- Email: [email protected]
UNIVERSITY COLLEGE HOSPITAL CASES OF COMPOUND FRACTURE.
entozoa in those climes; but they must be well known to physiologists. It is satisfactory to know, at least as far as this case goes to establish the fact, that in the sulphur fumigating baths, and perhaps other mineral fumigating baths, we have a positive and direct remedy for such ailments, and which I think may be thus easily explained : The moisture and heat of these baths softening and laxing the skin, the worms more easily get to the surface, whilst the sulphur (or perhaps other minerals)
that
are
used in the baths would make their
position
A Mirror OF THE PRACTICE OF
MEDICINE AND SURGERY IN THE
HOSPITALS OF LONDON.
there
untenable, and they are readily enabled to escape from the skin.
The lady whose case is just related was very desirous of getting well of her odious complaint, as she called it; it was a sad source of annoyance to her husband, as the worms were constantly escaping on to the pillows and sheets, and had been so doing for more than two years. She attributed, as the cause of the complaint, her having fallen asleep in the air, some near stagnant water, and on waking found her mouth and nose full, as she said, of young gnats. I suppose she got well, for after a few more baths I never heard anything more of her, which I judge I should have done had she not got well, for certain it is, she found a direct and powerful remedy in the use of the fumigations for dislodging these worms, not in hundreds, but I may safely say in thousands. In further elucidation of this rare case, I now briefly quote from the work of Professor Biagio Gastaldi, of the University of Turin, " Degli Elminti in Genere e di alcuni nuovi in Specie -
Cenni. Con due Tavole.
Torino, 1854." In Chapter L, the doctor says:" In this way, they must (to enable them to go through all the phases of their increase, and obtain their real organic proportion) perform migrations or changes of locality, which are sometimes limited between one organ and another, or one animal and another, and occasionally they extend to that point, that the entozoa can pass from the free state to that of the parasitical, or from the parasitical pass to the exterior, and become free and independent for the remainder of life. "-p. 14. "The Filaria medicusis, at the time of copulation, perforates of itself the skin of its mate, and placing its head, in the vicinity in which exists the orifice of the genital organs, it deposes externally the embryo, which developes itself internally. This is evident by the way in which the worms perforate the organic parts, by which they do not sever the net of tissue, but divide it, by drawing the fibres apart, so as to pass between them without tearing their compactness. "-p. 15. "It has often been denied that the eggs of the entozoa could possibly circulate in the bloodvessels; but at present we have facts that prove, that not only the eggs, but also the worms already developed, can inhabit the vessels, and circulate with the liquid blood. Valentin found mixed with the blood of frogs worms quite similar to the Amebe. Graby found others that he denominated" Trypanossoma sanguinis." Leydeg saw entozoa worms, of the order Nematoides, in the blood drawn from the umbilical cord of a bog-worm. Vogt discovered Filaria worms in the veins of the nittitant membrane of frogs. Ecker saw the same worms in the blood of crows. Dr. Vella and Professor Ercolani detected it in the blood of dogs. Finally, Dr. Bilhars discovered, in Egypt, a new distomum-Distomum hematobium-which he believes to be the cause of diarrhoea,, and of the entoro-cisti ulcers, so frequent with the Egyptians. "-
p. 16.
" The Entozoa worms are ever active in all these migrations, they attempt with the view of passing from the free state to that of the parasitical, or from the latter to the former. The G ordi, contrary to the Distomi, live, during their first period in the parasitical state, in body of the insects, and the remainder of their life in water and in bogs. When free, they prove themselves active in their migrations, breaking by their own efforts the prison formed by the dermasckeliton of their guest. "-p. 17. " In the regions where the Filaria medicusis is endemical, they are often found in the mine, in bogs, or water, and stick to the legs of animals that pass through them, and perforating the skin, penetrate underneath it. It is thus that the Filaria medicusis can sometimes be seen in the legs of horses, and could even present itself in persons who never visited intertropical countries where it is circumscribed, but who merely stand bare-footed in the water-on the keel of boats or ships coming from those countries. Above we have observed how the eggs of the Entozoa worms, being unable to develop themselves in the same spot of their birth, are mostly removed to the exterior of the same animal within which the parent worms
which
are
guests. "-p.
Great
20.
Marlborongh-street, 1856.
42
Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum etdissectionum historias, tam aliorum proprias, collectas habere et inter et Caus. Morb.lib. 14. Procemium.
sec omparare.—MORGANI.
De Sed.
UNIVERSITY COLLEGE HOSPITAL. CASES OF COMPOUND FRACTURE. (Under the care of Mr. ERICHSEN.) COMPOUND FRACTURE OF THE
CLAVICLE.
THE comparative rarity of cases of compound fracture of the clavicle will give an interest to the following sketch drawn up from notes furnished us by Mr. D. B. Beid, the house-sur. geon. John F-, aged fifteen, was admitted into No. 1 ward on the 24th of Nov. 1855. His left upper extremity was drawn in between the rollers of a printing press, as far as the elbow, and his shoulder was dragged violently against the frame-work of the machine. On admission, the left clavicle was found fractured about the union of the middle with the outer third, and a large wound, about four inches long, running over the fracture from above downwards. This wound merely implicated the skin and the subcutaneous tissue. There was a large lacerated wound over the metacarpal bone of the index-finger, through which the metacarpal three-fourths of the bone projected, quite detached from the surrounding structures, except by a few tendinous fibres at the end; the head of the bone, which was broken off, remaining attached to the first phalanx. There was a compound fracture of both the third and fourth metacarpal bones, just above their phalangeal extremities. Mr. Erichsen, happening to come to the hospital shortly after the boy’s admission, directed that no constriction should be applied to the limb, the parts being so much bruised and cut about that he anticipated considerable subsequent swelling, which would be certain to cause mortification, if the clavicle was kept forcibly in position by the ordinary bandages. Consequently, the protruding portion of the metacarpal bone was dissected out, and water-dressing applied to the wounds in the hand, which was then laid on a light splint, extending nearly to the elbow, and confined by a loose bandage. The lower three inches of the wound, over the clavicle, being rather clean cut, were brought together by two points of suture and strips of plaster ; the upper end, being jagged and contused, was let alone : the whole wound was covered with water-dressing. The boy was then put on his back, and the limb laid on pillows, in an extended position, and by these means alone the clavicle was kept in a good position. Middle diet. To have
opening draught directly. boy went on well for the next four daya, the only change being a considerable swelling, from extravasation of blood along an
The
the arm and forearm. On the 28th of November, he was suffering from all the general and local conditions of erysipelas. The arm and forearm, the axilla, and the whole left side of the neck, were considerably swollen, and the integuments were covered by a red blush. The wound over the clavicle, from which the sutures had been removed two days before, opened up, gaped considerably, and took on extensivesloughing action. The pulse was quick, and very weak, the tongue furred, but not dry, and the appetite gone. Large poultices to the hand and shoulder. To have a draught, consisting of three grains of sesquicarbonate of ammonia, and an ounce and a half of decoction of bark, every four hours. Wine, four ounces; four eggs; milk, a pint; beefa pint. During the next week, all active disease was arrested, the sloughing stopped, and the wounds began to granulate and discharge healthy pus. The strength came back. Above, however, the sloughing action had opened up the fracture of the clavicle, and the matter had burrowed backwards, so that
tea,
counter-opening had to be made behind. The clavicle was rough and bare for some extent. The wounds in the hand were cleaning, and looking well. Dec. 9th.-Patient progressing favourably; wounds contracting ; good discharge. Water-dressing; splint to hand and forearm, which are laid across the abdomen, to help to keep the clavicle in position; swelling abating rapidly. To have the following draught three times a day: Disulphate of quinine, two grains; dilute sulphuric acid, fifteen minims; and an ounce and Extra diet; milk, a pint. a half of water. During the course of treatment, some anxiety was felt lest the shoulder-joint should have been implicated by the suppuration and burrowing of matter; however, by full counteropenings and position these difficulties were avoided. No symptoms of hectic, except an occasionally flushed face. Occasional gastric irritation and constipation were relieved by opiates, pills containing mercury, and injections. The patient found difficulty in expelling faeces when the bowels were but slightly confined. 21st.-Looks rather emaciated; pulse irregular, and weak; respiration 18; skin dry; sleeps well; no night-sweating; no starting or throbbing pain when quiet; appetite a little impaired ; bowels confined; thirst, and tongue rather furred. Notwithstanding there having been no special apparatus, the clavicle is in a very good position, and the wound healing fast. All burrowing has ceased, but the sinus still remains over the shoulder, leading down to the exposed bone. The hand is progressing favourably. 3lst.-The patient is improving, but looks anaemic. The wound over the second metacarpal bone has quite healed up. A small piece of bone to come away from the third. He was dressed yesterday without the splint to the forearm. The ordinary bandages for fractured clavicle were applied, including a figure-of-8 bandage and pad in axilla; the elbow was raised, and the arm brought to the side; after which, the boy got up, and walked about the ward. Bone in a good position. To day, Mr. Erichsen applied ice and salt over the clavicle, and after whitening the skin, slit up the sinus on a director. The boy appeared to suffer little or no pain. The case is progressing rapidly and favourably. a
COMPOUND FRACTURE OF THE SURGICAL NECK OF THE HUMERUS.
M-, aged fifteen, was admitted into No. 1 ward the 9th of October, 1855. He fell from a window, and struck his left shoulder. On admission, a compound fracture of the humerus was seen, and the upper end of the lower fragment was projecting about an inch through the deltoid muscle and the skin; the fracture was quite transverse, and was reduced with considerable difficulty. Mr. Erichsen directed that the limb should be loosely bandaged to a light splint, with a slight angle corresponding to the elbow, the splint reaching up to above the shoulder; that water-dressing should be applied to the wound, and that the arm should be subjected to no constriction whatever. Low diet. To have a dose of house medicine directly. Oct. 4th.-Rather feverish; suffering from bronchitis. To have three grains of calomel directly, followed in three hours by a dose of house medicine. To have an ounce of the followiug mixture every three hours :-One grain of potassio-tartrate of antimony, two drachms of compound tincture of camphor, two ounces of mixture of gum-acacia, and six ounces of water. This plan of treatment was continued only for a few days. The boy became very weak, and a large abscess formed in the axilla, which was opened inferiorly. It was necessary on October 15th to keep him up by ammonia and bark, extra diet, porter, and milk. During this time the lower fragment was pulled upwards and inwards in front of the upper fragment, and its superior extremity was projecting under the skin, which threatened every moment to ulcerate. On rotating the limb by grasping the elbow, the projecting extremity moved. Mr. Erichsen was averse to all constrictive apparatus in this I case, in consequence of the severity of the contusion, and the extensive swelling and inflammation; and finding the displacement on October 19th, he enlarged the wound upwards, and then made another incision at right angles to the former one, turned out the end of the lower fragment, and sawed off one inch of it. The fracture was found to have been perfectly transverse. After this the fragments were got into admirable position, and were kept so in a light splint, bent at right angles at the elbow, and reaching above the shoulder, which was supported by a pad. After a few days it was necessary to put a pad in the axilla, and bring the arm gently to the side, William
on
a tendency to dragging inwards of the upper end of the lower fragment. Moderate pressure was maintained on the cavity of the abscess in the axilla. Nov. 28th.-A leather cap was fitted to the shoulder and arm, and a pad in the axilla; the limb brought to the side, and the hand suspended. The wound all but healed; only a little mucous exudation remaining from the wound. Abscess healed up, and the bone in excellent position. Dec. 30th.-Wound healed; scarcely any difference in the size and form of the shoulders. The leather cap has been left off for the last two weeks, when the fragments were found to be firmly united. Can move the shoulder-joint a little; passive motion a week ago.
to obviate
__
ROYAL
FREE
HOSPITAL.
A CASE OF FRAGILITAS OSSIUM.
(Under the
of Mr. T. WAKLEY.) THE instances recorded in surgery of the largest and strongest bones being broken by the ordinary action of the muscles of the limb, are numerous, and in most cases the disposition to fracture can be traced to lues venerea, cancer, rickets, scurvy. and scrofula. Sir Benjamin Brodie had a patient whose clavicle broke exactly at the point of a venereal node. Two thigh-bones, taken from a patient who had had recourse, for the cure of syphilis, to an excessive use of mercury, are in the museum of the University College, London; one has several nodes upon it, the other broke as he was turning himself in bed. A gouty patient, sixty years of age, once broke his arm above the elbow by the exertion of drawing on his glove. The arm of a nun of Saltpetriere was broken as she was being handed out of a carriage ; the fracture did not unite, and one day, not long subsequent to the accident, her thigh-bone broke as she was turning herself in bed. It was afterwards, on examination, discovered that the unfortunate woman had a cancer in her right breast. Leveille, in the Heitel Dieu, and Sir Astley Cooper, both met with similar cases; and in March, 1837, there was in the North London Hospital a woman with a cancer of the breast, whose humerus was fractured by the ordinary action of the muscles ; and in her case she, both before and after this accident, suffered a like catastrophe. But two of the most interesting cases on record, are mentioned by Cooper in his Surgical Dictionary, in the following words :-" We are told, says Leveille, by Poupee Desportes, that a negro, about twelve or thirteen years old, was seized with such violent spasmodic contraction of the muscles of the lower extremities, that the feet were turned backward, and the neck of each thigh-bone was fractured, the ends of the broken bones also protruding through the skin upon the outside of the thigh. A cure was effected after an exfoliation. We read also in the Miscellanea Curiosa Acad. Naturæ Curiosorum, that during a fit of epilepsy, a child, ten years old, had its left humerus and tibia broken, and that, upon opening the body, other solutions of continuity were observed." The case in the Royal Free Hospital is that of J. T-,a cabman, aged forty-two years, who was admitted into the ward on May 10th, with rupture of the ligament of the patella of the right leg.* The patient, a stout and robust man, states that he has generally enjoyed good health, and has never suffered from any injury in the leg before. His account of the accident is, that he was in the act of getting up to the seat of his cab, having placed his left leg on the wheel, and just raised his right leg, when he felt something give way in the knee, which he says felt as though a piece of cord had been cut through. He was unable to put the leg to the ground, and swelling immediately commenced above and below the knee. He was forthwith put in a cab, and conveyed to the hospital, when the house-surgeon found the patella about three inches above its natural situation. June 30th, (about seven weeks after the occurrence of the injury. )-The leg has much the same appearance as the sound one, with the exception of a little swelling around the knee and two inches below it. The patient has, however, the power to raise the limb, and to flex and extend it; but he is unable to walk, as he cannot support the weight of his body on the affected limb. July 7th.-The patient is up for the first time. An instrument has been made for him, consisting of three steel rods, connected at each end by a band of leather, one of which is fastened aboveand the other below the knee. With this instrument and a stick he is able to walk for a short time, but requires rest every five or ten minutes. care
* THE LANCET, vol. ii. 1855, p. 30.
43
that
are
used in the baths would make their
position
A Mirror OF THE PRACTICE OF
MEDICINE AND SURGERY IN THE
HOSPITALS OF LONDON.
there
untenable, and they are readily enabled to escape from the skin.
The lady whose case is just related was very desirous of getting well of her odious complaint, as she called it; it was a sad source of annoyance to her husband, as the worms were constantly escaping on to the pillows and sheets, and had been so doing for more than two years. She attributed, as the cause of the complaint, her having fallen asleep in the air, some near stagnant water, and on waking found her mouth and nose full, as she said, of young gnats. I suppose she got well, for after a few more baths I never heard anything more of her, which I judge I should have done had she not got well, for certain it is, she found a direct and powerful remedy in the use of the fumigations for dislodging these worms, not in hundreds, but I may safely say in thousands. In further elucidation of this rare case, I now briefly quote from the work of Professor Biagio Gastaldi, of the University of Turin, " Degli Elminti in Genere e di alcuni nuovi in Specie -
Cenni. Con due Tavole.
Torino, 1854." In Chapter L, the doctor says:" In this way, they must (to enable them to go through all the phases of their increase, and obtain their real organic proportion) perform migrations or changes of locality, which are sometimes limited between one organ and another, or one animal and another, and occasionally they extend to that point, that the entozoa can pass from the free state to that of the parasitical, or from the parasitical pass to the exterior, and become free and independent for the remainder of life. "-p. 14. "The Filaria medicusis, at the time of copulation, perforates of itself the skin of its mate, and placing its head, in the vicinity in which exists the orifice of the genital organs, it deposes externally the embryo, which developes itself internally. This is evident by the way in which the worms perforate the organic parts, by which they do not sever the net of tissue, but divide it, by drawing the fibres apart, so as to pass between them without tearing their compactness. "-p. 15. "It has often been denied that the eggs of the entozoa could possibly circulate in the bloodvessels; but at present we have facts that prove, that not only the eggs, but also the worms already developed, can inhabit the vessels, and circulate with the liquid blood. Valentin found mixed with the blood of frogs worms quite similar to the Amebe. Graby found others that he denominated" Trypanossoma sanguinis." Leydeg saw entozoa worms, of the order Nematoides, in the blood drawn from the umbilical cord of a bog-worm. Vogt discovered Filaria worms in the veins of the nittitant membrane of frogs. Ecker saw the same worms in the blood of crows. Dr. Vella and Professor Ercolani detected it in the blood of dogs. Finally, Dr. Bilhars discovered, in Egypt, a new distomum-Distomum hematobium-which he believes to be the cause of diarrhoea,, and of the entoro-cisti ulcers, so frequent with the Egyptians. "-
p. 16.
" The Entozoa worms are ever active in all these migrations, they attempt with the view of passing from the free state to that of the parasitical, or from the latter to the former. The G ordi, contrary to the Distomi, live, during their first period in the parasitical state, in body of the insects, and the remainder of their life in water and in bogs. When free, they prove themselves active in their migrations, breaking by their own efforts the prison formed by the dermasckeliton of their guest. "-p. 17. " In the regions where the Filaria medicusis is endemical, they are often found in the mine, in bogs, or water, and stick to the legs of animals that pass through them, and perforating the skin, penetrate underneath it. It is thus that the Filaria medicusis can sometimes be seen in the legs of horses, and could even present itself in persons who never visited intertropical countries where it is circumscribed, but who merely stand bare-footed in the water-on the keel of boats or ships coming from those countries. Above we have observed how the eggs of the Entozoa worms, being unable to develop themselves in the same spot of their birth, are mostly removed to the exterior of the same animal within which the parent worms
which
are
guests. "-p.
Great
20.
Marlborongh-street, 1856.
42
Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum etdissectionum historias, tam aliorum proprias, collectas habere et inter et Caus. Morb.lib. 14. Procemium.
sec omparare.—MORGANI.
De Sed.
UNIVERSITY COLLEGE HOSPITAL. CASES OF COMPOUND FRACTURE. (Under the care of Mr. ERICHSEN.) COMPOUND FRACTURE OF THE
CLAVICLE.
THE comparative rarity of cases of compound fracture of the clavicle will give an interest to the following sketch drawn up from notes furnished us by Mr. D. B. Beid, the house-sur. geon. John F-, aged fifteen, was admitted into No. 1 ward on the 24th of Nov. 1855. His left upper extremity was drawn in between the rollers of a printing press, as far as the elbow, and his shoulder was dragged violently against the frame-work of the machine. On admission, the left clavicle was found fractured about the union of the middle with the outer third, and a large wound, about four inches long, running over the fracture from above downwards. This wound merely implicated the skin and the subcutaneous tissue. There was a large lacerated wound over the metacarpal bone of the index-finger, through which the metacarpal three-fourths of the bone projected, quite detached from the surrounding structures, except by a few tendinous fibres at the end; the head of the bone, which was broken off, remaining attached to the first phalanx. There was a compound fracture of both the third and fourth metacarpal bones, just above their phalangeal extremities. Mr. Erichsen, happening to come to the hospital shortly after the boy’s admission, directed that no constriction should be applied to the limb, the parts being so much bruised and cut about that he anticipated considerable subsequent swelling, which would be certain to cause mortification, if the clavicle was kept forcibly in position by the ordinary bandages. Consequently, the protruding portion of the metacarpal bone was dissected out, and water-dressing applied to the wounds in the hand, which was then laid on a light splint, extending nearly to the elbow, and confined by a loose bandage. The lower three inches of the wound, over the clavicle, being rather clean cut, were brought together by two points of suture and strips of plaster ; the upper end, being jagged and contused, was let alone : the whole wound was covered with water-dressing. The boy was then put on his back, and the limb laid on pillows, in an extended position, and by these means alone the clavicle was kept in a good position. Middle diet. To have
opening draught directly. boy went on well for the next four daya, the only change being a considerable swelling, from extravasation of blood along an
The
the arm and forearm. On the 28th of November, he was suffering from all the general and local conditions of erysipelas. The arm and forearm, the axilla, and the whole left side of the neck, were considerably swollen, and the integuments were covered by a red blush. The wound over the clavicle, from which the sutures had been removed two days before, opened up, gaped considerably, and took on extensivesloughing action. The pulse was quick, and very weak, the tongue furred, but not dry, and the appetite gone. Large poultices to the hand and shoulder. To have a draught, consisting of three grains of sesquicarbonate of ammonia, and an ounce and a half of decoction of bark, every four hours. Wine, four ounces; four eggs; milk, a pint; beefa pint. During the next week, all active disease was arrested, the sloughing stopped, and the wounds began to granulate and discharge healthy pus. The strength came back. Above, however, the sloughing action had opened up the fracture of the clavicle, and the matter had burrowed backwards, so that
tea,
counter-opening had to be made behind. The clavicle was rough and bare for some extent. The wounds in the hand were cleaning, and looking well. Dec. 9th.-Patient progressing favourably; wounds contracting ; good discharge. Water-dressing; splint to hand and forearm, which are laid across the abdomen, to help to keep the clavicle in position; swelling abating rapidly. To have the following draught three times a day: Disulphate of quinine, two grains; dilute sulphuric acid, fifteen minims; and an ounce and Extra diet; milk, a pint. a half of water. During the course of treatment, some anxiety was felt lest the shoulder-joint should have been implicated by the suppuration and burrowing of matter; however, by full counteropenings and position these difficulties were avoided. No symptoms of hectic, except an occasionally flushed face. Occasional gastric irritation and constipation were relieved by opiates, pills containing mercury, and injections. The patient found difficulty in expelling faeces when the bowels were but slightly confined. 21st.-Looks rather emaciated; pulse irregular, and weak; respiration 18; skin dry; sleeps well; no night-sweating; no starting or throbbing pain when quiet; appetite a little impaired ; bowels confined; thirst, and tongue rather furred. Notwithstanding there having been no special apparatus, the clavicle is in a very good position, and the wound healing fast. All burrowing has ceased, but the sinus still remains over the shoulder, leading down to the exposed bone. The hand is progressing favourably. 3lst.-The patient is improving, but looks anaemic. The wound over the second metacarpal bone has quite healed up. A small piece of bone to come away from the third. He was dressed yesterday without the splint to the forearm. The ordinary bandages for fractured clavicle were applied, including a figure-of-8 bandage and pad in axilla; the elbow was raised, and the arm brought to the side; after which, the boy got up, and walked about the ward. Bone in a good position. To day, Mr. Erichsen applied ice and salt over the clavicle, and after whitening the skin, slit up the sinus on a director. The boy appeared to suffer little or no pain. The case is progressing rapidly and favourably. a
COMPOUND FRACTURE OF THE SURGICAL NECK OF THE HUMERUS.
M-, aged fifteen, was admitted into No. 1 ward the 9th of October, 1855. He fell from a window, and struck his left shoulder. On admission, a compound fracture of the humerus was seen, and the upper end of the lower fragment was projecting about an inch through the deltoid muscle and the skin; the fracture was quite transverse, and was reduced with considerable difficulty. Mr. Erichsen directed that the limb should be loosely bandaged to a light splint, with a slight angle corresponding to the elbow, the splint reaching up to above the shoulder; that water-dressing should be applied to the wound, and that the arm should be subjected to no constriction whatever. Low diet. To have a dose of house medicine directly. Oct. 4th.-Rather feverish; suffering from bronchitis. To have three grains of calomel directly, followed in three hours by a dose of house medicine. To have an ounce of the followiug mixture every three hours :-One grain of potassio-tartrate of antimony, two drachms of compound tincture of camphor, two ounces of mixture of gum-acacia, and six ounces of water. This plan of treatment was continued only for a few days. The boy became very weak, and a large abscess formed in the axilla, which was opened inferiorly. It was necessary on October 15th to keep him up by ammonia and bark, extra diet, porter, and milk. During this time the lower fragment was pulled upwards and inwards in front of the upper fragment, and its superior extremity was projecting under the skin, which threatened every moment to ulcerate. On rotating the limb by grasping the elbow, the projecting extremity moved. Mr. Erichsen was averse to all constrictive apparatus in this I case, in consequence of the severity of the contusion, and the extensive swelling and inflammation; and finding the displacement on October 19th, he enlarged the wound upwards, and then made another incision at right angles to the former one, turned out the end of the lower fragment, and sawed off one inch of it. The fracture was found to have been perfectly transverse. After this the fragments were got into admirable position, and were kept so in a light splint, bent at right angles at the elbow, and reaching above the shoulder, which was supported by a pad. After a few days it was necessary to put a pad in the axilla, and bring the arm gently to the side, William
on
a tendency to dragging inwards of the upper end of the lower fragment. Moderate pressure was maintained on the cavity of the abscess in the axilla. Nov. 28th.-A leather cap was fitted to the shoulder and arm, and a pad in the axilla; the limb brought to the side, and the hand suspended. The wound all but healed; only a little mucous exudation remaining from the wound. Abscess healed up, and the bone in excellent position. Dec. 30th.-Wound healed; scarcely any difference in the size and form of the shoulders. The leather cap has been left off for the last two weeks, when the fragments were found to be firmly united. Can move the shoulder-joint a little; passive motion a week ago.
to obviate
__
ROYAL
FREE
HOSPITAL.
A CASE OF FRAGILITAS OSSIUM.
(Under the
of Mr. T. WAKLEY.) THE instances recorded in surgery of the largest and strongest bones being broken by the ordinary action of the muscles of the limb, are numerous, and in most cases the disposition to fracture can be traced to lues venerea, cancer, rickets, scurvy. and scrofula. Sir Benjamin Brodie had a patient whose clavicle broke exactly at the point of a venereal node. Two thigh-bones, taken from a patient who had had recourse, for the cure of syphilis, to an excessive use of mercury, are in the museum of the University College, London; one has several nodes upon it, the other broke as he was turning himself in bed. A gouty patient, sixty years of age, once broke his arm above the elbow by the exertion of drawing on his glove. The arm of a nun of Saltpetriere was broken as she was being handed out of a carriage ; the fracture did not unite, and one day, not long subsequent to the accident, her thigh-bone broke as she was turning herself in bed. It was afterwards, on examination, discovered that the unfortunate woman had a cancer in her right breast. Leveille, in the Heitel Dieu, and Sir Astley Cooper, both met with similar cases; and in March, 1837, there was in the North London Hospital a woman with a cancer of the breast, whose humerus was fractured by the ordinary action of the muscles ; and in her case she, both before and after this accident, suffered a like catastrophe. But two of the most interesting cases on record, are mentioned by Cooper in his Surgical Dictionary, in the following words :-" We are told, says Leveille, by Poupee Desportes, that a negro, about twelve or thirteen years old, was seized with such violent spasmodic contraction of the muscles of the lower extremities, that the feet were turned backward, and the neck of each thigh-bone was fractured, the ends of the broken bones also protruding through the skin upon the outside of the thigh. A cure was effected after an exfoliation. We read also in the Miscellanea Curiosa Acad. Naturæ Curiosorum, that during a fit of epilepsy, a child, ten years old, had its left humerus and tibia broken, and that, upon opening the body, other solutions of continuity were observed." The case in the Royal Free Hospital is that of J. T-,a cabman, aged forty-two years, who was admitted into the ward on May 10th, with rupture of the ligament of the patella of the right leg.* The patient, a stout and robust man, states that he has generally enjoyed good health, and has never suffered from any injury in the leg before. His account of the accident is, that he was in the act of getting up to the seat of his cab, having placed his left leg on the wheel, and just raised his right leg, when he felt something give way in the knee, which he says felt as though a piece of cord had been cut through. He was unable to put the leg to the ground, and swelling immediately commenced above and below the knee. He was forthwith put in a cab, and conveyed to the hospital, when the house-surgeon found the patella about three inches above its natural situation. June 30th, (about seven weeks after the occurrence of the injury. )-The leg has much the same appearance as the sound one, with the exception of a little swelling around the knee and two inches below it. The patient has, however, the power to raise the limb, and to flex and extend it; but he is unable to walk, as he cannot support the weight of his body on the affected limb. July 7th.-The patient is up for the first time. An instrument has been made for him, consisting of three steel rods, connected at each end by a band of leather, one of which is fastened aboveand the other below the knee. With this instrument and a stick he is able to walk for a short time, but requires rest every five or ten minutes. care
* THE LANCET, vol. ii. 1855, p. 30.
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