. of the leg, and simple and compound dis- tion, by fixing the foot and the pelvis, a locations of the ancle, in such a manner assplint was applied along the outer side of to retain the limb of its proper length, and tu the limb, and secured in such a manner as to press the fractured surfaces strongly tobether. keep the fractured surfaces gently together, The apparatus had the effect of producing without pressing upon the soft parts sur. the fracture. pain in the fracture in a few hours after it On the following day, the limb was rather was applied. The pain increased, and became very severe on the third day, accom- swollen round the setoil, and the pulse had panied with startings of the limb : the pain, increased in frequency: tree suppuration however, though severe, was not of a de. took place in the course of two or three scription to produce any marked effect upon days, and the constitutional disturbance bethe system. On the fourth day the uneasi- came rather severe. The openings soon ness had much subsided, and the straps were discharged a large quantity of pus daily ; now tightened, which had the effect of in- and this being continued for some time, had creasing the pain in the fracture, but it soon a manifest effect in reducing the system. became moderate. He wore the apparatus About a fortnight after the introduction for about ten weeks, suffering more or less of the seton, it was observed that the matter pain in the fracture duringthe whole pe- began to burrow beneath the fascia, preriod, with the exception of two or three senting itself at the upper and inner part of days; but, notwithstanding the existence the thigh. This affected his constitution of the symptoms which precede union still more ; so much, indeed, was the man’s (pain and tenderness in the fracture) were health disturbed, that it was not deemed much more severe than in anv former case safe to allow the seton to remain in any Mr. Amesbury had witnessed, the only ap- longer, and it was accordingly removed on parent benefit derived, was a closer confine- the nineteenth day. It had produced great ment of the fractured ends, by the adhesion thickening of the soft parts surrounding the of the soft parts around them. fracture, such, Mr. Amesbury observed, as 2. Introduction of the Seton.-The plan of has been often mistaken for callus ; and treatment, by pressure and rest, having when the fractured ends were pressed to. failed in producing ull.iQu, it-became gether strongly, he experienced severe pain
, in
were
visable
extending
those
outer out
left
rounding
matter,
813
in the part. The matter was daily evacu- tured end of the upper portion of the bone ated from the upper part of the thigh, was brought into view. Upon clearing away where it lay very deep ; and it was found the muscles, it was seen that the two broken that the contents of the abscess gradually extremities of the bone were connected by diminished in quantity, and ultimately dis- a thick dense capsule, resembling the capappeared through the openings made by the sule of the hip-joint, the inner surfaces of seton needle. perfectly smooth and shining. After the seton was withdrawn, the con- The integrity of this capsule was destroyed, stitution soon began to rally, under the in- by a portion of it from the upper in consequence of the diffifluence of tonic medicines and a generous diet, so that the man was sufficiently reo. culty whichwas experienced in getting at covered, in the course of a few days, to feel the fractured end of the lower portion, himself able to take the common food of the (which, as has been said, lay on the inner hospital. Great care was taken to keep the side of the upper,) it was left, covered with surfaces in close apposition and at the ligamentous matter. In removing about rest, duringthe suppurative process; but, half an inch of the fractured end of the upper as it was necessary, for some time, to move fragment, by means of Hey’s saw in order the splints daily, in order to evacuate the to gain room, it was found that the bone matter which had burrowed along the outer had become soft and spongy at this part, side of the limb, for about two inches be- apparently from interstitial absorption. neath the vastus externus, as well as that From the manner in which the ends of the which had collected on the inner side, so bone lay, it was evident that the lower porthat the parts could not be kept in that per- tion could not be cleared of the ligat-nentous fect state of quietude, which it was desirable deposit which covered it, without enlarging at this time to maintain ; the matter could. the wound in the soft parts, a proceeding not be evacuated, without producing motion which, in the opinion of Mr. Green and some other surgeons, appeared objectionof the fractured extremities of the bone. At the expiration of about five weeks! able. Two or three small vessels were secured, from the time the seton was introduced, the discharge from the wounds had ceased, and the cut surfaces were suffered to fall but there still remained considerable tender- together, where they were lightly confined ness in the fracture, and thickening of the by a couple of adhesive straps, and a poulsurrounding parts. Three additional splints tice was then applied over the wound. The were now applied, and the whole secured pelvis was confined by the strap attached to round the limb, as the patient laid upon the the upper plane of the fracture bejstead, fracture bed, care being taken to press the (upon which he was placed previous to the fractured surfaces strongly together, and to operation,) and the foot was secured to the maintain them in tight apposition and at foot-board, The thigh was left free from rest. These splints were thus continued splints and bandages, being preserved of its upon the limb for a month ; and, at the ex- proper length and at rest. piration of this period, being nine weeks The man did not suffer much from the from the time the seton was introduced, operation, except when the finger was passed they were removed, and the limb examined, into the artificial capsule between the oblique but no ossific union had taken place. The surfaces of the fractured ends, which was limb was rendered stiffer by the thickening done in order to ascertain its extent. The of the soft parts, and this was the only capsule possessed a high degree of sensidifference that the seton had produced. bility, so much, indeed, that when the finger 3. The operation of ctttting down upon the was passed into it, the man could not help ends of the Bone.—The man was removed to crying out. He said, that the pain produced a common bed, and sometime afterwards it by the incision through the integuments was determined, in consultation, to cut down and muscles, was nothing compared to that upon the fiactured ends, with a view to as- which he experienced when the inner surface certain, if possible, the cause which still of the capsule was pressed with the finger. prevented the processof bony union, and He was a considerable time under the opethen to act in that manner which, upon ex- ration, and felt chilly when it was over, but posing the ends of the bone, might appear soon recovered his natural heat. most advisable. The man was again placed He passed a good night, and was so free upon the fracture-bed, with the limbs in the from constitutional disturbance, that he was bent position, in order to secure to the ope- ordered full diet on the day after the opera-
which were removing fragment ; but,
fractured
command over the muscles of A semicircular incision was made by Mr. Green, commencing at about the middle of the rectus, and then carried round through the belly of the vestus externus.
rator
a
perfect
the
thigh.
The
flap
was
The limb became moderatelv swollen. of incision, and was established on the third day. The greater part of the cut surfaces adhered, however, so that there was only asmall opening at the tion.
suppuration
at the seat
dissected back, and the frac- upper and outer
part of
the wound for the
814
Some of the pus bur-( view to remove the artificial capsule, a piece rowed towards the upper and inner part of of the fractured end of the upper portion was removed, and it was observed that the the thigh, where an abscess formed, bone was soft and spongy, apparently from made its way to the surface, producing but not severe, excitement of the interstitial absorption. This, however, was not the case higher up ; where the bone was The matter was evacuated by two made within a few days of each other, and sawed off in amputating, it was found perthe man’s health soon became good. On the fectly healthy. Though the integrity of the tenth day a splint was padded and applied artificial joint had been destroyed, it was along the outer side of the limb, with a view now again complete. The greater part of it of producing absorption of the ligament, was nearly the thickness of the capsule of which covered the fractured surfaces, by the hip joint, but, at the upper part, it was forcing them together ; but this was done in thin, like the capsule of the shoulder. The such a manner as not to press upon the capsule was accidentally torn at this part, wound, which could easily be dressed with- with the finger, and the inner side was seen out moving the splint. There was much smooth, and had very much the appearance tenderness in the fracture for the first month of synovial membrane, being moist and shinafter the operation, especially where even ing. Thp ends of the bone were rounded, the slightest motion was given to the limb. and, where they came in contact, they were Seven weeks after the operation, the flattened and covered with a dense fibrous splint was removed, and the limb examined. structure, very similar in appearance to the No union of the bone had taken place. The intervertebral substance, when divided horipunctures made for the evacuation of the zontally, but especially that part of it which found half way between the centre and matter of the abscess had now healed ; but there was still remaining a considerable por! In a few remarks, with which Mr. Amestion of the wound over the fracture. Thinking it possible that the splint cloth, bury followed up the case, he especially which had been placed round the limb over dwelt upon the circumstance of the man the splint, had not been sufficiently power. being’ in good health, a fact in perfect aeful in its action to produce absorption of the cordance with what he had observed in lio’amentous matter, which covered the ends forty-five cases of non-union that had fallen of the bone, a splint was applied on the under his care. The want of uuion in all inner side of the limb, extending the knee these cases, he thonght was attributable to to within a very short distance of the frac- the inadequacy of the means emploved, in ture ; and the outer splint being appiied as order to keep the fractured extremities in before, the limb was surrounded by the web apposition and at rest, although the plans of a tourniquet, which passed over the adopted were various. In the case undrr splints immediately below the fracture. By consideration, an artificial joint had formed pursuing this plan, the ends of the bone in the short space of six months, which he were very strongly forced together, by turn- considered as corroborative of the opinion, ingthe screw of the tourniquet. These that, where the fracture is very loose, and means did not, however, produce any mate- the powers of the constitution strong, artirial excitement on the fracture. There was ficial capsules form much sooner than where pain occasionally, but it was only slight and the ends of the bone are so connected, as to allow of but slight motion. transient. The action of the tourniquet was kept up The case of M’Lean, with another of as powerfully as the man could bear it for seven months standing, Mr. Amesbury said, a fortnight, making nine weeks from the were the only instances in which he had time of the operation. It was then removed, failed to procure union, by means of perfect and, on examining the limb, it was found rest, with pressure, under the use of his that no good whatever had resulted from own apparatus ; but, although it had failed the operation, or the treatment by which it in effecting a bony union in these two cases,it was followed. produced symptoms more severe, but similar The limb was perfectly useless ; and, see- in kind to those which preceded the uniting ing that all endeavours to bringabout union process, in all the successful instances. of the bone had failed, the poor fellow was Eighteen cases of non-union have been suenow desirous of losing it, which was accord. cessfully treated by Mr. Amesbury, with most of which the fracture had existed ingly agreed to. The operation was performed on Friday, above six months : one was of nine months Feb. la, in a very masterly manner, bv Mr. standing, one ten, one eleven, and two, Green. The bone was taken off fourteen months. None of the cases were above the artificial joint, and about half an under treatment more than ten weeks, and iach below the trochanter minor. some not more than a month. Examination of the Bone.—At the time of In contending for the superiority of his the operation, which was performed with a plan of treatment, whilst he admitted that matter to escape.
and
some, system. punctures
is circumference.
immediately
815
instsnce of failure
might now and then exerted in a straight line, whereas the feAmesbury argued upon its ad- mur has a considerable curvature forwards. vantages, by contrasting it with the twenty- The double inclined plane, now ordinarily four caseshe had seen otherwise treated, employed, was said to be objectionable, in in only one of which was union effected. In consequence of its allowing the body to ‘
an
occur, Mr.
(
like that under consideration, a very gravitate downwards in the bed, and thus loose fracture of long standing, he considered the upper part of the femur is tilted forit would be better after having unsuccess- ward. fully tried the plan of pressure and rest, to The whole of these defects, Mr. Amescut down upon the fractured ends of the bury contended, are obviated under the use
cases
i
with the knife, any liga-of his apparatus, of which, we presume, it is with which they might be unnecessary to enter into a full description, covered, and then to wash the ends of the it having been for some time before the bone with some stimulating iiuid calculated and probably is well known to our to produce inflammation, or to destroy the readers. connecting medium by caustic, and then The debate which ensued was brief. Mr. have iecourse to the assistance of me- CALLAWAY, whilst he bore testimony to the chanical support. A similar treatment had ingenuity of the apparatus, and admitted its been proposed in the case of M’L.ean, in great utility in some cases, at the same lieu of sawing off the ends of the bone ; time considered Mr. Amesbury was somebut Mr. Green (to whom Mr. Amesbury what too sweeping in his denunciation of paid a high compliment for his liberality) all other methods of treatment. Non-union, was fearful that it would be productive of Mr. Callaway said, is a rare circumstance, amidst the many thousand cases treated andangerous constitutional disturbance. The discussion which followed was brief, nually in the hospitals, showing that the as a large portion of the time of the society treatment there employed, although differhad been occupied in the reading of the ing much from that of Mr. Amesbury, is case, and the observations. Dr. Clutter- adequate to the cure of the accident. Duck objected to the expression " artificial Mr. BRIANT spoke of numerous cases of capsule," considering the phrase ’ pre- fracture of the thigh, which had fallen under ternatural capsule" as more applicable. his observation, successfully treated under Dr. Calso objected to the use of caustic, Some questions use of short splints. with a view of producing inflammation were put to Mr. Amesbury, with respect to the bone, arguing, that, under such a con- the essential difference between his appadition, the bone was not disposed to unite. ratus and the common double.inclined plane, Mr. LLOYD said, that he did not regardand this terminated the business of the the ordinary methods of treating fractures! Society. ofthe thigh, with short splints, to be so objectionable as 1Blr. Amesbury had stated. He (Mr. Lloyd) had treated a large number of cases at St. Bartholomew’s Hospital, WESTMINSTER MEDICAL SOCIETY. according to this plan, and perfect union, Saturday, February 23, 1828. without deformity, had been the invariable result. Mr. MAYO, in the Chair.
bone, and
remove
mentous matter
! public,
I
I inthe
Dr. BARRY, (with reference to the preceding discussion on diabetes,) in a manly Mr. AMESBumY this evening entered into and candid explanation, proved, to the saa long dissertation on fractures of the thigh, tisfaction of the Society, that a slight error illustrating his opinions by reference to va- as to dates, of which lie had been unconrious drawings. After speaking of the dif- sciously guilty, and which had been since ferent kinds of fracture in reference to di- corrected by a letter from the patient, rerection, Mr. A. proceeded to the considera- conciled the apparent contradictions betion of the plans of treatment employed in tween himself and Dr. Ayre, and fully acthese accidents. The use of short splints quitted patient and all of every thing like
February 85,
1828.
intentional incorrectness in their respective statements of the case. Dr. Barry then submitted to the consiprevent motion in the lower part of the deration of the Society some peculiar pathobone. The position, usually called Pott’s, logical views, .and a particular mode of was charged with the same defect; and, in treatment of typhus fever, contained in a addition, it was amrmed that the foot usually lecture delivered and published by his friend, becomes everted under this treatment. The Dr. W. R. Clanny, of Sunderland, to whose practice of Boyer, with the long splint, was talents he paid a well-merited tribute of
to the
thigh, placing the foot on the heel, pillow under the ham, was condemned, on the ground of its total inadequacy to
with
a
opposed, on the principle of the force being praiae.
The first
were
derived from
re’