REMARKS ON A CASE OF COMPOUND OBLIQUE FRACTURE OF THE TIBIA, WITH COMMINUTED FRACTURE OF FIBULA.

634 construction of the bed or mattress not being sufficiently to make a most careful examination. The first thing that yielding to enable it to adapt itself to the form of the body. struck me was the abundant haemorrhage proceeding from a To persons in health this is a matter of no great moment, but slight laceration in the anterior tibial artery; and on transferwhen patients, enfeebled by disease, are long confined to a ring my attention to the bones, I detected the tibia broken horizontal position, sloughing of the skin inevitably occurs, downwards and inwards immediately above the inner malunless means are adopted to prevent this undue pressure on leolus, so leaving a small piece of tibia attached to the joint; the projecting surfaces. The only effectual mode of this pre- while the very sharp, angular, upper fragment had pierced his vention is to place the patient on a bed so constructed that skin and stocking, and was besmeared with sawdust. The each portion of the body transmits its weight directly to the fibula was fractured in two places immediately above the surface on which it is placed, so that the retiring, as well as the outer malleolus, and again about two inches above that. The projecting portions of the body are equally pressed on. The integument was stretched tightly over the projected tibia, and water-bed, invented by Dr. Arnott, accomplishes this object the man was in great agony, and was naturally of an irritable most perfectly; but unfortunately, there are many very serious habit, little able to endure pain, with a constitution impaired objections to itsemployment, which in a great measure counter- by the dissipation of years; and to add to the complexity and balance the advantages to be derived from the uniform sup- unfavourable aspect of the case, the left leg presented an unport which it affords. In using the water-bed, it is found healthy, extensive ulcer. Under these circumstances, ampunecessary to interpose a mattress between the patient and the tation occurred to me as the first resource; but the rememwater-ps oof cloth which floats on the surface of the water, to brance of many severe cases about the ankle-joint, wherein enable him to maintain his position, and to shift it at will, and almost incredible reparations had been effected by Nature to also to prevent the heat of the body being conveyed away too restore extensive injury and mutilation, induced me to give rapidly by the surrounding water, which retains the tempera- the fellow a chance. After the greatest difficulty,I contrived to reduce the bone. ture of the room in which the bed is placed. This mattress being,in immediate contact with the water-proof cloth, all Having first made a long incision through the integuments, I evaporation is prevented from its lower surface; in conse- then applied a compress over the anterior tibial artery, and quence of this, the moisture which continually escapes from placed the limb in Liston’s splint-the double-inclined plane the body of the patient is condensed in the blanket and mat- -and left him. He was undisturbed for four days; and at tress, the lower surface of which is of the same temperature the end of that period he had not undergone much suffering, as the water in the tank, so that the patient is continually and the bleeding had stopped. On the removal of my applisurrounded by an atmosphere, and enveloped in clothing ances, however, I was much chagrined to find the bone pro-saturated with moisture. So rapidly does this accumulation truding as badly as ever. It would appear that the fracture, of moisture take place, that it is found necessary to remove I being below the attachment of the soleus altogether, that the patient every few days, (at least once a week,) for the pur- muscle acting from the os calcis as a fixed point, pulled the pose of changing the mattress and bedding, and allowing the superior fragment downwards and inwards. I determined to surface of the water-proof cloth to dry. This is a proceed- use every precaution to oppose the action of that muscle effecting at all times inconvenient, and sometimes dangerous to the tually, and again reduced the bone and re-applied the splint and bandages.* patient. The great desideratum in this case was an invincible barrier In the autumn of 1846, during the time I was acting as muscular action; and the chief object of this communihouse-surgeon of the Middlesex Hospital, some beds were sent to there for trial by the inventor,* which had been constructed cation is to point out what appeared to me, after many trials, by him with the view of securing all the advantages of the most effectually to answer this end. Perseveringly, every conArnott bed, without being liable to similar objections. These trivance I could imagine was tried to keep the bone in its beds consisted of a light iron frame, with transverse elastic situation; and though succeeding, perhaps, for two or three steel bars, to which were attached a number of iron springs days at a time, muscular spasm would suddenly come on, placed vertically, supporting a thin detached horse-hair mat- especially whilst my patient was asleep, and forcibly drag out tress. As these springs act independently of each other, and the bone. Extensive suppuration took place, to which exit yield in proportion to the pressure from above, the mattress was given. This was particularly the case about the outer adapts itself perfectly to the surface of the body, the pressure ankle. On Monday, July 9,removed upwards of half an inch of being as equally diffused as in the water-bed. As the body of the patient is separated from the air merely by a thin mat- bone with the cutting pliers. I then placed the limb in the tress, evaporation goes on as freely below as above, so that no straight position, resting on the calf with a long, straight accumulation of moisture can possibly take place-an advan- splint, notched at its extremity on the outer side. My patient tage which was speedily discovered by the first patient who was doing well, healthy and free granulations filled up the wound and covered the protruded end’ of bone. Waterwas placed on one of these beds, and who had been for some time confined to an Arnott bed. These beds being found fully dressing. I may mention that he was taking the following to answer the expectations formed of them, have since been medicine and diet, which was continued uninterruptedly to generally employed in the hospital in all cases where the the end of the cure :-Disulphate of quinine, one grain; tincArnott bed was formerly had recourse to. There are now six- ture of cinchona, and orange tincture, of each a drachm and teen in constant use in that establishment; they are portable, a half; dilute sulphuric acid, half a drachm; distilled water, an cheap, and not liable to get out of order. I saw one during a ounce and a half. To be taken three times a day. Threerecent visit to London, which had been in constant use since the quarters of a pound of solid meat; one pint of Dublin stout, autumn of 1846, and was in as serviceable a condition as when and accessories ad libituna. first sent in. Although these beds have thus been extensively July 10th.-Passed a very good night; the end of the upper and successfully employed in the Middlesex Hospital during a fragment of bone still projects greatly over the inner malleolus, period of three years, they do not yet appear to be generally but it is quite covered with some of the best granulations I known to the profession, and I feel that I am only doing my ever saw. Nature has formed a most beautiful provision to duty in directing attention to this valuable invention through keep down the bone; a firm band or cicatrix has arched itself over the end of the bone, attempting to keep it down. His the pages of your widely-circulated journal. bowels arc regular, and have been so since he commenced the East Grinstead, Sussex, 1849. quinine; tongue clean; pulse natural; in much better spirits. Up to the 21st he went on favourably, but still the bone REMARKS ON A CASE OF projected more than was desirable, and I now had recourse to I think, if it had been used in the first COMPOUND OBLIQUE FRACTURE OF THE TIBIA, a contrivance, which, have obviated much difficulty and trouble, instance, might WITH COMMINUTED FRACTURE OF FIBULA. and perhaps have done away with the necessity of removing the end of bone. I applied that modification of Liston and BY H. F. CARTER, ESQ., M.D., Surgeon, New Boyer’s splints, described in THE LANCET by Mr. Bottomley, of Sussex. Shoreham, (vol. ii.1847, p. 230,) consisting of a long straight splint, ON Wednesday, May 30,was called to Henry L—:—,aged aCroydon, belt to go round the waist, and a leather shoe; the upper end found him at the a down which bottom of sawpit, fifty-two, and fits into a pouch in the belt, and at the lower is a screw, to he had fallen, in a state of intoxication. About an inch and a which is attached the shoe; and the whole is so managed, that half of very sharp bone was protruded through the stocking, a nut with the finger and thumb, the most forcible and he bled profusely. I immediately had him conveyed by turning home on a shutter; and having uncovered the limb, proceeded * A similar catastrophe is recorded by Sir A. Cooper, in his work on" DisI

_

-

’

*

of

Mr. Edward Cottam, of No. whom they may be obtained.

2, Winsley-street, Oxford-street, London,

" As soon as," he says, " the bandages were removed, violent spasm threw the bones from the astragalus, and all the efforts I could make would not replace them. Amputation became inevitable."

locations," p. 306. a

635 possible that some plants of this family might by mistake have been gathered with the kale, but the identity of the symptoms in all the persons,-who were from very different parts of the

and the most gradual extension can be made. So insuperable an obstacle does this appliance offer to muscular action, that with it- the advantage of reducing the muscles of the calf by bending the leg on the thigh appeared of no moment whatI strikingly perceived, in this instance, the truth of a ever. remark often made by Liston, that even if a muscle be put on full stretch, it soon loses its tonicity, becomes flaccid, and In this way, then, if you ceases to act as a displacing agent. can only procure an apparatus which shall resist muscular action completely, you need not attend to position (quoad muscular action) at all; it only becomes necessary to relax the fibre when one cannot tire it out by perfect resistance. 24th.-Going on well; the leg is getting into better shape; the shaft of the tibia is much less oblique, straighter, and longer. This affords a remarkable proof of the susceptibility of callus, whilst in a soft state, to undergo stretching and

country, led me to abandon the idea. This was further confirmed by showing the patients the respective plants, when, in all instances, they at once distinguished the yellow racemes and cordate leaves of the Praiseach buidhe, or yellow kale, from any other. They stated that their mode of cooking the herb for food was to strip the leaves, rejecting the stalk, root, and flower and to boil them with common salt or soda. Most of them used the corn kale for a period extending from one week- to six before the unfavourable effects became manifest, and these were more rapidly produced in persons previously suffering from gastric or intestinal disturbance. I am not aware if the effects above described, and which at the time I thought it my duty to endeavour to prevent, by moulding. pointing out the injurious properties of the wild corn kale as 27th.-Very much better. Aug. 4th.-Heel has become exceedingly sore, tender, and an esculent, in the local papers, have been heretofore observed. bleeds profusely; but for this unfortunate complication, I The family of plants to which it belongs-namely, the crucibelieve I should have succeeded in making the limb of the ferae, have always borne a good reputation for salutary propersame length as the other, notwithstanding the removal of the ties ; but in many of its genera there exists a volatile oily end of bone. Discontinue all traction, and place the limb in principle, peculiarly irritating to the skin and digestive organs. This volatile oil, which in some genera, as the mustard tribe, the straight position merely. 14th.-Can move the entire limb easily; complete con- resides more particularly in the seeds, and in others in the solidation has taken place. Shortly after this, he left his bed, root, exists in the wild varieties of the colewort tribe also in and took to crutches, daily gaining strength, and being pos- the leaves, which give to the tongue a disagreeable biting sessed of a limb, which, though shorter than its fellow, is yet taste. By cultivation this acrid property becomes more diffused and diluted. The quantity of nitrogen also which the so useful, that he would not, in the words of Sir Astley Cooper, oruciferae contains, affords great facility for the formation of exchange it for a wooden one for all Europe." ammoniacal products, and the tympanitic condition of the Suffolk Cottage, New Shoreham, Sussex, 1849. abdomen is most likely due to this cause. The analogy which exists between the enfeebled capillary circulation and ulcerative tendency in the extremities arising from the use of the ON THE TOXICOLOGICAL PROPERTIES OF THE corn kale, to the moremarked gangrenous effects produced by the ergot of rye is apparent; but whether it would have proBRASSICA NAPUS, OR WILD CORN KALE. ceeded to sphacelus, I am not able to say, as, fortunately, the BY JOHN POPHAM, A.B., M.B., unsightly appearance presented by the patient led them to PHYSICIAN TO THE CORK NORTH INFIRMARY AND UNION WORKHOUSE. early for relief. The treatment used in these cases may apply in all of them be successful. It consisted of such medicines as IN the months of June and July of the present year, when were best adapted to restore the action of the skin and kidneys, very. great destitution prevailed in the southern and western together with mild purgatives, warm baths, rest in the horiparts of Ireland, I was surprised to find a large number of zontal position, and wholesome food. The state of the extrepersons from some of the famine-stricken districts of the Cork mities required careful stimulation until the circulation was union applying for admission into the workhouse hospital, restored, when the tepid water dressing was the best applicawith very peculiar and alarming symptoms. They were chiefly tion. It was some time before many of these patients regained the families of country labourers out of employment, emigrating their former health, and in some the blotches have left a perfrom place to place in search of work, and totally deficient of ,manent mark. means to procure the merest necessaries of life. They all exCamden-place, Cork, 1849. hibited indications of deteriorated health, the hue of the skin beinguniformly sallow and muddy-looking, totally different from the brown discoloration caused by exposure to the sun; the surNOTES OF CASES IN PRIVATE PRACTICE. face was also covered with that colourless downy hair, so chaBY A. C. SELKIRK, M.D., Carluke. racteristic of what the country people here callimpoverished Delirium Tremens; Chloroform.—Sometime in the beginning blood." An cedematous state prevailed generally of the whole body, but always of the face and lower extremities, the of February last, I was summoned to see J. H—,a young, former being sometimes swollen to an enormous extent, the unmarried man, who, the messenger stated, " had gone outof distended state of the eyelids and upper lip especially pro- his wits." I found the patient labouring under a severe attack ducing remarkable deformity. The abdomen was tympanitic ; of delirium tremens. His actions and language were of the the bowels torpid: the mucous membrane of the mouth and most whimsical description. Having read a good deal, the pharynx was inflamed, and in some parts ulcerated, and the illusions, in this instance, assumed rather a scientific direcgums spongy; the appetite was usually greater than natural, tion. In particular, he described to me an electric commuin some cases voracious; the urinary secretion was deficient nication between his bed and the locality of his previous and irritating, and that of the skin suspended; very distressing midnight orgies, by means of which he communicated and refrontal headach and tension was also compla:ned of; but the ceived the most ludicrous information imaginable. The treatment, in the first instance, consisted of opiates most curious symptom, next to the cedematous appearance of the patient, was the state of the hands and feet, which were alone. Large, frequently-repeated, and heroic doses, had no dry and shrunken, with blotches of a deep-red, resembling effect whatever in inducing sleep, but rather produced an burns, on the backs of the hands and dorsum of the feet, the aggravation of the symptoms. On the second day, opium was fingers and toes being frequently cold and livid. Similar exhibited, in combination with the wonted stimulus, with no blotches existed on the nose and forehead, and these varied better success. It may be stated," Tincture of opium, twenty in their consequences from simple discoloration to ulceration drops, every two hours, until the patient sleeps," was also tried, of a most troublesome description, terminating in loss of the as recommended by Dr.Watson, in his " Lectures on the Praccuticle and dropping off of the nails, with a marked disposition tice of Physic," published in the pages of the Medical Gazette in the aggravated cases to gangrene. The aedematous ap- several years ago. This method I found also unavailing. On the fourth day, from the obstinate nature of the attack, pearance of these patients was so like that of persons suffering from extreme cardiac or renal disease, that I formed at the length of time the patient had been without sleep-about first a very unfavourable prognosis, but on a closer inquiry, I a week-Idetermined to try chloroform. I had no precedent discovered that all the persons thus affected had made use of for the practice; and from the peculiar irritability of the nerthe field species of brassica as food. Some of the worst cases vous centre in this disease, the determination was followed out had used it almost as the sole means of support; others again rather as a dernier ressort than as a matter of choice. A teahad partaken of it at longer intervals, and with the addition spoonful, of specific gravity 1.480, was placed upon a pocketof Indian meal or other farinaceous food. From the similarity handkerchief, and held to the patient’s mouth. Contrary to of some of the symptoms to those produced in the human expectation, he appeared to relish the inhalation exceedingly, body by the acrid properties of the ranunculacese, I thought it when at once he exclaimed, " I’m going !" and threw his toes

had

i

I